Transsphenoidal adenomectomy (TSA) is the recommended primary therapy in most patients with acromegaly and results in remission for majority of microadenomas and a proportion of macroadenomas depending on extent of surgically accessible disease. Acromegaly is associated with significant mortality and morbidity, hence a combination of treatment modalities may be needed to achieve disease control.
Methods: A retrospective casenotes review was conducted and management audited against the 2014 Endocrine Society guidelines. Patients were identified from the departmental database and clinic. Post-operative cure, and disease control, were defined as normal age- and sex-adjusted IGF-1, and either a random serum GH<1 μg/L or GH nadir<1 μg/L on OGTT.
Results: Data were collected on 185 patients currently attending clinic (Males 52.7%) with mean follow-up 154 months (range 2587). Mean age at diagnosis was 44 years (59% macroadenomas; 30% microadenomas; 11% imaging not available): 167 (90%) were treated with TSA leading to cure in 62% (29/47) of microadenomas and 33% (33/101) of macroadenomas. Overall, 131/185 (71%) patients are controlled: 62 (33%) patients with surgery alone; 34 (18%) with surgery and pharmacotherapy (SSA and/or cabergoline and/or pegvisomant); 14 (7.6%) with surgery and radiotherapy; 15 (8%) with surgery, radiotherapy and pharmacotherapy; 10 (5.4%) patients with pharmacotherapy alone; 2 (1%) with radiotherapy alone. A further 28 patients (15%) have IGF-1/GH discordance with either normal IGF-1 (21) or GH<1 (7). In 12% of patients (8/65) who were initially cured after TSA, recurrence occurred after a mean duration of 7 years.
Conclusion: Our surgical remission rates are comparable to other published series. The 71% control with multimodal therapy compares favourably with other series. A recurrence rate of 12% emphasises the importance of long term follow-up. It is important to prioritise patients with uncontrolled acromegaly to reassess scope for treatment escalation.
19 Nov 2018 - 21 Nov 2018