Transsphenoidal Surgery for Acromegaly in Wales: Results Based on Stringent Criteria of Remission

• Published in: The journal of clinical endocrinology and metabolism 2003-08, Vol.88 (8), p.3567-3572
• Main Authors: De, P., Rees, D. A., Davies, N., John, R., Neal, J., Mills, R. G., Vafidis, J., Davies, J. S., Scanlon, M. F.
• Format: Article
• Language: English
• Subjects: Acromegaly - surgery; Adenoma - surgery; Adult; Aged; Aged, 80 and over; Female; Glucose Tolerance Test; Human Growth Hormone - blood; Humans; Insulin-Like Growth Factor I - metabolism; Magnetic Resonance Imaging; Male; Middle Aged; Neurosurgical Procedures - adverse effects; Pituitary Gland - diagnostic imaging; Pituitary Gland - pathology; Pituitary Gland - surgery; Pituitary Hormones, Anterior - deficiency; Pituitary Neoplasms - diagnostic imaging; Pituitary Neoplasms - pathology; Pituitary Neoplasms - surgery; Postoperative Complications - epidemiology; Retrospective Studies; Sphenoid Bone - surgery; Tomography, X-Ray Computed; Treatment Outcome; Wales
• ISSN: 0021-972X; 1945-7197
• DOI: 10.1210/jc.2002-021822

We retrospectively analyzed 90 patients who underwent transsphenoidal surgery (performed by three surgeons) in our center as initial therapy for acromegaly. We used a combination of modern, evidence-based remission criteria including mean day curve GH less than 2.5 μg/liter (5 mU/liter), a nadir GH less than 1.0 μg/liter (2 mU/liter) after an oral glucose tolerance test, and normal age-related IGF-I levels (where available). Fifty-seven of 90 (63%) patients remained in remission after surgery. Seventy-nine percent of patients with microadenomas but only 56% of patients with macroadenomas achieved remission (P < 0.001). Eighty-six percent of patients with preoperative GH levels below 10 μg/liter (day profile or after oral glucose tolerance test) went into remission, compared with 51% of patients with GH levels above 25 μg/liter at diagnosis (P < 0.002). The remission rate was also related to the period of surgery that was significantly higher in 1998–2001 (76%; P < 0.05) compared with 1990–1997 (54%) and 1980–1989 (63%). There were no recurrences or perioperative deaths. Meningitis occurred in 3% of patients, cerebrospinal fluid rhinorrhea in 7%, and permanent diabetes insipidus in 15%. The proportion of patients who developed new anterior pituitary hormone deficiencies and panhypopituitarism was significantly less in the period 1998–2001 (P < 0.001) when compared with the periods from 1990–1997 and 1980–1989. Transsphenoidal surgery is a safe and effective treatment for acromegaly, and our results compare favorably with those from published series. The presence of an intrasellar lesion and low preoperative GH levels is a good predictor of remission in the long term, but historically in our center this can only be achieved in a significant proportion of patients at the expense of some degree of hypopituitarism. However, surgical outcome in our center, including a reduced frequency of hypopituitarism, has improved significantly over time, coincident with the arrival of a dedicated pituitary neurosurgeon and the use of selective adenomectomy as the preferred surgical approach wherever possible.