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| EDITORIAL |
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| Year : 2015 | Volume
: 63
| Issue : 3 | Page : 312-314 |
Surgery for acromegaly
CE Deopujari
Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| Date of Web Publication | 5-Jun-2015 |
Correspondence Address:
C E Deopujari
Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.158183
How to cite this article:
Deopujari C E. Surgery for acromegaly. Neurol India 2015;63:312-4 |
Acromegaly was first described by Marie in 1886. [1] Benda suggested the existence of a causal relationship between acromegaly and a pituitary tumor at the turn of 19 th century. The discovery of X-rays around the same time allowed the sellar changes to be visualized. These advances enabled Lewis to propagate the concept of surgical treatment for acromegaly. [2] Although the first attempt to operate, using a craniotomy, a pituitary tumor causing acromegaly was done in 1893 by Caton and Paul under the supervision of Sir Victor Horsley, [3] the first successful surgery through a lateral rhinotomy can be credited to Schloffer in 1907 at Vienna. [4] This concept of the inferior extra-cranial route was soon modified by Harvey Cushing into the sublabial transsphenoidal approach. [5] Since then, the value of surgical removal of the pituitary tumor has been well-recognized in the management of acromegaly.
Many surgeons started preferring the open craniotomy approach after its advocacy by Cushing. The re-popularization of transsphenoidal surgery in 1970s by Guiot et al. [6] and the introduction of microscope to the operative technique of selective adenoma removal by Hardy [7] established the transsphenoidal approach as the main treatment modality for this disease. Several technical advances in recent times have further improved the overall results, and surgical treatment is considered safe, effective and the first choice of treatment for acromegaly. [8],[9],[10] Furthermore, the recent addition of endoscopic pituitary surgery has also favorably influenced outcomes. [11],[12],[13] Our own cure rate in the last 26 patients of macroadenomas treated with purely endoscopic surgery has been 67% (unpublished data).
The importance of dedicated centers and surgeons for pituitary disorders has been emphasized in achieving better cure rates by several workers. [14],[15],[16],[17],[18] This has also been an important factor for minimizing complications in the survey conducted on transsphenoidal surgery by Ivan Ciric. [19] More recently, there has been an emphasis on developing centers of excellence for better training of younger neurosurgeons. [20]
Dutta et al. have contributed an important review of their experience in assessing the changing trends in acromegaly in this issue. [21] With the present American Association of Clinical Endocrinologists (AACE) criteria, the patients have been assessed for cure and the importance of a multi-disciplinary management and the role of experience of the surgeons in determining outcome, have been emphasized. Although this point has been highlighted well in the paper with their experience resulting in an improvement from 12.5% to 56%, the cure rates are still low due to the application of the more stringent criteria that is now in place, as well as the influence of several other factors in acromegaly. This is well-documented in several studies with approximately a 70% cure rate in microadenomas and a 50% cure rate in macroadenomas. [22],[23]
There is a common feeling that tumor size (staging) and preoperative basal growth hormone (GH) levels are important predictors of outcome. [9],[10],[24],[25] Tumor size (micro, macro, and giant) alone may not have much influence on the outcome if there is a regular growth of the tumor in a confined compartment. But invasiveness certainly has an influence in determining the completeness of tumor removal and thereby on cure rates. [26] Cavernous sinus invasion is an important factor in some cases. Although the medial cavernous sinus may be entered safely for softer tumors, it is almost impossible to remove the firm, nonsuckable tumors using the transsphenoidal approach. An illustrative case shows a small residue in the cavernous sinus due to the fibrous nature of the lesion [Figure 1]a-c. This could later be tackled by radiosurgery. Dural invasion has been observed by Laws et al. and Scheithauer et al. [27],[28],[29] in a large percentage of pituitary adenomas. The invasiveness has been noted in almost 50% of GH-secreting tumors. This may explain the incomplete remission and the high recurrence rates in patients without demonstrable tumors on a postoperative scan. This situation may warrant institution of medical therapy. An illustrative example of a young boy with gigantism is presented [Figure 2]a and b. | Figure 1: In a patient with acromegaly (a) a macroadenoma with suprasellar and left cavernous sinus extension; (b) the endoscopic operative view showing the fibrous tumor infiltrating within cavernous sinus behind the internal carotid artery. The internal carotid artery is being located using the Doppler probe; and, (c) postoperative scan showing residual tumor in the left cavernous sinus. Growth hormone levels remained 3.8 ng/ml prompting further adjuvant treatment using a gamma-knife
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 | Figure 2: (a) A 14-year-old with gigantism due to a pituitary macroademona with suprasellar extension with the growth hormone (GH) levels being 106 ng/ml; and, (b) complete excision was confirmed by postoperative magnetic resonance imaging and the GH levels remained 3.5 ng/ml. Although the radiology did not reveal any visible tumor, it could not be termed as a cure based on the present criteria. After a clinical remission for 2 years, the patient again became symptomatic with increased GH levels
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According to the AACE medical guidelines for clinical practice for the diagnosis and treatment of acromegaly (update 2011), [30] in most patients, medical therapy is used as an adjuvant treatment in the setting of persistent disease despite prior surgical intervention. Similarly, in patients with acromegaly, radiotherapy should be considered as an adjunctive treatment in those not fully responding to either surgical or medical treatment (or both). Although surgery (microscopic or endoscopic) by the transsphenoidal route as a primary treatment, gives immediate and best chance of cure in acromegaly, dedicated centers, experienced surgeons, preoperative hormonal levels, and morphology of tumor considerably influence the cure or remission rates.
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[Figure 1], [Figure 2]
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