Surgery for acromegaly: Evolution of the techniques and outcomes

Abstract

This paper presents an overview of the evolution of pituitary surgery for acromegaly. It begins with the first case, attempted in 1893, through the initial transsphenoidal successes in 1907-1910, to the development of effective craniotomy approaches, and ultimately to the resurrection of the transsphenoidal approach in the 1970s and thereafter. Today, the minimally endoscopic transnasal endoscopic approach is fast becoming the norm. Indications for surgery include active acromegaly, visual loss and other forms of mass effect, pituitary tumor apoplexy, and failure of other therapies (medical, radiation). Contraindications include advanced age, debility or other medical conditions increasing the risk of general anaesthesia or surgery. Surgery for acromegaly has the advantage of immediate lowering of the growth hormone excess, with endocrine remission rates of 70% for microadenomas and 50% for macroadenomas. When surgery fails to obtain remission, a program of therapy is designed for the patient to include adjunctive medical therapy (dopamine agonists, somatostatin analogs, and growth hormone receptor antagonists), radiation therapy or radiosurgery (Gamma knife, Cyberknife, etc.).

Transsphenoidal surgery in patients with acromegaly: operative strategies for overcoming technically challenging anatomical variations

“…3). 15,16,24 Because of these variations, it is critical to assess the course of the ICA within the parasellar nasal and cavernous sinuses prior to the operation, as extension of the ICA into the sphenoid sinus (Fig. 4) and a narrow intercarotid distance (Fig.…”

“…are observed relatively frequently. 15,16,24 A small proportion of patients with acromegaly may have "kissing" carotid arteries, in which the surgical approach or plan may require reconsideration for safe tumor removal. 22 In addition, atypical anatomy of the ICA may be further complicated by complex bony sellar floor and sphenoid sinus anatomy, resulting in a higher likelihood of ICA injury (as occurred in the patient with ICA injury described in Patient Characteristics and Complications, above).…”

“…16 Growth hormone-secreting adenomas have been implicated as causing local vascular changes that may be associated with deterioration of vessel endothelium and parasellar or intrasellar ICA aneurysm formation. 1,3,11,25,28 It should be remembered that ICA injury may be more likely to occur in patients with GH-secreting adenomas than in those with any other kind of pituitary adenoma as a result of the anatomical and microvascular changes mentioned.…”

Long term follow-up of growth hormone-secreting pituitary adenomas submitted to endoscopic endonasal surgery

“…The surgical treatment provides rapid control of GH and IGF-1 levels and it is the first line of treatment for GH-secreting adenomas 1,9,10 . In 1893, in England, the first pituitary surgery for acromegaly was performed by Caton and Paul, under the supervision of Sir Victor Horsley 11,12,13 , while the first transnasal resection of a pituitary tumor was performed by Schloffer in 1907 14 . Cushing 15 systematically used a transsphenoidal approach in sellar lesions and this technique was subsequently refined and popularized by Guiot 16 and Hardy 17,18 .…”

Radiation treatment strategies for acromegaly

“…10,25,48,52,53,74,90 However, the optimal management of the 10%-50% of patients who do not enter remission after transsphenoidal surgery 13,52 and the 20% of patients who experience recurrence of acromegaly after transsphenoidal surgery 13 remains less clear. Radiation represents an evolving treatment modality for acromegaly that warrants consideration as an alternative to medical therapy for tumors refractory to transsphenoidal surgery.…”