Transsphenoidal Microsurgery for Growth Hormone-Secreting Pituitary Adenomas: Initial Outcome and Long-Term Results

Abstract

Treatment of acromegaly has long been recognized as necessary to relieve symptoms, halt progression of deformities, and decompress the sella turcica. More recently, treatment strategies have focused on decreasing GH levels to a point at which mortality rates normalize, thereby redefining previous concepts of a cure. No surgical series to date has investigated the long-term effect of treatment on mortality rates. We retrospectively reviewed 254 consecutive patients with acromegaly who underwent transsphenoidal microsurgery of GH-secreting adenomas between 1974-1992. Seventy-six percent of these patients had basal GH levels <5 ng/mL within 30 days of surgery, and 24% had persistent disease. Multivariate analysis revealed that higher stage, grade, and preoperative GH levels were all predictive of persistence (P < 0.01). Long-term follow-up was obtained on 129 of the patients in initial remission. Of these, 9 (7%) had disease recurrence and 120 remained in remission. The incidence of major postoperative complications was 8% (2% permanent diabetes insipidus, 2% cerebrospinal fluid leaks requiring surgery, 2% meningitis, and 2% hypopituitarism), with no mortality. In contrast to the 2.4- to 4.8-fold increased mortality among untreated acromegalics, the mortality rate among patients with posttherapy GH levels <5 ng/mL was equivalent to that of age- and sex-matched controls. Aggressive therapy to normalize GH levels should therefore be instituted at diagnosis.

Could different treatment approaches in acromegaly influence life expectancy? A comparative study between Bulgaria and Campania (Italy)

“…In accordance with our results of the Bulgarian cohort, increased vascular mortality has been reported in several studies (20,21,22,23,24). On the other hand, a tendency toward increased life expectancy has been observed in recent studies (22,23,24,25,26,27,28,29,30,31,32,33,34). They suggested that the improved survival rate could be due to more stringent criteria for remission and the introduction of modern and more efficient treatment options, such as SSAs and GHRAs.…”

“…Bates et al (38) were the first to demonstrate that an increased mortality was reduced to normal when GH levels reached !2.5 mg/l. Their observations were supported by numerous further studies (22,26,27,28,29,30,32,38,39) with a pooled SMR of 1.1 (0.9-1.4; PZ0.50) (7). Some research groups reported even lower GH targets: 2 mg/l by Ayuk et al and a further improvement in mortality when GH was reduced to !1 mg/l (23,26).…”

Mortality in acromegaly: a 20-year follow-up study

“…For instance, in 1980, Alexander and coworkers reported increased mortality in male compared with female patients with acromegaly after 15 years of follow-up (Alexander et al 1980), and in 1993, Etxabe and coworkers reported an SMR for men of 7.0 compared with 1.4 for women with acromegaly after 6.2 years of follow-up (Etxabe et al 1993). By contrast, in 1998, a two-fold SMR was reported for women compared with men with persistent acromegaly after a median follow-up of 11 years (Abosch et al 1998). The present study, which represents a more modern series of patients with acromegaly, all of whom had a follow-up of at least 20 years, sheds some light on this issue.…”

Treatment Factors That Influence Mortality in Acromegaly

“…Many previous studies have used multiple assays during the duration of the study [12,20,21,26] or multiple assays in different centres in multicentre studies both for GH and IGF-I [26]. Some studies do not describe the assays used [13,27,28]. Both IGF-I and GH assays, even those in use today, are prone to large variability and issues with regard to reference ranges that will impact on the result of the studies [29].…”