Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

Abstract

Object Acromegaly is a disease that has significant morbidity and mortality related to high levels of growth hormone (GH) and insulin-like growth factor–I (IGF-I), and is usually caused by pituitary adenomas. The goal in this study was to investigate the role of endoscopic transsphenoidal surgery and surgical experience in the treatment of GH adenoma cases in relation to surgical results and hormonal cure rates, and to perform a review of the literature. Methods The authors present a retrospective analysis of 214 GH adenoma cases. Restoration of IGF-I levels to normal for age and sex, suppression of GH levels below 0.4 μg/L on the oral glucose tolerance test, and demonstration of the total removal of the tumor on MRI studies obtained after administration of contrast material at the 3-month postoperative follow-up visit were the criteria for cure. Results In total 214 patients with a mean age of 41.9 ± 12 years (range 17–75 years) and a male/female ratio of 106/108 were enrolled in the study. Cure was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively, IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively. The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria. Conclusions In acromegaly treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4–1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up.

Endoscopic endonasal transsphenoidal treatment for acromegaly: 2010 consensus criteria for remission and predictors of outcomes

“…Tumor size predicted remission, and microadenomas had higher hormonal remission rates than macroadenomas in our series reported in numerous earlier publications (15,17,29). In our current study, remission was achieved in 80% of microadenomas and in 64.7% of macroadenomas.…”

“…The 2010 criteria are more stringent than 2000 criteria and it is more difficult to achieve a hormonal remission according to the new criteria. There are limited numbers of studies in literature according to the new criteria, and hormonal remission rates were reported between 46%-70% (12, 15,16,29). In our series, hormonal remission was achieved in 66.1% of patients.…”

“…33,15). In this study, we present hormonal remission results, outcomes, and predictive factors of endocrinological remission in acromagalic patients after pure endoscopic transsphenoidal pituitary surgery.…”

Endoscopic Transsphenoidal Approach for Surgical Treatment of Growth Hormone Secreting Pituitary Adenoma: Endocrinological Outcome in 49 Patients Based on 2010 Consensus Criteria for Remission - Preliminary Result

“…2017; 4(3):e14131. 5 ies using the 2010 criteria with the reported remission rates of 28.8% to 70.8% (7,19,(26)(27)(28)(29)(30)(31)(32)(33). The current study results showed an overall remission rate of 71.4% with the mean follow-up of 25.4 months.…”

“…In contrast to earlier publications, tumor size was not an important predictive factor for remission in the current study (19,32,33). Sarkar et al, revealed that an adenoma size < 20 mm was the predictor of outcome at follow-up (27).…”