Primary versus postoperative stereotactic radiosurgery for acromegaly: a multicenter matched cohort study

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OBJECTIVE

The role of primary stereotactic radiosurgery (SRS) in patients with medically refractory acromegaly who are not operative candidates or who refuse resection is poorly understood. The aim of this multicenter, matched cohort study was to compare the outcomes of primary versus postoperative SRS for acromegaly.

METHODS

The authors reviewed an International Radiosurgery Research Foundation database of 398 patients with acromegaly who underwent SRS and categorized them into primary or postoperative cohorts. Patients in the primary SRS cohort were matched, in a 1:2 ratio, to those in the postoperative SRS cohort, and the outcomes of the 2 matched cohorts were compared.

RESULTS

The study cohort comprised 78 patients (median follow-up 66.4 months), including 26 and 52 in the matched primary and postoperative SRS cohorts, respectively. In the primary SRS cohort, the actuarial endocrine remission rates at 2 and 5 years were 20% and 42%, respectively. The Cox proportional hazards model showed that a lower pre-SRS insulin-like growth factor–1 level was predictive of initial endocrine remission (p = 0.03), whereas a lower SRS margin dose was predictive of biochemical recurrence after initial remission (p = 0.01). There were no differences in the rates of radiological tumor control (p = 0.34), initial endocrine remission (p = 0.23), biochemical recurrence after initial remission (p = 0.33), recurrence-free survival (p = 0.32), or hypopituitarism (p = 0.67) between the 2 matched cohorts.

CONCLUSIONS

Primary SRS has a reasonable benefit-to-risk profile for patients with acromegaly in whom resection is not possible, and it has similar outcomes to endocrinologically comparable patients who undergo postoperative SRS. SRS with medical therapy in the latent period can be used as an alternative to surgery in selected patients who cannot or do not wish to undergo resection.

ABBREVIATIONS ARE = adverse radiation effects; GH = growth hormone; HR = hazard ratio; IGF-1 = insulin-like growth factor–1; IRRF = International Radiosurgery Research Foundation; SRS = stereotactic radiosurgery.

Article Information

Correspondence Jason P. Sheehan: University of Virginia, Charlottesville, VA. jps2f@virginia.edu.

INCLUDE WHEN CITING Published online April 26, 2019; DOI: 10.3171/2019.1.JNS183398.

Disclosures Dr. Kano reports that he has an Elekta research grant. Dr. Lunsford is a shareholder in Elekta AB, and a consultant for Insightec DSMB.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flowchart showing the patient selection process.

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    Kaplan-Meier plots comparing the actuarial initial remission rates between the matched primary versus postoperative SRS cohorts. The remission rates were similar between the 2 matched cohorts (p = 0.23, log-rank test).

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    Kaplan-Meier plots comparing the actuarial rates of recurrence-free survival between the matched primary versus postoperative SRS cohorts. The recurrence-free survival rates were similar between the 2 matched cohorts (p = 0.32, log-rank test).

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    Kaplan-Meier plots comparing the actuarial tumor control rates between the matched primary versus postoperative SRS cohorts. The tumor control rates were similar between the 2 matched cohorts (p = 0.34, log-rank test).

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