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

Clinical article

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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.

Abbreviations used in this paper:AUC = area under the curve; GH = growth hormone; ICA = internal carotid artery; IGF-I = insulin-like growth factor–I; OGTT = oral glucose tolerance test.

Article Information

Address correspondence to: Mustafa Berker, M.D., Ph.D., Hacettepe University School of Medicine, Department of Neurosurgery, Sihhiye, Ankara 06100, Turkey. email: mberker@hacettepe.edu.tr.

Please include this information when citing this paper: published online September 27, 2013; DOI: 10.3171/2013.8.JNS13224.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Intraoperative view of intrasellar cavity and medial view of the cavernous sinus after the excision of GH adenoma invading cavernous sinus. Inset: A T2-weighted MRI study of the adenoma. Asterisk, ICA; thin arrow, inferior hypophysial artery; thick arrow, diaphragma sella.

  • View in gallery

    Bar graph showing IGF-I serum level changes according to days postoperatively.

  • View in gallery

    Graph showing the receiver operating characteristic curves of the GH cut-off points for different follow-up dates with respect to cure. (Please refer to the online version for the key to the colors of the curves.)

  • View in gallery

    Bar graph showing comparison of the cure rates in patients before and after the cut-off points of the number of surgeries.

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