Preoperative Medical Treatment for Patients With Acromegaly: Yes or No?

Frederique Albarel; Thomas Cuny; Thomas Graillon; Henry Dufour; Thierry Brue; Frederic Castinetti

Disclosures

J Endo Soc. 2022;6(9) 

In This Article

Abstract and Introduction

Abstract

Transsphenoidal surgery is the first-line treatment for acromegaly. However, several factors can modify surgical remission rates, such as the initial hormone levels, the size and invasiveness of the tumor, and the degree of experience of the surgeon. Physicians treating patients with acromegaly should thus consider how to improve surgical remission rates. As stated in recent guidelines, the major point is to consider that any patient with acromegaly should be referred to an expert neurosurgeon to maximize the chances of surgical sure. The benefits of presurgical medical treatment, mainly using somatostatin receptor ligands (SRLs), given 3 to 6 months before surgery, remain controversial. By normalizing growth hormone and insulin-like growth factor 1 levels, SRLs may improve the overall condition of the patient, thus decreasing anesthetic and surgical complications. By decreasing the tumor size and modifying the consistency of the tumor, SRLs might also make surgical excision easier. This is however theoretical as published data are contradictory on both points, and only limited data support the use of a systematical presurgical medical treatment. The aim of this review is to analyze the potential benefits and pitfalls of using presurgical medical treatment in acromegaly in view of the contradictory literature data. We also attempt to determine the profile of patients who might most benefit from this presurgical medical treatment approach as an individualized therapeutic management of acromegaly.

Introduction

Acromegaly is a rare disease usually caused by a growth hormone (GH)–secreting pituitary tumor. It leads to several comorbidities, including left ventricular hypertrophy, hypertension, diabetes, and sleep apnea. When left untreated (or undiagnosed), acromegaly leads to an increased mortality rate.[1] Over the last 20 years, therapeutic management of acromegaly has changed, with a reduction in the use of radiation techniques and increased use of a combination of medical treatments, as is shown by the French Acromegaly Registry.[2] However, transsphenoidal surgery still represents the first-line treatment for acromegaly. It is a low-risk procedure when carried out by experienced surgeons,[3,4] with an efficacy that varies from 20% to 80%, depending on the size of the tumor, its invasiveness, the initial hormone levels (frequently correlated with tumor size), and the degree of experience of the surgeon. Surgery is currently the only treatment (apart from radiotherapy, which can lead to remission after a prolonged period) that can result in cure for the patient.[5–7] The aims of physicians treating patients with acromegaly should thus be to maximize the chances of obtaining a surgically induced remission and to avoid prolonged and costly medical treatment, and this first requires an expert neurosurgeon in an expert center. Since the original description of the use of somatostatin receptor ligands (SRLs) before transsphenoidal surgery[8] more than 20 years ago, the benefits of presurgical medical treatment (PSMT) in improving the rate of surgical cure have remained controversial. This subject has been explored by several original papers and has remained a matter of discussion in all the guidelines published over the last 15 years. The aim of this review will thus be to determine the potential benefits and pitfalls of using PSMT in patients with acromegaly.

First-generation SRLs represent the first-line medical treatment of choice in acromegaly.[5,6] They are recommended as first-line therapy in patients who are not suitable for surgery or who are unlikely to be cured by surgery owing to the tumor invading the cavernous sinus.[5] Moreover, preoperative SRLs are considered in cases of severe acromegaly-related comorbidities that increase the risk of anesthesia.[9] Their antisecretory and antitumor efficacy likely explains why they are considered as almost the sole option for PSMT. After a brief overview of their antisecretory and antitumor efficacy, and their tolerance in acromegaly, we will focus on their potential benefits for perioperative and postoperative outcomes of acromegaly. Cabergoline, a D2 receptor agonist, will also be briefly discussed as another potential PSMT.

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