Preoperative Medical Treatments and Surgical Approaches for Acromegaly

A Systematic Review

Christos Papaioannou; Maralyn Druce


Clin Endocrinol. 2023;98(1):14-31. 

In This Article

Abstract and Introduction


Objective: Acromegaly is a condition characterized by an overproduction of growth hormone which infers high morbidity and mortality if left untreated. The objective of this review is to analyse and appraise the current evidence for the generalized use of preoperative medications and the various surgical approaches as described in the literature.

Design: A thorough search from MEDLINE via PubMed, EMBASE, and Cochrane Library has been performed which identified a total of 37 papers.

Conclusion: The preoperative use of somatostatin receptor agonists (SAs) in acromegaly is a controversial topic with current guidelines suggesting against their generalized routine use. Most authors noticed an insignificant long-term remission of acromegaly when given SAs compared with nil preoperative therapy, except for invasive macroadenomas as SAs have been found to reduce the tumour volume and aid towards the total resection of the adenoma. Furthermore, according to the evidence available, endoscopic transsphenoidal surgery is the optimum method for hypophysectomy in terms of its remission and safety profile.


The clinical features observed in patients with acromegaly result from both an overproduction of growth hormone (GH) but also from the consequent overproduction of the insulin-like growth factor-1 (IGF1) and from the physical enlargement of the pituitary gland. This condition substantially affects the quality of life of patients and increases morbidity and mortality risk.[1]

Preoperative medical treatment may be employed to either achieve symptom relief or reduction in the size of the pituitary adenoma to aid in the surgical removal of the gland, or to mitigate any intra- and postoperative risks, or all of the above. There is a difficulty in establishing an evidence base that is reliable and of high quality because of the rarity and variability of these tumours. The current guidelines by the Endocrine Society suggest against the generalized routine use of presurgical medical treatment except in very specific cases.[2] The only preoperative treatments currently available are SAs (in particular octreotide and lanreotide), however, their use is limited to patients with severe nasopharyngeal thickening causing sleep apnoea or severe heart failure.[3] Following removal of the pituitary gland, the patients must have their IGF1 and GH levels measured. The soonest this should be done to establish the nadir value to assess for remission is at 12 weeks following the completion of surgery or later. Earlier measurements, however, can be of value. The regression of plasma IGF1 takes a long time to be accomplished due to the longer half-life in comparison with GH and due to the bound IGF1 on IGF-binding proteins. SAs—if administered perioperatively—can have a carry-on effect following the surgery due to their long half-life; thus they may still have an impact on residual somatotroph cells and early blood tests could provide inaccurate reassurance of cure.[4]

According to the current guidelines of the Endocrine Society, the first-line treatment for acromegaly is transsphenoidal surgery (TSS).[2] However, there are alternative options for the treatment of acromegaly including primary medical treatment, transcranial surgery, and radiation therapy. Treatment should be personalized to allow for an optimum rate of remission with low rates of postoperative morbidity. Surgical procedures could be carried out using a microscope or endoscope.[5] An older and now rarely used approach for pituitary surgery is via the transcranial route. This might still be used in an extremely large tumour with extensive invasion of nearby structures like the cavernous sinus and a large suprasellar component.

This article will focus on analyzing the evidence for the preoperative medical therapy on patients with acromegaly and on the various surgical approaches described in the literature.