Growth hormone pulsatility in acromegaly following radiotherapy

Radiotherapy continues to have an important role in the treatment of acromegaly and is particularly effective at halting tumour growth, causing tumour shrinkage and reducing growth hormone (GH) concentrations in the long term. The major disadvantages of radiotherapy include the slow reduction in GH levels and damage to the other hypothalamic-pituitary axes. The 24 hour GH profile in active acromegaly compared with normals, characteristically shows an increased frequency of GH pulses, increased disorderliness (approximate entropy) of GH release, increased mean GH valley nadir, increased non-pulsatile fraction of GH and either similar or increased GH pulse amplitude. Complete surgical excision of a GH secreting adenoma may reverse these abnormalities and reduce circulating insulin-like growth factor-1 (IGF-1) concentrations to normal. However, very few data are available regarding the effects of radiotherapy on GH pulsatility in patients with acromegaly. Radiotherapy rarely leads to normalisation of the pattern of spontaneous GH release and may therefore be associated with an elevated IGF-1 even when 24 hour GH concentrations are comparable to healthy controls. The impact of such a biochemical state on morbidity and mortality in acromegaly is unknown. The continuing effects of radiotherapy may potentially transform an individual from a state of GH excess, to a state of GH deficiency, with as yet undetermined effects. In addition, radiotherapy leads to significant hypothalamic dysfunction, with the possible loss of endogenous somatostatin (SMS) production. This may potentially alter somatostatin (SMS) receptor expression on somatotroph adenomas and alter their responsiveness to subsequent SMS analogue therapy.