Acromegaly--the place of the neurosurgeon

Over 12 years, we performed 498 operations for growth hormone (GH)-secreting pituitary adenomas (489 in acromegaly and nine for gigantism), with 479 by the trans-sphenoidal and 19 by the transcranial route. A consecutive series of 224 patients had an overall cure rate of 56%, with normalization in 71% when the criterion was only basal GH. Endocrine remission occurred in 72% of microadenomas, 50% of macroadenomas, and only 17% of giant adenomas. Seventy-three percent of the patients with preoperative GH levels less than 10 ng/mL were cured, but only 33% with GH greater than 100 ng/mL. Our cure rate for invasive adenomas was 38%. Surgical reexploration can lead to a 50% cure rate. Overall morbidity was low. Pretreatment of large adenomas with octreotide may soften them and facilitate their removal, and one third shrink. It also relieves the symptoms of acromegaly and improves the patient's general condition for surgery. Octreotide as first-line therapy is indicated in patients with risk factors for surgery, and it is becoming an alternative to radiotherapy after surgery. It is more potent than dopamine agonists in lowering GH levels. We recommend postoperative radiotherapy (+/- octreotide) if GH levels are fairly high after surgery or if the adenoma shows major invasiveness. Surgery is still the initial therapy of choice in acromegaly due to its high cure rate and low morbidity.