Elsevier

World Neurosurgery

Volume 108, December 2017, Pages 278-290
World Neurosurgery

Original Article
Endoscopic Transsphenoidal Approach for Acromegaly with Remission Rates in 401 Patients: 2010 Consensus Criteria

https://doi.org/10.1016/j.wneu.2017.08.182Get rights and content

Background

Transsphenoidal surgery is the first-choice treatment for acromegaly. Postoperative remission is an important predictor of outcome. Various factors have been described as markers of remission: preoperative mean growth hormone (GH) and insulin-like growth factor-1 levels, cavernous sinus invasion, tumor size, extrapseudocapsular resection, and experience of the surgeon.

Materials and Methods

A total of 401 patients underwent 432 endoscopic transsphenoidal surgeries between August 1997 and June 2016 at the Pituitary Research Centre of Kocaeli University. The remission rates were evaluated according to the 2010 consensus criteria using preoperative and postoperative data including overall remission, cavernous sinus invasiveness, extrapseudocapsular resection, resection rate, and preoperative and postoperative GH levels.

Results

Total resection was performed in 311 (77.56%) of 401 patients according to early (24-hour) postoperative magnetic resonance imaging. Overall, remission was achieved in 273 (68.1%) of 401 patients. Remission was achieved in 186 (63.3%) of 294 patients with macroadenomas, 87 (81.3%) of 107 patients with microadenomas, and 35 (40.7%) of 86 patients with cavernous sinus invasion. Remission was seen in 21 (75%) of 28 patients who underwent pseudocapsular resection. According to preoperative GH levels, remission was achieved in 205 (72.4%) of 273 patients with GH levels below 20 ng/mL but decreased to 11 (37.9%) of 29 patients with GH levels over 60 ng/mL. There was, conversely, a very strongly significant correlation with cavernous sinus invasion (P < 0.001; r: −0.953) and also a very strongly significant correlation with extrapseudocapsular resection (P < 0.001; r: 0.810). However, remission was very weakly but reversely significantly correlated with adenoma size and volume.

Conclusion

The most significant factors for remission are cavernous sinus invasion and extrapseudocapsular resection. Higher remission rates can be achieved with the removal of small remnants by meticulous sweeping and by total resection. Preoperative and postoperative GH levels are predictive of remission.

Introduction

Acromegaly is a disease described by high levels of growth hormone (GH) and insulin-like growth factor-1 (IGF-1), mostly due to GH secretion by a pituitary adenoma.1 The clinical characteristics of acromegaly are related skeletal, tissue, and organ growth that leads to dysmorphic craniofacial features, musculoskeletal deformity, and cardiovascular, metabolic, and respiratory complications due to increased GH secretion.2, 3 Normalization of GH levels alleviates symptoms and reduces mortality rates to the levels found in the general population.2 The annual incidence of acromegaly is 5 cases per 1,000,000 individuals, and the treatment options are surgery, medical therapy, and radiotherapy.4 Transsphenoidal surgery is the first-choice treatment for acromegaly.5, 6, 7, 8, 9, 10, 11, 12, 13 At present, endoscopic transsphenoidal surgery is preferred because of the benefits of improved surgical visualization, less nasal trauma, enhanced patient comfort, and better results of tumor removal than transsphenoidal microsurgery.14, 15, 16 A published series described several factors as markers of remission, including preoperative mean GH and IGF-1 levels,5, 17 cavernous sinus invasion,5, 18 tumor size,19, 20, 21 extrapseudocapsular resection,22, 23 and experience of the surgeon.8 According to the 2010 consensus guidelines, remission is interpreted as IGF-1 levels normal for age and sex, and a postoperative random GH level of <1 ng/mL or GH level of <0.4 ng/mL after an oral glucose tolerance test.24 The reported rates of biochemical remission of acromegaly after surgery range from 34% to 83%.4, 16, 17, 25, 26, 27, 28

Section snippets

Patients

A total of 401 consecutive patients underwent 432 endoscopic transsphenoidal surgeries between August 1997 and June 2016 at the Pituitary Research Centre of Kocaeli University, Kocaeli, Turkey. The medical records of 401 patients with GH-secreting adenomas were retrospectively reviewed. Informed consent was obtained from all patients, and the study was approved by the Ethical Committee of Kocaeli University, Turkey. Neurologic and endocrinologic assessments were performed before and after

Demographic Data, Symptoms, and Signs of the Patients

A total of 432 surgeries were performed for the 401 patients (2 surgeries for 23 patients, 3 for 4 patients). The patient cohort included 189 (47.1%) female patients and 212 (52.9%) male patients (mean age, 42.04 ± 11.7 years; median age, 41 years; age range, 11–71 years). The follow-up duration was 13 to 182 months (Table 1).

Signs and symptoms of acromegaly constituted the majority complaint of the patients. There were visual field abnormalities in 54 patients. Visual field findings of both

Discussion

Surgical intervention is recommended for the primary management of GH-secreting adenomas. Patients who do not experience remission with surgery often require adjuvant medical or radiation therapy.31 An endoscopic approach offers the advantages of improved surgical visualization, less nasal trauma, increased patient comfort, and better results of total tumor removal.17, 19, 21, 32

In the literature, reported remission rates range from 31.9% to 84.7% (Table 8).31, 32, 33, 34, 35, 36, 37, 38, 39, 40

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      Citation Excerpt :

      Similarly, in the patients with initially larger adenomas, the frequency of recurrence after remission was also found to be increased. Contradictory results regarding the prognostic values of factors such as the patient's age, gender, cavernous sinus invasion, compression of optic chiasm, hypopituitarism, and IHC staining pattern of the adenoma have been reported in prior studies [12–27]. The present study found that the optic chiasm compression, but not the patient's age, gender, cavernous sinus invasion, hypopituitarism, or IHC staining pattern, was of prognostic value in relation to both remission and recurrence.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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