Impact of tumor characteristics and pre- and postoperative hormone levels on hormonal remission following endoscopic transsphenoidal surgery in patients with acromegaly

Neurosurg Focus. 2020 Jun;48(6):E10. doi: 10.3171/2020.3.FOCUS2080.

Abstract

Objective: Acromegaly is a disease of acral enlargement and elevated serum levels of insulin-like growth factor-1 (IGF-1) and growth hormone (GH), usually caused by a pituitary adenoma. A lack of consensus on factors that reliably predict outcomes in acromegalic patients following endoscopic endonasal transsphenoidal surgery (EETS) warrants additional investigation.

Methods: The authors identified 52 patients with acromegaly who underwent an endoscopic endonasal approach (EEA) for resection of a GH-secreting pituitary adenoma. Preoperative and postoperative tumor and endocrinological characteristics such as tumor size, invasiveness, and GH/IGF-1 levels were evaluated as potential indicators of postoperative hormonal remission. Endocrinological remission was defined as postoperative IGF-1 levels at or below the age- and sex-normalized values.

Results: The 52 patients had a mean age of 50.7 ± 13.4 years and a mean follow-up duration of 24.4 ± 19.1 months. Ten patients (19%) had microadenomas and 42 (81%) had macroadenomas. Five patients (9.6%) had giant adenomas. Forty-four tumors (85%) had extrasellar extension, with 40 (77%) exhibiting infrasellar invasion, 18 (35%) extending above the sella, and 7 (13%) invading the cavernous sinuses. Thirty-six patients (69%) underwent gross-total resection (GTR; mean maximal tumor diameter 1.47 cm), and 16 (31%) underwent subtotal resection (STR; mean maximal tumor diameter 2.74 cm). Invasive tumors were significantly larger, and Knosp scores were negatively correlated with GTR. Thirty-eight patients (73%) achieved hormonal remission after EEA resection alone, which increased to 87% with adjunctive medical therapy. Ninety percent of patients with microadenomas and 86% of patients with macroadenomas achieved hormonal remission. Preoperative IGF-1 and postoperative day 1 (POD1) GH levels were inversely correlated with hormonal remission. Postoperative CSF leakage occurred in 2 patients (4%), and none experienced vision loss, death, or injury to internal carotid arteries or cranial nerves.

Conclusions: Endoscopic transsphenoidal resection of GH-secreting pituitary adenomas is a safe and highly effective treatment for achieving hormonal remission and tumor control in up to 87% of patients with acromegaly when combined with postoperative medical therapy. Patients with lower preoperative IGF-1 and POD1 GH levels, with less invasive pituitary adenomas, and who undergo GTR are more likely to achieve postoperative biochemical remission.

Keywords: DI = diabetes insipidus; EEA = endoscopic endonasal approach; EETS = endoscopic endonasal transsphenoidal surgery; EOR = extent of resection; GH = growth hormone; GTR = gross-total resection; IGF-1 = insulin-like growth factor–1; IHC = immunohistochemistry; Knosp; LAC + USC = Los Angeles County + University of Southern California; OGTT = oral glucose tolerance test; POD1 = postoperative day 1; SRL = somatostatin receptor ligand; STR = subtotal resection; TSH = thyroid-stimulating hormone; acromegaly; adenoma; cavernous sinus; endoscope; invasion; pituitary; somatotroph; surgery.

MeSH terms

  • Acromegaly / blood*
  • Acromegaly / diagnostic imaging
  • Acromegaly / surgery*
  • Adenoma / blood
  • Adenoma / diagnostic imaging
  • Adenoma / surgery
  • Adult
  • Aged
  • Basic Helix-Loop-Helix Transcription Factors / blood
  • Female
  • Growth Hormone-Secreting Pituitary Adenoma / blood
  • Growth Hormone-Secreting Pituitary Adenoma / diagnostic imaging
  • Growth Hormone-Secreting Pituitary Adenoma / surgery
  • Human Growth Hormone / blood*
  • Humans
  • Insulin-Like Growth Factor I / metabolism*
  • Male
  • Middle Aged
  • Neuroendoscopy / methods*
  • Neuroendoscopy / trends
  • Postoperative Care / methods*
  • Preoperative Care / methods*
  • Preoperative Care / trends
  • Remission Induction / methods
  • Retrospective Studies
  • Sphenoid Bone / diagnostic imaging
  • Sphenoid Bone / surgery

Substances

  • Basic Helix-Loop-Helix Transcription Factors
  • IGF1 protein, human
  • TCF21 protein, human
  • Human Growth Hormone
  • Insulin-Like Growth Factor I