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Endoscopic transnasal, transsphenoidal pituitary microsurgery removes the adenoma while preserving anterior pituitary function in most patients Surgical remission is achieved in about 70% of patients followed over 3 years GH levels fall immediately; diaphoresis and carpal tunnel syndrome often improve within a day after surgery Transsphenoidal surgery is usually well tolerated, but complications occur in about 10% of patients, including infection, cerebrospinal fluid leak, and hypopituitarism Transsphenoidal pituitary surgery may be difficult in patients with McCune Albright syndrome because of fibrous dysplasia of the skull base Hyponatremia can occur 4 13 days postoperatively and is manifested by nausea, vomiting, headache, malaise, or seizure It is prudent to monitor serum sodium levels postoperatively Dietary salt supplements for 2 weeks postoperatively may prevent this complication Corticosteroids are administered perioperatively and tapered to replacement doses over 1 week; hydrocortisone is discontinued and cosyntropin stimulation test is performed about 6 weeks after surgery At that time, a serum T4 can be checked (to screen for secondary hypothyroidism) and the patient is screened for secondary hypogonadism (see above)

tension In acromegalic diabetics, hypoglycemic drugs are reduced to avoid hypoglycemia during pegvisomant therapy The effectiveness of pegvisomant is reduced by coadministration of opioids or propoxyphene Pegvisomant is extraordinarily expensive Acromegalic patients who have not had a complete remission with transsphenoidal surgery or medical therapy may be treated with stereotactic radiosurgery administered by gamma knife, heavy particle radiation, or adapted linear accelerator Some medical centers are using pituitary gamma knife radiosurgery as the initial treatment with reported success rates of 20 90% Radiosurgery precisely radiates the pituitary tumor in a single session and reduces radiation to the normal brain However, it cannot be used for pituitary tumors with suprasellar extension due to the risk of damaging the optic chiasm Radiosurgery can be used for pituitary tumors invading the cavernous sinus, since cranial nerves III, IV, V, and VI are less susceptible to radiation damage Radiosurgery can also be used for patients who have not responded to conventional radiation therapy

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Castinetti F et al Outcome of gamma knife radiosurgery in 82 patients with acromegaly: correlation with initial hypersecretion J Clin Endocrinol Metab 2005 Aug;90(8):4483 8 [PMID: 15899958] Feenstra J et al Combined therapy with somatostatin analogues and weekly pegvisomant in active acromegaly Lancet 2005 May 7 13;365(9471):1644 6 [PMID: 15885297] Galland F et al McCune-Albright syndrome and acromegaly: Effects of hypothalamopituitary radiotherapy and/or pegvisomant in somatostatin analog-resistant patients J Clin Endocrinol Metab 2006 Dec;91(12):4957 61 [PMID: 16984995] Melmed S Acromegaly N Engl J Med 2006 Dec 14;355(24): 2558 73 [PMID: 17167139]

Women: Menstrual cycle disturbances (oligomenorrhea, amenorrhea); galactorrhea; infertility Men: Hypogonadism; decreased libido and erectile dysfunction; infertility Elevated serum PRL CT scan or MRI often demonstrates pituitary adenoma

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Patients with acromegaly have increased morbidity and mortality from cardiovascular disorders and progressive acromegalic symptoms; those who are treated and have a glucose-suppressed serum GH level less than 25 ng/mL (radioimmunoassay) or under 1 ng/mL (immunofluorometric assay) and normal age-adjusted serum IGF-I levels have reduced morbidity and mortality Transsphenoidal pituitary surgery is successful in 80 90% of patients with tumors less than 2 cm in diameter and GH levels less than 50 ng/mL Extrasellar extension of the pituitary tumor, particularly cavernous sinus invasion, reduces the likelihood of surgical cure Adjuvant medical therapy has been quite successful in treating patients who are not cured by pituitary surgery Postoperatively, normal pituitary function is usually preserved Soft tissue swelling regresses but bone enlargement is permanent Hypertension frequently persists despite successful surgery Conventional radiation therapy (alone) produces a remission in about 40% of patients by 2 years and 75% of patients by 5 years after treatment Gamma knife or cyberknife radiosurgery reduces GH levels an average of 77%, with 20% of patients having a full remission after 12 months Patients with pituitary adenomas that abut the optic chiasm can be treated with cyberknife radiosurgery, controlling tumor growth and preserving vision in most patients Heavy particle pituitary radiation produces a remission in about 70% of patients by 2 years and 80% of patients by 5 years Radiation therapy eventually produces some degree of hypopituitarism in most patients Conventional radiation therapy may cause some degree of organic brain syndrome and predisposes to small strokes Patients must receive lifelong follow-up, with regular monitoring of serum GH and IGF-I levels Serum GH levels over 5 ng/mL and rising IGF-I levels usually indicate a recurrent tumor Hypopituitarism may occur, due to the tumor itself, pituitary surgery, or radiation therapy Hypopituitarism may develop years following radiation therapy, so patients must have regular clinical monitoring of their pituitary function.

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