Abstract
PurposeAcromegaly has high morbidity and mortality when growth hormone secretion remains uncontrolled. Stereotactic radiosurgery (SRS) may be used when pituitary surgery is not suitable or unsuccessful, but there are few very long-term safety data available, especially for significant adverse events such as stroke.Methods118 patients with acromegaly were treated with SRS between 1985 and 2015, at the National Centre for Stereotactic Radiosurgery, Sheffield, UK. Data were gathered from case notes, hospital databases, and patient questionnaires. Stroke incidence in comparison to the normal population was quantified using the standardised incidence ratio (SIR), and visual complications assessed.Results88% (104/118) had complete morbidity follow up data for analysis. The mean follow-up was 134 months, and median SRS dose was 30 Gy. 81% of tumours had cavernous sinus invasion. There was no excess stroke rate relative to that seen in two age- and sex-matched large population studies (SIR = 1.36, 95% CI 0.27–3.96; SIR = 0.52, 95% CI 0.06–1.89). In 68/104 patients who had MRI-guided SRS with no further radiation treatment (SRS or fractionated radiotherapy) there was no loss of visual acuity and 3% developed ophthalmoplegia. There was a positive correlation between > 1 radiation treatment and both ophthalmoplegia and worsening visual acuity.ConclusionStroke rate is not increased by SRS for acromegaly. Accurate MRI-based treatment planning and single SRS treatment allow the lowest complication rates. More than one radiation treatment (SRS or fractionated radiotherapy) was associated with increased visual complications.
Highlights
Uncontrolled acromegaly results in a three-fold increase in all-cause mortality which is reversible with normalisation of GH and IGH-1 levels [1,2,3]
The sparsity of stroke incidence means it is unlikely the conclusions would change appreciably, were other reference populations used. This is the longest reported follow-up of any cohort of patients with acromegaly treated by gamma knife, assessing morbidity and mortality
Our data show that there is no excess risk of stroke following stereotactic radiosurgery (SRS) for acromegaly, and we believe that it is likely that this observation is generalisable to SRS for other pituitary tumours
Summary
Uncontrolled acromegaly results in a three-fold increase in all-cause mortality which is reversible with normalisation of GH and IGH-1 levels [1,2,3]. Pituitary surgery is the recommended first line treatment for acromegaly [3, 4] and achieves immediate tumour and biochemical control in 65% of patients (45–64% of patients with macroadenomas and in 72–90% with microadenomas) [3,4,5,6]. In cases of inadequate control or poorly tolerated side effects using medication, fractionated radiotherapy (RT) (multiple low radiation doses over several weeks) or stereotactic radiosurgery (SRS) (high dose radiation using multiple axes of delivery) are established treatments that control tumour size and GH secretion [3, 4, 7]. Radiotherapy is, an independent risk factor for increased mortality [5, 8]. This increased mortality rate may not apply to SRS [3]
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