Abstract
The availability of various first-line treatment modalities for acromegaly and evolving surgical techniques emphasize the need for accurately defined predictors of surgical outcome. We retrospectively analysed the outcome of 30 patients with acromegaly after initial endoscopic transsphenoidal surgery in two university hospitals from 2001 until 2009, and reviewed comparable literature investigating predictive tumor characteristics. Medical records were monitored for patient characteristics. Each pituitary magnetic resonance imaging (MRI) scan was revised independently by two neuroradiologists using a standardised analysis form to record distinctive predefined tumor characteristics. All characteristics were independently analysed as predictors for persistent disease, and a multivariable predictive model was created. Literature from 2000 onwards was searched for studies describing tumor characteristics predictive for surgical outcome. The cohort consisted of 27 macroadenomas with 90 % demonstrating signs of parasellar extension. The surgical cure rate overall was 30 %. Independently, next to male sex and increasing tumor size, infrasellar and parasellar extension based on MRI staging tended to increase the risk of persistent disease. In a multivariable analysis, sex and parasellar extension of the tumor were demonstrated to be the variables allowing for the best fitted predictive model for persistent disease. Earlier studies on preoperative tumor characteristics showed comparable results, although these were based on several different tumor classification systems. This retrospective study demonstrates that accurately defined tumor characteristics based on imaging, especially for cavernous sinus invasion, can be helpful in predicting surgical outcome. Comparative studies on different treatment modalities are essential for clinical practice within the scope of re-evaluation of the role of surgery in GH-secreting adenomas.
Highlights
Growth hormone (GH)-secreting pituitary adenomas lead to the clinical picture of acromegaly
When a multivariable predictive model was made for both patient and tumor characteristics, sex and parasellar extension were included to make the best fitted model (Hosmer–Lemeshow test p = 0.84), with an area under the curve of 0.83 and an explained variance of 42 % (Table 3). In this retrospective study reviewing surgical outcome in a group of 30 acromegaly patients treated in two university hospitals in Amsterdam, the initial cure rate was 30 %, regardless of tumor size
Surgical cure rates for acromegaly patients have been studied in several cohorts with different numbers of cases, and using different definitions of cure, but in general ranges between 40 and 80 %
Summary
Growth hormone (GH)-secreting pituitary adenomas lead to the clinical picture of acromegaly. Treatment of choice is transsphenoidal surgery (TSS) for microadenomas, for non-invasive macroadenomas, and for adenomas causing compression symptoms. Together with improvements in radiotherapeutic techniques these developments have led to the idea of refraining from surgery in the cavernous sinus. Both developments stress the need for accurate radiological predictors of surgical outcome. A classification system for defining tumor size and invasiveness is needed as exemplified by the recently updated guidelines for acromegaly management [12]. Magnetic resonance imaging (MRI) is the reference standard for analysing pituitary adenomas, providing invaluable information about tumor size and extension [13]. Predicting surgical outcome on the basis of preoperative pituitary MRI has not been fully worked out in acromegaly
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