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acromegaly [2018/11/12 22:31]
administrador
acromegaly [2019/02/06 18:31] (current)
administrador [Treatment]
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 see [[Acromegaly diagnosis]]. see [[Acromegaly diagnosis]].
  
-====Treatment==== +===== Treatment =====
-From the beginning of the 20th century, acromegaly could be treated by pituitary surgery and/or radiotherapy. After 1970, medical therapies were introduced that could control acromegaly. First, [[dopamine agonist]]s were introduced, followed by somatostatin analogues and GH-receptor blockers.+
  
-Now surgery is the first-line therapy for patients with surgically accessible lesions. Surgery provides the greatest value for management of patients with acromegaly. However, in accordance with the Acromegaly Consensus Group'​s recent recommendations,​ somatostatin analogs provide the greatest value and should be used as first-line therapy for patients who cannot be managed surgically. At present, the substantial cost is the most significant negative factor in the value of medical therapies for acromegaly +see [[Acromegaly treatment]].
-((Kimmell KT, Weil RJ, Marko NF. Multi-modal management of acromegaly: a value +
-perspective. Pituitary. 2015 Jan 4. [Epub ahead of print] PubMed PMID: 25557288. +
-)). +
- +
-===Conservative=== +
-Asymptomatic elderly patients. +
- +
-===Surgery=== +
- +
-Surgical removal of as much tumor mass as possible is usually considered the first step of treatment in acromegaly, unless the patients are unfit for surgery or refuse an operation. To date, in almost all cases, minimally invasive, transsphenoidal microscopic or endoscopic approaches are used. Whether a curative approach is feasible or a [[debulking]] procedure is planned, can be anticipated on the basis of preoperative [[magnetic resonance imaging]]. It mostly depends on localization,​ size, and the invasive character of the lesion. The surgical results depend on tumor-related factors such as size, extension, the presence or absence of invasion, and the magnitude of [[IGF-1]] and [[growth hormone]] oversecretion,​ respectively. However, even surgeon-related factors such as experience and case load of the centers have been shown to strongly affect surgical results and complication rates. A [[reoperation]] can be considered at various stages in the treatment algorithm. There are several new technical gadgets which might aid in the surgical procedure: [[navigation]],​ the [[Doppler]] probe, and variants of intraoperative imaging +
-((Buchfelder M, Feulner J. Neurosurgical Treatment of Acromegaly. Prog Mol Biol  +
-Transl Sci. 2016;​138:​115-39. doi: 10.1016/​bs.pmbts.2015.11.002. Epub 2016 Jan 22. +
-PubMed PMID: 26940389. +
-)). +
- +
-see [[transsphenoidal approach]]. +
- +
-==Endoscopic endonasal approach== +
-Acromegaly ​patients present a particular challenge to the endoscopic skull base surgeon. Despite preoperative anesthesia and otolaryngology evaluation, many of these patients will experience an unanticipated airway challenge during intubation. Preoperative preparation and perioperative awareness of anatomic and physiologic abnormalities of acromegalic patients is essential for successful endoscopic surgery in this unique population +
-((Friedel ME, Johnston DR, Singhal S, Al Khalili K, Farrell CJ, Evans JJ, +
-Nyquist GG, Rosen MR. Airway management and perioperative concerns in acromegaly  +
-patients undergoing endoscopic transsphenoidal surgery for pituitary tumors. +
-Otolaryngol Head Neck Surg. 2013 Dec;​149(6):​840-4. doi: 10.1177/​0194599813507236. +
-Epub 2013 Oct 3. PubMed PMID: 24091425.)). +
- +
-The [[endoscopic endonasal approach]] in 214 cases was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively,​ IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively. The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs. 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria. +
- +
-In acromegaly ​treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4-1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up +
-((Hazer DB, Işık S, Berker D, Güler S, Gürlek A, Yücel T, Berker M. Treatment of +
-acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 +
-cases and cure rates according to current consensus criteria. J Neurosurg. 2013 +
-Dec;​119(6):​1467-77. doi: 10.3171/​2013.8.JNS13224. Epub 2013 Sep 27. PubMed PMID:  +
-24074496.)). +
- +
-===Radiotherapy=== +
-Variable efficacy of pituitary radiotherapy in acromegaly is reported. +
- +
-High precision CONFORMAL FRACTIONATED RADIOTHERAPY (CRT) is an effective modality to achieve remission in patients with acromegaly after failed [[TRANSSPHENOIDAL SURGERY]] (TSS) +
-((Patt H, Jalali R, Yerawar C, Khare S, Gupta T, Goel A, Lila A, Bandgar T, Shah +
-NS. HIGH PRECISION CONFORMAL FRACTIONATED RADIOTHERAPY IS EFFECTIVE IN ACHIEVING  +
-REMISSION IN PATIENTS WITH ACROMEGALY AFTER FAILED TRANSSPHENOIDAL SURGERY. +
-Endocr Pract. 2015 Oct 22. [Epub ahead of print] PubMed PMID: 26492545.)) +
- +
-===Medical therapy=== +
-Patients not cured by surgery +
- +
-Who cannot tolerate surgery +
- +
-Recurrence after surgery or radiotherapy +
- +
-Current pharmacotherapy includes: +
- +
-[[Somatostatin analog]]s  +
- +
-GH receptor antagonist: [[pegvisomant]].  +
- +
-More satisfactory surgical outcomes for noninvasive macroadenomas treated with presurgical SA may be achieved, although controversy of such adjuvant therapy exists. Combination of SA and pegvisomant or cabergoline shows advantages in some specific cases. Thus, an individual treatment program should be established for each patient under a full evaluation of the risks and benefits +
-((Wang JW, Li Y, Mao ZG, Hu B, Jiang XB, Song BB, Wang X, Zhu YH, Wang HJ. Clinical applications of somatostatin analogs for growth hormone-secreting pituitary adenomas. Patient Prefer Adherence. 2014 Jan 6;8:43-51. eCollection 2014. Review. PubMed PMID: 24421637; PubMed Central PMCID: PMC3888346.)).+
  
 ====Outcome==== ====Outcome====
acromegaly.txt · Last modified: 2019/02/06 18:31 by administrador