audit of outcome of treatment in patients with acromegaly at mansoura University Hospital

ABSTRACT

Aim: In the last decade, there has been much change concerning treatment of patients with acromegaly. Although stringent criteria for cure or remission in acromegaly are advocated by many authors, there is still much controversy about cure rates using different endocrinologic criteria and factors behind the different outcomes in different centers. Because patients with acromegaly are cared for by many specialties including the endocrinologist, the neurosurgeon, and the radiotherapist, pooled data about the outcome of different modalities of treatment are lacking in our hospital. The aim of the present study was to review our patients with acromegaly, therapeutic modalities used, and to evaluate the outcome in lights of the international reports. Subjects and A series of 26 cases with acromegaly due to pituitary adenoma attending the Mansoura Endocrinology and Neurosurgery outpatient clinics and inpatient departments, were assessed retrospectively. Clinical, full endocrinologic and biochemical assessment including serum GH, prolactin, TSH and ACTH were made. Neuroimaging data including MRI and/or CT of the pituitary were examined. Ophthalmologic examination including fundus and field of vision, both pre- and postoperatively were analyzed. Remission was considered at GH level of less than 5 ng/ml. Twenty four patients have undergone transsphenoidal pituitary adenomectomy, combined with external conventional radiotherapy and bromocriptin therapy at a dose of 10 mg/day in divided doses. Two patients accepted only medical treatment. Follow up period ranged from 1 to 6 years with an average of 3 years with serial endocrinal, biochemical and neuroimaging assessment. Patients analyzed included 6 females and 20 males with an age ranging from 27 to 62 years. All females were postmenopausal and were significantly older than males. Clinical features of acromegaly, as abnormal facial features, hyper-hidrosis, hypertension, diabetes, and musculoskeletal abnormalities were not different from those reported in the literature. Pituitary microadenoma was found only in one patient, while macroadenoma confined to the sella was found in 12 cases [46%], and macroadenoma with extrasellar extensions was found in 13 cases [50%]. Serum GH in both types of macradenoma was not significantly different [56 +/- 8ng/ml versus 59 +/- 8 ng/ml, respectively]. Serum prolactin level was high in 10 cases [38%] with a mean of 104 +/- 29 ng/ml. Preoperative defect in the field of vision was found in 10 cases. No case of central diabetes insipidus [CDI] was found at diagnosis in all patients. The outcome of surgery, in terms of postoperative GH less than 5 ng/ml, was zero%. After institution of external radiotherapy and bromocriptin therapy, 3 cases fulfilled the remission criteria after a 3 years' period. Those patients also, developed panhypopituitarism including TSH, ACTH and were given replacement thyroxine and cortisol treatment. Diabetes insipidus was found in the postoperative period in 14 cases [58%], but it vanished within one month in 12 cases and persisted in two patients. The number of patients with CDI rose to 4 [15%] with long term follow up. Pathology studies revealed eosinophil adenoma in 16 cases and chromophobe adenoma in 8 cases. Field of vision improved in 8 cases out of 10 patients with preoperative field defects. Serum postoperative prolactin level showed a significant decrease compared to the preoperative level in the 10 cases with high prolactin serum level, but only 3 cases reached the normal range. Conclusions: The poor outcome in acromegalic patients of the present series, inspite of the combined use of surgery, radiotherapy and medical treatment, is explained by the late diagnosis of the condition with higher prevalence of macroadenoma with extrasellar extensions, dispersion of operated patients among different neurosurgeons with different skills and experience, and lack of more effective drugs. Also, the relatively short period of follow up in relation to the delayed effects of radiotherapy adds to the poor results: