Endoscopic surgery confers higher acromegaly remission rate than microscopic surgery
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Endoscopic transsphenoidal surgery has the best remission rates and fewest postoperative complications for adults with acromegaly, according to findings from a systematic review.
In an article published in Clinical Endocrinology, Christos Papaioannou, MSc (Hons), a medical student in the Centre for Endocrinology at the William Harvey Research Institute, Barts and The London School of Medicine and Dentistry at Queen Mary University of London, and colleagues conducted a review of current evidence regarding preoperative therapy and surgical approaches for adults with acromegaly. In addition to endoscopic transsphenoidal surgery being the preferred surgical approach, the researchers found preoperative therapy is most beneficial for adults with invasive pituitary macroadenomas and not effective at altering long-term remission rates for those with pituitary microadenomas.
“Current guidelines suggest not giving any patients preoperative somatostatin analogue therapy, except if they have heart failure or severe nasopharyngeal thickening,” Papaioannou told Healio. “Therefore, this review would encourage physicians to give pre-op medical therapy to patients with invasive macroadenomas.”
Researchers conducted a systematic review of studies related to preoperative medical therapy and surgical approaches for adults with acromegaly. The MEDLINE, PubMed, Cochrane Library and Embase databases were searched through June 14, 2021. Original studies published in English from 2000 onward were included. Outcomes of interest included complications and mortality during or after surgery, as well as short-term remission and long-term remission. Remission was defined as a lack of clinical features of recurrence and not receiving adjuvant treatment. Short-term remission was defined as remission for 6 months or less, and long-term remission was any remission lasting more than 6 months.
Preoperative therapy most effective with macroadenomas
The review included 37 articles, of which 14 examined preoperative medical therapy for acromegaly and 23 analyzed surgical approaches.
Of the studies examining preoperative medical therapy, four compared the use of octreotide (Sandostatin, Novartis) vs. no therapy, two compared the use of lanreotide (Somatuline Depot, Ipsen) with no therapy, five compared the use of octreotide or lanreotide with no therapy and three were noncomparative. No studies compared octreotide with lanreotide.
Five articles found a significant difference between the two groups. All of the articles comparing octreotide with no therapy found better remission rates in the octreotide group. Most articles subdivided participants into a group with microadenomas and a group with macroadenomas. Two studies found a higher remission rate in adults with macroadenomas taking somatostatin receptor agonists compared with those receiving no treatment, whereas only one article found a significantly different remission rate between those with microadenomas receiving therapy and those not receiving therapy.
The highest rate of postoperative complications was hypopituitarism, observed in 33 patients. Most complications were minor in nature and almost immediately resolved.
Remission rate highest with endoscopic surgery
Of the 23 studies analyzing surgical approaches, 17 examined long-term remission of patients and six examined short-term remission. There were 11 cross-sectional studies examining endoscopic transsphenoidal surgery, four analyzing microscopic transsphenoidal surgery and two regarding transsphenoidal surgery without specifying the subtype.
Independent of transsphenoidal surgery subtypes, the median remission rate was higher in adults with microadenoma compared with the overall and macroadenoma remission rates (67% vs. 58% vs. 60%). The median remission rate was 66.25% with endoscopic transsphenoidal surgery and 57.7% with microscopic transsphenoidal surgery. Complication rates were higher overall with microscopic transsphenoidal surgery compared with endoscopic transsphenoidal surgery, with the biggest difference observed in the levels of postoperative hypopituitarism (9.3% vs. 5%).
All of the randomized controlled trials examining preoperative medical therapy had an overall low risk of bias. All but one cohort study also had a low risk of bias, whereas 17 of the 22 cross-sectional studies had an intermediate risk of bias.
“High-quality evidence was lacking in the field of comparing different types of surgical approaches to cure acromegaly,” Papaioannou said. “Most papers were cross-sectional with only a handful of randomized controlled trials. More research needs to be done to compare endoscopic vs. microscopic transsphenoidal surgery. Furthermore, more research needs to be done to compare lanreotide vs. octreotide as preoperative therapy.”
For more information:
Christos Papaioannou, MSc (Hons), can be reached at c.papaioannou@smd17.qmul.ac.uk.
Perspective
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Adriana G. Ioachimescu, MD, PhD, FACE
Papaioannou and Druce performed a systematic review of studies reporting outcomes of surgery in acromegaly pertaining to preoperative somatostatin receptor ligands therapy and microscopic and/or endoscopic approach. The studies had heterogenous designs, remission rates and follow-up periods.
There were five preoperative randomized controlled trials with preoperative somatostatin receptor ligands. Higher short-term biochemical remission in the pretreated vs. surgery-first group was reported for macroadenomas, especially invasive macroadenomas, and one study showed overall higher remission rates. Notably, biochemical parameters of remission at 3 months postoperatively can be lower in the pretreated patients. Long-term remission data are required to determine which patients would benefit from preoperative use of somatostatin receptor ligands. Comorbidities, tumor invasiveness and the access to a neurosurgeon with expertise should be carefully considered.
There were no randomized controlled trial comparing microscopic vs. endoscopic techniques. Of the narrated studies, three performed comparisons and found similar remission rates. Overall, the number of surgical outcomes studies published since 2000 was higher for the endoscopic approach, reflecting the current trend in neurosurgical practice. The endoscope allows for better exposure and visualization, which can potentially translate into more complete resection and fewer complications. Based on current evidence, treatment at pituitary multidisciplinary centers with surgery performed by experienced neurosurgeons is recommended.
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