Surgical outcome after repeated transsphenoidal surgery in acromegaly

Abstract

Transsphenoidal selective adenomectomy is the most efficient primary treatment for acromegaly. However, management of persistent or recurrent disease remains controversial. The objective of the present study was to evaluate the early and long-term efficacy and safety of a second transsphenoidal surgery performed in those cases. The results of a retrospective study of 16 patients undergoing reoperation by the senior author (J.H.) between 1970 and 1991 are reported. Reoperation was performed for persistent or progressive acromegaly in 11 patients, visual impairment in four, and disease recurrence in one. Normalization of growth hormone (GH) was defined as a basal GH level of less than 5 micrograms/L and suppression to less than 2 micrograms/L during the oral glucose tolerance test. Long-term follow-up data were available in 15 patients. The second transsphenoidal surgery induced a greater than 50% decrease of GH level in 11 patients. Three (19%) of 16 patients were cured according to the authors' criteria and remained so after 2, 7, and 20 years. Two more patients had a postoperative basal GH level of less than 5 micrograms/L but incomplete suppression during the oral glucose tolerance test. Thus, a total of five patients (31%) achieved a basal GH of less than 5 micrograms/L. One other patient who had no initial improvement after the second transphenoidal surgery had spontaneous normalization of his GH level after 13 years. The following complications of the second surgery occurred in three patients: one subarachnoid hemorrhage, two new visual field defects, one cranial nerve palsy, and one meningitis. Moreover, 10 patients (62.5%) developed one or more new pituitary hormone deficiencies. In conclusion, reoperation for persistent or recurrent acromegaly has low success and high complication rates. According to the authors' experience, this procedure should be reserved for patients unresponsive to other forms of therapy or with progressive visual impairment despite medical therapy.

Effectiveness of Secondary Transnasal Surgery in GH-Secreting Pituitary Macroadenomas

“…In fact, our remission rate in microadenomas was 100%, as previously reported [7]. Although several authors reported that the complication rate for secondary surgery was high [1,2,4,5,8], there were no major and only rarely minor morbidity in our series.…”

“…However, there is at present no consensus as to the best therapeutic strategy for unsuccessfully operated or recurring patients. Although several authors have reported that a low success rate for reoperation [1][2][3][4][5][6], we obtained favorable surgical outcome in cases with residual or recurring growth hormone (GH)-secreting adenoma including microadenoma-like tumors [7]. Tumor size, extension, and invasiveness of the adenoma are important predictive factors of the outcome even in secondary surgery [1,4,7,8].…”

“…Although several authors have reported that a low success rate for reoperation [1][2][3][4][5][6], we obtained favorable surgical outcome in cases with residual or recurring growth hormone (GH)-secreting adenoma including microadenoma-like tumors [7]. Tumor size, extension, and invasiveness of the adenoma are important predictive factors of the outcome even in secondary surgery [1,4,7,8]. In microadenomas selective tumor removal is relatively easily achieved, but the success rate declines in patients with macroadenomas [1,2,[6][7][8][9][10][11][12][13].…”

Composite MET-PET Fusion MRI is a Novel Method to Determine Adjuvant Therapy for Growth Hormone Secreting Adenomas

“…However, it is often difficult to detect an adenoma using MRI. Additionally, the granulation tissue that forms after a surgical procedure increases the difficulty of identifying a residual tumor [10]. Considering these limiting factors, the adjuvant therapy that was selected based on MRI findings may prove to be ineffective.…”

Endoscopic Endonasal Surgery for Recurrent Pituitary Tumors: Technical Challenges to the Surgical Approach

“…The cure rate of the second transsphenoidal selective surgical resection is thought to be significantly lower than that of primary surgery, with significant increased morbidity. 8,11,12 Revision surgery presents with technical challenges related to scarring and an altered anatomy from the previous dissection. The second operation is usually more difficult and harbors more risks secondary to the distorted anatomy such as septal and intrasellar scarring, as well as sequelae of the previous surgery, such as postoperative mucoceles.…”