Success rate of treating acromegaly at national hospital of Sri Lanka

Abstract

Introduction: Pituitary surgery, radiotherapy and medical therapy with dopamine agonists (DA), somatostatin analogues (SA) and growth hormone receptor agonists (GHRA) are the main treatment modalities that are recommended for treating acromegaly. Most of these treatment modalities are too expensive or not available in most of the resource settings like ours. The objectives of this study were to describe the demographic factors, presentation and comorbidities in acromegaly patients and to analyze the outcome of the treatment modalities used in our clinical setting, which include remission, recurrence and mortality among patients with acromegaly. Materials and methods: This was a descriptive cross sectional study conducted among 72 acromegaly patients attending endocrinology and pituitary clinics at national hospital of Sri Lanka between January 2012 and June 2013. Pituitary adenomas were classified based on Hardy’s classification. A remission criteria of nadir growth hormone level <1 mu/l after oral glucose tolerance test (OGTT) or less than 5 mu/l in a five point growth hormone (GH) day curve was used. Results: 54.1% of the patients were females. The mean age of the patients at the time of presentation was 39.52 (SD± 12.8) years and the mean duration of symptoms on presentation was 3.28 years (SD±2.7). The commonest presentations were the changes in facial appearances and the increase in shoes and ring sizes (88%). 81.8% had tumour grade II and above. 14.2% had prolactin co-secretion with GH. 86.1% underwent transsphe noidal surgery (TSS). 37.5% of patients with grade I tumour and 33.3% of patients with grade II tumour achieved remission following TSS. None of the patients with tumour grade III or above achieved remission following (TSS). In our series, overall remission was 22.5%. External beam radiotherapy (EBRT) was effective in 20% in achieving remission. Medical therapy (either cabergoline or bromocriptine) as bridging /primary therapy achieved remission in only 20.8%. Irrespective of the mode of treatment, no recurrence was noted in the patients who achieved remission. The mortality in this case series was 2.7%. Conclusions: Although the grade III and IV tumours has limited success, TSS remains the treatment of choice in acromegaly. EBRT and medical therapy with dopamine agonist have limited efficacy. Most of the other recommended options are very costly or unavailable in Sri Lanka. This study further highlights the importance of establishing specialist pituitary surgery services and introducing modern medical therapy to improve patient outcome.

Keywords

• acromegaly, dopamine agonists, radiotherapy, transsphenoidal surgery