Modern approaches to treating acromegaly

Only a couple of months ago in the Times , acromegaly was described as a serious disease causing grotesque appearances and crippling arthritis.1 The aim of this article is to discuss the recent advances and developments in management of acromegaly that make the likelihood of this situation developing vanishingly small. Acromegaly leads to reduced life-expectancy, with a 2–3-fold increase in mortality. However, patients with post-treatment growth hormone (GH) of <5 mU/l have been shown to have the same mortality as the general population2–,4 and recently, normalization of IGF-1 has also been shown to reduce mortality to that of the general population.5 Therefore the main aims of management of patients with acromegaly are to control the tumour and its effects, and to reduce GH and IGF-1 levels. There have been many recent developments, in currently accepted modalities of treatment as well as novel approaches to therapy. Trans-sphenoidal adenomectomy remains the initial treatment of choice for the majority of patients with acromegaly. Auditing the outcome from this procedure is important, but requires appropriate definition of successful treatment. Much of the older literature contains reports where \`cure' is reported when GH levels reach <10 mU/l (5 ng/ml). The epidemiological data available demonstrate that this level of GH secretion is still associated with an increased mortality and morbidity, and therefore a more stringent value of GH <5 mU/l has been introduced. This is not normal, so \`cure' is not strictly accurate. We prefer to refer to `safe' GH levels. Application of these criteria to various different centres, and taking into account tumour size, reveals startlingly different outcomes from surgery.6 It has recently become clear that the number of surgeons operating in a particular centre influences the rate of achievement of `safe' post-operative GH levels. Perhaps this is intuitive, …