Pros and cons in endocrine practice: pre-surgical treatment with somatostatin analogues in acromegaly
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PROS AND CONS IN ENDOCRINE PRACTICE
Pros and cons in endocrine practice: pre-surgical treatment with somatostatin analogues in acromegaly Marco Losa1 • Jens Bollerslev2,3
Received: 12 October 2015 / Accepted: 30 December 2015 / Published online: 19 January 2016 Ó Springer Science+Business Media New York 2016
Abstract The aim of this commentary is to balance the pros and cons for pre-surgical SSA treatment in a modern perspective ending up with a pragmatic recommendation for treatment based on the current evidence and expertise of the authors. Even though prospective and randomized studies in this particular area are hampered by obvious limitations, the interpretation of the four published trials has in general been in favor of pre-treatment with SSA, showing a better outcome following surgery. However, major drawbacks of these studies, such as non-optimal diagnostic criteria for cure, potential selection bias, and timing of the postoperative evaluation in SSA pre-treated patients, limit their overall interpretation. Three matchedcontrolled studies showed remarkably similar results with no apparent beneficial effect of SSA pre-treatment on surgical outcome. Both prospective, randomized studies and retrospective studies did not find any significant difference in the rate of endocrine and non-endocrine complications related to surgery, despite the beneficial clinical effects of SSA treatment in most acromegalic patients. The newly diagnosed patient with acromegaly should be carefully evaluated in the trans-disciplinary neuroendocrine team and treatment individualized accordingly. The issue of SSA pre-treatment to improve surgical outcome is yet to
& Marco Losa [email protected] 1
Pituitary Unit, Department of Neurosurgery, Istituto Scientifico San Raffaele, Universita` Vita-Salute, Via Olgettina 60, 20132 Milan, Italy
2
Section of Specialized Endocrinology, Medical Clinic B, Oslo University Hospital, Oslo, Norway
3
Faculty of Medicine, University in Oslo, Oslo, Norway
be settled and further methodologically sound studies are probably necessary to clarify this point. Keywords Acromegaly Somatostatin analogues Pituitary neoplasms Pituitary surgery Abbreviations SSA First generation somatostatin analogue DA Dopamine agonist Peg Pegvisomant TS Transsphenoidal surgery Pas Pasireotide
Background As widely convened by recent guidelines and panel of experts, transsphenoidal surgery is regarded as a first line treatment option in most patients with newly diagnosed acromegaly [1–4], however with a notion of potential primary or pre-surgical treatment with a somatostatin analogue (SSA) in patients not expected to be cured by surgery. The surgical remission rate is stabilized around 60–75 % in large series from expert centers [5–8]. When performed by low volume surgeons or in minor centers the cure rate has been more modest, as illustrated by the Manchester experience [9], underscoring how the success of surgery can be increased by a focused trans-disciplinary team including high-volume surgeons. Moreover, criteria
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