(A) Current status of diagnosis and treatment of acromegaly in China
In the past 30 years, China has made great progress in the diagnosis and treatment of acromegaly, but there are many problems that cannot be ignored.
1. Low consultation rate and untimely consultation: The consultation rate in China is very low, and doctors and patients lack sufficient knowledge of the disease. Some patients suffering from acromegaly do not realize the need for consultation until the late stage of chronic complications (such as diabetes, hypertension, heart disease, etc.), and doctors often fail to detect and diagnose the disease at an early stage.
2. The level of diagnosis, treatment and follow-up monitoring in hospitals at all levels varies: the main manifestation is that the measurement of growth hormone and IGF-1, which are the main biochemical indicators reflecting the activity of the disease, is not popular (only available in big cities) and the measurement methods are not uniform.
3. Uniform cure criteria: The level of growth hormone (GH) for acromegaly to reach the cure criteria in China is not uniform: in some regions, plasma GH <10ug/L or <5ug/L after glucose loading is the standard; in other regions, basic plasma GH <5ug/L after surgery and plasma GH <2ug/L after glucose loading are used as the cure criteria.
4. No extensive multidisciplinary intervention system and lack of treatment standard: The treatment of acromegaly requires multidisciplinary collaboration among endocrinology, neurosurgery and radiotherapy departments.
5.Low follow-up rate: Because doctors do not know enough about the disease and do not pay attention to the follow-up after treatment, and secondly, it is inconvenient for patients to visit the clinic, so some patients do not fully reach the standard of cure.
The key to solve the above problems is to improve the early consultation rate and standardize treatment: that is, to improve the overall awareness of doctors and the whole society about the disease; and to establish diagnostic and treatment centers in provinces and cities including neurosurgery, endocrinology, radiotherapy and other related departments; to establish clinical norms for diagnosis and treatment; to formulate diagnostic and treatment guidelines; and to improve the patient follow-up tracking system, preferably in the patient’s local area.
(II) Diagnostic progress
1, biochemical diagnostic indicators of acromegaly GH and IGF-1 level determination, OGTT GH inhibition test is the basis for the diagnosis of acromegaly and determination of disease activity; and serum IGF-1 level is the most sensitive and credible indicator for the diagnosis of acromegaly and determination of disease activity.
2, biochemical diagnostic criteria of acromegaly: GH: OGTT test, GH trough value > 1ug/L; IGF-1: 2 standard deviations above the level of normal people of the same age and sex
(C) Treatment progress
1. Treatment goals for acromegaly.
1) To control GH levels to random GH levels <2,5ug/L and GH levels <1ug/L after oral glucose loading.
2) To bring IGF-Ⅰ levels down to a normal range that matches age and sex.
3) eliminating or shrinking the tumor and preventing its recurrence
4) elimination or reduction of complicating manifestations, especially cardiovascular, pulmonary and metabolic disorders.
5) preservation of pituitary function and re-establishment of endocrine homeostasis.
2.Treatment modalities
(1) Surgery remains the preferred route of treatment for acromegaly.
In terms of gaining control of the disease, the role of surgery is to remove the tumor and significantly and rapidly reduce its size, so surgical removal of pituitary growth hormone adenoma is the treatment of choice for acromegaly. With the continuous development of medical technology and the increasing accuracy of microsurgery, the treatment of pituitary adenomas has become the most refined area of intracranial tumors.
The advantages of surgical treatment are rapid reduction of GH levels and shrinkage or complete removal of the tumor. According to the latest foreign studies, transsphenoidal surgical excision of pituitary adenomas is safe and effective in patients with acromegaly. In patients with newly diagnosed acromegaly, approximately 75% are macroadenomas and 25% are microadenomas, while the cure rates (international standards) for transsphenoidal surgery are 80%-91% for microadenomas and 40%-52% for macroadenomas, respectively. In terms of postoperative complications of hypopituitarism, microadenomas are rare and macroadenomas are about 5-10%. All patients need regular, long-term postoperative follow-up, observation of clinical symptoms, monitoring of GH and IGF-I levels, and regular imaging examinations.
(2) Drug therapy is gaining importance in the various treatment stages of acromegaly
Currently, there are three types of drugs used clinically for the treatment of acromegaly: growth inhibitor receptor ligands (SRL), i.e., growth inhibitor (SST) analogs, dopamine agonists, and GH receptor antagonists. Based on clinical efficacy and safety results, growth inhibitor analogs are the drugs of choice. Among the growth inhibitor analogs, two long-acting growth inhibitor analogs, DD oxytocin long-acting formulation (santoprene) and lanreotide, are currently the most important therapeutic drugs recommended internationally and nationally.
(3) Radiotherapy is an important adjuvant treatment for GH-secreting pituitary adenoma
Pituitary radiotherapy is not usually the first treatment option, but is most often used as an adjuvant treatment for residual tumors with incomplete remission after surgery. In a study by Italian authors, 47 postoperative residual tumors treated with conventional radiotherapy had a GH compliance rate of 77% local tumor control rate of 95% at 15 years, but a pituitary hypoplasia rate of 85%. Therefore, conventional radiotherapy is effective for GH-secreting pituitary adenomas, but the incidence of pituitary hypoplasia is also high. It remains an appropriate approach for patients with acromegaly that is not controlled by surgery or drugs. New radiotherapy methods include stereotactic radiotherapy, stereotactic radiosurgery, and proton therapy. The aim is to reduce the dose around the target, improve the efficacy and reduce radiation damage. Because of the long survival period of patients with acromegaly, it is important to require excellent radiotherapy techniques and precise doses to obtain the best results while minimizing radiation damage.