I. Introduction
Acromegaly (hereafter referred to as “acromegaly”) is a chronic progressive endocrine disease with an insidious onset, which may be several years or even 10 years old at the time of presentation. More than 95% of patients with acromegaly are caused by GH-secreting pituitary adenomas. Long-term overproduction of GH can lead to excessive hyperplasia of soft tissues, bone and cartilage throughout the body, causing facial changes, hypertrophy of hands and feet, thick skin, enlarged internal organs, bone and joint lesions, and sleep apnea syndrome. In addition, the incidence of pituitary tumor compression symptoms, diabetes, hypertension, cardiovascular and cerebrovascular diseases, respiratory diseases, and malignant tumors such as colon cancer will increase accordingly. These metabolic disorders and complications seriously affect patients’ health and quality of life, resulting in shorter life expectancy. Clinically, delays in diagnosis and treatment can significantly increase the incidence of these complications.
This diagnosis and treatment guideline aims to summarize and learn from the existing diagnosis and treatment experience of limbomegaly in China, combine the latest evidence-based evidence from home and abroad, improve the understanding of limbomegaly among Chinese physicians, and advocate a standardized diagnosis and treatment management model of limbomegaly.
II. Diagnosis
2.1 Diagnosis of acromegaly Clinical manifestations such as cosmetic changes, headache and visual field disorders are usually the main reasons for patients with acromegaly to visit the clinic. The final clarification was made by the examination of complications. Very few patients with large limbs are due to single gene defects, such as multiple endocrine adenoma type 1 (MEN-1), McCune-Albright syndrome and Carney syndrome, which require further screening and diagnosis of associated co-morbidities.
2.2 Clinical manifestations Acromegaly has characteristic appearance, such as ugly face, large nose, thick lips, enlarged hands and feet, thickened skin, excessive sweating and sebaceous glands, longer head shape, prominent brow arch, long oblique forehead, protruding jaw, sparse teeth and backbite, enlarged posterior occipital ridge, forehead and scalp folds, barrel chest and hunchback. Other clinical manifestations are.
(i) headache, visual dysfunction, increased intracranial pressure, hypopituitarism and pituitary stroke due to pituitary adenoma compression and invasion of surrounding tissues.
(ii) Insulin resistance, reduced glucose tolerance, diabetes mellitus and its acute or chronic complications.
(iii) Cardiovascular system involvement: hypertension, cardiac hypertrophy, cardiac enlargement, arrhythmia, cardiac decompensation, atherosclerosis, coronary artery disease, cerebral infarction and cerebral hemorrhage.
④ respiratory system involvement: tongue hypertrophy, low voice, ventilation disorders, wheezing, snoring and sleep apnea, respiratory tract infections.
⑤ bone and joint involvement: synovial tissue and articular cartilage hyperplasia, hypertrophic osteoarthropathy, impaired hip and knee function.
(vi) Amenorrhea, lactation, and infertility in women, and sexual dysfunction in men.
(7) The incidence of colon polyps, colon cancer, thyroid cancer, and lung cancer may be increased.
The possibility of limbomegaly needs to be considered and screened when the patient has 2 or more of the following symptoms without obvious characteristic manifestations of limbomegaly, including: new onset diabetes mellitus, multiple joint pains, new or uncontrollable hypertension, heart disease such as ventricular hypertrophy or systolic and diastolic dysfunction, fatigue, headache, carpal tunnel syndrome, sleep apnea syndrome, excessive sweating, vision loss, colon polyps, and progressive Progressive jaw protrusion .
2.3 Laboratory tests
2.3.1 Measurement of serum GH levels Serum GH levels are consistently elevated in patients with active limbomegaly and are not suppressed by hyperglycemia. Therefore, the diagnosis of patients with limbomegaly should be determined not only by fasting or random GH levels, but also by whether serum GH levels are suppressed to normal after glucose loading. A fasting or random serum GH level <2.5ng/mL is considered normal; if it is ≥2.5ng/mL, an oral glucose tolerance test (OGTT) is required to determine the diagnosis. OGTT is usually performed with 75g of oral glucose and blood is taken at 0min, 30min, 60min, 90min and 120min to determine blood glucose and GH level. Patients with confirmed diabetes can replace OGTT with 75g bun meal, and it is recommended to use GH assay with sensitivity ≤0.05mg/L.
2.3.2 Determination of serum IGF-1 level The effect of GH is mainly mediated by IGF-1, and the correlation between serum IGF-1 level and the disease activity of patients with limbomegaly is closer than that of serum GH. Serum IGF-1 levels are elevated in patients with active limbomegaly. Since the normal range of IGF-1 levels is significantly correlated with age and gender, the results should be compared to the age- and gender-matched normal range (normal mean ± 2 standard deviations). When the patient’s serum IGF-1 level is higher than the normal range of values matched with gender and age, the serum IGF-1 level is considered to be elevated.
2.4 Imaging cranial MRI and CT scans can provide insight into the size of pituitary GH adenomas and the relationship between adenomas and adjacent tissues, and MRI is superior to CT. techniques such as high-resolution thin fractionation, enhanced scanning and dynamic enhanced MRI scanning can improve the detection rate of pituitary microadenomas. These techniques can be used for large adenomas to understand whether the adenoma is growing aggressively and whether it is compressing and involving the visual cross-section (paracranial or subsaddle).
2.5 Evaluation of other pituitary functions Blood levels of prolactin (PRL), follicle stimulating hormone (FSH), luteinizing hormone (LH), thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH) and their corresponding target gland functions should be measured. Posterior pituitary function should be assessed if the patient has significant polyuria, irritable thirst and excessive drinking.
2.6 Visual acuity and visual field examination To observe the visual field changes before treatment, and also as one of the evaluation indicators of treatment effect.
2.7 Diagnosis of complications of acromegaly Patients with acromegaly should undergo blood pressure, lipids, electrocardiogram, cardiac ultrasound, respiratory sleep function after qualitative diagnosis; thyroid ultrasound, colonoscopy and other tests can be selected according to clinical manifestations. Based on the patient’s clinical manifestations, laboratory tests and imaging examinations, the diagnosis of acromegaly should be made through comprehensive analysis, and a clear judgment should be made on the patient’s disease activity, acute and chronic complications of each system and the control of disease activity after treatment.
III. Treatment
3.1 Treatment goals for acromegaly ① Control serum GH levels to random GH <2.5ng/ml and OGTT GH trough <1ng/ml; ② Decrease serum IGF-1 levels to a normal range that matches age and gender; ③ Eliminate or shrink pituitary tumors and prevent their recurrence; ④ Eliminate or reduce clinical symptoms and comorbidities, especially cardiovascular, respiratory and (5) Preserve pituitary endocrine function as much as possible, and patients with existing hypopituitarism should undergo replacement therapy with the appropriate target gland hormones. After treatment of acromegaly with randomized GH values <2.5ng/mL and OGTT GH trough values <1ng/mL, patient survival is similar to that of the normal population. Surgery, radiation therapy and pharmacotherapy are all options to achieve these treatment goals. However, to maximize the efficacy and preserve pituitary function, each of these three treatment options has its own advantages and disadvantages, and therefore individualized treatment plans should be designed for each patient.
3.2 Treatment of acromegaly
3.2.1 Surgical treatment Surgical removal of the tumor is the treatment of choice for patients with pituitary GH adenomas. Surgery is recommended as the first-line treatment option for patients with microadenomas, as well as for patients with focal growth of pituitary macroadenomas with potential surgical cure, because it provides effective long-term control of the tumor and normalizes the associated biochemical parameters. Transsphenoidal sinus surgery to remove pituitary adenomas is safe and effective in patients with large limbs, with fewer complications and lower mortality than other surgical approaches (e.g., craniotomy).
3.2.1.1 Surgical approach The main surgical approach for pituitary adenomas is transnasopalatine sinus adenomectomy, with craniotomy used only in rare cases. The overall cure rate of conventional microsurgery is 57.3% for newly diagnosed patients with large limbs, 80% to 91% for microadenomas and 40% to 52% for macroadenomas. Endoscopic transsphenoidal sinus surgery is a minimally invasive surgical procedure that has been widely performed in recent years and is suitable for the removal of small and medium-sized adenomas, as well as for some large adenomas, which can help improve the surgical cure rate . The surgery should be performed by an experienced neurosurgeon. Some patients can be treated with growth inhibitor analogues preoperatively to improve the surgical outcome. Neuronavigation and intraoperative MRI techniques can improve surgical resection rates.
3.2.1.2 Pathologic features Pituitary GH hypersecretion is predominantly adenoma. pathologic types include dense granular or sparse granular GH cell adenoma or hyperplasia, mixed GH and PRL cell adenoma, eosinophilic stem cell adenoma, and multihormone-secreting cell adenoma. immunohistochemical staining such as Ki67 is helpful to understand the proliferative capacity of adenoma cells.
3.2.1.3 Advantages of surgical treatment In principle, all patients with confirmed diagnosis are suitable for surgical treatment. Patients with severe acute tumor compression (e.g., progressive loss of visual function or diplopia) and hypopituitarism should receive early surgical treatment. Most cases can be cured in a single operation by an experienced surgeon. For patients with microadenoma, surgery is recommended as the first choice of treatment.
Surgery is recommended as the primary treatment for patients with large adenomas that have a high chance of cure (e.g., not invading the cavernous sinus).
For patients with macroadenomas that are not curable with surgery and have local compression symptoms, partial tumor resection can be performed first to improve their response to subsequent drug therapy or radiotherapy. Successful surgery can immediately lower serum GH levels and relieve tumor compression symptoms. Another advantage of surgical treatment is the availability of tissue specimens for pathological diagnosis and scientific study. The main factors affecting the outcome of surgery are: (i) tumor volume, texture and aggressiveness; (ii) preoperative GH and IGF-1 levels (numerous studies have shown a negative correlation between preoperative GH and IGF-1 levels and surgical outcome). Microadenomas that do not invade the cavernous sinus and have preoperative GH and IGF-1 levels only slightly higher than normal can be cured by more than 80%, while tumors that invade the cavernous sinus or have preoperative GH >200ng/ml are less likely to be cured.
3.2.1.4 Complications of surgical treatment Although great progress has been made in surgical treatment of acromegaly, there are still certain risks and problems, such as possible hypopituitarism, damage to important intracranial nerves, blood vessels and brain tissue, optic nerve dysfunction, cerebrospinal fluid nasal leakage or meningitis, and even death. Patients with pituitary GH adenomas are at significantly higher risk of receiving general anesthesia than other types of pituitary tumors. It is well documented that operator experience is associated with surgical cure rates, complication rates, and mortality, with complication rates ranging from approximately 3% to 10% among experienced neurosurgeons.
Therefore, surgery for pituitary adenomas should be performed in a center with a team of specialists in the appropriate discipline to achieve the most optimal surgical outcome. This team should include specialists in endocrinology, neurosurgery, radiosurgery, neuropathology, and radiological imaging.
3.2.1.5 Preoperative growth inhibitor analogue (SSA) therapy
3.2.1.5.1 Preoperative growth inhibitor analogs (SSA) can improve surgical outcomes The role of preoperative pharmacotherapy has been controversial, especially with SSA, and several national and international studies have now shown that preoperative SSA for 3-6 months can improve postoperative remission rates, especially in patients with macroadenomas. However, further high-quality, multicenter, prospective studies are needed to confirm the efficacy of preoperative SSA and to determine the types of patients who may benefit from preoperative SSA use. and IGF-1 are significantly elevated.
3.2.1.5.2 Preoperative growth inhibitor analogs (SSA) may reduce cardiopulmonary comorbidities and anesthesia-related risks Patients with acromegaly may present with comorbidities such as cardiovascular disease, pulmonary insufficiency, and metabolic disorders, which place patients at higher anesthetic and surgical risk. Therefore, controlling these comorbidities may reduce surgical risk and improve surgical outcomes. Studies have reported that up to 30% of patients with acromegaly have difficulty with intubation during anesthesia, and 20%-80% of patients have sleep apnea syndrome due to oropharyngeal swelling and macrophagia. SSA treatment in these patients significantly reduces soft tissue swelling after a few days and one study showed that sleep apnea disappears after 6 months of octreotide treatment. Therefore, it is predicted that preoperative SSA treatment may lead to a reduction in intubation-related complications. However, this still needs to be supported by further trials to obtain higher quality evidence.
Patients with acromegaly are also at risk for comorbid cardiac disorders, including left ventricular hypertrophy, increased output per beat and cardiac index, cardiomyopathy, reduced ejection fraction or heart failure in advanced patients. Domestic and international studies have found that SSA therapy can significantly improve cardiovascular function, including lowering heart rate, systolic and diastolic blood pressure, reducing posterior left ventricular wall thickness and septal thickness, increasing ejection fraction, and prolonging activity tolerance time.
3.2.2 Pharmacological treatment of limb enlargement includes growth inhibitor receptor ligands (SRL), i.e., growth inhibitor analogs (SSA), dopamine agonists (DA), and GH receptor antagonists, which are mainly used as adjuvant therapy for patients with unremitting disease after surgery. Drug therapy may also be preferred for patients with large adenomas that are not expected to be completely removed by surgery and do not have symptoms of tumor compression, patients who are not candidates for surgery (including: patients with poor general condition who are difficult to tolerate the risks of surgery; patients with high risk of anesthesia due to airway problems; patients with severe systemic manifestations of large limbs such as cardiomyopathy, severe hypertension, and uncontrolled diabetes), or patients who do not want to undergo surgery . Growth inhibitor analogs are the first choice in pharmacological treatment.
The natural SST has a plasma half-life of less than 3 min, and synthetic growth-stimulating analogs (octreotide, octreotide LAR, lanreotide) can mimic the physiological effects of SST and inhibit GH overproduction.
3.2.2.1.1 Five phases of growth inhibitor analogs in the treatment of limb enlargement
First-line therapy: for patients with large adenomas that are not expected to be completely resected by surgery and do not have tumor compression symptoms, patients who are reluctant to undergo surgery, and patients who are not candidates for surgery, including: patients with poor systemic conditions that make it difficult to tolerate the risks of surgery; patients with high risk of anesthesia due to airway problems; and patients with severe systemic manifestations of limbomegaly (including cardiomyopathy, severe hypertension, and uncontrolled diabetes).
Pre-operative treatment: For patients with severe complications and poor underlying conditions, such as significant respiratory dysfunction, cardiac insufficiency and severe metabolic disorders, pre-operative drug therapy can reduce serum GH and IGF-1 levels, and combined with related medical treatment can improve cardiopulmonary function to reduce anesthesia and surgical risk, and at the same time can reduce tumor volume, so it is possible to improve surgical outcomes. As mentioned above, preoperative use of SSA may improve the postoperative remission rate in patients with macroadenoma.
? Adjuvant therapy for residual tumor after tumor resection: Studies have shown that approximately 10% of patients with microadenoma and 55% of patients with macroadenoma require adjuvant therapy after surgery if a trough OGTT GH value of <1.0ng/ml is the goal of cure. Therefore, it is recommended that 1) patients with postoperative OGTT GH trough <1.0ng ml="" igf-1="" ogtt="" gh="" >1.0ng/ml, or elevated IGF-1, or those who still have significant symptoms such as headache, should be treated with SSA for at least 3 to 6 months, with long-term treatment or combined radiation therapy depending on the changes in GH and IGF-1. The decision of long-term treatment or combination of radiation therapy is based on the change of GH and IGF-1.
Transitional treatment after radiotherapy: Since serum GH and IGF-1 levels decrease slowly after radiotherapy, SSA can be used for transitional treatment during the waiting period before the full effect of radiotherapy.
Complication treatment: SSA treatment can improve the complications related to limb size such as hypertension, cardiac insufficiency and respiratory dysfunction.
3.2.2.1.2 Efficacy of growth inhibitor analogues
Reduction of tumor volume: tumor growth was controlled in more than 97% of patients treated with SSA.
Control of serum GH and IGF-1 levels: SSA normalized GH and IGF-1 levels in approximately 55% of patients, and drug efficacy was negatively correlated with tumor volume and the level of GH hypersecretion.
? Improvement of clinical symptoms: SSA can effectively control GH and IGF-1, reduce tumor volume, and thus comprehensively control the symptoms of limbomegaly, for example, SSA can significantly improve 5 common symptoms of limbomegaly: headache, fatigue, excessive sweating, arthralgia, and abnormal sensation.
? Control of complications: As mentioned before SSA can bring significant cardiovascular benefits, improve respiratory dysfunction, even left ventricular hypertrophy and sleep apnea syndrome will disappear after receiving SSA treatment .
3.2.2.1.3 Adverse effects of growth inhibitor analogs
Adverse reactions to SSA are mainly injection site reactions and gastrointestinal symptoms, usually mild to moderate, and the percentage of discontinuing medication due to adverse reactions is very small. 10% to 20% of patients have local discomfort, erythema or swelling, pain and itching at the injection site. 5% to 15% of patients have gastrointestinal symptoms, diarrhea, abdominal pain, bloating, steatorrhea, nausea and vomiting, but they are usually transient. Long-term use of SSA can increase the incidence of gallbladder sludge or gallstones, which are usually asymptomatic, not clinically significant, and generally do not require surgical intervention and can be detected by periodic ultrasound. Rare adverse effects also include alopecia, bradycardia, and constipation.
3.2.2.2 Dopamine receptor agonists
Dopamine receptor agonists inhibit GH release through dopamine receptors in the hypothalamus. The most commonly used dopamine agonists include the ergot derivatives bromocriptine and capsaicin, which have the advantage that they can be taken orally and are relatively inexpensive. 10% to 20% of patients with mild to moderately elevated GH levels have satisfactory GH and IGF-1 levels at doses 2 to 4 times higher than those used to treat PRL tumors. Side effects of dopamine agonists include gastrointestinal discomfort, upright hypotension, headache, nasal congestion, and constipation. Only the first-generation dopamine agonist bromocriptine is available in China, and it is suitable for patients with mildly elevated GH levels who are otherwise unable to use SSA.
3.2.2.3 Drug combination therapy
Combinations of drugs with different mechanisms of action may have synergistic effects. Combination therapy with dopamine agonists may further reduce GH or IGF-I levels in patients who have had a partial response to SSA therapy.
3.2.3 Radiation and radiosurgery treatment
3.2.3.1 Status of radiotherapy Given the complications of slow decline in serum GH levels and hypopituitarism, radiotherapy is not usually the treatment of choice for pituitary GH adenomas, but is most often used as an adjuvant treatment for incomplete postoperative remission and for residual and recurrent tumors. Patients with a hypersecretory state of GH after surgery may be treated with radiotherapy. Radiotherapy may also be the treatment of choice for patients who are inoperable.
3.2.3.2 Radiosurgery
Conventional fractionated radiotherapy usually takes 6 months to 2 years to be effective, with some taking 5-15 years to be fully effective, and has been used in the past to control tumor growth and achieve biochemical remission. Recently, studies have looked at the effectiveness of high-dose targeted radiotherapy (single or multiple doses) for residual pituitary tumor foci. These methods include stereotactic radiosurgery (gamma knife and X-ray knife) and proton beam therapy.
Studies of outcomes and complications have shown that stereotactic radiotherapy and stereotactic radiosurgery (e.g., Gamma Knife) provide more rapid relief than conventional radiotherapy. Studies have shown that 40% of patients have normal GH levels at 12 months, but not all patients are candidates for radiosurgery because of its effect on vision. In general, stereotactic radiosurgery is used for small to medium diameter residual or recurrent tumors and for patients who cannot tolerate or refuse surgical treatment. The distance between the tumor and the optic cross or optic nerve should preferably be greater than 2-5 mm to avoid visual impairment. Secondly radiosurgery requires special attention to the impact on fertility.
The recurrence rate of large limbs reported in the literature is 2% to 14%. Prophylactic radiotherapy is not recommended for patients who have undergone successful surgery and have normal serum GH levels. However, each patient should be routinely followed up and evaluated every 6 to 12 months for at least 5 years to facilitate timely detection of any signs of recurrence and immediate treatment if necessary.
3.2.3.3 Complications of radiotherapy and radiosurgery
The most common complication is impaired anterior pituitary function, with an incidence of about 30%, which usually requires hormone replacement therapy. Long-term follow-up studies have shown a high incidence of impaired pituitary function with conventional radiotherapy. Less common complications include impaired vision, radiation brain necrosis, and malignancy secondary to radiation field. The potential neuropsychiatric effects of radiotherapy and the incidence of secondary tumors, especially in patients with cerebrovascular disease and organic encephalopathy, need to be further investigated. Disadvantages of conventional radiotherapy also include the slow decrease in GH levels.
3.2.4 Treatment flow
The most important aspect of the treatment process for limbomatosis is the need to develop an individualized treatment plan that takes into account the local pituitary tumor treatment center and the patient’s actual condition. Factors to be considered are.
Availability of a local treatment team consisting of endocrinologists, neurosurgeons, radiologists, and imaging specialists.
The patient’s degree of endocrine activity of the tumor and the degree of visual impairment. (iii) The status of the patient’s limb major related complications at the time of presentation.
The patient’s treatment claims.
Whether the patient can afford the cost of examination and long-term treatment, etc.
Treatment options should be selected on a region-by-region, person-by-person basis.
All treatment options should aim to control GH secretion at normal levels as the ultimate goal. The treatment team should weigh the risks and benefits, contraindications to treatment, and side effects for each patient while striving to achieve control of biochemical parameters and relief of tumor suppression. Factors to be considered include severity of disease, tumor compression of surrounding structures, potential long-term pituitary damage, and, especially in young, fertile patients, preservation of pituitary function. Most patients in the flow chart (Figure 1) should be treated with surgery as first-line therapy or, if surgery fails to cure, with pharmacologic therapy. If maximal doses of SSA or dopamine agonists do not adequately control the disease, radiotherapy should be considered, or surgery again, depending on the clinical activity of the disease and biochemical indicators. In some patients who opt for surgery, SSA treatment may be advanced for 12-24 weeks to create the conditions for surgery if tumor size reduction is needed to reduce the difficulty of surgery, improve the chances of total surgical resection, or ameliorate major limb complications, especially severe cardiac and respiratory comorbidities. SSA drug therapy may also be preferred in some patients, and if serum GH and IGF-1 biochemical indicators are still abnormal, DA therapy may be used in combination.
Figure 1 Recommended treatment flow for acromegaly
DA: dopamine receptor agonist; IGF-1: insulin-like growth factor-1; SSA: growth inhibitor analog; RT: radiotherapy. *Some patients: patients with large adenomas that are not expected to be completely resected by surgery (e.g. invading cavernous sinus) and do not have symptoms of tumor compression, patients who are not suitable for surgery or patients who do not want to undergo surgery. **RT: Patients with residual lesions after surgery can be treated with radiotherapy; if radiotherapy is chosen, factors such as the patient’s age, reproductive status, pituitary function, and willingness to receive long-term drug therapy should be considered.
IV. Diagnosis and treatment standard
4.1 Diagnosis and treatment process
4.1.1 When a patient is first diagnosed, a qualitative diagnosis (serum random GH, OGTT GH and IGF-1 test) should be made, and a local diagnosis (MRI or CT of the saddle area) should be made. A comprehensive evaluation of pituitary function [blood PRL, FSH, LH, epinephrine (E2), ACTH, cortisol (F), TSH, triiodothyronine (T3), thyroxine (T4), etc.] should also be performed, along with an evaluation of complications.
4.1.2 An individualized treatment plan (surgery, drugs or radiotherapy) was adopted after a comprehensive evaluation (see Figures 1 and 2).
4.1.3 After treatment, regular follow-up should be performed every 3-6 months to re-evaluate pituitary function, and imaging of the saddle area should be done if necessary. Lifelong follow-up should be performed regardless of whether the disease is well controlled or not. Routine annual checkups are recommended to adjust the treatment plan and management of related complications when appropriate. Complications of pituitary GH adenoma can be caused by local compression of the tumor, high serum GH and IGF-1 levels, and decreased secretion of other pituitary hormones. To reduce morbidity and mortality due to cardiovascular disease, respiratory disease and malignancy, risk factors should be actively controlled and early screening should be performed to standardize the management of limbomegaly complications.
Figure 2 Individualized treatment plan for acromegaly
4.2 Postoperative monitoring and long-term follow-up (see Table 1)
Blood GH was measured at 1 d postoperatively and at discharge.
When patients were discharged from the hospital, health education was emphasized, and the importance of long-term follow-up was instructed to control their disease and improve the quality of survival, and follow-up cards were given to inform the follow-up process. Patients will receive annual follow-up questionnaires, and the follow-up physician will be informed of any change in address or telephone number.
Pituitary hormone testing will be performed at weeks 6 to 12 postoperatively to assess pituitary function and the need for hormone replacement therapy, and patients with complications will be followed up with the appropriate tests.
OGTT GH levels, IGF-1 levels, and pituitary enhancement MRI were repeated at 3 months postoperatively.
OGTT GH, IGF-1, and pituitary MRI were selectively reviewed at 6 months postoperatively based on the 3-month postoperative follow-up results.
For patients with good control, OGTT GH level and IGF-1 level should be reviewed once a year after surgery, and saddle MRI should be reviewed annually after surgery according to the degree of patient’s disease control; for patients with complications, evaluation of complications should be performed once a year.
Note: 1) OGTT GH measurement is required in hospitals where available, otherwise at least random GH measurement should also be performed.
2) MRI may be performed as needed for patients in the active phase.
3) After 5 years postoperatively, the follow-up interval should be extended appropriately, and lifelong follow-up should be performed
Since acromegaly is a relatively rare and chronic disease involving multiple disciplines and fields, it is easy to delay the diagnosis and treatment, thus causing a corresponding increase in complications and morbidity and mortality of patients. Therefore the treatment plan for acromegaly should ideally be developed by a panel of experts who will weigh the pros and cons of each case and develop an individualized treatment plan to achieve the most optimal outcome. This treatment team should include experts in endocrinology, neurosurgery, radiotherapy, diagnostic radiology and pathology. To standardize and improve the diagnosis and treatment of limbomegaly as much as possible, taking into account the actual situation in China. Improving the cure rate and reducing complications and mortality is a very important task that requires the collaboration of multidisciplinary specialists.