Acromegaly due to

Pituitary maroadenoma
4) Functions of Pituitary Glands
The pituitary gland is a pea-sized structure located at the base of the
brain, just below the hypothalamus and attached to it by nerve fibers. It is
part of the endocrine system and produces hormones which control other
glands as well as various bodily functions. The pituitary is divided into
three sections known as the anterior, intermediate and posterior lobes,
each of which produces specific hormones. The anterior lobe is mainly
involved in development of the body, sexual maturation and reproduction.
Hormones produced by the anterior lobe regulate growth and stimulate
the adrenal and thyroid glands as well as the ovaries and testes. It also
generates prolactin, which enables new mothers to produce milk. The
intermediate lobe of the pituitary gland releases a hormone which
stimulates the melanocytes, cells which control pigmentation through the
production of melanin. The posterior lobe produces antidiuretic hormone,
which reclaims water from the kidneys and conserves it in the
bloodstream to prevent dehydration. Oxytocin is also produced by the
posterior lobe, aiding in uterine contraction during childbirth and
stimulating the production of milk.

Pituitary Gland Essentials

The hormones of the pituitary gland help regulate the functions of other
endocrine glands.
The pituitary gland has two partsthe anterior lobe and posterior lobe
that have two very separate functions.
The hypothalamus sends signals to the pituitary to release or inhibit
pituitary hormone production.

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The pituitary gland is often dubbed the master gland because its
hormones control other parts of the endocrine system, namely the thyroid
gland, adrenal glands, ovaries, and testes. However, the pituitary doesnt
entirely run the show.
In some cases, the hypothalamus signals the pituitary gland to stimulate
or inhibit hormone production. Essentially, the pituitary acts after the
hypothalamus prompts it.
Anatomy of the Pituitary Gland
The pituitary gland is only about 1/3 of an inch in diameter (thats about
as large as a pea) and located at the base of the brain.
Since their functions are so intertwined, its no surprise that the
hypothalamus and pituitary are located near each other. Theyre actually
connected by the pituitary stalk, or more technically, the infundibulum.
The pituitary glands are made of the anterior lobe and posterior lobe. The
anterior lobe produces and releases hormones. The posterior lobe does
not produce hormones per sethis is done by nerve cells in the
hypothalamusbut it does release them into the circulation.
Hormones of the Pituitary Gland
The hormones of the pituitary gland send signals to other endocrine
glands to stimulate or inhibit their own hormone production. For example,
the anterior pituitary lobe will release adrenocorticotropic hormone (ACTH)
to stimulate cortisol production in the adrenal glands when youre
stressed.
The anterior lobe releases hormones upon receiving releasing or inhibiting
hormones from the hypothalamus. These hypothalamic hormones tell the
anterior lobe whether to release more of a specific hormone or stop
production of the hormone.
Anterior Lobe Hormones:

Adrenocorticotropic hormone (ACTH): ACTH stimulates the adrenal

glands to produce hormones.

GEOLOGY 101 REPORT

Follicle-stimulating hormone (FSH): FSH works with LH to ensure

normal functioning of the ovaries and testes.

Growth hormone (GH): GH is essential in early years to maintaining

a healthy body composition and for growth in children. In adults, it aids
healthy bone and muscle mass and affects fat distribution.

Luteinizing hormone (LH): LH works with FSH to ensure normal

functioning of the ovaries and testes.

Prolactin: Prolactin stimulates breast milk production.

Thyroid-stimulating hormone (TSH): TSH stimulates the thyroid

gland to produce hormones.

The posterior lobe contains the ends of nerve cells coming from the
hypothalamus. The hypothalamus sends hormones directly to the
posterior lobe via these nerves, and then the pituitary gland releases
them.
Posterior Lobe Hormones:

Anti-diuretic hormone (ADH): This hormone prompts the kidneys to

increase water absorption in the blood.

Oxytocin: Oxytocin is involved in a variety of processes, such as

contracting the uterus during childbirth and stimulating breast milk
production.

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5) Acromegaly caused by Macroadenoma (DEFINE,

CLASSIFICATION, PATHOGENESIS)
What is acromegaly and what causes it?
Acromegaly is a condition where you make too much growth hormone. In
over 99 in 100 cases, the excess hormone comes from a small tumour in
the pituitary gland. This is a benign (non-cancerous) growth called a
pituitary adenoma. The adenoma may grow up to 1-2 cm across.
However, as it is benign, it does not spread to other areas of the body. The
abnormal cells in the adenoma make lots of growth hormone. It is not
known why the adenoma develops.
Rarely, acromegaly is caused by an excess of GHRH which is made in the
hypothalamus. This stimulates the cells in the pituitary to make too much
growth hormone. Very rarely, other tumours in the body can make growth
hormone.
Who gets acromegaly?
Acromegaly is rare. About 3 or 4 people in a million develop acromegaly
each year in the UK. It mainly first develops in adults between the ages of
25-40. Men and women are equally affected.
Rarely, it affects children. If it develops in a child (usually occurs between
the ages of 15 to 17), it causes the condition called gigantism because
growth hormone promotes growth of bones in the body.

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Note: the rest of this leaflet is about acromegaly in adults.

What are the symptoms and problems of acromegaly?
Acromegaly literally means 'enlarged extremities' or 'enlarged hands and
feet'. This is a typical feature, but there are many other symptoms. The
symptoms develop gradually. Some people have symptoms which develop
over 10-15 years before the diagnosis is made.
It is useful to divide the symptoms into two types: those caused by too
much growth hormone, and those caused by the enlarging tumour
(adenoma) in the pituitary.
Symptoms caused by too much growth hormone
The excess of growth hormone in your bloodstream can affect various
tissues in your body which can make them thicken or grow.
So, over time one or more of the following may develop:

Hands and feet become larger and broader. Your glove and shoe size
may increase over the years. You may not be able to get a wedding ring
off.

Your skin may thicken (particularly on the face) and become more
greasy and sweaty.

Changes to your face which may include: thickened lips and nose,
thickening of your scalp, your jaw becoming more prominent. These
changes develop very gradually so may not actually be noticed by your
family or friends. However, looking back at old photographs may suggest
your facial appearance has changed.

Your vocal cords thicken which may cause your voice to deepen.

Your tongue may enlarge so you may often bite your tongue.

Thickening of cartilage may cause arthritis in various joints.

Thickening of the nasal passages can make you snore loudly and
may cause obstruction in airflow when you are asleep (sleep apnoea).
This can make you have a poor night's sleep with daytime drowsiness.

GEOLOGY 101 REPORT

Carpal tunnel syndrome. This is where a nerve going through the

wrist is squashed by thickened tissue. It can cause pain, tingling and
weakness in parts of the hands or arms.

Irregular or absent periods (in women) may occur.

Other effects of too much growth hormone may include:

General tiredness.

Some muscle weakness.

About 1 in 5 people with acromegaly also develop diabetes as

growth hormone counters the effects of insulin.

High blood pressure. This develops in about 1 in 3 cases.

Increased risk of heart disease and stroke. This is probably because

of the increased risk of developing high blood pressure and diabetes.

People with acromegaly have an increased chance of developing

polyps (small benign growths) in the bowel and a slightly increased
chance of developing bowel cancer. People with acromegaly are now
routinely screened for these conditions (see below).

Also, in about 1 in 3 cases, the adenoma also makes too much of another
hormone called prolactin. This can cause sexual and menstrual problems,
and a milky discharge from the nipple. Many men with acromegaly also
develop erectile dysfunction (impotence).

Symptoms caused by the growing tumour

In many cases the tumour remains small and does not cause pressure
symptoms. However, in some cases the tumour grows enough to cause
pressure on the nearby tissues. This can lead to:
Headaches.
Problems with vision. The tumour may press on the optic nerves (the
nerves going from the eyes to the brain) which are just next to the
pituitary.

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Other normal cells in the pituitary may become squashed and damaged.
Therefore, you may develop a lack of other hormones that are made by
the pituitary. This can cause an underactive thyroid gland and/or an
underactive adrenal gland which can cause various other symptoms.
How is acromegaly diagnosed?
A blood test can measure the level of growth hormone. However, a single
test is not reliable. This is because the levels of growth hormone in the
body fluctuate a lot throughout the day in all people.
The diagnosis of acromegaly is made by a glucose tolerance test. In this
test you drink a sugar drink containing 75 grams of glucose. You then
have a series of blood tests over two hours. The glucose should lower the
blood level of growth hormone. However, if you have acromegaly, the
growth hormone level remains high.
A blood test to measure the level of IGF-1 (see above) may be measured if
acromegaly is suspected. This may also be used as an index of disease
activity to assess how well treatment is working.
A magnetic resonance imaging (MRI) scan can show the size of any
tumour.
Eye and visual tests can assess if the tumour is pressing on the optic
nerve.
If you are confirmed as having acromegaly, other tests will be needed to
see if the tumour is causing a lack or excess of other hormones made by
the pituitary.
Other tests may include chest X-ray, electrocardiogram (ECG) and X-rays
of some of your joints.
What are the treatments for acromegaly?
The aim of treatment is to reduce the level of growth hormone in the
blood to normal, and to reduce the size of an enlarged tumour. Many of
the symptoms and features of acromegaly will reverse or improve with
successful treatment (apart from any fixed extra bone growth that had
occurred).
Surgical treatment
The most common treatment is to remove the adenoma by surgery. This is
done using very fine instruments. There are two different ways to operate
on the pituitary gland:

GEOLOGY 101 REPORT

The first method is known as endonasal trans-sphenoidal surgery. This

involves the surgeon reaching your pituitary gland through a small cut
(incision) in wall of one of your nostrils. In the other way, the surgeon
approaches the pituitary gland through a small incision behind your upper
lip, just above your front teeth. The instruments are passed through the
base of your skull - the sphenoid bone. The aim is to remove the
adenoma, but to leave the rest of the pituitary gland intact.
The operation is successful, with no further treatment needed, in around 9
out of 10 cases with smaller tumours. The operation is less successful in
those with larger tumours. However, sometimes it is not possible to
remove all the cells of the tumour. If not all is removed and your growth
hormone level remains high following surgery, other treatments listed
below are likely to work.
Your surgeon will advise on the possible complications which can
sometimes occur. For example, sometimes the operation may damage
some other parts of the pituitary gland. This may cause a reduced
production of some other hormones. If this occurs, you will need to take
replacement hormone therapy.
Medication
Medication can be used if surgery is not possible, or not wanted. It is also
used whilst waiting for surgery or radiotherapy. It can also be used in
cases where surgery fails to remove the tumour totally and the level of
growth hormone remains high.
Somatostatin analogues (octreotide and lanreotide) reduce the level of
growth hormone to normal in over half of cases, and reduce the size of the
tumour in about 8 in 10 cases. However, these medicines need to be
given as an injection. They work in a similar way to somatostatin
(described above) which is a hormone that prevents growth hormone from
being released from pituitary cells. These medicines used to be injected
several times a day. However, longer-acting preparations are now
available as monthly or fortnightly injections. Side-effects are not common
with these medicines. Some people develop tummy (abdominal) pains and
diarrhoea, but these usually wear off with time. Gallstones can also occur
but rarely cause problems.

GEOLOGY 101 REPORT

Dopamine agonists (such as cabergoline, bromocriptine and quinagolide)

can be taken as tablets. They work by preventing the release of growth
hormone from tumour cells. However, they only work well in about 1 in 5
cases. Side-effects such as feeling sick and dizzy are also quite common.
Pegvisomant (Somavert) is taken as a daily injection. However, unlike
the other medicines listed above, it does not act directly at the pituitary.
Pegvisomant works by blocking the action of growth hormone on your
body's cells. Therefore, although many of the symptoms of growth
hormone excess will be eased, it does not reduce the size of the tumour
and headaches are not eased.
Radiotherapy
Radiotherapy is an option to reduce the size of the tumour and hence
reduce the production of growth hormone. Radiotherapy focuses highintensity radiation at your pituitary tumour to destroy the abnormal cells.
It may be used if you are not able to have surgery, or if surgery was only
partially successful. However, it can take months or years after the
radiotherapy is given for the level of growth hormone to reduce to normal.
You can take medication whilst waiting for the effects of radiotherapy to
work.
A possible side-effect of pituitary radiotherapy is damage to other normal
pituitary cells. This can cause a reduced level of some other hormones.
However, if this occurs you can take replacement hormone therapy.
Acromegaly and bowel cancer screening
As mentioned earlier, people with acromegaly have an increased chance
of developing bowel (colonic) polyps and bowel cancer. Therefore, if you
are diagnosed with acromegaly and are aged 40 or more you will normally
be offered a routine colonoscopy every 3-5 years. A colonoscopy is a test
where an operator (a doctor or nurse) looks into your large bowel (colon)
with a flexible telescope. It can diagnose bowel problems such as polyps
and bowel cancer. The aim is to detect those people who develop cancer
as early as possible (before symptoms develop) when the chance of a
complete cure is high.
However, you should always tell you doctor if you develop any new
symptoms from your bowel such as persistent diarrhoea, passing mucus,
passing blood, or tummy (abdominal) pain.

GEOLOGY 101 REPORT

Acromegaly: Physiology
The normal pituitary gland secretes growth hormone (GH):Screening for
Acromegaly using IGF-1
In childhood, GH is important for proper development and growth of the
body.
In adults, GH maintains healthy bone and muscle function.
GH has direct effects on the body, such as on muscle growth. It also acts
on specialized gland cells in the liver:
This leads to the release of a hormone called insulin-like growth factor
(IGF-1, or somatomedin-C) into the blood stream.
IGF-1 blood levels are much steadier compared to GH, which changes
dramatically throughout the day.
IGF-1 affects many organs of the body, particularly bone and cartilage.
A pituitary tumor that secretes an excessive amount of GH causes
changes in the body that lead to disfigurement. If the disfigurement
severely affects the internal organs, it could lead to death.
While acromegaly is nearly always caused by an adenoma, there are rare
cases when it occurs due to excess growth hormone secretion outside the
pituitary. These tumors most commonly occur:
In the lung (bronchial carcinoid)
In the pancreas (pancreatic carcinoid)
Acromegaly typically presents in adulthood. Because the physical changes
occur so slowly, it can take an average of seven to eight years before the
condition is diagnosed. If a pituitary tumor produces an excessive amount
of GH in childhood, gigantism occurs.

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10

6) Causes and risk factors

Understanding the Causes of Acromegaly
There are 3 important hormones that circulate throughout your body that
regulate many of the most basic activities of your body. These hormones
play a key role in acromegaly:
Growth Hormone (GH) - The pituitary releases GH in short spurts
throughout the day and night, resulting in constantly varying GH levels.
When a person has acromegaly, abnormally high levels of GH are released
by the pituitary. Too much GH causes changes in physical characteristics
and other aspects of your body.
Insulin-like Growth Factor-1 (IGF-1) - IGF-1 levels rise whenever GH levels
rise; however, IGF-1 (made mostly in the liver) is released more evenly
than GH, and IGF-1 levels remain higher longer. When both of these levels
are elevated together, they can also cause many of the signs and
symptoms of acromegaly.
Somatostatin - One of the main effects of somatostatin is its ability to
control the amount of GH in the body. Researchers have taken advantage
of this knowledge in developing treatments for acromegaly.
2
Acromegaly is caused by prolonged overproduction of GH by the pituitary
gland. The pituitary produces several important hormones that control
body functions such as growth and development, reproduction, and
metabolism. But hormones never seem to act simply and directly. They
usually "cascade" or flow in a series, affecting each other's production or
release into the bloodstream.
GH is part of a cascade of hormones that, as the name implies, regulates
the physical growth of the body. This cascade begins in a part of the brain
called the hypothalamus. The hypothalamus makes hormones that
regulate the pituitary. One of the hormones in the GH series, or "axis," is
growth hormone-releasing hormone (GHRH), which stimulates the
pituitary gland to produce GH.
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11

Secretion of GH by the pituitary into the bloodstream stimulates the liver

to produce another hormone called insulin-like growth factor I (IGF-I). IGF-I
is what actually causes tissue growth in the body. High levels of IGF-I, in
turn, signal the pituitary to reduce GH production.
The hypothalamus makes another hormone called somatostatin, which
inhibits GH production and release. Normally, GHRH, somatostatin, GH,
and IGF-I levels in the body are tightly regulated by each other and by
sleep, exercise, stress, food intake, and blood sugar levels. If the pituitary
continues to make GH independent of the normal regulatory mechanisms,
the level of IGF-I continues to rise, leading to bone overgrowth and organ
enlargement. High levels of IGF-I also cause changes in glucose (sugar)
and lipid (fat) metabolism and can lead to diabetes, high blood pressure,
and heart disease.
RISK FACTORS
Although pituitary tumors can occur at any age, they're most likely to
occur in older adults. People with a family history of certain hereditary
conditions, such as multiple endocrine neoplasia, type I (MEN I), have an
increased risk of pituitary tumors. In MEN I, multiple tumors occur in
various glands of the endocrine system. Genetic testing is available for
this disorder.
What are the risk factors for pituitary tumors?
A risk factor is anything that changes a persons chance of getting a
disease. For example, smoking is a risk factor for cancer of the lung and
many other cancers.
But having a risk factor, or even several risk factors, does not mean that
you will get the disease. And many people who get the disease may have
few or no known risk factors.
Pituitary tumors have very few known risk factors, and these are related
to genetics. There are no known environmental or lifestyle-related risk
factors for pituitary tumors.
Family history

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12

Most people who develop pituitary tumors dont have a family history of
the disease. But rarely, pituitary tumors can run in families.
Sometimes when pituitary tumors run in families, they are found along
with other types of tumors as part of an inherited genetic syndrome (see
the next section).
Sometimes, though, only pituitary tumors occur. Researchers have found
that some of these are due to certain changes in a persons genes that are
inherited from a parent (see Do we know what causes pituitary
tumors?).
Most often, though, the cause of pituitary tumors that run in families is not
known.
Genetic syndromes
Pituitary tumors can be a part of a syndrome that includes an increased
risk of other types of tumors. These syndromes are caused by abnormal
changes (mutations) in a persons genes. They include:
Multiple endocrine neoplasia, type I (MEN1): This is a hereditary condition
in which people have a very high risk of developing tumors of 3 glands:
the pituitary, parathyroid, and pancreas. It is caused by changes in the
gene MEN1, and is passed on to about half of the children of an affected
parent. If the MEN1 syndrome affects your family, you should discuss
testing for this condition with your doctor.
Multiple endocrine neoplasia, type IV (MEN4): This rare syndrome includes
increased risks of pituitary tumors and certain other tumors. MEN4 is
caused by inherited changes in a gene called CDKN1B.
McCune-Albright syndrome: This syndrome is caused by changes in a gene
called GNAS1 that arent inherited but occur before birth. People with this
syndrome have brown patches on their skin (called caf-au-lait spots) and
develop many bone problems. They can also have hormone problems and
pituitary tumors.

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13

Carney complex: This is a rare syndrome in which people can have heart,
skin, and adrenal problems. They also have a high risk of a number of
different types of tumors, including pituitary tumors. Many cases are
caused by inherited changes in the gene PRKAR1A, but some are caused
by changes in other genes that have not yet been identified.
You can learn more about inherited cancer syndromes in our document
Family Cancer Syndromes.

7) Complications
By Mayo Clinic Staff
Pituitary tumors usually don't grow or spread extensively. However, they
can adversely affect your health, possibly causing:

Vision loss. A pituitary tumor can put pressure on the optic nerves,
which are close to your pituitary gland, and cause loss of vision.

Permanent hormone deficiency. The presence of a pituitary tumor or

the removal of one may permanently alter your hormone supply, which
may need to be replaced with hormone medications.

Diabetes insipidus. This is a possible complication of a large

pituitary tumor or of some treatments for pituitary tumors. Not to be
confused with the more common diabetes mellitus, which involves high
sugar levels in the blood and urine, diabetes insipidus is the result of the
pituitary making too little vasopressin, which controls the concentration
of urine in the kidneys. Diabetes insipidus causes excess amounts of
urine and severe thirst, which can lead to dehydration.

A rare but potentially serious complication of a pituitary tumor is

pituitary apoplexy, when sudden bleeding into the tumor occurs.
Pituitary apoplexy requires emergency treatment, usually with
corticosteroids and possibly surgery.

Acromegaly Complications

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14

Osteoporosis, Type 2 Diabetes, and Cardiovascular Problems

Written by Daniel J. Toft MD, PhD
If left untreated, acromegalywhen your body produces too much growth
hormonecan lead to various complications. The most common
acromegaly complications involve joint problems, pituitary hormone
deficiency, and respiratory problems.
It's also possible to develop complications if acromegaly is undertreated,
which is why it's so important to work closely with your doctor to monitor
hormone levels.
Bone Complications from Acromegaly
Excess growth hormone (GH) secreted by a tumor (usually a pituitary
tumor) can cause your bones to grow too much.
Bone overgrowth is especially noticeable in the face, and it can cause
problems for your teeth if your jaw grows too much. Unfortunately, it's not
possible to reverse this bone overgrowth, but it is possible to stop it by
treating acromegaly.
To deal with enlarged bones, you may need to have surgery to reshape
the bones, but that isn't recommended until your growth hormone and
insulin-like growth factor-1 (IGF-1) levels are back in a normal range.
Bone health can also be affected by acromegaly. Too much GH can change
the way your body uses vitamin D, a vitamin that's absolutely essential for
bone health. Without it, your body can't use calcium well, so your bones
don't get the calcium they need. This may lead to osteoporosislow bone
densityand that puts you at a higher risk of a fracture.
Hypercalcemia (too much calcium in the blood) and hypercalciuria (too
much calcium in the urine) are possible complications of acromegaly; both
of them mean that your body isn't using calcium. However, with
treatment, your body should again be able to properly use vitamin D and
calcium to build strong, healthy bones.
Soft Tissue Complications from Acromegaly

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Unlike bone overgrowth, soft tissue changes are often reversible with
acromegaly treatment to control GH and IGF-1. Soft tissues, such as
cartilage and ligaments, can become bigger and that can lead to joint
problems. Enlarged soft tissues can make it painful to move because joints
may not be able to work as well as they should.
Once your GH and IGF-1 levels return to normal, soft tissues should also
return to a more normal size, and you should have less joint pain.
However, if your joint pain is caused by arthritisand not just by enlarged
soft tissuesthen your joint pain may not change because of acromegaly
treatment. If that's the case (you have arthritis in addition to acromegaly),
your doctor will treat the arthritis separately from the acromegaly.
Pituitary Hormone Deficiencies
In some people with pituitary tumors causing acromegaly, the tumor can
actually affect the other hormones that the pituitary gland releases. The
pituitary gland helps regulate the function of other endocrine glands; if its
hormones are off, that can cause other endocrine-related problems. Your
doctor should closely monitor the levels of other pituitary hormones to
make sure they stay in a normal range.
Sleep Apnea
Because of overgrowth in the airway, people with acromegaly can
sometimes develop sleep apnea (when you have extended pauses in your
breathing while sleeping). This leads to not-as-restful sleep, and a lack of
sleep can affect many areas of your life.
Acromegaly treatment may eliminate sleep apnea and help the soft
tissues in the airway return to their normal size. Treatment isn't a
guarantee that you won't have sleep apnea anymore, though; you and
your doctor should be monitoring to see if the sleep apnea goes away.
Heart Problems
Excessive growth hormone can cause the heart to grow too large, putting
people with acromegaly more at risk for cardiovascular disease, including
arrhythmia (abnormal heart beat). Your doctor should monitor your heart
health and see if lowering the GH levels improves your heart function.
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16

Diabetes
As you may know, excessive GH secretion causes the body to produce too
much insulin-like growth factor-1. Too much IGF-1 in the body changes the
way your body uses glucose (an energy source), in addition to causing
tissue overgrowth. People with acromegaly may develop diabetes because
of the changes in how their body processes glucose.
Again, controlling GH levels may help you better control your blood
glucose levels. If you do develop diabetes, your doctor will give typical
treatment recommendations for thatread our article on diabetes
treatments to find out more.
Colon Polyps
In addition to causing growth of bones, ligaments, and cartilage, GH can
lead to the growth of polyps in the colon. Polyps can be a precursor to
colon cancerand people with acromegaly need to be watched for the
formation of polyps to prevent them from becoming cancerous. Your
doctor will recommend regular colonoscopies to find and treat any polyps.
Acromegaly Complications Conclusion
With an accurate diagnosis of acromegaly and a carefully monitored
treatment plan, you should be able to avoid many of the complications
associated with too much growth hormone in the body.

8) Treatment and Management

What are the treatments for acromegaly?
The aim of treatment is to reduce the level of growth hormone in the
blood to normal, and to reduce the size of an enlarged tumour. Many of
the symptoms and features of acromegaly will reverse or improve with
successful treatment (apart from any fixed extra bone growth that had
occurred).
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17

Surgical treatment
The most common treatment is to remove the adenoma by surgery. This is
done using very fine instruments. There are two different ways to operate
on the pituitary gland:
The first method is known as endonasal trans-sphenoidal surgery. This
involves the surgeon reaching your pituitary gland through a small cut
(incision) in wall of one of your nostrils. In the other way, the surgeon
approaches the pituitary gland through a small incision behind your upper
lip, just above your front teeth. The instruments are passed through the
base of your skull - the sphenoid bone. The aim is to remove the
adenoma, but to leave the rest of the pituitary gland intact.
The operation is successful, with no further treatment needed, in around 9
out of 10 cases with smaller tumours. The operation is less successful in
those with larger tumours. However, sometimes it is not possible to
remove all the cells of the tumour. If not all is removed and your growth
hormone level remains high following surgery, other treatments listed
below are likely to work.
Your surgeon will advise on the possible complications which can
sometimes occur. For example, sometimes the operation may damage
some other parts of the pituitary gland. This may cause a reduced
production of some other hormones. If this occurs, you will need to take
replacement hormone therapy.
Medication
Medication can be used if surgery is not possible, or not wanted. It is also
used whilst waiting for surgery or radiotherapy. It can also be used in
cases where surgery fails to remove the tumour totally and the level of
growth hormone remains high.
Somatostatin analogues (octreotide and lanreotide) reduce the level of
growth hormone to normal in over half of cases, and reduce the size of the
tumour in about 8 in 10 cases. However, these medicines need to be
given as an injection. They work in a similar way to somatostatin
(described above) which is a hormone that prevents growth hormone from

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18

being released from pituitary cells. These medicines used to be injected

several times a day. However, longer-acting preparations are now
available as monthly or fortnightly injections. Side-effects are not common
with these medicines. Some people develop tummy (abdominal) pains and
diarrhoea, but these usually wear off with time. Gallstones can also occur
but rarely cause problems.
Dopamine agonists (such as cabergoline, bromocriptine and quinagolide)
can be taken as tablets. They work by preventing the release of growth
hormone from tumour cells. However, they only work well in about 1 in 5
cases. Side-effects such as feeling sick and dizzy are also quite common.
Pegvisomant (Somavert) is taken as a daily injection. However, unlike
the other medicines listed above, it does not act directly at the pituitary.
Pegvisomant works by blocking the action of growth hormone on your
body's cells. Therefore, although many of the symptoms of growth
hormone excess will be eased, it does not reduce the size of the tumour
and headaches are not eased.
Radiotherapy
Radiotherapy is an option to reduce the size of the tumour and hence
reduce the production of growth hormone. Radiotherapy focuses highintensity radiation at your pituitary tumour to destroy the abnormal cells.
It may be used if you are not able to have surgery, or if surgery was only
partially successful. However, it can take months or years after the
radiotherapy is given for the level of growth hormone to reduce to normal.
You can take medication whilst waiting for the effects of radiotherapy to
work.
A possible side-effect of pituitary radiotherapy is damage to other normal
pituitary cells. This can cause a reduced level of some other hormones.
However, if this occurs you can take replacement hormone therapy.

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9) Causes of acromegaly

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