Owfrequencyoffamilialpituitarytumors, thesmallsizeofaffectedfamilies,andtheverylowprevalenceof mutationswithinthesefamilies,costlygeneticscreeningisnotyet convincinglywarranted.Accuraterelativelylow-costmeasurement ofserumIGF1levelsiscurrentlythemosteffectivescreeningfor affectedpatientswithGH-secretingpituitarytumors. Acromegaly remedy Severaltreatmentoptionsarecurrentlyavailableforacromegaly (Table2). Surgery ResectionofGH-secretingpituitaryadenomasistechnicallychallengingbecauseoftheanatomicinaccessibilityofthepituitary andbonysellarconfinesandtheproximityofvitalbrainandvascularstructures.Functioningtumormicrofociofteninvadedural spaces,arenotreadilyvisibleatsurgery,andcontinuetosecrete GHaftertumorresection.GH-secretingtumorshaveapropensitytoinvadelaterallyintothecavernoussinus,precludingsafe resection.Tumor-associatedinternalcarotidarterytortuosityand microaneurysmsalsorequiresurgicalcautionandalertness.Over 90 ofresectionsareperformedviaanendonasaltranssphenoidal strategy,oftenwithminimallyinvasiveendoscopictechniques. ComputerizedimageguidanceandintraoperativeMRIcoupled with improvement of microinstrumentation and optics have resultedinsafe,helpful,andminimallytraumaticprocedures whenperformedbyskilledandexperiencedneurosurgeons(S23). Thegoalofsurgeryistobalancemaximaltumormassresection withpreservationofnormalpituitarysecretoryfunction. About70 ofpatientsharboringwell-circumscribedGH-secretingmicroadenomaslessthan10mmindiameterachievelongtermbiochemicalcontrolaftersurgery(81).Unfortunately,over65 ofGH-secretingadenomasareinvasivemacroadenomasatthe timeofdiagnosis,andsurgicaloutcomesforthesepatientsarefar lessfavorable,withanapproximately50 successratereported frommostexperiencedclinicalcenters(82,S24).Ertapenem sodium Markersofsurgicalremissionincludebiochemicalcontrol,normalpituitaryand parasellarMRIvisualization,andrecurrence-freepostoperative duration.Indole-3-carbinol Determinantsofsurgicalremissionincludetheexperienceofthesurgeoninresectingthesechallengingadenomas(83), tumorsize,anddegreeofinvasiveness(82).PMID:23522542 Transientsideeffectsofsurgeryincludelocalhemorrhage,CSF leak,diabetesinsipidus,andrarely,localinfection.Permanentside effectsreportedinlessthan5 ofpatientsincludediabetesinsipidusandpituitaryhormonedeficiency.Clearly,themajordisadvantageofsurgeryispersistentpostoperativeGHhypersecretion. Radiotherapy Conventionalexternal-beamradiotherapyisadministereduptoa maximumof4000000cGyin180-cGyweeklydosesspreadover sixweeks.Overall,about50 ofpatientsachievebiochemicalremission(GH2g/landnormalizedIGF1)after10years(846).In 77 of884irradiatedpatients,GHlevelswereattenuatedtoless than2.5g/lby20years.Therelativelylonglatencyperiodrequired toachieveremissionisamajordisadvantage.Acquiredresidualpituitarydamageisevidentinapproximately50 ofpatientsby10years. 27 exhibitedTSHdeficiency,18 FSH/LHdeficiency,and15 ACTHdeficiency(84).Rarelyencounteredlocalsideeffectsinclude visualdeficits,especiallyifthetumorabutstheopticchiasm,cerebralradionecrosis,cerebrovasculardamage,andcognitivedeficits. Onepercentofpatientsdevelopsecondaryintracranialtumors, withalatencyupto24years(86).Thereportedincidenceofthese sideeffectsisimprecise,duetoabsenceofwell-controlledstudies andheterogeneityofradiationmethodology. Stereotactic radiosurgery Usinga 60Cobaltsource,relativelynarrowbeamsofhigh-dose, focusedradiationaredeliveredwithstereotacticprecisiontoa smalltumor,andtheapproachisparticularlyeffectiveintumors lessthan3cmindiameteranddistantfromtheoptictract.FiveTheJournalofClinicalInvestig.