Chronic growth hormone (GH) excess from a GH-producing pituitary tumor results in the clinical syndrome of acromegaly. Acromegaly was the ﬁrst pituitary syndrome to be recognized, described by Pierre Marie in 1886. If untreated, this syndrome is associated with increased morbidity and mortality. Although the annual incidence is estimated to be only three per 1 million persons in the general population, a GH-secreting pituitary adenoma is the second most common hormone-secreting pituitary tumor. The effects of the chronic GH excess include acral and soft tissue over- growth, progressive dental malocclusion (underbite), degenerative arthritis related to chondral and synovial tissue overgrowth within joints, a low-pitched sonorous voice, headaches, malodorous hyperhidrosis, oily skin, perineural hypertrophy leading to nerve entrapment (e.g., carpal tunnel syndrome), proximal muscle weakness, carbohydrate intolerance (the initial presentation may be diabetes mellitus), hypertension, colonic neoplasia, obstructive sleep apnea, and cardiac dysfunction. The mass effects of GH-producing pituitary macroadenomas (10 mm) are similar to those of other pituitary macroadenomas and include visual ﬁeld defects, oculomotor pareses, headaches, and pituitary insufﬁciency.
Patients with acromegaly have a characteristic appearance with coarsening of the facial features, prognathism, frontal bossing, spadelike hands, and wide feet. Often there is a history of progressive increase in shoe, glove, ring, or hat size. These changes may occur slowly and may go unrecognized by the patient, family, and physician. The average delay in diagnosis from the onset of the ﬁrst symptoms to the eventual diagnosis is 8.5 years. Comparison with earlier photographs of the patient is helpful in conﬁrming the clinical suspicion of acromegaly.
High plasma GH levels are not diagnostic of acromegaly. Basal plasma GH levels are increased in patients with poorly controlled diabetes mellitus, chronic hepatic or renal failure, or conditions characterized by protein-calorie malnutrition such as anorexia nervosa. The diagnosis of acromegaly depends on two criteria: a GH level that is not suppressed to less than 0.4 ng/ dL after an oral glucose load (75–100 g) and an increased serum concentration (based on normal range adjusted for age and gender) of insulinlike growth factor 1 (IGF-1, a GH-dependent growth factor responsible for many of the effects of GH and previously known as somatomedin C). Serum IGF-1 levels are rarely falsely elevated. IGF-1 levels do rise in pregnancy two to threefold above the upper limit of gender and age-adjusted normal values. The laboratory assessment of acromegaly is supplemented with magnetic resonance imaging of the pituitary and with visual ﬁeld examination by quantitative perimetry. If imaging of the pituitary fails to detect an adenoma, then plasma GH-releasing hormone (GHRH) concentration and CT of the chest and abdomen are indicated in search of an ectopic GHRH-producing tumor (e.g., pancreatic or small cell lung neoplasm).
Treatment is indicated for all patients with acromegaly. The goals of treatment are to prevent the long- term consequences of GH excess, remove the sellar mass, and preserve normal pituitary tissue and function. Treatment options include surgery, targeted irradiation, and medical therapy. Surgery—transsphenoidal adenectomy by an experienced neurosurgeon—is the treatment of choice and should be supplemented, if necessary, with Gamma knife radiotherapy, pharmacotherapy, or both.
After successful surgical treatment, there is a marked regression of the soft tissue excess, but the bone changes are permanent. After the soft tissue changes have stabilized, combined oral and plastic surgery may be indicated (e.g., mandibular osteotomies, recession of the supraorbital ridges, rhinoplasties, and reduction of tongue size). Disabling hypertrophic osteoarthropathy of the hip or other large joints may require joint replacement. Because of the increased risk of colorectal adenomas and cancer, patients with acromegaly should be offered regular colonoscopic screening.