Transsphenoidal surgery is the initial treatment of choice for most patients with proved or highly suspected Cushing’s disease. Published reports demonstrate that at experienced centers, such as the California Center for Pituitary Disorders at UCSF, remission following surgery can be expected in 80 to 90% of patients with microadenomas and 50 to 60% of patients with macroadenomas. Recurrent hypercortisolism can be expected in approximately 10% of patients with microadenomas and 30% of patients with macroadenomas who enter remission after surgery.
Goals of treatment for patients with prolactinomas include normalization of serum prolactin concentrations, reduction in tumor size, resolution of any visual deficits, restoration of sexual function and fertility, and resolution of galactorrhea.
Transsphenoidal surgery remains the treatment of choice for most patients with acromegaly. Optimal management of the 10 to 50% of patients who do not undergo remission after transsphenoidal surgery and the 20% of patients who experience recurrence of acromegaly after initial transsphenoidal surgery remains less clear. Radiation represents an evolving treatment for acromegaly that warrants consideration as an alternative to medical therapy for cases refractory to transsphenoidal surgery.
Some patients will have residual acromegaly despite undergoing a successful transsphenoidal surgical procedure by experienced neurosurgeons. Fortunately, there are a number of pharmacologic agents that have demonstrated effi cacy in the management of patients with residual and recurrent acromegaly and in those who are not candidates for primary surgery. Some of these drugs have changed the natural history of treated acromegaly. As a result, many of the more severely distressing end-stage manifestations of the disorder are now seen only infrequently.