Debulking of pituitary adenomas improves hormonal control of acromegaly by somatostatin analogues

A large number of issues remain regarding the optimal treatment of patients with acromegaly. One debate that is current is whether surgery or primary medical treat- ment is indicated in patients with tumours, usually with extrasellar extensions, that are unlikely to be cured by surgical means. Will debulking surgery help the subsequent response to medical therapy? The recent article by Petrossians et al. (1) goes someway to answering this important question. We know that in the best surgical hands microade- nomas have a high cure rate of around 90% in acro- megaly (2). These patients often have lowish growth hormone (GH) levels. Indeed any treatment - be it sur- gery, medical therapy or radiotherapy - is most suc- cessful in patients with low GH levels. However, at least 60% of patients have macroadenomas when they present with acromegaly. These patients often have higher GH levels and there may even be an exten- sion of the lateral side of the pituitary tumour into the cavernous sinus, making surgery much more difficult. In these circumstances success by surgical means, usually using the transphenoidal route, is very much less frequent, around 50% (3). Suprasellar extensions