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Acromegaly is an uncommon condition with a prevalence in European populations of about 40 per million, and an incidence of four to six new cases per million population per year. The vast majority (99%) of cases of acromegaly are due to a pituitary somatotrophinoma, the occasional rare case being caused by ectopic production of growth hormone-releasing hormone by bronchial carcinoid, pancreatic neuroendocrine, or hypothalamic tumours, giving rise to somatotroph hyperplasia. The onset of the condition is most often very insidious, especially so in the older patient; photographs may reveal evidence of acral expansion 5–10 years before biochemical confirmation of the diagnosis. This long exposure of tissues to excessive secretion of growth hormone (GH) before treatment may be significant with respect to the long-term mortality outcome. Furthermore, it may also explain why about 60–70% of somatotrophinomas are macroadenomas (>1 cm in diameter) at diagnosis, and only a minority (30–40%) are microadenomas. The presentation of acromegaly is very variable, and a fair proportion of cases are diagnosed coincidentally on the basis of the characteristic appearance of a patient presenting with unrelated problems. However, the consequences of GH excess such as enlargement of the hands, feet, jaw and face, sweating, greasy skin and carpal tunnel syndrome are the most common forms of presentation, although the metabolic consequences of diabetes mellitus, hypertension and renal calculus formation may provide the initial clues to the diagnosis. Other patients may present with symptoms directly attributable to an expanded pituitary gland, such as headache, visual impairment or hypopituitarism. This varied presentation and rarity of the condition often means that the disease goes unrecognised by the non-specialist physician. Accordingly, the specialist endocrinologist frequently encounters the patient when complications have developed. Moreover, the endocrinologist is committed to the long-term care of patients with acromegaly because of the implications of the complications and GH excess for long-term morbidity and mortality. This is not a condition that should be managed by generalists. Morbidity and mortality in acromegaly

New developments in the management of acromegaly. Should we achieve absolute biochemical cure?