Acromegaly Perioperative management Surgical resection PS Q Can the patient safely undergo surgery? Q Is surgery likely to be successful? Q Is surgery acceptable to the patient? No to any Consider primary medical therapy if surgery is contraindicated or if a poor likelihood of success is expected owing to patient-specific and/or tumor-specific factors. Yes to all Perform transsphenoidal surgery as the primary treatment in most patients with acromegaly. B Consider performing repeat surgery in patients with residual intrasellar disease following initial surgery. C Preoperative somatostatin receptor ligands Avoid administering routine preoperative medical therapy to improve biochemical control after surgery. D Consider administering preoperative somatostatin receptor ligands to reduce surgical risk from severe comorbidities in patients with severe pharyngeal thickness and sleep apnea, or high-output HF. C Serial laboratory assessment, after surgery Obtain IGF-1 and a random GH level measurement at 12 weeks or later following surgery. B Consider obtaining a nadir GH level measurement after a glucose load in patients with a GH level > 1 g/L. C Consider monitoring LFTs monthly for the first 6 months and then every 6 months in patients receiving pegvisomant, with consideration of discontinuation of pegvisomant if the transaminases are increased > 3-fold. C Therapeutic targets Consider targeting a normal age-adjusted serum IGF-1 level. C Consider targeting a random GH level of < 1.0 g/L. C Consider maintaining the same GH and IGF-1 assays in the same patient throughout management. C Indications for medical therapy ACC Q Does the patient have persistent disease following surgery? Yes Initiate medical therapy in patients with persistent disease after surgical resection of the adenoma or if surgery is not appropriate. A Individualize the therapeutic approach according to patient-specific and disease-specific factors, although the choice for initial therapy will largely be driven by tumor and biochemical characteristics. B Use tumor location and size and the presence of local effects of the tumor mass, such as visual field defects and headache, to determine treatment choice based on the likely effect of therapy on tumor volume. A Serial imaging assessment (after surgery) No Obtain imaging at least 12 weeks after surgery to visualize the residual tumor and adjacent structures. B Consider obtaining MRI as the imaging modality of choice. Obtain CT if MRI is contraindicated or unavailable. B Radiotherapy Q Does the patient have residual tumor mass following surgery? Yes Consider offering radiotherapy in patients with residual tumor mass following surgery, or if medical therapy is unavailable, unsuccessful, or not tolerated. C Consider offering stereotactic radiotherapy over conventional radiotherapy in patients with acromegaly unless the technique is not available, there is significant residual tumor burden, or the tumor is too close to the optic chiasm resulting in exposure of > 8 Gy. C Obtain annual GH/IGF-1 reassessment following medication withdrawal to monitor the efficacy of radiotherapy. B Obtain annual hormonal testing following radiotherapy to monitor for hypopituitarism and other delayed radiation effects. A No Continue management as clinically appropriate.