Acromegaly When Combination Medical Therapy Has Not Normalized IGF-1

Clinical Scenario

This protocol addresses patients with acromegaly who have residual tumor mass following surgery and whose serum IGF-1 has not normalized despite combination medical therapy. When escalating beyond combination treatment, a distinct approach is required.

Previous Treatment — Goal Not Achieved

Combination medical therapy — continuing the somatostatin receptor ligand (octreotide LAR or lanreotide depot/autogel) with the addition of pegvisomant or cabergoline — did not achieve normalization of serum IGF-1. This outcome is the indication for escalation to the next treatment step.

Next Step — Partial Overview

Following failure of combination medical therapy, a radiotherapy approach targeting residual tumor tissue becomes the relevant intervention. Which specific technique is appropriate depends on anatomical and clinical factors particular to each patient — the full selection criteria and protocol are available in the complete regimen.

Treatment Goals

Normalized serum IGF-1 and GH below 1 µg/L, assessed on annual reassessment following medication withdrawal.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1210/jc.2014-2700

We suggest use of radiation therapy in the setting of residual tumor mass following surgery, and if medical therapy is unavailable, unsuccessful, or not tolerated.

We suggest use of stereotactic radiotherapy (SRT) over conventional radiation therapy 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 an exposure of more than 8 Gy.

To monitor the efficacy of radiation therapy, we recommend annual GH/IGF-1 reassessment following medication withdrawal.

View source ↗