This protocol addresses the clinical step taken in mild acromegaly — modest elevation of serum IGF-1 with mild signs and symptoms of growth hormone excess — after a prior combination regimen did not achieve serum IGF-1 normalization.
Combination therapy (adding a somatostatin receptor ligand — octreotide LAR or lanreotide depot/autogel — to cabergoline) was trialled but did not reach the target of serum IGF-1 normalization. This protocol is the defined next step after that failure.
Patient presents with modest elevation of serum IGF-1 and mild signs and symptoms of growth hormone excess. Serum IGF-1 remains above the normalized range despite prior adjuvant medical therapy.
The protocol involves radiation therapy directed at residual tumor mass. A specific radiotherapy technique is preferred based on defined clinical criteria. The full selection rationale, monitoring schedule, and step-by-step guidance are contained in the complete regimen.
Normalized serum IGF-1 and GH < 1 µg/L on annual reassessment following medication withdrawal.
DOI: 10.1210/jc.2014-2700
In a patient with only modest elevations of serum IGF-1 and mild signs and symptoms of GH excess, we suggest a trial of a dopamine agonist, usually cabergoline, as the initial adjuvant medical therapy.
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.
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