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Hypothalamic Dysfunction in "Cured" Acromegaly Is Treatment Modality Dependent

Department of Endocrinology, Christie Hospital, Manchester, United Kingdom M20 4BX

Address all correspondence and requests for reprints to: Prof. S. M. Shalet, Department of Endocrinology, Christie Hospital, Wilmslow Road, Manchester, United Kingdom M20 4BX.

The current definition of cure after treatment for acromegaly stipulates a reduction in GH levels to less than 2 ng/mL (<5 mU/L), as such GH concentrations are believed to be associated with normalization of long term survival. We sought to further define the nature of the cure in such patients, when cure has been achieved by alternative therapeutic modalities, in the expectation that hypothalamic neuroregulatory control of GH secretion might be affected differently by radiotherapy or surgery. In particular we wished to determine the effect of therapy modality on endogenous somatostatin (SMS) tone, using the GH response to iv arginine as a paradigm. We studied 20 patients with cured acromegaly (mean 24-h GH concentration, <2 ng/mL). Eight patients had been cured by surgery only (S; 4 women and 4 men; mean ± SEM age, 52 ± 5 yr), and 12 patients had been cured by radiotherapy (R; 4 women and 8 men; age, 52 ± 3 yr). Sixteen healthy subjects were studied as a control group (C; 6 women and 10 men; age 53 ± 3]. The median (range) GH during 24-h profiles was similar in each group: S, 1.3 (0.7–1.8) ng/mL; R, 0.6 (0.4–1.8) ng/mL; and C, 0.7 (0.4–3.2) ng/mL (P = 0.57). The median incremental GH responses to arginine were significantly lower in the R group compared with those in the S and C groups: S, 6.4 (2.1–16.6) ng/mL; R, 0.1 (0–1.7) ng/mL; and C, 9.2 (0–16.1) ng/mL (P = 0.0002; S vs. R, P < 0.01; S vs. C, P > 0.05; R vs. C, P < 0.001). We conclude that in acromegalic patients deemed to be cured (GH, <2 ng/mL), the mode of therapy has considerable influence on the remaining hypothalamic-somatotroph function. In view of the putative mechanism by which arginine releases GH, we suggest that radiotherapy leads to a reduction or complete loss of endogenous SMS tone. This may have implications for the treatment of those acromegalic patients who are not cured (GH, >2 ng/mL) and who require SMS analog therapy.

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