- The evidence on the effects of surgical and non-surgical (for example, medication) approaches for the management of pituitary tumours that secrete growth hormone is very limited.
- Outcomes that are particularly important for people with the disease, such as disease-related complications, side effects and disease recurrence, were not, or only sparsely, reported.
- When reported, we found that surgery may have little or no effect on the outcomes compared to non-surgical treatment.
What are growth-hormone-secreting pituitary adenomas?
Growth hormone-secreting pituitary adenomas, a severe hormone disease, are tumours in a small gland located at the base of the brain that releases growth hormones into the blood.
How are they treated?
Currently, patients with these types of tumours are treated by removing the tumour with surgery. However, non-surgical methods, such as medication and radiation therapy, which target these tumours, may be used to treat them or may improve results even after surgery.
What did we want to find out?
The effects of surgical and non-surgical strategies for treatment of growth hormone-secreting pituitary adenomas in adults.
What did we do?
We looked at the evidence from research studies to see if surgical and non-surgical strategies were effective in treating growth hormone-secreting pituitary adenomas in adults. We compared surgical and non-surgical interventions used in the treatment of these tumours.
What did we find?
We found eight randomised controlled trials (clinical studies where people are randomly put into one of two treatment groups) involving 445 individuals with these types of tumours, looking at whether surgery, medication, or medication followed by surgery can improve outcomes. We found no studies that examined radiation therapy. Follow-up of the study participants ranged from 12 weeks to 5 years.
The studies did not describe possible complications of the disease and unwanted effects of treatment in great detail. The recurrence of tumours was not reported at all. After combining the available information in the studies, it is uncertain whether there is any difference between surgery and medications or between surgery and medications followed by surgery in terms of our main outcomes.
What are the limitations of the evidence?
We are not confident in the evidence because many of the studies included in this review were very small, they did not report information that we could use, and some of the results were inconsistent across the different studies. Moreover, some studies did not clearly report how they were conducted, for example, how the study participants were randomly put into one of the two treatment groups. Our lack of confidence in the evidence means that future studies may likely change our results.
How up to date is the evidence?
This evidence is up to date as of August 2022.
Within the context of GH-secreting pituitary adenomas, patient-relevant outcomes, such as disease-related complications, adverse events and disease recurrence were not, or only sparsely, reported. When reported, we found that surgery may have little or no effect on the outcomes compared to the comparator treatment. The current evidence is limited by the small number of included studies, as well as the unclear risk of bias in most studies. The high uncertainty of evidence significantly limits the applicability of our findings to clinical practice.
Detailed reporting on the burden of recurrent disease is an important knowledge gap to be evaluated in future research studies. It is also crucial that future studies in this area are designed to report on outcomes by tumour subtype (that is, macroadenomas versus microadenomas) so that future subgroup analyses can be conducted. More rigorous and larger studies, powered to address these research questions, are required to assess the merits of neoadjuvant pharmacological therapy or first-line pharmacotherapy.
Growth hormone (GH)-secreting pituitary adenoma is a severe endocrine disease. Surgery is the currently recommended primary therapy for patients with GH-secreting tumours. However, non-surgical therapy (pharmacological therapy and radiation therapy) may be performed as primary therapy or may improve surgical outcomes.
To assess the effects of surgical and non-surgical interventions for primary and salvage treatment of GH-secreting pituitary adenomas in adults.
We searched CENTRAL, MEDLINE, WHO ICTRP, and ClinicalTrials.gov. The date of the last search of all databases was 1 August 2022. We did not apply any language restrictions.
Randomised controlled trials (RCTs) and quasi-RCTs of more than 12 weeks' duration, reporting on surgical, pharmacological, radiation, and combination interventions for GH-secreting pituitary adenomas in any healthcare setting.
Two review authors independently screened titles and abstracts for relevance, screened for inclusion, completed data extraction, and performed a risk of bias assessment. We assessed studies for overall certainty of the evidence using GRADE. We estimated treatment effects using random-effects meta-analysis. We expressed results as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) for continuous outcomes, or in descriptive format when meta-analysis was not possible.
We included eight RCTs that evaluated 445 adults with GH-secreting pituitary adenomas. Four studies reported that they included participants with macroadenomas, one study included a small number of participants with microadenomas. The remaining studies did not specify tumour subtypes. Studies evaluated surgical therapy alone, pharmacological therapy alone, or combination surgical and pharmacological therapy. Methodological quality varied, with many studies providing insufficient information to compare treatment strategies or accurately judge the risk of bias. We identified two main comparisons, surgery alone versus pharmacological therapy alone, and surgery alone versus pharmacological therapy and surgery combined.
Surgical therapy alone versus pharmacological therapy alone
Three studies with a total of 164 randomised participants investigated this comparison. Only one study narratively described hyperglycaemia as a disease-related complication. All three studies reported adverse events, yet only one study reported numbers separately for the intervention arms; none of the 11 participants were observed to develop gallbladder stones or sludge on ultrasonography following surgery, while five of 11 participants experienced any biliary problems following pharmacological therapy (RR 0.09, 95% CI 0.01 to 1.47; 1 study, 22 participants; very low-certainty evidence). Health-related quality of life was reported to improve similarly in both intervention arms during follow-up. Surgery alone compared to pharmacological therapy alone may slightly increase the biochemical remission rate from 12 weeks to one year after intervention, but the evidence is very uncertain; 36/78 participants in the surgery-alone group versus 15/66 in the pharmacological therapy group showed biochemical remission. The need for additional surgery or non-surgical therapy for recurrent or persistent disease was described for single study arms only.
Surgical therapy alone versus preoperative pharmacological therapy and surgery
Five studies with a total of 281 randomised participants provided data for this comparison. Preoperative pharmacological therapy and surgery may have little to no effect on the disease-related complication of a difficult intubation (requiring postponement of surgery) compared to surgery alone, but the evidence is very uncertain (RR 2.00, 95% CI 0.19 to 21.34; 1 study, 98 participants; very low-certainty evidence). Surgery alone may have little to no effect on (transient and persistent) adverse events when compared to preoperative pharmacological therapy and surgery, but again, the evidence is very uncertain (RR 1.23, 95% CI 0.75 to 2.03; 5 studies, 267 participants; very low-certainty evidence). Concerning biochemical remission, surgery alone compared to preoperative pharmacological therapy and surgery may not increase remission rates up until 16 weeks after surgery; 23 of 134 participants in the surgery-alone group versus 51 of 133 in the preoperative pharmacological therapy and surgery group showed biochemical remission. Furthermore, the very low-certainty evidence did not suggest benefit or detriment of preoperative pharmacological therapy and surgery compared to surgery alone for the outcomes 'requiring additional surgery' (RR 0.48, 95% CI 0.05 to 5.06; 1 study, 61 participants; very low-certainty evidence) or 'non-surgical therapy for recurrent or persistent disease' (RR 1.22, 95% CI 0.65 to 2.28; 2 studies, 100 participants; very low-certainty evidence). None of the included studies measured health-related quality of life.
None of the eight included studies measured disease recurrence or socioeconomic effects. While three of the eight studies reported no deaths to have occurred, one study mentioned that overall, two participants had died within five years of the start of the study.