Acromegaly was first described by Marie as a 

disease entity in the late 1800s,

literally translated the name implies large 

extremities,

which seems an apt label.

Even prior to 1900,

it was believed that there was some association of the 

pituitary Gland with this is the disease.

Later investigation has established that the basic 

disorder is an excess or inappropriate secretion 

of growth hormone produced by a pituitary tumor.

Significant advances have been made both in diagnostic 

techniques and therapeutic management in recent 

years and our discussion will focus on these two 

aspects.

We are fortunate in having two distinguished authorities in the 

field to discuss this disease.

The first Panelist I would like to introduce is Dr William 

Dowd,

who is professor of medicine and director 

of the metabolism division of Washington University 

School of Medicine.

ST louis Missouri.

Among his many important positions.

He is also co editor of the journal of clinical 

endocrinology and metabolism.

He has written many papers on the subject of endocrinology,

including the chapter on the ad no hypothesis 

in William's textbook of endocrinology.

Our other distinguished panelists is Dr William 

Collins,

who is professor and chairman of the section of 

neurosurgery.

Yale University School of Medicine,

New Haven Connecticut.

In addition to his duties at Yale Medical School,

Dr Collins is a member of the american board of 

neurological surgery and also holds 

important positions in several neurosurgical 

societies over the past several years.

Dr Collins has made many contributions on the 

subject of pituitary tumors as well as 

hypothesis.

Ectomy.

The overall organization of today's program 

will begin with a briefcase presentation by Dr 

Scott Mcclanahan,

who is a resident in neurosurgery at Emory 

University School of Medicine.

This will be followed by a discussion between the 

panelists and if time permits 

between the panelists and our audience,

which consists of a nurse of a clinical specialist 

and for neurosurgical residents from Emory 

University.

So at this point I will ask Dr Mcclanahan to 

present the case,

which will serve as a starting point for our discussion.

I would like to express our gratitude to our patients 

for coming here today to assist us in making this 

videotape dr Mcclanahan.

This was the first hospital admission for 

a 35 year old man today,

seated on my left who entered with 

a chief complaint of headaches and a progressive 

enlargement of his feet and hands of one year's 

duration over the same period of time.

He had also noted changes in his facial features 

and morning joint stiffness and swelling of the ankles 

and hands.

He had also noted some numbness and para seizures 

involving the thumbs and forefingers of 

both hands.

These extremity symptoms and the joint 

stiffness would typically improve as the day 

progressed but would be worse again.

The following morning sexual function was 

described as normal On 

examination.

The patient's height was 72" and his weight 

was £184. On 

general physical examination.

He was felt to be normal with the exception of 

puffiness of the face,

hands and ankles and a deep voice 

and a grade 2/6.

Systolic murmur heard best over the apex 

neurological testing.

He was felt to have an entirely normal neurological 

exam.

No visual field defect could be 

demonstrated grossly.

Nor were there any other cranial nerve findings.

An ophthalmological evaluation was obtained and 

this was felt to be normal with respect to visual 

acuity,

ease and visual fields.

A C.

T.

Scan was obtained and this was normal even 

with eight millimeter cuts through the area of the 

seller.

A complete laboratory 

examination and endocrine neurological 

work up was normal.

With the exception of growth 

hormones shown on the slide.

The fasting level was 

elevated and this level did not 

suppress to normal values.

Even with administration of a 

glucose load skull 

series obtained at an outside hospital 

including polit tomes of the 

cellar were interpreted as normal.

Following his initial evaluation uh 

The patient was taken to the operating room where an 

open transfer nautile micro surgical 

removal of an eosinophilic 

adenoma was done.

The adenoma measured eight x 8 x 

seven.

At the time of surgery the 

patient's postoperative course was 

entirely uncomplicated and he was 

discharged On the 10th postoperative 

day following 

repeat testing of growth hormone levels 

which were shown to be normal.

Both on fasting 

and on administration 

glucose to suppress 

to normal levels.

Thank you.

Dr mcclanahan.

So either dr DAO day or dr Collins have 

questions for either are patient or 

doctor Mcclenahan?

I'd like to ask the patient a few 

questions.

This disease is very insidious and its onset and 

it's very difficult for the physician or the patient to 

recognize When it first began.

I notice you're wearing a ring.

Has it been necessary to increase the size of that ring?

If so,

when I did increase the size of the ring?

Perhaps six months after the first come 

on symptoms.

How about your shoe size?

The shoe size,

neck,

collar size both changed and 

those also had to be increased about 6-8 months after 

first symptoms and 

a common complaint of other patients 

with this condition is 

excessive sweating.

Have you had any of that?

I did not know that if it was there.

I understand you are quite athletic.

Have you noticed any decrease in your 

ability to perform?

I think perhaps uh the initial 

symptoms,

the taking the numbness swelling did prompt 

a decrease in the desire to 

do basic cal aesthetics.

But I did increase or rather sustained a jogging 

program.

Even during the period that I was undergoing examination 

and has a dentist noted any change in your 

jaw?

Not that was described to me.

Thank you Dr Collins.

I have a couple.

You keep saying the first symptom.

What was your first symptom?

Her symptoms were swelling and pain in the 

lower extremities,

the ankles and feet?

All right.

Dr McClellan.

You mentioned in your 

history of paris?

These asia's and particularly night para seizures the hand.

Did you have anything in your work up that would indicate a 

peripheral neuropathy or an entrapment?

Rap tunnel sign was slightly 

positive bilaterally,

but there was no other suggestion of a peripheral 

and certainly in my experience it would be unusual to 

have a normal skull films 

in the face of anak metallic.

I think certainly the volume of the seller may appear 

normal.

If we take a look at these films,

just go over a little more carefully perhaps 

first is this lateral I 

think really suggest the double floor that you can see the 

cone down view of the next film.

I think it's even more apparent and this 

double floor as it's commonly called,

even though the volume of the solo appears 

normal suggests an erosion on one 

side.

If we go to the anterior posterior view,

I think this is really shows 

slamming of the floor towards the left cone.

Down on this next film,

there is quite apparent.

But the polit oma I think 

must verify this out.

And if we have the next film on this 

lateral,

I think you can see that the cortex of 

the floor of the seller is 

eroded here and about the mid portion as well as 

portion of it posterior lee where it's along the dorsal klein 

oid but in the anterior posterior polit.

Um ah here there's really a definite break 

in the cortical continuity which is over on the left 

side probably is even more 

significant in the fact that the patient has been having symptoms 

which have been referred to this side.

And in contrast to interpreting 

this normal,

these are really quite confirmatory of a 

mass lesion in the cella,

the Akram,

a gallic patient.

The tumor very often is in the lateral 

inferior portion of the gland and it has a very high 

incidence of pressure erosion of the floor of the cellar,

which I think these films have.

This this case is relatively early,

brings up some I think 

interesting valuable points for our audience and I'm sure our 

audience would be interested in what you would consider 

important clinical findings to establish 

the diagnosis of acromegaly dr dowdy.

I wonder if you could comment on that.

I think our problem from the point of view 

of the internist or the primary physician 

is recognizing the early clues of 

acromegaly and instituting the proper 

screening tests.

Some of the features presented by this patient 

are important.

It's well to remember that the increasing 

the apparent size of the face and hands 

that occurs early in the disease is not that of bony 

enlargement but the soft tissue and 

swelling so that the change 

in appearance is important and many times we 

review family pictures to 

see if there really has 

been changed.

I think that when we deal with pre pure little Children,

we are on the lookout 

for accelerated growth velocity and the 

absence of perpetual changes.

And this helps us recognize 

a rare case 

gigantism.

Some of our patients are first recognized by the 

dentist in terms of an abnormality.

Yeah.

And bye.

Would you consider signs such as symptoms of 

carpal tunnel compression of peripheral neuropathy?

Important clinical signs.

And I think they're important because there are signs that bring 

the particularly the 

entrapment,

bring the position to the communication 

to the position with complaints.

And I think that evaluation 

at least consideration of the possibility of 

growth hormone excess should be 

made in all patients with in travel 

neurosurgeons are interested in the what 

laboratory tests we should order.

Could you tell us what is your laboratory investigation 

of a patient with acromegaly?

What do you consider important in that regard?

I think the problem presented to the endocrinologist or 

the primary physician.

He's the one that the 

patient many times 

with suggestive 

symptoms which are by no means 

established,

represent hard data.

Most of these patients are evaluated initially on 

ambulatory setting and what we really need is a 

effective screening procedure for this.

And I think that rather than 

send in an isolated growth hormone measurement the way 

most positions are inclined 

to do.

I always give the patient in the office 

a mm hmm Load of 

75 : 100 g of glucose.

Has the patient wait quietly in the office and 

get growth hormone measurements at 60 and 

90 minute.

I think if these come back entirely normal.

The chances That is below 

five nanograms 

per amount the chances of having 

important clinical disease?

Mm hmm.

Really quite remote in these patients without 

definitive physical things.

It's important to recognize that 

perhaps a third of these patients do not secrete 

growth hormone at a continuous level 

but have 

markedly sometimes 

dramatically variable growth hormone 

levels so that the first point I would like to 

make is that you should not 

evaluate the severity of the growth from on high 

persecution on a single value.

I think the glucose tolerance test is 

a useful procedure.

There are certain fraction of 

patients who because of 

anxiety and stress will have elevated 

fasting levels,

but this is rapidly 

suppressed by glucose 

administration.

I should say that 

relatively high growth hormone conditions are not absolutely 

pathetic pneumonic of acrobatically,

there are functional conditions associated 

with increased growth hormone 

secretion that's been observed in cirrhosis.

Deliver certain patients with 

a.

So to me,

I have it in 

severe nutritional disturbance,

patients with anorexia,

nervosa have this certain 

disturbances associated with short stature 

may have high growth hormone levels so that 

we certainly require,

mm hmm.

Some evidence in the patient that 

has manifestations of growth hormone 

excess.

Before we blindly accept 

growth hormone values.

I would like to pull dr Collins more or less into this 

and come back to this issue of the rationale for the 

large number of endocrine tests that are performed in these 

patients.

What are your opinions on this issue?

Well,

really,

there are two issues on it.

One of them is pituitary tumor,

the others acromegaly and acromegaly.

Usually I will see the patient what the 

diagnosis has already made and 

confirmed.

But then I have 

needs that are different than diagnosing the patient.

As a surgeon,

I'd like to know how the gland functions 

because particularly with microsurgery,

the gland,

I'd like to be able to evaluate what I've done in a patient 

afterwards.

So I'd like to know as the adrenal function.

I'm gonna tell Trophic function,

thyroid function.

Are they normal?

Are they abnormal?

Do they respond?

So that I think even though it isn't necessary for an 

exam,

it does give me a feedback as to how I'm 

doing things.

And I might say in this time,

I think it also gives some protection 

against possible malpractice or something of this nature.

If you'd like to bring it up if someone said before 

I was operated on,

I had normal pituitary and I don't I think it's well to 

document it.

Either both of the has been 

preserved or it was not there to begin with.

I think another part of this is one 

which has been significant in 

my thinking about other tests that we'd be doing 

and the endocrine work up that is to measure anti 

diuretic hormone function and 

the reason for this has been so rare with a straight 

pituitary to have 

anything by the test we're using which is 

12 hour dehydration plus 

exogenous,

a th anti diuretic hormone given to the patient,

it's been very rare for a pituitary tumor to 

have any functional loss in this.

And when it has happened it usually signifies some 

extension up towards the hypothalamus or into the stock 

or a diagnosis that's different.

So do you use this test sometimes to guide you in making a 

decision about further studies such as neuro diagnostic studies?

Yes.

I think if we find that there's inadequate anti 

diuretic hormone on our testing,

then this has led me at least to be 

much more demanding of the neuro 

radiologist to clarify all the area around the 

paras ella structures the chaos and the 

cosmetic recess and get a good picture of the third ventricle and so 

forth.

Dr Collins.

This patient had a CT 

scan,

did not have an arteriogram and anemones instagram.

Uh He had polly tomography which you've shown is 

probably abnormal films.

This brings up the issue of 

what is an appropriate neuro diagnostic work 

up now for the patient with acromegaly 

we have a tendency to 

use neuro radiological 

Diagnostic procedures for two or 3 reasons.

One of them I think we've mentioned already is that if the 

patient has 

evidence of a involvement of this 

stalker hypothalamus by having 

an inadequate a th were very likely to 

Carefully look at the 3rd ventricle,

the cosmetic recess and where we might 

not be in somebody else.

The second is as if the technique by 

Newman said photography with laminar graffiti and 

combined.

And I'm not willing to accept the computerized 

scan to tell me there's a difference 

in the sky asthmatic Recess 

of the 3rd ventricle or something which may be all we'll see.

I don't think it's quite that fine.

Now on the other hand,

if there's nothing to suspect this and we have 

a pituitary tumor that's producing a hormone.

So we know that it's a tumor of the pituitary gland,

then I am.

If the scan does not show any super 

seller or paracel extension,

I will accept this.

Now on our particular scanner.

I might say that our previous generation scanner,

I was not willing to.

So we're right on the border and our tier Graham is really 

only done when we have an enlarged seller and we do 

not have a hormone that we can pick up and 

then we will go to the entire 

a group of testing including 

Newman cephalon graffiti.

To be certain that we don't have an empty cell at this time 

and to be certain that we don't have a 

vascular lesion.

Such an aneurysm that could be eroding the seller and giving us the 

signs of an interstellar lesion.

But without any and technological signs of it 

or that we may not have a different type of tumor such as the 

meningioma or something of this nature.

But to clarify this patient though in in non 

acromegaly.

Do you normally perform an arteriogram?

No,

we would not perform an arteriogram on this 

patient.

I think the only time we might have of his 

workups say is optimal,

logical workups had shown that this left side of 

pain had involved 

also a major involvement or minor involvement of this left 

optic nerve or something like this.

Now we might have done a new one such program,

but I'm not sure this computerized scan was normal and 

with the erosion being at the 

inferior anterior portion on the left side of his 

palette owns,

which tells you where it is.

I don't think that I would have gone for a new mindset program.

But now what I'm doing is I'm taking two or three facts 

and putting it together and and not 

doing a test,

which is certainly not a dangerous test but an uncomfortable one.

If at any point.

And the information I'm pulling together 

says something which would such as the 

and or chronological ophthalmological 

or the x rays of the skull.

Don't answer the question I'm asking.

Then I would go on.

Our patient had a transfer nodal,

uh not hypothesis.

Ectomy,

but micro surgical removal of an adenoma with sparing 

of his gland.

Yet,

as you look over the,

even the recent literature,

you find medical treatments,

you find radiation treatments.

proton beam treatments,

Various measures designed at treating patients 

with acromegaly,

I would I think our audience would be most 

interested in just your overall philosophy.

Dr Dowd a on uh your 

treatment of a patient with early acromegaly or 

advanced acromegaly.

I I believe that the reasons 

for treating early acromegaly are 

probably stronger than the 

treatment of a difficulty 

uh control late acromegaly 

where most of the damage has been done 

and frequently the fire is 

abated to a certain extent.

Early in acromegaly,

mm hmm.

We can present to prevent the physical 

disfigurement can 

prevent the neurologic 

complications.

We are concerned in acromegaly about the 

cardiovascular complications 

of the disease.

I think these are all very cogent arguments in 

terms of treatment.

Well,

for the I think for the benefit of our audience,

I think many people realize that there are 

facilities where proton beam 

or Bragg peak radiation of Akram a gallic seems to be an 

appropriate therapy and I have no argument one way or 

the other.

But let's just suppose for the sake of argument,

you as an experienced endocrinologist who have dealt with 

this disease many years 

has a facility for delivering this 

proton beam radiation directly across the street.

And you have a good neurosurgeon who can do transfer 

nodal surgery.

Is it a fair question to ask you,

what would you choose?

And the majority of your early cases of acromegaly 

that presumably the tumors are still in the cellar.

I think the verdict is not in at the present 

time.

The major concern that Yeah,

one would have 

about surgical treatment is in the young 

individual.

What fraction of patients 

after a micro surgical procedure 

will be left with disturbed gonadotropin 

funky.

There are indications 

that certainly not all the patients 

who are operated on are going to retain their 

gonna trope and function.

Okay.

I think the evidence from the 

centers that are doing proton beams have 

been are pretty well established.

So it's really up to neurosurgery to show that their 

results in terms of continued gonadotropin 

function are as good as those who have been 

reported.

Bye.

The proton beam therapy.

I think that's a major concern.

I think both forms of 

therapy in the early 

patients with mild and moderate growth hormone 

excess.

Both forms of therapy have been quite successful 

in controlling the growth hormone 

level dr Collins.

We're talking about philosophy of treatment and I know that you 

have opinions on many things and I would like your opinion on 

this.

I think that we have to get more information 

even on proton beam radiation as to the fact that 

malignant change in these patients is not going to occur.

In contrast to this.

I think the Uh this 

was a more acceptable risk as far as 

radiation when the only approach to this condition 

surgically was trans cranial craniotomy which 

had a significant mortality and a significant 

morbidity and by significant I mean five and 

six or 7% and in some hands as high as 10%.

In contrast the micro surgical approach And I think as 

people have worked more with the micro surgical transfer nodal 

approach,

this has come down almost to the 

mortality of anesthesia in patients who are 

handled medically well.

And the morbidity is extremely brief 

so that I see 

no reason to accept 

a possible delayed morbidity in an early case of acromegaly.

So I have no qualms at all of 

recommending strongly to a patient that the patient ought to be 

explored.

An attempt at removal of it.

I think in the late,

which dr dougherty started to 

discuss,

you have another problem because really we 

have two things that occur in late 

acromegaly or any late pituitary tumor.

One of them is the mass effect and one is the endocrine apathy.

And in acromegaly they don't always go together.

We certainly have patients with very large 

tumors and relatively low but 

elevated growth hormones.

And we have the opposite with very high growth hormones and 

relatively small tumors.

But so to me,

the in the late case,

what we're after is to get the mass 

effect.

Whether this is effect on the optic 

chasm or even on the brain itself or whether 

it's an invasive destructive effect on the base of the 

skull.

So that could lead to gonorrhea or 

breakdown in the protection of the 

coverings of the brain to the subarachnoid 

space.

I think this is now a question of removal of 

mass and treatment in this group of patients,

I've very much recommend 

since I know the surgery in this invasive or rapidly growing 

tumor is not the best way of controlling it that we 

get the mass under control by surgical decompression 

and radiate them.

So,

on the one hand,

recommending radiation,

on the other hand,

not recommending radiation and it really relates to the 

situation that you're in.

Acma gallic certainly are have a relatively 

small percentage have a 

mass effect as their major problem.

Uh this has been estimated in some series down around 

12 or 15%.

I think the most accepted is around 18 or 20%.

About one in five have mass effect.

In contrast to the chroma foam patient,

which was extremely higher.

It seems as though the emphasis or at least part of the 

emphasis of the discussion here has been to pick up 

the small tumor 

dr hardy has stated and 

has written that the ultimate diagnostic 

test for pituitary tumor 

can be considered the transmission oil 

exploration of the seller.

Would you agree with that?

Well,

I think,

you know,

we're now operating on patients with diagnostic 

work up that would have passed as 

normal 10 years ago so that 

I'd have to agree in part with it.

I might say that we have at least one portion of 

our endocrine and perhaps dr dougherty could 

talk about our endocrine section.

Who feel that the morbidity and mortality 

of expiration.

The cell is so low that when there's a 

question of diagnosis that this is 

worthwhile,

I think 

the statement probably is correct,

but it's rarely should be able to shouldn't have to be 

applied to a person or a patient.

Because I think with present 

techniques for evaluation both 

from clinical laboratory and 

neuro radiological,

there really is very rare that you have a doubt.

I'm not certain that going after a one millimeter 

adenoma or something of this nature is 

is possible.

Doctor Dad,

I would like your comment on Dr mcclanahan question about 

hardy's approach and hardy statements.

Well,

I would agree with DR 

Collins.

The functional diagnosis is a combined clinical 

and radiologic diagnosis 

and the 

I would 

not myself 

submit the patient to the operation until I 

was essentially certain about the 

diagnosis because 

en endocrine such 

as parathyroid adenomas,

patriotic adenomas,

we give the charge to the surgeon to 

operate it.

They're committed to 

looking in the organ until they find it even 

to the total removal of the organ.

So that I would be opposed to 

a view that say,

well let's just go and take a quick look.

I would rather spend a little more time in the diagnostic 

work up and saying the patient has this and so 

disease and you go in 

remove glandular tissue until you find it.

I would like to ask DR Collins if you could comment 

on some of the technical aspects 

of pituitary 

microsurgery,

particularly on the dilemma 

of recognizing the location of the 

adenoma.

Once the pituitary itself has been exposed.

Well,

I think the the 

technique has been fairly well standardized 

with variations from the standard 

and our approach to the seller for 

instance is now does not include 

respecting the cartilaginous septum.

That includes moving it over and 

just taking the mucosa off one side and going up that way.

I think this has simplified two things.

One is the healing process and two if 

we have to approach the second time,

uh for some reason it allows the other 

side or it also allows separation of mucosa 

from the septum cartilaginous septum without 

perforation.

That's really minor.

I think uh in Aquaman legally at least 

the vast majority of them have localized 

erosion on their polyrhythms.

And uh even on the plane skull films.

And we have a tendency to go to this.

I say we use two or three little tricks when you're 

starting.

One of them consists of the fact that 

if you remember the blood supply of the pituitary 

does not come in from inferior or laterally so 

that when we open the dura,

the covering of the cell of the door of the seller,

I have a tendency to 

sweep the gland from that,

covering all the entire inferior 

surface and coming up laterally 

quite a way up the uh sides 

of the gland and then do superior early until I 

see the diaphragm and the start just to see the 

diaphragmatic opening,

I do this before I do anything else unless the 

tumor is so large that as soon as I open the dura which 

is you know occasionally in the necrotic large tumor will just start 

pouring out at you.

I do this because I find that it's an easier time 

before any staining of the cells 

with blood or anything else occurs to 

have the definition of my dural 

dissection on the surface of the gland.

All done.

Then I have a tendency to look at the surface with 

irrigation and look for changes in color.

And in general I think the endocrine active tumors 

tend to have a color which has 

a reddish gray Colour as 

compared to the more yellow pituitary.

Although this is not always 100%.

Some of them may actually be quite light and white 

and fiber optic from Probably 

previous bleeding or previous infarction or something.

So this can be confusing just taking the one color 

if I don't see on the surface.

And I think quite a few of them.

I don't see it on the surface.

I then have a tendency to split the gland and 

I split it with blood to section and go on down.

And I used very general compression 

of the lateral portions of the gland 

where I've dissected it clear of the dura 

to have the tumor deliver 

into the uh 

incision in the gland.

I've made let me back up on your splitting the gland.

Do you split it transverse,

Split it vertically.

I assume that the majority of the blood supply coming 

down is in a sagittal plane of the of the 

gland.

So I make my incisions actually.

And if I know like in this particular patient that the 

Chaims are about 90% it's on the left side.

I'll have a tendency to make my vertical incision 

About 25 or 30° off the 

midline towards that side.

If I don't know where it is I'll have it.

I think in the cushing where you so commonly 

find it in the middle of the gland.

I will be very careful in it.

The pro actions.

We've had them almost 

everywhere.

I have not had the experience that they're out laterally.

The metallics have a tendency to be 

just where we found this one and 

the laterally laterally and in fairly 

after the treatment of these patients 

particularly with surgical means.

Are there any problems that we 

experience or encounter inter chronologically in 

following these patients,

Do you?

I'm sure that you see a number of these patients post up.

Are there certain problems or complications?

I think we've talked about the patients who 

failed to be cured by.

No actually unfortunately 

are not rare.

I think we have the replacement 

of 

other hormonal deficits 

come up thyroid adrenal.

Gonna do and the most 

difficult one is the 

Gonna tell we're gonna have a trope in 

replacement.

I think that the patients had is disease for a 

long period of time,

muscular weakness.

Probably on the basis of irreversible 

neuropathy and muscular atrophy can be a 

particular generally,

but not always a headache 

relieved by the procedure.

I think those patients who have gone 

on to the stage of 

hypertension and 

LTD my cardio function 

may not be benefited by a 

late operation.

You touched on an important issue that unfortunately 

surgeons,

regardless of the skill,

still have a certain incidents of patients with 

acromegaly not cured are in whom 

recurrence of an abnormal growth hormone.

A curse.

I really would like for both of you to 

uh tell our audience how this type of 

patient should be handled.

Let's say that a man has a transfer normal 

operation.

The tumors removed the growth hormone comes down to normal but 

later Rikers,

what should I do?

I think this brings up the subject of possible medical treatment of these 

patients.

I don't,

I myself believe that medical treatment will 

be a first line approach 

in the management of acromegaly.

What sort of medical treatment?

And I think that the most promising 

medical treatment at the present time 

is the use of 

medication similar to our Roma 

krypton Roma Christine 

is a the substance 

which probably 

acts as a 

dopamine type dopamine ergic 

type drugs.

Ah in 

About 70% of the patients with Acromegaly.

Given there will 

be a lowering of growth 

hormone levels 

and symptomatic improvement.

They does that treat the symptoms or the tumor 

yet probably 

blocks the secretion.

Oh,

growth hormone directly by the tumor.

That's a mechanism of action.

It does not.

There is at the present time 

no data which would 

suggest that it inhibits the growth 

of the growth 

hormone secreting tumors.

Start his from ergo krypton available 

hysteria investigational drug has been extensively 

used in europe,

particularly in Britain.

The long term results are just beginning to 

appear.

I would like to entertain questions from our audience.

Uh and I would like to ask our patient 

if he has any questions related to his own 

problem or the disease in general,

that he would like to ask either Dr DAO day or 

Dr Collins.

Let me make a brief statement if I may At this point 

as the patient,

I found this discussion particularly valuable.

Many questions being answered that I didn't previously have 

answered not to the fault of anyone,

but there is a very complex area and I 

think that the patient needs information 

and I think that people are seeing this program ought to keep in mind that 

the patient ultimately is the 

the most important if you will in terms of what you're all doing.

Uh So the voluntary and overt 

conveying of information to the patient,

particularly of his options involved here 

is something that the doctors could keep in 

mind.

I'd like to thank our panelists dr DAO day and 

Dr Collins for taking the time today to 

come here and help us make this tape.

I would also like to acknowledge our support 

of our audience and most of 

all the help that we had from our patients.

Thank you.

Mm hmm mm 

hmm mm hmm.

Yeah.

Mm hmm 

mm hmm.

Yeah.

Mm hmm mm hmm mm hmm.

Yeah.

Okay.

Yeah.