After presurgical assessment and before surgery, the surgical objective and its role in the overall management plan should always be considered. This is usually simple. For example, in the otherwise healthy patient in whom a clinically nonfunctioning macroadenoma is compromising vision, the surgical objectives would be decompression of the optic apparatus and an attempt at gross total tumor resection. The management plan would include long-term postoperative surveillance for and treatment of hypopituitarism and possible tumor recurrence. However, treatment decisions can be more complicated. For example, in the patient with acromegaly with a macroadenoma whose size and invasiveness are too great for a surgical cure, the aim would be decompression of neural structures and maximal reduction of tumor burden. The management plan would include normalization of growth hormone (GH)/insulin-like growth hormone factor (IGF)-1 levels with various forms of pharmacotherapy, consideration of radiation therapy (radiosurgery or conventional irradiation), and long-term surveillance/treatment of acromegaly-related complications (secondary neoplasms, cardiovascular disease, and so forth). The surgical objectives, the surgical management alternatives, and the potential need of additional therapy should be understood by both surgeon and patient at the outset.
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