How do you decide between repeat resection and radiosurgery when MRI imaging suggests limited residual tumor in the cavernous sinus in patients treated for acromegaly?

If residual tumor is not surgically curable, another surgery is not advisable. Given available pharmacological treatments, I do not consider XRT until I run out of medical options, particularly in young patients with intact pituitary function. Even if a patient does not respond to SRL, including pasireotide, pegvisomant is an option as long as the residual adenoma is not large and close to the optic chiasm.

Resection of residual tumor in the cavernous sinus is difficult, and most neurosurgeons will not do it. If acromegaly is controlled on medical treatment with octreotide, which can also help reduce tumor size, repeat surgery or radiation may not be needed.