through the nostrils with microsurgical instruments. the second method is transsphenoidal surgery during which an incision is made into the gum beneath the upper lip. further incisions are made to cut through the septum to reach the nasal cavity, where the pituitary is located. endonasal transsphenoidal surgery is a less invasive procedure with a shorter recovery time than the older method of transsphenoidal surgery, and the likelihood of removing the entire tumor is greater with reduced side effects. consequently, endonasal transsphenoidal surgery is the more common surgical choice. these procedures normally relieve the pressure on the surrounding brain regions and lead to a lowering of gh levels. surgery is most successful in people with blood gh levels below 40 ng/ml before the operation and with pituitary tumors no larger than 10 mm in diameter. success depends on the skill and experience of the surgeon. the success rate also depends on what level of gh is defined as a cure. the best measure of surgical success is the normalization of gh and igf-1 levels. ideally, gh should be less than 2 ng/ml after an oral glucose load. a review of gh levels in 1,360 people worldwide immediately after surgery revealed that 60% had random gh levels below 5 ng/ml. complications of surgery may include cerebrospinal fluid leaks, meningitis, or damage to the surrounding normal pituitary tissue, requiring lifelong pituitary hormone replacement. even when surgery is successful and hormone levels return to normal, people must be carefully monitored for years for possible recurrence. more commonly, hormone levels may improve, but not return completely to normal. these people may then require additional treatment, usually with medications. radiation therapy radiation therapy has been used both as a primary treatment and combined with surgery or drugs. it is usually reserved for people who have tumor remaining after surgery. these people often also receive medication to lower gh levels. radiation therapy is given in divided doses over four to six weeks. this treatment lowers gh levels by about 50 percent over 2 to 5 years. people monitored for more than 5 years show significant further improvement. radiation therapy causes a gradual loss of production of other pituitary hormones with time. loss of vision and brain injury, which have been reported, are very rare complications of radiation treatments. selection of treatment the initial treatment chosen should be individualized depending on the person's characteristics, such as age and tumor size. if the tumor has not yet invaded surrounding brain tissues, removal of the pituitary adenoma by an experienced neurosurgeon is usually the first choice. after surgery, a person must be monitored long-term for increasing gh levels. if surgery does not normalize hormone levels or a relapse occurs, a doctor will usually begin additional drug therapy. the current first choice is generally octreotide or lanreotide; however, bromocriptine and cabergoline are both cheaper and easier to administer. with all of these medications, long-term therapy is necessary, because their withdrawal can lead to rising gh levels and tumor re-expansion. radiation therapy is generally used for people whose tumors are not completely removed by surgery, for people who are not good candidates for surgery because of other health problems, and for people who do not respond adequately to surgery and medication. prognosis life expectancy of people with acromegaly is dependent on how early the disease is detected. life expectancy after the successful treatment of early disease is equal to that of the general population. acromegaly can often go on for years before diagnosis, resulting in poorer outcome, and it is suggested that the better the growth hormone is controlled, the better the outcome. upon successful surgical treatment, headaches and visual symptoms tend to resolve. one exception is sleep apnea, which is present in around 70% of cases but does not tend to resolve with successful treatment of growth hormone level. while hypertension is a complication of 40% of cases, it typically responds well to regular regimens of blood pressure medication. diabetes that occurs with acromegaly is treated with the typical medications, but successful lowering of growth hormone levels often alleviates symptoms of diabetes. hypogonadism without gonad destruction is reversible with treatment. acromegaly is associated with a slightly elevated risk of cancer. notable people mary ann bevan (1874–1933), an english woman, who after developing acromegaly, toured the sideshow circuit as "the ugliest woman in the world". salvatore baccaro (1932–1984), italian character actor. active in b-movies, comedies, and horrors because of his peculiar features and spontaneous sympathy. paul benedict (1938–2008), american actor. best known for portraying harry bentley, the jeffersons' english next door neighbour eddie carmel, born oded ha-carmeili (1936–1972), israeli-born entertainer with gigantism and acromegaly, popularly known as "the jewish giant". ted cassidy (1932–1979), american actor. best known for portraying lurch in the tv sitcom the addams family rondo hatton (1894–1946), american journalist and actor. a hollywood favorite in b-movie horror films of the 1930s and 1940s. hatton's disfigurement, due to acromegaly, developed over time, beginning during his service in world war i. sultan kösen, the world's tallest man. maximinus thrax, roman emperor (c. 173, reigned 235–238). descriptions, as well as depictions, indicate acromegaly, though remains of his body are yet to be found. the great khali (born dalip singh rana), indian professional wrestler, is best known for his tenure with wwe. he had his pituitary tumor removed in 2012 at age 39. maurice tillet (1903–1954), russian-born french professional wrestler, is better known by his ring name, the french angel. richard kiel (1939–2014), actor, "jaws" from two james bond movies and mr. larson in happy gilmore pío pico, the last mexican governor of california (1801–1894), manifested acromegaly without gigantism between at least 1847 and 1858. some time after 1858, signs of the growth hormone-producing tumor disappeared along with all the secondary effects the tumor had caused in him. he looked normal in his 90s. his remarkable recovery is likely an example of spontaneous selective pituitary tumor apoplexy. tony robbins, motivational speaker carel struycken, dutch actor, 2.13 m (7.0 ft), is best known for playing lurch in the addams family film trilogy, the giant in twin peaks, lwaxana troi's silent servant mr. homn in star trek: the next generation, and the moonlight man in gerald's game, based on the stephen king book. irwin keyes, american actor. best known for portraying hugo mojoloweski, george's occasional bodyguard on the jeffersons neil mccarthy (1932-85), british actor. known for roles in zulu, time bandits, and many british television series nikolai valuev, russian politician and former professional boxer antônio "bigfoot" silva, brazilian kickboxer and mixed martial artist. (leonel) edmundo rivero, argentine tango singer, composer and impresario. it has been argued that lorenzo de' medici (1449–92) may have had acromegaly. historical documents and portraits, as well as a later analysis of his skeleton, support the speculation. pianist and composer sergei rachmaninoff, noted for his hands that could comfortably stretch a 13th on the piano, was never diagnosed with acromegaly in his lifetime, but a medical article from 2006 suggests that he might have had it.