Introduction: Pituitary adenomas are benign intracranial tumors. However, some of them are resistant to multiple medical treatments and are clinically considered to be aggressive.
Case report: Twenty years old male patient presented with symptomatic hyperglycemia and general weakness. With suspected diagnosis of type 1 diabetes patient was hospitalized in Kauno Klinikos, Endocrinology Department. In further clinical observation acromegalic appearance noticed. After additional investigation elevated STH 126.05 ng/l (ULN<10) determined, pituitary MRI revealed 2.0×3.0 mm microadenoma. Patient was diagnosed with acromegaly and transsphenodal pituitary adenoma surgery was performed in 2000. However, 4 months after surgery STH 34 ng/ml (ULN<10) and IGF-1 951 nmol/l (ULN ×2) remained elevated. Pituitary MRI revealed 0.9×0.9 cm adenomas regrowth and invasion into cavernous sinus. Despite of initiated treatment with dopamine agonist -Bromocriptine and dose escalation up to 35 mg/per day, no positive clinical effects were observed. One year after surgery hormones markedly increased STH 268 ng/ml (ULN×26), IGF 1613 nmol/l (ULN×3). Pituitary MRI revealed tumor extension 1.0×0.9×1.3 cm - second transsphenoidal pituitary adenoma surgery was performed, continuing treatment with Bromocriptine as well. 3 years after diagnosis of acromegaly, patient visited endocrinologist complaining of low libido, erectile dysfunction, headache and sweating. STH persisted elevated STH 30 ng/ml (ULN<20), MRI disclosed recurrence of pituitary adenoma, PRL (<10 mLU/l (LLN 50<) was suppressed due to continuation of treatment with dopamine agonists. As initial treatment with surgerys and dopamine agonist was insufficient radiotherapy was started. One year after RT MRI disclosed empty sella syndrome. Since modern medical treatment for acromegaly became available in 2007, treatment with subcutaneous injections of somatostatin receptor ligands was started. 3 years later patient developed hypopituitarism (1.97 mU/l (LLN 10<), 3.56 nnmol/l (LLN 20<), TTH 2.75 mU/l (ULN 3.6), FT4 8.5 pmol/l (LLN 10<), Cortisol 43.2 nmol/l (LLN 61), Testosterone <0.17 nmol/l (LLN 9.26), LH 1U/l (LLN 1), FSH <0.17 U/l (LLN 1.3), HbA1c 6% - with no diabetes treatment. Hormone replacement therapies with L-Thyroxine, Testosterone and Hydrocortisone were started.
Conclusions: This is a challenging patients clinical case which illustrates the acromegaly treatment evolution during 18 years period and difficulties to achieve stable remission.
18 - 21 May 2019
European Society of Endocrinology