Endocrine Abstracts

A 45-year-old HGV driver was referred with a five-year history of reduced libido and erectile dysfunction. He was found to have gonadotrophin deficiency with consistently low testosterone levels on multiple occasions. On clinical assessment, he exhibited classical features of acromegaly, including coarsening of facial features and acral enlargement, although he reported no symptoms suggestive of growth hormone (GH) excess. Laboratory investigations confirmed acromegaly with elevated insulin-like growth factor 1 (IGF-1) levels and a failure to suppress GH on an oral glucose tolerance test. Additionally, he was found to have TSH deficiency. Testosterone replacement and levothyroxine therapy were initiated. MRI demonstrated a pituitary macroadenoma measuring 11.5 × 8 × 18.5 mm, with suprasellar extension, contacting the right optic nerve and optic chiasm. The lesion exhibited an unusual morphology, extending beyond the pituitary stalk. Methionine PET imaging showed tracer by the entirety of the pituitary gland. The multidisciplinary team (MDT) concluded that surgical resection would carry a very high risk of cerebrospinal fluid (CSF) leak and permanent arginine vasopressin (AVP) deficiency. Given these risks, medical therapy with lanreotide was initiated. However, IGF-1 and GH levels remained persistently elevated despite treatment. This case raises a critical management dilemma: Should medical therapy with somatostatin receptor ligands be continued, or should alternative approaches such as pegvisomant, radiotherapy, or high-risk surgical intervention be considered for better disease control or potential cure?