Endocrine Abstracts

We present the case of a 65 year old woman with history of difficult to control essential hypertension for many years, and subarachnoid haemmorhage in 1992 requiring insertion of surgical clips for aneurysms at both internal carotid arteries and right middle cerebral arteries.

She presented in 2004 with a 3 week history of headaches and a history over one year of increasing size of her hands, feet and nose, goiter and hoarse voice. Serum IGF-1 was 84 nmol/l with normal IGFBP3 levels. She failed to suppress growth hormone on glucose tolerance testing (8.9 u/l baseline, 22.7u/l at 60 minutes, 20.5 u/l at 120 minutes) providing a biochemical diagnosis of acromegaly. Her pituitary hormone profile was otherwise within normal limits.

On further investigation from her neurosurgical notes, it became apparent that her intracranial clips are not compatible with MRI scanning. A CT scan with contrast was performed as an alternative, which did not reveal any significant abnormality at the pituitary. She was started on long acting somatostatin receptor ligand therapy - Somatuline Autogel 60mg monthly to control her growth hormone levels and her symptoms. Her management dilemma persists with the lack of clear pathology at the pituitary on CT scanning and the inability to perform an MRI, making planning surgical intervention difficult. The general recommendation in the literature advocates surgery as the first line therapy followed by medical therapy should surgery not be curative. With an aim to achieve appropriate biochemical control a balance must be drawn between risk and benefit, treatment side effects and contraindications for each patient. Hence in the absence of an identifiable tumour on the available imaging, we would argue to commit the patient to long term somatostatin receptor ligand treatment. If there is inadequate control on maximal doses , treatment with growth hormone receptor antagonists, or further exploring surgical options would be considered.