Endocrine Abstracts

An 82 year old gentleman was admitted with lethargy, shortness of breath and weight loss of 26% total body weight over a two-year period. His past medical history included hypertension, pulmonary fibrosis, thalassaemia trait and unexplained thrombocytopenia.

He had previously been investigated for weight loss with a CT thorax/abdomen/pelvis in 2014 which demonstrated no evidence of malignancy and FDG PET had shown no disease.

On admission he was cachectic. He was anaemic - haemoglobin 69 g/L and thrombocytopenic - platelets 115. His thyroid function tests demonstrated a TSH of 0.86 mU/L and free T4 of 7.6 pmol/L; cortisol was 276 nmol/L. CT thorax/abdomen/pelvis showed appearances consistent with portal vein thrombosis and an ill-defined 25 mm high density area in the right lobe of the liver suspicious of hepatocellular carcinoma (HCC). Alpha-fetoprotein was significantly elevated at >30,000 KU/L. Ferritin was mildly raised at 673 ng/ml. Therapeutic dose low molecular weight heparin was commenced as well as hydrocortisone and levothyroxine replacement. MRI liver with contrast demonstrated liver cirrhosis with splenomegaly, ascites with extensive portal vein thrombosis. The adrenal glands appeared normal.

In view of discordant thyroid function, a detailed anterior pituitary profile was requested, which revealed - prolactin 8127 mU/L, ACTH 25 ng/L, LH 0.2 U/L, FSH 1.5 U/L, testosterone less than 0.3 nmol/L, IGF-1 2.7 nmol/L (NR 6–36). MRI pituitary scan demonstrated a 26×29 mm partially thrombosed aneurysm of the right internal carotid artery. CT angiography confirmed a partially thrombosed giant aneurysm from the cavernous segment of the right internal carotid artery extending into and expanding the pituitary fossa with no evidence of pituitary apoplexy. His case was discussed at the Neurovascular MDT and the decision was for conservative management with anticoagulation in view of the expected poor prognosis from HCC.

This is an interesting case of hypopituitarism secondary to carotid artery aneurysm complicating a new presentation of HCC.