Endocrine Abstracts

Case history: This 32 year old lady developed anterior and posterior pituitary failure following chemotherapy, radiotherapy and bone marrow transplant for acute lymphoblastic leukaeamia in childhood and subsequent CNS recurrence. During her teens, she required GH replacement with which she was poorly compliant. She had a mastectomy and currently takes hormonal treatment for oestrogen receptor positive T2N1M1 breast cancer, which is possibly a consequence of her total body irradiation. Complications of her pituitary dysfunction have been adrenal insufficiency during acute illness and fluid balance problems during a trip to the tropics. Additionally, she has developed bilateral posterior subcapsular ocular lens opacities, mixed dyslipidaemia and classical migraines.

Investigations: Latest blood tests; TSH <0.01 munit/l, FT₄ 20.00 pmol/l, 25-hydroxyvitamin D 35 nmol/l, cortisol day curve confirmed adequate replacement, ACTH <5 ng/l, FSH 1.3 unit/l, LH 0.7 unit/l, oestradiol <19 pmol/l, prolactin 249 munit/l, SHBG 134 nmol/l. A brain MRI scan in 2005 was unremarkable. DEXA scan showed a T score of −2.2.

Current management: Pituitary replacement: hydrocortisone 10/5/2.5 mg, L-T₄ 75 μg OD, desmopressin 10 μg BD intranasal. Bone health: Calcium supplementation and alendronic acid 70 mg once per week. Breast cancer management: Letrozole OD and the patient is considering prophylactic bilateral mastectomy and breast reconstruction. She was also previously also taking GH 0.9 mg/1.0 mg on alternate days, ethinlyoestradiol 2 μg OD and norethieterone 5 mg OD on days 1–14 of menstrual cycle; stopped on account of the breast cancer.

Conclusion and points for discussion: This is a case of an adult with anterior and posterior hypopituitarism because of childhood lymphoblastic leukaemia and its treatment. It illustrates the complexity of late effects of cancer treatments and important interactions of disease management. Points for discussion include the peri-operative management of patients with pituitary failure, management of symptoms of ovarian failure in the presence of a co-existing oestrogen-receptor positive tumours and the use of exogenous GH in patients with pituitary failure and concomitant malignancy.