Endocrine Abstracts

45 years old male of Romanian origin presented with shortness of breath and reduced exercise tolerance over 3 months with increased sweating and weight gain from 90 kgs to 118 kgs over 2 years. Also reported hands/fingers/feet size increase. He also complained that his breathlessness worse by as tongue and lips were ‘large’. Denied any visual disturbance, especially peripheral vision. On examination, coarse features, prognathism and possible macroglossia noted. Photographs from 3 years ago revealed changes in facial features. No obvious visual field abnormalities on confrontation. 9AM cortisol was 158 nmol/l, TSH1.73 mIU/l (normal 0.27-4.20 mIU/l) with T4 9 pmo/l (normal 12-20 pmo/l), prolactin was 24041mIU/l (normal 86-324 mIU/l) with a raised IGF-1 111 nmol/l (normal 8.5-31 nmol/l). Macroprolactin levels were 21425 mIU/l (normal 63-245 mIU/l) MRI Pituitary revealed pituitary fossa grossly enlarged with an abnormal mass lesion arising from left side of the anterior pituitary measuring 34*26*27 mm demonstrating mild enhancement. Lesion surrounded the cavernous portion of the left internal carotid artery, involving the left cavernous sinus, extending superiorly to the left of the midline posterior to the terminal left ICA and proximal portion of the left MCA. Pituitary stalk was displaced to the right and didn’t impact undersurface of the right optic chiasm. Formal perimetry - incongruous, homonymous, left upper quadrantanopia. Regional pituitary MDT opined co-secretory Prolactin/IGF-1 secreting tumour. Started on lanreotide 120 mg a month, cabergoline 500 mg thrice a day along with physiological dose hydrocort (10 mg, 5 mg, 5 mg) and levothyroxine. He is for medical management and will be followed up with serial MRI in 3 months for further surgical consideration. Co-secretion of prolactin in pituitary adenomas may buy time for medical management and conservative management may be appropriate at the outset