Endocrine Abstracts

A male patient was diagnosed with acromegaly in July 2007 (at the age of 38). His biochemistry showed IGF-1 123 (14.6-39.9) nmol/l; paradoxical rise in GH during OGTT; and evidence of hypopituitarism (Testosterone 5.2 nmol/l, LH 4.0 iu/l FSH 3.7 iu/l, SHBG 8 nmol/l and prolactin 112 mu/l) HBa1c 6.5%. MRI Pituitary revealed a poorly enhancing mass within the right side of the pituitary gland within a slightly expanded pituitary fossa. There was no parasellar extension, no compression of the optic apparatus. He remains normotensive throughout. He underwent two trans-sphenoidal surgeries in 2007; both resulted in significant intra-operative bleeding due to anomalous blood vessels. No pituitary tissue was identified histologically. He went on to receive external beam radiotherapy in 2008. A third trans-sphenoidal surgery was attempted in 2009, but again resulted in profuse venous bleeding. In 2010 he went on to receive stereotactic radiotherapy to accelerate achievement of biochemical control. Over this time medical therapy was introduced to aid biochemical control whilst awaiting the effects of the radiotherapy. Unfortunately, he was intolerant of somatostatin analogues, commencing Pegvisomant after a positive outcome from an IFR submitted to NHS England. The patient discontinued pegvisomant in 2022, as he no longer wished to self-inject. Off of GH lowering medications he now has good biochemical control of his disease (GH <0.1 mg/l, IGF-3.8 nmol/l, HbA1c 41 mmol/mol). MRI Pituitary in 2023 showed a slight reduction in the overall adenoma size. Unfortunately, his disease was complicated by severe degenerative arthropathy affecting mainly the wrists and knees which has required multiple intraarticular steroid injections and regular analgesics. He remains under regular review with the rheumatology and orthopaedic teams. The severity of the arthropathy has impacted negatively on his mood, quality of life and led to significant functional limitation. Additionally, he suffers from chronic sinus disease with purulent discharge from the nose, under review by the ENT team. Surveillance colonoscopy, Bone Densitometry and echocardiography have shown normal studies.

Learning points: This case demonstrates how Acromegaly frequently require multiple therapeutic modalities introduced both in parallel and concurrently to achieve long-term biochemical control. Additionally, the case demonstrates how associated complications can significantly affect the quality of life and daily functioning. It is therefore important to adopt a holistic approach in managing patients with acromegaly aimed at both biochemical remission and management of comorbidities with timely multidisciplinary team involvement.