Abstract #1407996: Co-secreting Pituitary Tumors: A Clinical Challenge

Abstract

Co-secreting pituitary adenomas are rare, with complex clinical presentation and challenging long-term management. We present a small case series of co-secreting pituitary tumors, highlighting the importance of evaluating all pituitary hormones in the setting of a pituitary adenoma. Case 1: Active acromegaly with a functioning pituitary FSHoma A 46-year-old married male, presented with bilateral vision loss, headache, and weight gain for the last 18 months. He had also noticed enlarging hands and decreased libido. He was obese (BMI of 32.2 Kg/m2). Red reflex was present in the right eye, while temporal hemianopia was noted in the left eye. He had phenotypic features of acromegaly, had enlarged testicles measuring more than 25mls bilaterally. Acromegaly and FSHoma were confirmed with raised IGF-1 levels (733.70 ng/ml) and FSH levels, checked twice (108.9 & 107 mIU/ml respectively) with low LH (2.40 mIU/ml) and T (1.27 pg/ml); PRL, ACTH, and TSH were normal. MRI pituitary revealed a large mass measuring ∼ 2.9 x 3.6 x 4.7 cm. He was referred for pituitary surgery but was lost to follow-up thereafter. Case 2, 3, 4, 5: Acromegaly with co-secretion of prolactin Two single females, aged 18, and 33; one married, aged 33, and a 23-year-old single male presented with enlarging hands and feet and weight gain. All females had secondary amenorrhoea and galactorrhoea. A male patient and two of the females also had headaches and visual disturbances. The youngest of them did not have any classical signs of acromegaly but had bitemporal hemianopia. The male patient had right-sided temporal hemianopia. They all had raised IGF-1 levels (1195.0, 701.0, 1136.0, & 516.7ng/mL). PRL levels were 458.1, 303.0, 53.0, and 1825 ng/ml. Their LH, FSH, and FT4 levels were low. All had normal ACTH and Cortisol levels. MRI pituitary revealed pituitary macroadenomas. All were started with cabergoline and referred for surgery. Only the youngest patient underwent surgery. The other three declined surgery for the time being and were started on monthly long-acting Octreotide. Case 6: Prolactinoma with late co-secretion of growth hormone A 40-year-old female, with a history of micro prolactinoma diagnosed in 2004, recently presented in 2021 with complaints of enlarging hands and feet. There was no history of headache or visual symptoms. She presented, 16 years ago with secondary amenorrhoea with isolated hyperprolactinemia. Her MRI showed a pituitary mass measuring 1.2 x1.6 cm. Since that time, she was on cabergoline. She also had subtle signs of acromegaly. Showed raised IGF-1 (410.0) and GH nadir of 3.12mcg/L after a 75 g oral glucose challenge. Her FSH, LH, Estradiol, FT4, and cortisol were normal, while PRL was raised (49.6 ng/ml). Her cabergoline dose was increased and was referred for Trans-sphenoidal surgery. The literature review revealed a very rare synchronous presentation of acromegaly and FSH-secreting pituitary adenoma. FSH and FSHoma is specified in the etiology of macroorchidism, as present in our case. Up to 25% of GH adenomas co-secrete prolactin. The Third Type occurs due to Primitive acidophilic stem cell adenomas with dual hormone secretion from a single cell.