THU025 Acromegaly And Central Hyperthyroidism

Abstract

Abstract Disclosure: A. Akhtar: None. M.A. Mahmood: None. Introduction: Pituitary adenomas are usually benign neoplasms that are the third most common type of central nervous system tumors. Although TSH releasing tumor accounts for 1% of pituitary adenomas, about one-third of the time it co-secretes Growth Hormone. Co-secretion of TSH and GH can further promote the prognosis of the tumor, therefore, must be immediately treated medically or surgically. Case Report: The case is of a 42 years old male patient who presented to his orthodontist with the complaint of loosening teeth and was referred to a primary care physician. According to the patient, he has observed an increase in his ring size up to 3 times his usual size, one and a half increase in his shoe size, some degree of joint pain, occasional visual blurriness, no weight loss, and snoring. He has no history of headaches, breast tenderness, or discharge. He works at a farm and has no family history of pituitary tumors. His laboratory findings in May 2021 show IGF-1 1028 ng/mL (normal less than 278 ng/mL), ACTH 72.2 pg/mL (normal <60pg/mL), Prolactin, TSH, LH and FSH levels were normal. These findings suggested an IGF-producing pituitary adenoma. During further workup, he had high levels of free T4 and free T3, 2.7 ng/dL and 8.2pg/mL (Normal 2.3 - 4.2pg/mL), respectively, along with elevated TSH levels, which were 8.1mIU/L (normal 0.27-4.2mIU/L). Magnetic resonance imaging showed a pituitary mass of 1.8cm x 2.0cm x 1.6cm in the suprasellar region, abutting the optic chiasm, and showed heterogeneous enhancement. There were no signs of hemorrhage. His visual field examinations were normal. He was prescribed to take 50mg of octreotide every 8 hours. In six weeks, the patient had improved levels of serum TSH which was lowered to 0.785mIU/L, and free T4 and free T3, which were 1.62pmol/L and 3.45pmol/L, respectively. He had transsphenoidal pituitary surgery. Pathology showed a 2.6 x 2.0 x 0.3 cm tumor of somatotropic type. Post-surgery MRI showed no tumor residues. Discussion: We report a middle-aged man with a rare case of the pituitary tumor with acromegaly and central hyperthyroidism. Thyrotropinomas, also known as TSHomas, are benign pituitary adenoma that produces thyroid stimulating hormones. Although rare, they are macroadenomas 80% of the times and 20-25% of the time co-secrete other pituitary hormones. These tumors may show elevated fT3, fT4, and TSH, and increased alpha-subunit. There is not enough evidence to proof the exact origin of the pathology, however, immunohistologically, the tumor cells arise from PIT1-lineage adenohypophyseal cells and could be associated with MEN 1 mutation on chromosome 11q13. Surgical removal of the tumor is a preferred approach to TSHomas, but recent studies have shown a significant improvement with medial therapy of somatostatin analogs by interacting with somatostatin receptors. Octreotide, a somatostatin analog has been clinically shown to bring the thyroid hormones to a normal level in 80% if cases and shrinkage of tumor size in pituitary adenoma in 60% of cases. It can be used as a pre-operative therapy to reduce the levels of free thyrotropin. It also reduces GH and serum IGF-1 levels. Co-secretion of TSH and GH promotes the prognosis of tumors which may be prevented with early diagnosis and treatment. Presentation: Thursday, June 15, 2023