Category: Pituitary Disorders/Neuroendocrinology

Monitor: 29

29 - SUSTAINED REMISSION OF ACROMEGALY AFTER MEDICAL THERAPY

Thursday, Apr 25
12:30 PM – 1:00 PM

Objective :

We present an unusual case of complete resolution of acromegaly in a patient treated with somatostatin receptor analogue and dopamine agonists.


Methods : N/A


Results : The patient who is now a 73 year old man was initially diagnosed with acromegaly and hypogonadism in Russia in 1987. He had coarse facial features and prognathism. At the time of diagnosis his pituitary adenoma was considered too large to be operable and he was started on bromocriptine in response to which he had only partial improvement in IGF-1 levels. The patient was started in 2002 on octreotide LAR 20 mg monthly injections in addition to cabergoline. His GH and IGF-1 levels started to trend down and, by July 2005 his GH level was undetectable (from 30ng/ml in 1992) and IGF-1 was 319 ng/ml (from 585ng/ml in 1999, normal range:71-290). His IGF-1 level has been in the normal range with GH level of <1ng/ml since May 2006. MRI brain done in January 2009 did not show any pituitary lesion. Cabergoline was tapered and stopped in Feb 2014 and octreotide LAR was also titrated down and stopped in April 2017. The patient remains clinically asymptomatic and in good health. His last IGF-1 from November 2018 remains normal and his last MRI from 2016 was still negative for pituitary adenoma.


Discussion :

The treatment of choice of acromegaly is surgical resection. Medical management is reserved for patients who have remnant disease after surgery or for those who are unable to undergo surgery. Somatostatin receptor analogues (octreotide/sandostatin and lanreotide), are currently the first line medical therapy and they are generally well tolerated. It is well known that octreotide use in acromegaly reduces headaches, arthralgias, acral growth, and also reduces GH levels, with possible minor tumor shrinkage. Biochemical remission of acromegaly after somatostatin analogs withdrawal has been described in a small number of patients, mostly when used in postoperative recurrences. It is considered an uncommon and frequently unsustainable event. The mechanisms involved are thought to be related to the antiproliferative, antiangiogenic and antisecretory properties of somatostatin analogs and in certain cases to apoplexy of the tumor. Our case is remarkable because the patient did not have any surgical or radiation therapy, and no symptoms suggestive of apoplexy. The remission was achieved both biochemically and radiologically with complete resolution of the pituitary adenoma on MRI.


Conclusion :

Although minor tumor shrinkage is known to occur with sandostatin, we present a rare case of complete biochemical and radiologic sustained remission of acromegaly following 15 years therapy with sandostatin and cabergoline.

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Sujata Shrestha

Fellow
Endocrinology Department, SUNY Downstate Medical Center
Brooklyn, New York

Current endocrinology fellow at SUNY Downstate

Vladimir Lokshin

Fellow
Endocrinology Department, SUNY Downstate Medical Center

A current fellow of Endocrinology Department in SUNY Downstate Medical Center

Jean Pujals-Kury

Fellow
Endocrinology Department, SUNY Downstate Medical Center

Currently a Fellow of Endocrinology Department, State University of New York, Downstate Medical Center

Alan Sacerdote

Chief of Endocrinology
Woodhull Medical Center

Chief of Endocrine division at Woodhull Medical Center

Jocelyne Karam

Chief of Endocrinology
Maimonides Medical center

Chief of Endocrinology division at Maimonides Medical Center