Case Study: Management of Residual Disease After Surgery for Acromegaly

A 37-year-old woman presented to her family physician with complaints of acne, hirsutism, and excessive sweating, along with irregular menstrual periods and enlargement of her hands and feet, requiring her to resize her wedding ring and change her shoe size. The patient denied any visual changes, but reported frequent morning headache. Family history was negative for endocrine tumors or pituitary disease.

On physical examination, the patient had some acromegaloid facial features, with coarsening of her face, prognathism, mild facial hirsutism, and frontal bossing. Blood pressure was normal. Visual fields were intact to confrontation. Investigation revealed a significantly elevated insulinlike growth factor-1 (IGF-1) level of 1123 ng/mL (normal range, 93-285 ng/mL) and a random growth hormone level of 28.1 ng/mL. Growth hormone suppression testing with oral glucose load confirmed the diagnosis, as nadir growth hormone was 6.9 ng/mL (normal, <0.4 ng/mL). Pituitary magnetic resonance imaging revealed an 18-mm macroadenoma invading the right cavernous sinus, with no evidence of optic chiasm compression.

The patient was referred for transsphenoidal resection of the pituitary tumor after a thorough conversation with her endocrinologist and neurosurgeon, who explained that it would not possible to remove the entire tumor surgically, and that the goal of the debulking procedure was to improve her chances to respond to medical treatment. The procedure was completed with no complications; pathology examination confirmed this was a densely granulated somatotroph tumor. At follow-up 3 months after the surgery, IGF-1 levels were still elevated at 762 ng/mL, and pituitary magnetic resonance imaging revealed a residual 6-mm mass within the right cavernous sinus.

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