THE SLEEPING GIANT

AN ATYPICAL CASE OF A GIANT PITUITARY ADENOMA PRESENTING AS ACROMEGALY WITH MINIMAL SYMPTOMS OF MASS EFFECT

Abstract

INTRODUCTION
This is a case of patient with giant pituitary adenoma (GPA) presenting with acromegalic features, minimal symptoms of mass effect who underwent surgical resection via transcranial approach with minimal surgical morbidity.

CASE
A 40-year-old female presented with typical acromegalic features over 14 years, occasional mild frontal headaches and blurred vision. She had elevated growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Cranial MRI revealed a 6.4x7x5.5 cm lobulated pituitary mass with cystic degeneration, areas of necrosis with mass effect on several intracranial structures. Excision via craniotomy reduced mass size to 5.9x5.8x4.7 cm. Histopathology revealed a mixed GH- and prolactin-secreting pituitary adenoma. She was maintained on bromocriptine and underwent radiotherapy. Repeat IGF-1 levels remained elevated but symptoms did not progress.

CONCLUSION
This is a case of a patient with GPA with minimal symptom of mass effect, with no hormonal improvement postsurgery and radiotherapy. Ideally, a multi-staged surgery can be done with optimization of medical management. In the absence of these medications locally and reluctance of patient for re-surgery, the team opted to monitor tumor size, hormone levels and maximize management of co-morbidities.