AMPULLARY HYPERPLASIA IN A PATIENT WITH POORLY CONTROLLED ACROMEGALY

A CASE REPORT

Abstract

INTRODUCTION
The complexity of acromegaly management increases exponentially when a patient is still uncontrolled after undergoing primary pituitary surgery, pituitary radiotherapy and concomitant somatostatin analogue treatment. Poorly controlled disease has definite increased risk of malignancy.

CASE
A 60-year-old lady with acromegaly and concomitant diabetes and hypertension had undergone transsphenoidal pituitary surgery in 2011. Post-operatively, somatostatin analogue (octreotide) was started since she had residual tumour and elevated IGF-1 levels. Despite this her IGF1 levels remained elevated. Conventional pituitary radiotherapy was opted partly due to her fear of second surgery in 2016. Unfortunately, her disease remained active, evidenced with persistently elevated IGF-1 levels, poorly controlled diabetes and hypertension and frequent headaches. In December 2018, she developed symptoms of obstructive jaundice and subsequent ERCP revealed presence of ampullary tumour with choledocho-doudenal fistula and grossly dilated common bile duct with no filling defects. Tumour marker CA19-9 was markedly elevated. HPE of tumour biopsy revealed high-grade glandular dysplasia. Acromegaly patients have increased risk of developing colonic polyps and malignancy but association of acromegaly and biliary duct tumour has not been established and rarely reported. Though in uncontrolled disease, elevated levels of IGF-1 promotes angiogenesis and malignancy.

CONCLUSION
This case illustrates a rare finding of obstructive jaundice and ampullary tumour in poorly controlled acromegaly. This patient would require Whipple’s procedure for the tumour but optimisation for surgery would be extremely difficult. This include controlling her diabetes, hypertension and growth hormone excess. In this reassessment for pituitary surgery would be vital.