SAT-259 Acromegaly by Pituitary Adenoma Associated with ACTH-Independent Cushing Syndrome by Adrenal Carcinoma: Case Report

Introduction: The coexistence of acromegaly and Cushing’s syndrome is quite rare. Case reports with this association have been described in the literature, including both ACTH-dependent and ACTH-independent Cushing’s syndrome. In these cases, when considering ACTH-independent hypercortisolism, the main etiology reported is adrenal adenoma. We will describe the case of an acromegalic patient with ACTH-independent cushing syndrome due to adrenal cortical carcinoma. Clinical Case: A 62-year-old male patient with acromegaly diagnosed by headache investigation. He had a previous medical history of T2DM for 20 years, grade III obesity (BMI 40.3), hypertension, obstructive sleep apnea and depression. Initial investigation showed IGF-1 levels of 818 ng/mL (81–225), GH: 3.39 ng/mL (<0.97), prolactin diluted: 2.578 ng/mL (2.1–17, 7), LH: <0.07 mIU/mL (1.5–9.3), FSH: 0.6 mIU/mL (1.4–18.1), total Testosterone: 51 ng/dL (241- 827) Cortisol at 8 AM: 15 µg/dL, TSH: 1.54 µg/dL (0.55–4.78), free T4: 1.0 ng/dL (0.89–1.76) and brain MRI with a large expansive sella turcica process, invading the right cavernous sinus, with growth to the sphenoid sinus and suprasellar compressing the optic chiasm, suggestive of pituitary macroadenoma. He underwent transsphenoidal resection with histology confirming a prolactin and GH co-secretory pituitary adenoma with Ki-67: 5%. He started treatment with octreotide LAR (30 mg/month) and cabergoline (3.5 mg/week) and underwent 25 radiotherapy sessions. Three years after the diagnosis of acromegaly, the patient underwent CT scan of the abdomen, which identified a 3.8 cm left adrenal nodular lesion that evolved in the 12-month control exam to nodular image with lobulated contours (5.0 x 3.4 cm) and non-contrast phase density > 25 HU. At that time, he had two 24-hour cortisoluria samples: 640.9 and 637 µg/24hs (54–403) and ACTH <5.0 pg/mL (<46).The patient underwent videolaparoscopic adrenalectomy confirming the pathology of the lesion compatible with adrenal cortical carcinoma with invasion of the capsule and peri-adrenal adipose tissue and Ki-67: 20%. Even after primary resection of the adrenal lesion, the patient evolves with local and metastatic progression of the disease, dying a few months later, due to infectious complications of a new surgical approach. Conclusions: To the best of our knowledge, this is the first case of ACTH-independent Cushing’s syndrome caused by adrenocortical carcinoma in an acromegalic patient.

Gastric volvulus or just a large stomach? a case report with literature review of gastric volvulus and gastrointestinal pathology in acromegaly

Gastric volvulus is a surgical emergency that requires prompt recognition and management. The acromegalic patient has a number of pathophysiological factors that predispose to gastric volvulus and slow gastrointestinal (GI) transit. Authors aimed to present a case of hiatus hernia and gastric volvulus in a patient with acromegaly and review the current literature on GI anomalies in this population. A 70-year-old female presented to our institute with epigastric pain and coffee-ground vomiting on the background of acromegaly secondary to pituitary adenoma (resected in 1997). She was found to have a gastric volvulus and hiatus hernia which was repaired laparoscopically. She was discharged home but re-presented six days later with abdominal distension and vomiting. Computed tomography (CT) scan of abdomen showed recurrent gastric volvulus with involvement of the transverse colon. She underwent a laparotomy but no evidence of gastric or colonic volvulus was seen intra-operatively. The CT findings were attributed to a large stomach and coiled redundant transverse colon which could be misinterpreted as volvulus on imaging. Gastroparesis and slow bowel transit were the likely aetiology of this second presentation. This is consistent with literature reporting slow bowel transit and dolichocolon in acromegalic patients. Gastric volvulus is a rare finding associated with acromegaly. Structural anomalies in the anatomy of the acromegalic patient can make CT diagnosis challenging. This case demonstrates the need for caution when interpreting imaging in this cohort, as well as the need for further research on GI pathology associated with acromegaly.

Pseudoaneurysm of Internal Carotid Artery following Endoscopic Endonasal Pituitary Surgery requiring Endovascular Treatment in an Acromegalic Patient with a Difficult Airway

A pituitary tumor scheduled for surgical excision can eventuate with a myriad of challenges. A 49-year-old acromegalic patient was admitted to our hospital for trans-nasal trans-sphenoidal pituitary surgery. Magnetic resonance imaging (MRI) of his brain revealed a well-defined lesion involving right half of the anterior lobe of pituitary. In the operating room, we encountered difficulty in management of the airway. The trachea could be intubated using fiberoptic bronchoscope via a proseal laryngeal mask airway after five attempts of failed intubation. Intraoperatively, the right internal carotid artery (ICA) was injured during excision of lateral part of the tumor with a blood loss of 3.5 L. Adenosine use to aid hemostasis was unsuccessful. Endovascular coil embolization was done to treat the pseudoaneurysm developed in the right ICA, to restore the blood flow. During this process, the patient developed medial rectus palsy and ptosis in the right eye, which improved gradually. The above amalgamation of maladies commanded an integrated and well-coordinated team approach to manage the catastrophic complications.

Disease Activity May Not Affect the Prognosis of Coexisting Thyroid Cancer in Acromegalic Patients

Acromegaly is known to be associated with high incidence of malignancies probably due to the mitogenic effects of IGF-1. Differentiated thyroid cancer (DTC) is reported to be one of the most frequent malignancies associated with acromegaly. But there is no data about the clinical course of DTC in acromegalic patients. In this study, we evaluated the course of DTC in 14 acromegalic patients retrospectively. Fourteen papillary thyroid cancer patients without acromegaly, who were matched with the acromegalic patient group for age, gender and properties of thyroid cancer, were investigated as the control group. We identified no change in the course and treatment responses of DTC in association with the acromegaly activity, gender, age and disease duration, and all patients were found to be in remission for DTC at the time of investigation. Retrospective analysis of this cohort suggests that the activity of acromegaly may not affect the treatment responses and prognosis of coexisting DTC.