Poster Presentation ESA-SRB-ANZBMS 2024 in conjunction with ENSA

Delayed return of pituitary hormone function after apoplexy and trans-sphenoidal surgery (#629)

Felicity Stringer 1 , Mark Kotowicz 1 2
  1. Barwon Health, Geelong, VICTORIA, Australia
  2. Barwon Endocrinology, Geelong, Victoria, Australia

Case

A 27-year-old male presented with vomiting and severe hyponatraemia (112mmol/L). Investigations revealed pan-hypopituitarism and hyperprolactinaemia(table 1).

MRI Brain revealed a 38mm sellar mass with supra-sellar extension and optic chiasm compression(image 1). He commenced hydrocortisone, thyroxine, and cabergoline 0.25mg twice-weekly. Serum prolactin levels normalised after 3-months, with reduced tumour volume and recovery of visual fields, but he required testosterone replacement after 12-months due to persistent hypogonadism.

He presented with pituitary apoplexy 2-years later, and underwent transphenoidal hypophysectomy. Post-operatively, there was no change to hormonal requirements.

The patient wished to conceive 2-years after surgery, and after ceasing testosterone and commencing human chorionic gonadotropin stimulation his partner fell pregnant. Interestingly, spontaneous recovery of the pituitary-gonadal axis was noted, with normalisation of LH, FSH and testosterone without treatment. Thyroxine was successfully weaned, remaining euthyroid off treatment, and cortisol and ACTH levels suggested some recovery of the pituitary-adrenal axis. He is planned for repeat morning cortisol, with potential wean of hydrocortisone.

Discussion

This case demonstrates recovery of pituitary function several years after apoplexy and hypophysectomy. 

Post transsphenoidal surgery, pituitary dysfunction can resolve [1,2]. Therefore, it is routine to repeat investigations immediately post-surgery and 2-3 months post-operatively to allow for potential recovery from expansion of the previously compressed normal pituitary gland [3]. Patients may not have repeat stimulation testing after this point, and remain on long-term hormonal replacement.

However, studies suggest delayed recovery of pituitary function can occur. A small retrospective analysis showed an 11% increase in recovery from ACTH and GH insufficiency from an insulin tolerance test performed 12-months post-operatively compared to 3-months [4].

This case therefore supports ongoing clinical evaluation for potential recovery of pituitary function even several years post-surgery. This is important to detect, as it may alleviate significant health burden for patients, and limit potential side effects from unnecessary medications.

 

 

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  1. Roelfsema F, Biermasz NR, Pereira AM. Clinical factors involved in the recurrence of pituitary adenomas after surgical remission: a structured review and meta-analysis. Pituitary 2012; 15: 71–83
  2. Lo AC, Howard AF, Nichol A, et al. Long-term outcomes and complications in patients with craniopharyngioma: the British Columbia Cancer Agency experience. Int J Radiat Oncol Biol Phys 2014; 88: 1011–1018.
  3. Prete A, Corsello SM, Salvatori R. Current best practice in the management of patients after pituitary surgery. Ther Adv Endocrinol Metab. 2017 Mar;8(3):33-48. doi: 10.1177/2042018816687240.
  4. Berg C, Meinel T, Lahner H, Mann K, Petersenn S. Recovery of pituitary function in the late-postoperative phase after pituitary surgery: results of dynamic testing in patients with pituitary disease by insulin tolerance test 3 and 12 months after surgery. Eur J Endocrinol. 2010 May;162(5):853-9. doi: 10.1530/EJE-09-0997.