A case of acromegaly and disseminated follicular thyroid carcinoma

INTRODUCTION

A particularly challenging case of concurrent acromegaly and follicular thyroid carcinoma in a patient of the Clinic of Endocrinology, UJCM in Krakow is discussed.

CASE DESCRIPTION

A 59-year-old male with post total thyroidectomy performed in 2005 and histopathologically confirmed metastases of the follicular thyroid carcinoma to the lungs was admitted to the Clinic in April 2006 for complementary ¹³¹I treatment. Acromegaly was treated in 1996 by trans-sphenoidal surgery. In December 2005 a relapse of pituitary adenoma was shown by MRI, which correlated with increased levels of hGH and IGF-1. Biochemical control of acromegaly was achieved with Sandostatin LAR. Pre-therapeutic whole-body scintigraphy (WBS) revealed numerous conjoined hot spots of ¹³¹I accumulation in both lungs and in thyroid remnants. In May and November 2006 the patient received ¹³¹I treatment. Post-therapeutic WBS in November 2006 revealed complete ablation of the thyroid remnants. Laboratory tests confirmed lowering of thyroglobulin concentration. In the years 2007, 2008, and 2009 the patient was qualified for therapy with ¹³¹I aided by rhTSH, achieving further reduction of Tg levels. Post-therapeutic WBS performed in 2009 revealed weak bilateral tracer uptake in the lung parenchyma. In 2010, chest CT revealed fibrosis in left lung segments, no infiltrative changes, and no lymph node enlargement. Patient follow-up continues at our Department.

CONCLUSIONS

Disseminated thyroid cancer in a patient with pituitary insufficiency may be successfully treated by rhTSH-supported ¹³¹I treatment.

[Gastrointestinal tract polyps in acromegaly patients]

Acromegaly is a rare, chronic disease due to hypersecretion of growth hormone (GH) by pituitary adenoma arising from somatotrophs. The course of the disease is related to long-term organ and systemic complications and malignancies. Colon polyps seem to constitute the most frequent tumours in acromegaly apart from thyroid nodules. The aim of this study was to evaluate the prevalence of colon polyps in patients with acromegaly. Thirty one acromegaly patients, 22 females and 9 males (mean age 46.3 +/- 11.9 yrs), were enrolled to the study. Colonoscopy with histopathological assessment of specimens taken during examination was carried out in all patients. Colon polyps were found in 13 patients (41.9%) i.e. 8 females and 5 males. In two patients multiple polyps were discovered (2 and 3 respectively). Polyps were histopatologically verified as tubular adenoma with low-grade dysplasia (10 patients, 76.9%) and hyperplastic polyps (3 patients, 23.1%). The prevalence of colon polyps was significantly related to the duration of uncontrolled acromegaly (p < 0.01). Median duration of uncontrolled acromegaly in patients with and without colon polyps were 10.0 (IQR = 2.0) yrs and 6.5 (IQR = 5.0) yrs, respectively. IGF-1, GH basic and in 120 min of OGTT serum concentrations on diagnosis were not significantly related to the prevalence of colon polyps. Our study indicates that duration of uncontrolled acromegaly, contrary to IGF-1, GH basic and in OGTT serum concentrations at diagnosis are essential for the colon polyps development. Colonoscopy is considered to be routine in patients with acromegaly.

The prevalence of benign and malignant neoplasms in acromegalic patients

INTRODUCTION

In acromegalic patients, the prevalence of certain benign and malignant neoplasms is higher than that in the healthy population. We retrospectively evaluated the prevalence of tumours in acromegalic patients treated at our department: the regional centre for acromegalic patients for the Małopolskie voivodeship in Poland.

MATERIAL AND METHODS

During the years 1983-2008, a hundred and one acromegalic patients (30 males and 71 women), of mean age 51.8 +/- 15.4 years, were diagnosed and treated. Pituitary macroadenoma and microadenoma were stated in 63.4% and 25.7% of these patients, respectively. In 10.9% of these patients no data on tumour diameter were available. The mean observation period was 9.4 +/- 6.5 years. The median levels of hGH and IGF-1 prior to neurosurgery were 20.2 (IQR = 34.9) ng/ml and 764.5 (IQR = 569.6) ng/ml, respectively.

RESULTS

In the studied group of patients, we found the following prevalence of various tumours: nodular goitre - 64/101 patients (63.0%), polyps of the colon - 13/101 patients (13.0%); uterine polyps - 4/101 patients (4.0%); and prostate adenoma - 2/101 patients (2.0%). Among malignant tumours, thyroid cancer, endometrium and cervix cancer were the most frequent, each of these occurring in 3 patients (3.0%). Colon cancer prevalence was 2.0% (in 2 patients).

CONCLUSIONS

From our retrospective study, we suggest an overall increase of tumour incidence in acromegalic patients. Prospective multicentre studies are required to resolve the significance of this observation. In our study group, the number of malignant neoplasms was significantly higher in patients with long-lasting uncontrolled disease (over 5 years), compared to patients with controlled disease. (Pol J Endocrinol 2010; 61 (1): 29-34).

[Evaluation of the efficacy of Octreotide LAR in the treatment of acromegaly--a yearly observation]

Since acromegaly is associated with high rates of comorbidities and increased mortality risk compared to the general population, over the last few years somatostatin analogues have been used to treat acromegaly patients who, following surgery, have not fulfilled cure criteria (basal hGH < 2.5 ng/ml, IGF-1 below normal ranges for age and sex and hGH < 1.0 ng/ml in the 120th min of the OGTT test). We assessed the efficacy of Octreotide LAR (OCT-LAR) in managing such patients. 72 patients underwent diagnostic tests to qualify them for Octreotide LAR treatment. Treatment efficacy evaluation was based on measuring the concentration of hGH and IGF-1 prior to and 3 and 12 months and performing control MRI 6 and 12 months after the beginning of OCT-LAR treatment. The dose of O ctreotide LAR was 20 mg/month, increased to 30 mg/month if unsatisfactory response was observed. We evaluated the efficacy of Octreotide LAR in 48 acromegaly patients (66.7% of 72 evaluated), in whom criteria of postsurgery cure were not fulfilled. 24 patients (33.3%) did not require further treatment. After 3 months of OCT-LAR treatment, hGH < 2.5 ng/ml was stated in 37.0% of patients, median value--3.4 ng/ml (IQR = 5.3), as compared to median value of 5.5 ng/ml (IQR = 5.6) before treatment (p < 0.05). After 3 months of treatment IGF-1 below normal ranges for age and sex was stated in 55.5% of patients, median value--336.8 ng/ml (IQR = 290.0), as compared to median value of 520.0 ng/ml (IQR = 351.0) prior to OCT-LAR treatment (p < 0.05). After 12 months hGH < 2.5 ng/l ml and IGF-1 below normal ranges for age and sex were found in 63.0% and 54.5% of patients, respectively. In control MRI recurrence, correlated with enhanced concentration of IGF-1, was stated in 7 patients (14.6%). Thus, we conclude that satisfactory acromegaly control, in terms of hGH and IGF-1 levels, was obtained in above 50% of patients treated with Octreotide LAR. Since in the studied group hGH secretion had achieved cure criteria after 3 months in 37.5% as compared to 63.0% after 12-months, assessment of OCT-LAR treatment should be extended over periods exceeding 3 months.

[Prevalence of the metabolic syndrome and its components in adult inhabitants of Krakow]

OBJECTIVES

There are only few studies on the prevalence of the metabolic syndrome in Polish population. The aim of the study was to assess the prevalence of the metabolic syndrome according to NCEP definition in adult inhabitants of Krakow.

MATERIAL AND METHOD

The study was conducted in 2004-2005 in 42 Krakow's primary health care units in patients aged over 25, not treated due to the diabetes type 2 and/or coronary artery disease, with no history of myocardial infarction or stroke. In all study participants anthropometric examination, blood pressure, fasting total cholesterol and fasting glucose were measured. In those with total cholesterol > 5.2 mmol/l additional triglicerides and HDL-cholesterol were measured.

RESULTS

40989 people (67.2% women and 32.8% men) aged 25 to 97 (54.1 +/- 14.1 years) were examined. In 19,4% of the examined population the MS was diagnosed (20.9% women and 16.2% men). In age group below 55 years the MS was more frequent in men than in women. Impaired glucose tolerance was found in 5394 study participants (3239 women and 2155 men). Mean systolic blood pressure was higher in men than in women (131.5 +/- 16,1 vs 127.0 +/- 17.5, p < 0.0001), the same was found for diastolic blood pressure (81.5 +/- 0.3 vs 78.6 +/- 9.6 p < 0.0001). 33.5% of women and 34.9% of men (p < 0.01) were treated from hypertension. In age group below 55 years men were more frequently treated due to hypertension than women (p < 0.001). In 8.7% of women and 14.1% of men (p < 0.001) newly diagnosed hypertension was found. In all age groups untreated hypertension was more frequent among men than in women. In 26.1% women and 33.5% men hypertriglicrdymia was found. In age group below hypertiglicerydemia was more frequent in men than in women (p < 0.001). Low HDL-cholesterol was found in 20.9% of women and 10.1% of men (p < 0.001). Visceral fat distribution was found in 19.9% of men and 33.3% of women.

CONCLUSIONS

The MS was found in 20% of examined inhabitants of Krakow. Special attention should be paid to high prevalence of the MS among men younger than 45 years, as well as high prevalence of hypertriglicerydemia and newly diagnosed hypertension present in this group of men. The study results confirm the necessity of implementation of screening and early prevention of cardiovascular disease programs especially focused on younger men.

[Prevalence of the glucose metabolism disturbances in screening of adult inhabitants of Krakow]

OBJECTIVES

In Poland, similarly like in the other European countries type 2 diabetes screening and prevention projects have been run. In Krakow, Krakow's Municipality had undertaken a decision of financing a prevention program directed to adult inhabitants of the city. The aim of the study was to assess the prevalence of the glucose metabolism disturbances in adult inhabitants of Krakow city.

MATERIAL AND METHOD

The study was conducted in 2004-2005 in 42 Krakow's primary health care units in patients aged over 25, not treated due to the diabetes type 2 and/or coronary artery disease, with no history of myocardial infarction or stroke. In all study participants anthropometric examination, blood pressure and fasting glucose were measured. Diabetes risk score (DRS) and fasting glyceamia were used to classify patients to receive oral glucose tolerance test (OGTT).

RESULTS

40989 people (67.2% women and 32.8% men) aged 25 to 97 were examined. 12495 people received OGTT, in 1858 fasting glycaemia measurement was repeated. In 15.1% of men and 12.7% of women impaired glucose metabolism was found (p < 0.01). IFG was found in 5.9% men and 4.7% women (p < 0.01). The prevalence of IGT was the same in men and women (3.7% vs 3.8%, ns). Newly diagnosed diabetes type was found in 5.5% men and 4.2 % of women (p < 0.01). The prevalence of impaired glucose metabolism was increasing with age in men and women, in all categories of glucose disturbances, age related trends were statistically significant. Overweight was more frequent in men than in women (50.3% vs 36.8%, p < 0.0001), while obesity was more frequent in women compared to men (20.7% vs 19.5%, p < 0.02). Obesity was statistically more frequent in people with impaired glucose metabolism compared to those with normal glucose tolerance. Overweight was more frequent in women with impaired glucose metabolism compared to women with normal glucose metabolism, no relation with overweight was observed in men.

CONCLUSIONS

The prevalence of newly diagnosed type 2 diabetes is increased in people aged over 55, what confirms the necessity of screening in this group of age. Due to more prevalent newly diagnosed type 2 diabetes and IFG in men, in all age groups implementation of routine screening for impaired glucose metabolism in men aged over 35 should be considered. Results of the study confirm the importance of the implementation of early prevention programs focused on lifestyle modification, especially addressed to men.