A 79 year old male was diagnosed to have non-functioning pituitary adenoma compressing the optic chiasma in 2011. Patient was subsequently operated in 2011. Anterior pituitary assessment post-surgery was not done and patient was on some anterior pituitary hormone replacement on and off. Patient developed a fracture neck femur on minimum trauma. He was admitted for the same and endocrinology consultation was sought for the anterior pituitary assessment and management of osteoporosis.
Patient had a residual pituitary mass and postoperative changes in MRI pituitary. The mass was found infiltrating into the left cavernous sinus and engulfing the left ICA.
[FIG 4.1 AND 4.2]
The pituitary evaluation showed
1. Low T3, T4 and TSH- Suggestive of central hypothyroidism
2. Low testosterone and FSH/LH
3. Normal Prolactin
4. Serum cortisol – 7 mcg/dl- post stimulation of 12 mcg/dl
5. GH deficiency
6. No evidence of Diabetes insipidus
Hence the patient is having panhypopituitarism following the pituitary surgery. Patient was started on glucocorticoid and thyroid hormone replacement.
was started on glucocorticoid and thyroid hormone replacement.
The questions are
Q What is the Hardy grading of the Pituitary mass described above ?
Since it involves the cavernous sinus it would be classified as Hardy Grade E
Q. Does the patient need a DEXA scan for evaluation of osteoporosis ? Is treatment for osteoporosis indicated in this patient ?
Men with hip or vertebral fracture with low trauma with a clear risk of having osteoporosis as in this case donot require DEXA scan for BMD evaluation and the patient can be presumed to have osteoporosis.
Q. Deficiency of which hormones in this can may lead to osteoporosis ?
GH and Testosterone deficiency are the reasons for osteoporosis.
Q. What would be the ideal treatment for osteoporosis and prevention of further fracture in this patient ?
1. I would consider replacing both testosterone and GH in this patient (if there are no contraindications to either). There are recent studies which have shown benefit of GH on improving bone mineral density in adults with GHD
2. Since the fracture is recent, I would withhold bisphosphonate for now. Whether to use bisphosphonate or not on follow-up is controversial.
3. Overtreatment with glucocorticoids and thyroid hormones needs to avoided.
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It’s difficult to quantify the contribution of pan hypopituitarism and age in this case of osteoporosis. It’s obviously multifactorial. I think bisphosphonate is going to help apart from hormone replacement and cal vitamin D supplement. It’s also important to prevent frequent falls which might be happening because of poor vision.
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T
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Thank you Dr.Om Lakhani. In such clinical scenario of 79 year old man, I think it is so difficult to differentiate between senile osteoporosis (age-related) and secondary one due to hypogonadism. I would say that bisphosphonates plus calcium & vitamin D supplement is a more reasonable therapeutic approach in such patient. A proper thyroid and adrenal hormones replacement is very important to avoid overtreatment as you mentioned. Testosterone replacement in such patient should be used with extra caution and individualized to patient`s profile. It is very interesting to know that GH replacement may have a role in treatment of osteoporosis, however it is not recommended by many guidelines at time being.
Mustafa Al-Abousi
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Thank you Dr.Om Lakhani. I think osteoporosis must be confirmed by Deax scan with excluding metastasis to bone from example from prostate or ca colon and to ass other sites of osteoprosis . once steoporosis confirmed treatment done according to severity of osteoprosis and sites but in general bisphosphonate will be help more hormonal therapy specially in this patient who is not on regular fellow up if patient tolarate the treatment of bisphophonate
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