case_images: PMC8020339_01
case_images: (A, B) In thyroid echography, both lobes of the thyroid gland were swelling although increase of blood flow was not observed. (C, D). In brain magnetic resonance imaging, there was a giant tumor (51 x 34 x 22 mm) around pituitary fossa, pressuring on optic chiasm from the middle. Bilateral internal carotid arteries were surrounded by the tumor, and infiltration into the cavernous sinus was observed.
case_images: fendo-12-659076-g001.jpg
case_images: PMC8020339_01_fendo-12-659076-g001.jpg
case_images: f1
case_images: In thyroid echography, both lobes of the thyroid gland were swelling although increase of blood flow was not observed ( Figures 1A, B  ). In brain magnetic resonance imaging (MRI), there was a giant tumor (51 x 34 x 22 mm) around pituitary fossa, pressuring on optic chiasm from the middle ( Figures 1C, D  ).
case_images: (A) In hematoxylin and eosin (HE) staining, solid proliferation of chromophobe cells was observed. (B) In CAM5.2 staining, many cytokeratin-producing cells were observed. (C) In MIB1 staining, percentage of MIB1-positive cells was about 3%, indicating that the proliferative activity was relatively low. (D-F) In GH staining, many GH-positive cells were observed, and in TSH staining, many TSH-positive cells were observed, whereas in prolactin staining, prolactin-positive cells were not detected at all.
case_images: fendo-12-659076-g002.jpg
case_images: PMC8020339_01_fendo-12-659076-g002.jpg
case_images: f2
case_images: In hematoxylin and eosin (HE) staining of the resected pituitary adenoma, solid proliferation of chromophobe cells was observed ( Figure 2A ). In CAM5.2 staining, many cytokeratin-producing cells were observed ( Figure 2B ). In MIB1 staining, percentage of MIB1-positive cells was about 3%, indicating that the proliferative activity was relatively low ( Figure 2C ). TSH staining, many TSH-producing cells were observed ( Figure 2E ), whereas in prolactin staining, prolactin-producing cells were not detected at all ( Figure 2F ). These findings further confirmed our diagnosis that this subject had pituitary adenoma producing GH and TSH simultaneously.
case_images: (A) Time course of GH and IGF-1 levels for 6 years. After the diagnosis of GHoma and TSHoma, pituitary tumor resection was performed. After about 1 year later, cyber knife therapy was performed together with the treatment with somatostatin analog and GH receptor antagonist. After these therapies, GH and IGF-1 levels were suppressed for a long period of time. (B) Time course of TSH, FT3 and FT4 levels for 6 years. After the operation, since thyroid function was not sufficiently suppressed, we started the treatment with anti-thyroid drug thiamazole. Since thyroid function was normalized after about 3 years later, we stopped the treatment with thiamazole. After then TSH, FT3 and FT4 levels were not increased for a long period of time.
case_images: fendo-12-659076-g003.jpg
case_images: PMC8020339_01_fendo-12-659076-g003.jpg
case_images: f3
case_images: After the surgery, IGF-1 level was also markedly decreased and became within normal range (reference range in our institution: 141-328 ng/ml) ( Figure 3A ). After the cyber knife therapy together with octreotide, IGF-1 was marked decreased and became within normal range ( Figure 3A ). After then, GH and IGF-1 levels did not increase at least for 6 years ( Figure 3A ). But TSH, FT3 and FT4 levels did not increase at least for 6 years ( Figure 3B ).
case_images: There were no particular abnormalities in brain MRI taken 1 month after operation (A), 1 year after operation (half year after cyber knife therapy) (B) and 4 years after operation (C).
case_images: fendo-12-659076-g004.jpg
case_images: PMC8020339_01_fendo-12-659076-g004.jpg
case_images: f4
case_images: In addition, there were no particular abnormalities in brain MRI taken 1 month after operation ( Figure 4A ), 1 year after operation (half year after cyber knife therapy) ( Figure 4B ) and 4 years after operation ( Figure 4C ).