Step 1: View clinicals

A 55 year old man complains of progressive changes in his facial appearance over the last year, as noted by his wife and co-workers. He has also gained 15 kg of weight in that time. Further questioning reveals a history of numbness and tingling in his fingers for the last 3 months, and intermittent headaches for the past 5 months. He has also gained a shoe size since the onset of symptoms. His medical, surgical, and family histories are unremarkable. He does not smoke, and only drinks socially.

Step 2: Order all relevant investigations

Endocrine Profile

Growth Hormone: 6.12 ng/mL (<5) TSH, Prolactin, FSH, LH, Random Cortisol: within normal parameters

Serum IGF-1 Levels

Serum IGF-1: 245ng/mL (45-173)

GH Suppression Test

GH levels were 2.43ng/ml (normal <1ng/ml), two hours following administration of 75g glucose.

MRI Brain

The MRI shows the pituitary gland to be slightly enlarged, and asymmetrical.

Step 3: Select appropriate management

Transsphenoidal Surgery
Stereotactic Radiotherapy

Score: ★★☆