Introduction: This is a case of patient with giant pituitary adenoma (GPA) presenting with acromegalic features, minimal symptoms of mass effect who underwent surgical resection via transcranial approach with minimal surgical morbidity. Case: A 40-year-old female presented with typical acromegalic features over 14 years, occasional mild frontal headaches and blurred vision. She had elevated growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Cranial MRI revealed a 6.4x7x5.5 cm lobulated pituitary mass with cystic degeneration, areas of necrosis with mass effect on several intracranial structures. Excision via craniotomy reduced mass size to 5.9x5.8x4.7 cm. Histopathology revealed a mixed GH- and prolactin-secreting pituitary adenoma. She was maintained on bromocriptine and underwent radiotherapy. Repeat IGF-1 levels remained elevated but symptoms did not progress Conclusion This is a case of a patient with GPA with minimal symptom of mass effect, with no hormonal improvement post-surgery and radiotherapy. Ideally, a multi-staged surgery can be done with optimization of medical management. In the absence of these medications locally and reluctance of patient for re-surgery, the team opted to monitor tumor size, hormone levels and maximize management of co-morbidities.
Acromegaly ; Pituitary Neoplasms

Background: Armand Trousseau (1801-1865) stated that an unexpected or migratory thrombophlebitis could be a forewarning of an occult visceralmalignancy.1 The classical manifestations of Troussseau's syndrome are caused by venous thrombosis, nonbacterial thrombotic endocarditis often in conjunction with arterial embolization and arterial thrombosis.Setting: St. Luke's Medical Center, Quezon City, PhilippinesCase: We report here a case of a 67-yearold male with multiple strokes as the initial presentation of a pancreatic malignancy. He had a three-month history of epigastric pain and had two strokes in a span of one month, with multiple infarcts in both hemispheres, anterior and posterior circulation. A large silent pancreatic mass was seen on abdominal CT scan measuring 4.4 x 3.7 cm. On the 30th hospital day, patient had his third stroke, withsevere disability, Modified Rankin Scale8 (MRS) grade of 5 and NIHSS of 22.Diagnostics: Cranial MRI showed multiple recent infarcts in both cerebral and cerebellar hemispheres without confirmation to a vascular territory. Thereis stenosis of both anterior and middle cerebral artery and right posterior cerebral artery. Elevated transaminases and alkaline phosphatase, conjugatedhyperbilirubinemia, hypoalbuminemia, and deranged bleeding parameters were noted. A non-contrast abdominal CT scan showed a soft density at thepancreatic tail measuring 4.4x3.7 cm, with multiple hypodensities seen in the liver and spleen.Conclusion: Stroke as the initial manifestation of a pancreatic malignancy is rare. However, in patients with repeated strokes and a steep downhill course, this should prompt further investigation such as a possible underlying malignancy.
X