Surgery, Octreotide, Temozolomide, Bevacizumab, Radiotherapy, and Pegvisomant Treatment of an AIP Mutation-Positive Child

Pinaki Dutta, Kavita S. Reddy, Ashutosh Rai, Anil K. Madugundu, Hitendra S. Solanki, Anil Bhansali, Bishan D. Radotra, Narendra Kumar, David Collier, Donato Iacovazzo, Prakamya Gupta, Remya Raja, Harsha Gowda, Akhilesh Pandey, Jagtar Singh Devgun, Márta Korbonits

Research output: Contribution to journalArticle

6 Scopus citations

Abstract

Context: Inactivating germline mutations in the aryl hydrocarbon receptor interacting protein (AIP) gene are linked to pituitary adenoma predisposition. Here, we present the youngest known patient with AIP-related pituitary adenoma. Case Description: The patient presented at the age of 4 years with pituitary apoplexy and left ptosis with severe visual loss following a 1-year history of abdominal pain, headaches, and rapid growth. His IGF-1 level was 5× the upper limit of normal, and his random GH level was 1200 ng/mL. MRI showed a 43 × 24 × 35-mm adenoma with suprasellar extension invading the left cavernous sinus (Knosp grade 4). After transsphenoidal surgery, histology showed a grade 2A sparsely granulated somatotropinoma with negative O6-methylguanine-DNA methyltransferase and positive vascular endothelial growth factor staining. Genetic testing identified a heterozygous germline nonsense AIP mutation (p.Arg81Ter). Exome sequencing of the tumor revealed that it had lost the entire maternal chromosome-11, rendering it hemizygous for chromosome-11 and therefore lacking functional copies of AIP in the tumor. He was started on octreotide, but because the tumor rapidly regrew and IGF-1 levels were unchanged, temozolomide was initiated, and intensity-modulated radiotherapy was administered 5 months after surgery. Two months later, bevacizumab was added, resulting in excellent tumor response. Although these treatments stabilized tumor growth over 4 years, IGF-1 was normalized only after pegvisomant treatment, although access to this medication was intermittent. At 3.5 years of follow-up, gamma knife treatment was administered, and pegvisomant dose increase was indicated. Conclusion: Multimodal treatment with surgery, long-acting octreotide, radiotherapy, temozolomide, bevacizumab, and pegvisomant can control genetically driven, aggressive, childhood-onset somatotropinomas.

Original languageEnglish (US)
Pages (from-to)3539-3544
Number of pages6
JournalJournal of Clinical Endocrinology and Metabolism
Volume104
Issue number8
DOIs
StatePublished - Aug 1 2019

ASJC Scopus subject areas

  • Endocrinology, Diabetes and Metabolism
  • Biochemistry
  • Endocrinology
  • Clinical Biochemistry
  • Biochemistry, medical

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    Dutta, P., Reddy, K. S., Rai, A., Madugundu, A. K., Solanki, H. S., Bhansali, A., Radotra, B. D., Kumar, N., Collier, D., Iacovazzo, D., Gupta, P., Raja, R., Gowda, H., Pandey, A., Devgun, J. S., & Korbonits, M. (2019). Surgery, Octreotide, Temozolomide, Bevacizumab, Radiotherapy, and Pegvisomant Treatment of an AIP Mutation-Positive Child. Journal of Clinical Endocrinology and Metabolism, 104(8), 3539-3544. https://doi.org/10.1210/jc.2019-00432