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Thyrotropin (TSH)-secreting adenoma is a rare entity and may be overlooked as a cause of clinical hyperthyroidism. Since the introduction of ultrasensi- tive assays for TSH and direct methods for free thyroid hormone measurements as first-line tests of thyroid function, thyrotropinomas have been recognized with increasing frequency (1). Somatostatin analogues have been proposed for the treatment of thyrotropinomas. The dopamine agonist bromocriptine has been reported to be ineffective in more than 75% of those adenomas (2). We present the case of a 44-year-old woman with TSH-producing microadenoma who has been treated successfully with lanreotide and subsequently cabergo- line for 3 years. The then 40-year-old nurse presented in October 1996 in our outpatient clinic with a clinical pattern consisting of restlessness, paroxymal tachycar- dia, loss of weight, tremor and depression. The symptoms had started 2 months previously. Laboratory findings showed elevated levels of circulating thyroid hormones despite inadequately high levels of TSH (Table 1). A stimulation test with TRH doubled the basal level of TSH. Sonography of the thyroid demon- strated normal volume (16 ml). Scintiscan with Tc99m detected an elevated uptake of 2.6% (normal range: 0.5-1.5%) and a homogeneous picture of the thyroid. Antibodies for thyroglobulin, thyroid peroxydase and thyrotropin receptor were measured repeatedly in the following months - always with negative result. TSH was not suppressed at any time when observed. Various controls always showed normal values of a -subunits. MRI of the pituitary demonstrated a 5 mm micro- adenoma, which was not enhanced after gadolinium administration. There was no evidence for familiar protein binding anomaly, the existence of T3- and T4-autoantibodies was excluded. Therefore the diagnosis of the micro- thyrotropinoma was established. In August 1997 endocrine screening of anterior pituitary hormones (LH, FSH, PRL, ACTH and HGH), estradiol, cortisol and IGF-1 revealed normal physiological levels. Sympto- matic treatment with atenolol (20 mg every 8 h) was started as an intermediate therapeutic approach. Pituitary surgery was recommended but the patient refused and insisted on conservative treatment. Lanreo- tide (30 mg i.m.) therapy was started in August 1997 initially with a 2 week interval between injections, which was later extended because the patient remained free of thyrotoxic symptoms for longer. For 3 weeks after medication thyroid hormone levels remained within the normal physiological range. Diarrhea and abdominal discomfort for 2-3 days after injection of lanreotide were reported by the patient. These side effects were tolerated well at first, but after a while the patient decided to discontinue the treatment because of colics, which appeared more frequently.

Long-term treatment of thyrotropin-secreting microadenoma with lanreotide and cabergoline