Uneventful octreotide LAR therapy throughout three pregnancies, with favorable delivery and anthropometric measures for each newborn: a case report.

Abstract

The safety of octreotide use, in its short-acting preparation, in pregnancy is still unclear. This report provides the first documentation of uneventful octreotide LAR use during three pregnancies in a woman with bronchial carcinoid-associated adrenocorticotropic hormone-dependent Cushing's syndrome.
A 25-year-old Arabic woman presented to our emergency department with rapid onset of headache, flaring acne and hirsutism, facial puffiness, weight gain and paroxysmal myopathy, and paranoiac thoughts of rape and sexual intimidation. After undergoing surgical removal of a mass by left lower lung lobectomy, her residual lung disease medical therapy failed. Chronic octreotide LAR injections were initiated as indicated by a positive octreoscan.Follow-up revealed a long-lasting positive response to octreotide. Avidity of octreotide to somatostatin receptor sub-type 2 was later confirmed by a positive somatostatin receptor sub-type 2 in the resected tumor specimen. Against our instructions, the patient had three spontaneous pregnancies leading to delivery of three full-term healthy children while her octreotide LAR therapy continued.
This case adds more data supporting the potential for the safe use of octreotide and the feasibility of octreotide LAR use during pregnancy, making compliance with the patient's preference not to withdraw octreotide therapy as soon as her pregnancy is confirmed a thoughtful option.

Full text

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CASE REPORTOpen Access
Uneventful octreotide LAR therapy throughout
three pregnancies, with favorable delivery and
anthropometric measures for each newborn:
a case report
Deeb Daoud Naccache1*, Adnan Zaina1, Zila Shen-Or1, Michal Armoni1, George Kontogeorgos2and Ali Yahia3
Abstract
Introduction: The safety of octreotide use, in its short-acting preparation, in pregnancy is still unclear. This report
provides the first documentation of uneventful octreotide LAR use during three pregnancies in a woman with
bronchial carcinoid-associated adrenocorticotropic hormone-dependent Cushing’s syndrome.
Case presentation: A 25-year-old Arabic woman presented to our emergency department with rapid onset of
headache, flaring acne and hirsutism, facial puffiness, weight gain and paroxysmal myopathy, and paranoiac
thoughts of rape and sexual intimidation. After undergoing surgical removal of a mass by left lower lung
lobectomy, her residual lung disease medical therapy failed. Chronic octreotide LAR injections were initiated as
indicated by a positive octreoscan.
Follow-up revealed a long-lasting positive response to octreotide. Avidity of octreotide to somatostatin receptor
sub-type 2 was later confirmed by a positive somatostatin receptor sub-type 2 in the resected tumor specimen.
Against our instructions, the patient had three spontaneous pregnancies leading to delivery of three full-term
healthy children while her octreotide LAR therapy continued.
Conclusion: This case adds more data supporting the potential for the safe use of octreotide and the feasibility of
octreotide LAR use during pregnancy, making compliance with the patient’s preference not to withdraw octreotide
therapy as soon as her pregnancy is confirmed a thoughtful option.
Introduction
The safety of octreotide use during pregnancy does not
lend itself to conducting a controlled prospective study.
Hence, such assessment is presently dependent on case
reports. Ectopic adrenocorticotropic hormone (ACTH)-
dependent Cushing’s syndrome associated with bron-
chial carcinoid is well recognized. Though infrequent, it
is the leading etiology (30%) of ectopic, non-pituitary
ACTH secretion (EAS) [1]. Currently, the prognosis for
patients with bronchial carcinoid EAS is good [1-4],
even when it persists or manifests as multiple lesions
[5]. This outcome is in contrast to the poor prognosis
attributed to this disease in the past [6].
When feasible, surgical removal of the causative tumor
is the mainstay of treatment. Medical treatment can
bridge the gap until surgery is performed or provide
adjunctive long-term therapy to suppress hormonal
excess of residual disease.
Medical treatments include blockers of steroid synthesis
[7] and somatostatin analogues [8]. In many case reports
published during the past decade, somatostatin analogues
were routinely discontinued once pregnancy was diag-
nosed. Of special interest is that these case reports com-
prised seven pregnant women, five of whom had pituitary
acromegaly [9-13], one of whom had nesidioblastosis [14],
and one of whom had a thyroid stimulating hormone
(TSH)-producing pituitary macroadenoma [15], who had
uneventful deliveries concomitant to octreotide therapy
throughout all trimesters. Five of these women were trea-
ted with the short-acting preparation of octreotide, and in
* Correspondence: d_deeb@rambam.health.gov.il
1Institute of Endocrinology, Diabetes and Metabolism, Rambam Health
Campus and Rappaport Faculty of Medicine, Technion, Haifa, Israel
Full list of author information is available at the end of the article
Naccache et al. Journal of Medical Case Reports 2011, 5:386
http://www.jmedicalcasereports.com/content/5/1/386
JOURNAL OF MEDICAL
CASE REPORTS
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two women octreotide LAR was administered [12,15].
Until recently, only one case report described short-period
(one-month) use of a long-acting somatostatin analogue
preparation, lanreotide, before it was discontinued at the
time of pregnancy confirmation [16]. Herein we present
the first case report describing a patient who delivered
three healthy babies following three consecutive pregnan-
cies while being treated with octreotide LAR for residual
ectopic EAS.
Case presentation
A 25-year-old Arabic woman presented to the emer-
gency department of our medical facility with rapid
onset of headache, flaring acne and hirsutism, facial puf-
finess, weight gain and paroxysmal myopathy, and para-
noiac thoughts of rape and sexual intimidation. Her
physical examination revealed pronounced facial acne
and hirsutism, oily skin, moon face, buffalo hump, and
classical Cushing’s syndrome purplish skin striae in the
abdominal, axillary, and flank regions. Her blood pres-
sure was 150/90 mmHg.
Table 1 presents the patient’s relevant endocrine pro-
file. High-dose (2 mg four times daily) dexamethasone
failed to suppress both serum cortisol and urinary free
cortisol (UFC) levels. Her serum testosterone, 5-dehy-
droepiandrosterone sulfate, and 17-OH progesterone
levels were within normal limits. Chest computed tomo-
graphy revealed a 22 mm × 15 mm × 10 mm mass in
the upper segment of the left lower pulmonary lobe. No
adrenal mass was detected.
She underwent a left lower lung lobectomy. The histo-
pathological examination showed a typical carcinoid
tumor without mitotic figures or necrosis and with posi-
tive immunohistochemical stains for synaptophysin,
neuron-specific enolase, and chromogranin A, as well as
strong positive staining for ACTH.
The patient became completely free of symptoms with
abnormal, though decreasing, UFC levels. A year and a
half after surgery she regained weight. Her physical
examination confirmed moon face and re-darkening of
previous striae. Her UFC levels were high and remained
unsuppressed by either low or high doses of dexametha-
sone (Table 1).
Computed tomography of the chest and abdomen
were normal, as was subsequent pituitary tomography.
An indium-111 pentetreotide scan obtained to locate an
occult focus of the carcinoid revealed a hot focus in the
left lower pulmonary lobe and the upper right mediasti-
num. Treatment with steroid synthesis blockers was
initiated.
Mediastinal and paratracheal histopathology of lymph
node material obtained by performing a thoracoscopy
showed a metastatic carcinoid. Following treatment with
octreotide LAR 30 mg/month, she became symptom-free.
Her endocrine laboratory results normalized (Table 1).
Almost three years after surgery, while undergoing
octreotide LAR treatment, the patient became pregnant.
She refused our recommendation to discontinue octreo-
tide LAR therapy during the first trimester, as is routine
[17]. Rather, she insisted on continuing octreotide LAR
for the duration of the pregnancy because of its effec-
tiveness in maintaining disease remission. A healthy
full-term baby was born (Table 2). Two and three years
later, respectively, our patient delivered two more
healthy full-term babies (Table 2). All three deliveries
were by cesarean section. Octreotide LAR treatment was
continued throughout this time period.
Recent routine follow-up chest tomography 10 years
after the patient’s initial presentation revealed normal
mediastinal lymph nodes, with permanent post-surgical
changes at the basal portion of the left lung. The result
of a concomitant test for urine 5-hydroxyindoleacetic
acid was 6.9 mg/day, which is within normal limits (1 to
7 mg/day).
An immunohistochemistry assay was performed to
determine the somatostatin receptor (SSTR) sub-types
in the tissue of the original carcinoid in the lung lobe as
previously described [18]. The carcinoid tumor tested
positive for SSTR types 2A and 2B and negative for
SSTR types 1, 3, 4, and 5. The samples taken from the
lymph node metastases were inadequate for SSTR
immunohistochemistry. Our patient’s three babies had
Table 1 Patient’s endocrine-biochemical laboratory testsa
Time phase
Steroid blocker treatment
20 months
Test Baseline1 month post-
surgery
Recurrence
15 months
Octreotide LAR treatment
102 months
Plasma cortisol, nmol/L*
Urinary free cortisol**
Plasma ACTH
Urinary 5-HIAA‡
1700
1994
21.1†
6
1193
2952
> 1379
5171
23.2†
8.4
495
1107
17.3†
219
120
10.2††
3.7
aACTH, adrenocorticotropic hormone; 5-HIAA, 5-hydroxyindoleacetic acid; *normal range 138 to 690 nmol/24 hours; **normal range 55 to 248 nmol/24 hours;
†normal range 4.4 to 17.6 pmol/L; ††normal range 0 to 10 pmol/L; ‡normal range 1 to 84 mg/g creatinine.
Naccache et al. Journal of Medical Case Reports 2011, 5:386
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normal growth patterns during 128 months of follow-up
(Figure 1).
Discussion
In its short-acting preparation, octreotide has been used
safely in humans since 1998. However, its safety during
pregnancy is still uncertain. Its administration is usually
stopped once pregnancy is confirmed [17]. Information
regarding its safety during pregnancy is sparse. We
document the safe use of octreotide LAR (its long-acting
compound) during one woman’s three consecutive full-
term pregnancies, all of which were uneventful and
yielding healthy babies.
Octreoscan scintigraphy helps select carcinoid patients
for somatostatin analogue treatment [19]. A positive
octreoscan indicates binding of the analogue for investi-
gation (111In-diethylenetriaminepentaacetic acid-D-Phe1]
octreotide) to SSTR sub-types 2, 3, and 5 [20]. However,
18% of patients with positive octreoscan results do not
respond to somatostatin analogues [20]. It is noteworthy
that patients who have a good biochemical response or
disease stabilization with octreotide treatment stain
positive for SSTR2. Those patients who are non-respon-
sive are negative for SSTR2 staining [21]. It seems that a
positive response is a result of octreotide binding to
SSTR2 [20]. Though not essential for therapeutic deci-
sion making, SSTR sub-typing may elucidate our under-
standing of this rare and heterogeneous disease.
Octreotide crosses the placenta, where it remains
stable [12,13,15,22,23]. Previously reported maternal and
infant umbilical cord serum octreotide concentrations
have been measured, respectively, as 1009 pg/mL vs.
353 pg/mL [12], a range of 4638 pg/mL to 3676 pg/mL
vs. 3483 pg/mL [13], 890 pg/mL vs. 251 pg/mL [22],
and a range of 2888 pg/mL to 5021 pg/mL vs. 101 pg/
mL [15]. Moreover, the half-life elimination time of
octreotide approaches 350 minutes in the infant [22]
compared to 90 to 110 minutes in adults [24]. Fetal
exposure to octreotide due to placental transfer and
increased half-life in fetal serum has raised concern
about its potential hazard to the fetus [9].
Fetuses seem to be protected from the effects of
octreotide. Of primary concern are fetal growth and
growth hormone (GH) levels during fetal life. During
the third trimester, increasing placental GH production
leads to a significant rise in insuling-like growth factor 1
(IGF-1) levels. In this regard, physiological changes in
placental GH and IGF-1 were observed during octreo-
tide therapy throughout pregnancy [14]. Similar changes
Table 2 Data regarding patient’s three pregnancies
MotherNewborn
PregnancyAge at delivery,
years
Delivery,
weeks
Weight,
g
Apgar
score
1
2
3
27
29
31
41
40
39
3010
3085
3395
9/10
9/10
8/9
A.
B.
C.
0
10
20
30
40
50
60
020 4060 80100 120 140
Body Length (cm)
Age (in weeks)
#1st child
#2nd child
#3rd child
0
20
40
60
80
100
02040 6080100 120 140
Head Circunf. (cm)
Age (in weeks)
#1st child
#2nd child
#3rd child
0
3000
6000
9000
12000
Body Weight (gr)
15000
020 40 6080100 120 140
Age (in weeks)
#1st child
#2nd child
#3rd child
Figure 1 Anthropometric measures of the patient’s three
children. (A) Body length. (B) Head circumference. (C) Body weight.
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during the last part of pregnancy were reported in a
woman with a TSH-producing pituitary adenoma who
was undergoing octreotide treatment at the time [15].
Octreotide-driven suppression of GH, however, is
tampered because placental SSTRs are mainly of sub-
type 4, while SSTR1 remains non-functional as a result
of its low affinity for octreotide [25]. In another report,
investigators found scanty binding of somatostatin and
its analogues to both placental and umbilical cord
diverse SSTR1 through SSTR5 [13], which caused the
maternal-fetal barrier to sufficiently hamper the func-
tional response of SSTR1 through SSTR5 response to
octreotide.
Detection of SSTR2 in the primary tumor of our
patient is in accordance with both the effectiveness of
octreotide therapy and its lack of detriment to the three
fetuses as assessed by their normal post-birth anthropo-
metric measurements.
Seven cases in the literature have reported the safe
and effective use of octreotide for the treatment of nesi-
dioblastosis, acromegaly, and TSH-secreting pituitary
macroadenoma throughout pregnancy. No deleterious
effects on anthropometric measurements during preg-
nancy [10,14] or breastfeeding under octreotide treat-
ment [9] have previously been observed. Only one case
report described low intra-uterine growth (5th to 10th
percentile) with no other unusual morphological fea-
tures [12].
Herein we present the first case report in which
octreotide LAR was used to treat carcinoid-associated
Cushing’s syndrome during pregnancy. Additional case
reports are needed to verify the safety of octreotide and
octreotide LAR therapy during pregnancy.
Conclusions
First, our report demonstrates increased evidence for the
safety of octreotide treatment throughout pregnancy in
addition to that described in the seven previous case
reports of safe octreotide therapy, using short- or long-
acting preparations, during pregnancy. Second, it sup-
ports the effectiveness of octreotide LAR for bronchial
carcinoid-associated EAS. Third, it supports the correla-
tion between a good response to somatostatin analogue
therapy and the presence of SSTR2 in the diseased tar-
get tissue. Fourth, it demonstrates the safe use of
octreotide LAR throughout pregnancy and after birth on
the basis of the anthropometric data of three babies to
the age of two years and older.
Patient’s perspective
“Soon after the disease remission I realized that I
resumed my health. I felt powerful enough to challenge
the illness and overcome it. Establishing a family was
my desire and inspiration. In my opinion having and
growing babies, is a clear declaration that I won the
combat! I wanted to see them leaving to the kindergar-
ten with bags on their shoulder, exactly the same way
other mothers say ‘Bye bye’ to their children. My father
unconditionally supported me; he even stopped smoking
for the sake of the first baby’s health. The first success
with treatment drove me to another two, thank God. All
I need is a routine visit to the clinic, and doing some
analysis. So what if all I need is a tiny injection every
month!?”
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompany-
ing images. A copy of the written consent is available
for review by the Editor-in-Chief of this journal.
Abbreviations
ACTH: adrenocorticotropic hormone; EAS: ectopic ACTH secretion; SSTR:
somatostatin receptor.
Acknowledgements
The authors express their gratitude to Prof Eddy Karnieli for his critical
reading of the manuscript and for his remarks, as well as to his
administrative assistant, Margalit Levi, who was helpful in editing the
manuscript.
Author details
1Institute of Endocrinology, Diabetes and Metabolism, Rambam Health
Campus and Rappaport Faculty of Medicine, Technion, Haifa, Israel.
2Department of Pathology, G. Gennimatas Athens General Hospital, Athens,
Greece.3Department of Medicine, E. Rambam Health Campus and
Rappaport Faculty of Medicine, Technion, Haifa, Israel.
Authors’ contributions
DDN was the attending physician in the out-patient clinic and the attending
endocrinologist while the patient was in the hospital. He also drafted and
edited the manuscript and obtained the patient’s consent and perspective.
AZ searched for previous relevant cases in the literature and reviewed and
edited the manuscript. ZSO analyzed the laboratory samples obtained
throughout the investigation and follow-up period. MA created the figures
and reviewed the anthropometric data. GK performed the somatostatin sub-
typing in the pathological material. AY was the attending physician while
the patient was hospitalized twice during the course of her disease. All
authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 27 April 2010 Accepted: 16 August 2011
Published: 16 August 2011
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doi:10.1186/1752-1947-5-386
Cite this article as: Naccache et al.: Uneventful octreotide LAR therapy
throughout three pregnancies, with favorable delivery and
anthropometric measures for each newborn: a case report. Journal of
Medical Case Reports 2011 5:386.
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