thyroid - stimulating hormone ( tsh)-secreting pituitary adenoma ( tshoma ) , also called thyrotropinoma , comprises 2% of all pituitary adenomas . tshoma displays itself by hyperthyroidism symptoms most usually milder than the ones stemming from the thyroid or mass effects onto its neighbors . patients with this type of thyrotoxicosis can exhibit thyroid crisis because of stress or prior to surgery that must be intervened . antithyroid drugs such as thiamazole afford to control hyperthyroidism relevant to tshomas , but long - term use of these agents may induce expansion of the tumor over a negative feedback mechanism ending in a decrease of thyroid hormone levels . the concomitant mixed pituitary adenoma secreting growth hormone and prolactin at the same time complicate the condition in the existence of a tshoma accompanying thyroid disease . it acts over its receptors and these receptors are present in many tumors ( mainly neuroendocrine tumors ) and activated leukocytes of granulomatous and chronic inflammatory diseases . a 37-year - old female was examined with thyroid function tests because of vague exophthalmos at the 20 week of her pregnancy . free - t3 was found 8.96 pg / ml ( normal range : 2.3 - 4.2 pg / ml ) , free - t4 2.79 ng / dl ( normal range : 0.89 - 1.76 ng / dl ) , tsh 5.54 microiu / ml ( normal range : 0.35 - 5.5 microiu / ml ) , and alpha - subunit of tsh 32 miu / ml . because of this inappropriate tsh secretion , a contrast magnetic resonance ( mr ) imaging was requested for a possible tshoma . a macroadenoma of 13 mm  11 mm in size adjacent to optic chiasm was detected in pituitary gland on mr . she was treated by 3  50 mg / day of propylthiouracil orally and followed , for she did not accept the operation . she bore a healthy baby of full term and 3000 g in weight without any complication of this pituitary macroadenoma suspected of secreting tsh during her pregnancy and birth . these findings were strongly implying that macroadenoma in pituitary gland was a tsh - secreting tumor causing the hyperthyroidism symptoms of the patient . a solid thyroid nodule of 11 mm  10 mm in dimension , hypoactive on tc-99 m pertechnetate thyroid scintigraphy , was detected by ultrasonography and her tsh receptor antibody was 30 fine - needle aspiration biopsy of the nodule revealed oxyphilic changes ( bethesda 4 ) . indium-111 ( in-111 ) octreotide scintigraphy was performed to confirm the functional status of pituitary adenoma . focal uptake within sella turcica consistent with the pituitary adenoma on mr [ figure 1 ] was seen and no other pathologic finding was observed on whole - body screening . surgical specimen was confirmed as oxyphilic nodular goiter and graves disease pathologically [ figure 2a ] . immunohistochemical pathology reported the diagnosis as a tsh - secreting adenoma [ figure 2b ] . indium-111 octreotide single photon emission computed tomography shows focal uptake in sella turcica consistent with thyrotropinoma on coronal single photon emission computed tomography ( a ) , coronal magnetic resonance ( b ) , and fused images of indium-111 octreotide and magnetic resonance ( c ) graves disease and oxyphilic nodular goiter ( h and e , 20 ) ( a ) and pituitary thyrotroph adenoma ( h and e , 40 ) ( b ) octreotide is a somatostatin analog which can be easily labeled with in-111 and is primarily used to detect neuroendocrine tumors . coexistence of tshoma with graves disease is very rare and only six cases of such association with histological confirmation , all of whom are female , have been reported previously . our patient had signs of thyrotoxicosis , goiter , and exophthalmos with elevated thyroid hormone and tsh receptor antibodies , but normal tsh values . she was exhibiting all these typical diagnostic criteria and also had a mass in pituitary gland on mr strongly suggesting a thyrotropinoma . it was necessary to establish the functional status of this mass carrying strong evidence of tshoma . however , her pregnancy precluded all invasive imaging modality and surgical interventions . it is possible to show tshoma by in-111 octreotide scintigraphy if it is somatostatin receptor positive . as hyperthyroidism symptoms and abnormality of biochemical markers persisted at postpartum period , we decided to show the functional relation between the abnormal laboratory tests causing patient 's complaints and the mass by in-111 octreotide scintigraphy . proving of this mass as a functional tumor with a focal uptake within sella turcica led to an ultimate decision of surgery reinforcing the hand of physician . a different and interesting feature of our case is the concomitant existence of graves disease and thyrotropinoma , which is different than the previous 6 cases of thyrotropinoma in the literature . in routine management of such a patient , pituitary surgery for macroadenoma is performed first , total thyroidectomy is performed later . however , in this case , total thyroidectomy was performed first because of malignancy suspicion . in-111 octreotide scintigraphy may be useful in illumination of such masses in pituitary gland , particularly in association of tshoma with graves disease especially when tsh values are not compatible with either the clinical history or other thyroid functions tests .
thyroid - stimulating hormone - secreting pituitary adenoma ( tshoma ) is a rare benign endocrinological tumor which produces tsh in the pituitary gland . 
 herein , we presented a female patient having tshoma with graves disease during and just after pregnancy that we found by indium-111 octreotide scintigraphy while investigating the patient for hyperthyroidism symptoms .