Neurenteric cyst of the anterior cranial fossa: case report and literature review

Intracranial neurenteric cysts are rare congenital lesions that typically occur in the posterior fossa. We report a case of a 70-year-old gentleman presenting with gait disturbance, found to have a neurenteric cyst primarily arising from and expanding the sella turcica. A review of the literature revealed 27 reports of supratentorial neurenteric cysts. Clinical presentation, radiological characteristics, treatment, prognosis and embryological origin are discussed. Intracranial neurenteric cysts should be included in the differential with any well-demarcated cystic lesion without enhancement on magnetic resonance imaging (MRI). Complete surgical excision is the treatment of choice, with good prognosis.

Update in pituitary 2010

This manuscript is based on an invited lecture entitled "The Year in Pituitary," presented at the 91st Annual Meeting of The Endocrine Society in San Diego, California, on June 21, 2010. The purpose of the lecture was to highlight new or evolving issues in the management of pituitary disease. Papers selected were published in major journals between January 2009 and June 2010. Issues addressed include the safety of cabergoline in pregnancy, recurrence of hyperprolactinemia after dopamine agonist withdrawal, pegvisomant and hepatic dysfunction, and high-dose hydrocortisone as a predictor of mortality in patients with acromegaly.

Preoperative preparation of patients with pituitary gland disorders

This paper presents the most common disorders of pituitary function: acromegaly, hypopituitarism, diabetes insipidus and syndrome similar to diabetes insipidus, in terms of their importance in preoperative preparation of patients. Pituitary function manages almost the entire endocrine system using the negative feedback mechanism that is impaired by these diseases. The cause of acromegaly is a pituitary adenoma, which produces growth hormone in adults. Primary therapy of acromegaly is surgical, with or without associated radiotherapy. If a patient with acromegaly as comorbidity prepares for non-elective neurosurgical operation, then it requires consultation with brain surgeons for possible delays of that operation and primary surgical treatment of pituitary gland. If operative treatment of pituitary gland is carried out, the preoperative preparation (for other surgical interventions) should consider the need for perioperative glucocorticoid supplementation. Panhypopituitarism consequences are different in children and adults and the first step in diagnosis is to assess the function of target organs. Change of electrolytes and water occurs in the case of pituitary lesions in the form of central or nephrogenic diabetes insipidus as a syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Preoperative preparation of patients with pituitary dysfunction should be multidisciplinary, whether it is a neurosurgical or some other surgical intervention. The aim is to evaluate the result of insufficient production of pituitary hormones (hypopituitarism), excessive production of adenohypophysis hormones (acromegaly, Cushing's disease and hyperprolactinemia) and the influence of pituitary tumours in surrounding structures (compression syndrome) and to determine the level of perioperative risk. Pharmacological suppressive therapy of the hyperfunctional pituitary disorders can have significant interactions with drugs used in the perioperative period.

[Autoimmune hypophysitis]

Autoimmune hypophysitis (AH) - often referred to as lymphocytic hypophysitis - is a rare disease that affects the pituitary gland and causes inflammation. The disease enlarges the pituitary gland and the clinical presentations are lack of pituitary function and headaches. AH is mostly seen in women during pregnancy or postpartum, but also occurs in males and children. AH is often associated with other autoimmune diseases, most frequently with Hashimoto's thyroiditis. The symptoms are caused by enlargement of the pituitary gland and disturbances of the hormone function. Treatment is either immunosuppressive treatment or surgery.

Anti-CTLA-4 antibody therapy associated autoimmune hypophysitis: serious immune related adverse events across a spectrum of cancer subtypes

Anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4) therapies represent a novel approach to cancer treatment via disruption of immune tolerance to antigens located on tumor cells. Disruption of immune tolerance, however, may occur at a cost. A host of immune related adverse events (IRAEs) are associated with anti-CTLA-4 therapy. Autoimmune hypophysitis has been reported in up to 17% of patients with melanoma and renal cell carcinoma treated with this therapy. Familiarity with the spectrum of IRAEs connected to these therapies is paramount for endocrinologists, oncologists and those involved in the care of these subjects. We review here key aspects of diagnosis and treatment of anti-CTLA-4 antibody therapy resultant IRAEs. We describe the first two cases of hypopituitarism in prostate cancer subjects undergoing experimental therapy with ipilimumab. The clinical evidence strongly suggests that the prostate cancer subjects developed autoimmune hypophysitis as a consequence of anti-CTLA-4 treatment. High dose glucocorticoid treatment resulted in markedly improved symptoms, and resolution of focal symptoms and diabetes insipidus. One subject recovered pituitary-thyroid axis function after 9 months; however, both continue to require GC replacement. These cases highlight the importance of early screening and treatment for hypopituitarism in all subjects undergoing treatment with anti-CTLA-4 therapy to prevent a potentially fatal outcome from secondary adrenal insufficiency, a readily treatable disease. We recommend mandatory long term follow-up to monitor the development of other hormonal deficits.

[Pituitary disorders in pregnancy and after delivery]

Pregnancy is associated with a number of changes in endocrine physiology that substantially alter hormone levels and affect a number of disease processes. Consequently, both pregnancy and the postpartum period may influence the course of pre-existing pituitary disorders and lead to the development of those that are found exclusively or almost exclusively during these periods. Overlapping clinical and biochemical features of pregnancy sometimes cause that the diagnosis of pituitary disorders during pregnancy may be missed. Moreover, their clinical picture may range from non-specific symptoms to even life-threatening conditions, and the manifestation of the same pituitary disease often change from one patient to another. If not evaluated and managed appropriately, these disorders may negatively affect both mother and fetus. The purpose of this review is to provide an update on the pathophysiology, clinical picture, diagnosis and treatment of different pituitary disorders during pregnancy and after delivery. The reader is also provided with some practical recommendations on dealing with pregnant and nursing women suffering from these disorders.

Autoimmune hypophysitis: a single centre experience

INTRODUCTION

Autoimmune hypophysitis (AH) is a rare primary autoimmune inflammatory disorder involving the pituitary gland.

METHODS

A retrospective analysis of the clinical features and outcome of patients diagnosed with AH between 1988 and 2006, was carried out.

RESULTS

15 patients (14 females and one male) with AH were identified. Three patients presented in the peripartum period. Headache, vomiting and visual field defects, suggestive of an expanding sellar mass, were the most common presenting symptoms (67 percent). The most common deficient hormone was adrenocorticotropic hormone (ACTH) (67 percent), followed by thyroid stimulating hormone (53 percent) and gonadotropins (40 percent). Imaging revealed a definite, enhancing sellar mass in 87 percent of the patients and stalk thickening in 33 percent of the patients. Three patients underwent surgery. On serial monitoring, the sellar mass regressed or disappeared spontaneously without any immunosuppressive treatment in the other ten patients with a definite sellar mass.

CONCLUSION

We report a higher female to male ratio and a lower incidence of peripartum cases in our series. Symptoms of mass effect were the most common presentation, while ACTH was the most commonly-deficient hormone. Surgery was rarely needed, and most patients experienced a spontaneous resolution of the mass.

[Spontaneous pregnancy in a patient with lymphocytic hypophysitis]

Lymphocytic hypophysitis(LH) is a rare but increasingly recognized autoimmune endocrine condition that causes partial or total hypopituitarism and is often associated with peripartum young women. We here report a 28-year-old patient who had a spontaneous and uneventful pregnancy following LH that had been treated with transspenoidal surgery and followed by anti-inflammatory agent. The woman failed to lactate and developed frontal headaches 3 months after normal delivery of her first child 3 years ago. Lab test showed the reduced concentrations of thyroxine, estradial and cortisol, suggesting hypopituitarism. Magnetic resonance imaging of the brain with contrast was performed and showed a uniformly enhancing pituitary mass with elevated optic chiasm. She underwent transsphenoidal surgery and histological examination of the resected specimen was consistent with lymphocytic hypophysitis. Anti-inflamation was started with prednisolone 40 mg per day because of a recurrence of headache that had completely recovered after surgery and regularly withdrawn to a long term maintenance dose of 10 mg per day. Physiological thyroxine replacement therapy was maintained. Her menstruation was restored without sex hormone replacement after 3 months. Three years after surgery, she got pregnant spontaneously and had normal breastfeeding after delivery. LH did not recur during this peripartum.

Update in pituitary disease

The pituitary gland secretes vital trophic hormones that maintain homeostatic regulation of the metabolic milieu. Not surprisingly, several thousand papers relevant to the pituitary gland were published this past year, including publication of important transforming advances in our understanding of the pathogenesis, diagnosis, and treatment of pituitary disorders. In an attempt to focus on outstanding key articles reporting highlights of the year, quality inclusion criteria were applied. High-quality articles were selected for their translational impact, scientific advances, enrichment of new knowledge, influence on how we understand pituitary disorders, transformation of therapeutic principles, and opening up new research vistas. Using these selection criteria, highlighted papers within the following categorical topics were further selected for analysis and review: advances in understanding subcellular mechanisms subserving the pathogenesis of pituitary disorders including pituitary tumors and pituitary failure; new challenges facing the physician treating patients harboring prolactinomas with dopamine agonists; and the appearance of new publications reporting the efficacy of long-term prospective medical treatment of acromegaly that now provide more rigorous patient outcome information. Selected papers categorized by these topics all serve to significantly impact how the endocrinologist views disease pathogenesis, diagnosis, and treatment outcomes of patients with pituitary disease in 2007. The results of these publications have transformed our understanding of important principles underlying normal and abnormal pituitary function, as well as our approach to the management of pituitary disorders. Notably, they open up new vistas for creative scholarship in unraveling the challenges of pituitary medicine.

Pituitary abscess: a report of two cases

Pituitary abscess (PA) is an infrequent disease, which consists of an infection within the sella turcica that might be life-threatening. We present here two cases of this rare entity. Case 1: A 53-year-old woman was followed for an incidentally found pituitary cyst. Six years later the cyst enlarged and transsphenoidal surgery was performed. Two years later, the patient developed sudden onset of intense headache and nausea. The MRI showed a 2 by 2.5 cm sellar and suprasellar mass, that enhanced peripherally with gadolinium contrast and became hyperintense in T2-weighted images, suggesting a new-onset cystic lesion. During transsphenoidal surgery, large amounts of purulent material were drained from the sella. The cultures were positive for Klebsiella Ozaenae. Case 2: A 63-year-old woman, 4 years after transsphenoidal resection of a GH-secreting macroadenoma, developed a new sellar 2.6 cm cystic mass. On re-operation, purulent material was drained from the sella. The lesion persisted on the MRI and visual acuity worsened so a repeat pituitary decompression was carried out 6 months later, obtaining the same pathological results. Three years later, the MRI still shows the same mass. She feels well and her physical examination and clinical history are unremarkable. These cases illustrate the difficulties in the diagnosis and management of this rare entity.

Psychosocial impairment in patients treated for pituitary disease: a controlled study

OBJECTIVE

To verify whether patients with pituitary disorders in remission and on appropriate treatment display significant differences in psychological distress compared to healthy controls and other patients treated for nonpituitary endocrine disorders.

DESIGN

A single-centred, controlled study.

PATIENTS

Eighty-six outpatients cured or in remission for at least 9 months following appropriate treatment by surgery, irradiation and/or pharmacological interventions for pituitary disease were compared with 86 healthy subjects. A sample comprising 60 outpatients cured or in remission from nonpituitary endocrine disorders was also compared.

MEASUREMENTS

(1) A modified version of the Structural Clinical Interview for DSM-IV; (2) a shortened version of the structured interview for the Diagnostic Criteria for Psychosomatic Research (DCPR); (3) the Psychosocial Index (PSI); and (4) the Medical Outcomes Study (MOS) short form General Health Survey (SF-20) were employed.

RESULTS

Patients with pituitary disease displayed a higher prevalence of psychiatric disease (P < 0.001) compared to controls, but not when compared to nonpituitary endocrine patients. They also showed a higher prevalence of DCPR clusters compared to controls (P < 0.001), but not when compared to nonpituitary endocrine patients. At PSI and MOS (SF-20), patients with endocrine disease, whether pituitary or not, reported more psychological distress, and less well-being (P < 0.001) compared to controls.

CONCLUSIONS

At follow-up after appropriate treatment, we documented a high prevalence of psychopathology in patients with pituitary disease, which was however, similar to that found in nonpituitary endocrine patients. This is consistent with an increasing body of literature that reports difficulties in obtaining full recovery in patients treated for endocrine disorders.

Excess mortality in women with pituitary disease: a meta-analysis

BACKGROUND

Increased mortality has been reported in patients with pituitary disease, with some studies showing higher standard mortality rates (SMR) in women than in men.

OBJECTIVE

To assess overall SMR for men and women with benign pituitary disease without excessive ATCH or GH secretion and to investigate associations between SMR and time period of diagnosis.

DESIGN

From searches in PubMed, Embase and Web of Science databases, and reference lists of major reviews and original articles, we included original studies providing SMR values and 95% confidence intervals (CI) for men and women separately. Thirty articles were studied in detail. Six studies were eligible for the meta-analysis of sex-specific mortality, and seven for the analysis of association between SMR and diagnosis period.

RESULTS

Individual studies (total 5412 patients) reported total SMR values (men and women together) ranging from 1.21 to 3.80. SMR varied from 0.98 to 3.36 in men and from 2.11 to 4.54 in women. Weighted SMR values were significantly higher in women (2.80; CI 2.59-3.02) than in men (2.06; CI 1.94-2 20) (P < 0.0001). SMR was negatively correlated with first year of diagnosis in individual studies (partial correlation analysis controlling for sex, P = 0.017), and approached normal in recent studies in men but not in women.

CONCLUSIONS

In our meta-analysis of patients with pituitary disease without ACTH or GH excess, SMR was significantly higher in women than in men. SMR reached normal levels in men treated in recent decades, but remained elevated in women.

A case of lymphocytic panhypophysitis (LPH) during pregnancy

A 37-year-old pregnant woman developed continuous headache in the 10th week of pregnancy, followed by bilateral visual field defect and general malaise in the 24th week. The brain magnetic resonance imaging showed a pituitary mass. In laboratory examination, plasma concentration of free thyroxine, thyroid stimulating hormone (TSH), cortisol, and adrenocorticotropic hormone (ACTH) was low. General malaise vanished shortly after the replacement therapy of glucocorticoid and thyroid hormone, but partial central diabetes insipidus (CDI) appeared, which could be treated with desmopressin acetate (DDAVP). The visual field defect having enlarged, transsphenoidal surgery was performed in the 31st week of pregnancy. Adenohypophysis could be resected, and it showed infiltration of mature lymphocytes. After the surgery, the visual defect had improved, but hormone replacement was still necessary. She delivered a baby in the 38th week without any trouble. Provocative tests after delivery revealed a low response in TSH, prolactin (PRL), and follicle stimulating hormone (FSH). Hormone replacement and DDAVP administration was necessary in the same doses after delivery. The diagnosis was lymphocytic panhypophysitis (LPH). In the case of pregnant woman, LPH should be included in the differential diagnosis of pituitary mass for the fetomaternal safety.

Primary aspergillosis of the sphenoid sinus with pituitary invasion - a rare differential diagnosis of sellar lesions

Aspergillosis belongs to the group of mycotic diseases of paranasal sinuses. The invasive forms, and particularly the fulminant forms, are potentially fatal. Isolated aspergillosis of the sphenoid sinus or the clivus is a difficult diagnosis, since the often misleading clinical manifestations of this rare disease develop late. These patients become apparent by neurological signs such as cavernous sinus syndrome, pseudotumor of the pituitary or the orbit. Diagnosis is often made intra-operatively or on histological examination. We report a case of invasive aspergillosis uniquely involving the sellar area revealed by clinical features suggesting a pseudotumor of the pituitary. Although such lesions are almost always seen in immune suppressed subjects, in our case, the patient was immune competent and had no past history of sinusitis.The question of whether, and when to perform limited or extensive surgery remains an issue for discussion, owing to the rarity of this disease honed by lack of experience. It depends on several factors: the kind of disease, the immunity, the subtype of invasive fungal sinusitis and the degree of tissue invasion.

Pituitary transcription factors: from congenital deficiencies to gene therapy

Despite the existence of interspecies phenotypic variability, animal models have yielded valuable insights into human pituitary diseases. Studies on Snell and Jackson mice known to have growth hormone, prolactin and thyroid-stimulating hormone deficiencies involving the hypoplastic pituitary gland have led to identifying alterations of the pituitary specific POU homeodomain Pit-1 transcription factor gene. The human phenotype associated with rare mutations in this gene was found to be similar to that of these mice mutants. Terminal differentiation of lactotroph cells and direct regulation of the prolactin gene both require interactions between Pit-1 and cell type specific partners, including panpituitary transcriptional regulators such as Pitx1 and Pitx2. Synergistic activation of the prolactin promoter by Pitx factors and Pit-1 is involved not only in basal condition, but also in responsiveness to forskolin, thyrotrophin-releasing-hormone and epidermal growth factor. In corticotroph cells, Pitx1 interacts with Tpit. Tpit mutations have turned out to be the main molecular cause of neonatal isolated adrenocorticotrophin deficiency. This finding supports the idea that Tpit plays an essential role in the differentiation of the pro-opiomelanocortin pituitary lineage. The effects of Pit-1 are not restricted to hormone gene regulation because this factor also contributes to cell division and protects the cell from programmed cell death. Lentiviral vectors expressing a Pit-1 dominant negative mutant induced time- and dose-dependent cell death in somatotroph and lactotroph adenomas in vitro. Gene transfer by lentiviral vectors should provide a promising step towards developing an efficient specific therapeutic approach by which a gene therapy programme for treating human pituitary adenomas could be based.

A little learning

Diseases of the pituitary can have far-reaching effects but are often diagnosed late. The Society of Endocrinology offers a three-day specialist course. Education in endocrine disorders for nurses and doctors is lacking, with the exceptions of diabetes mellitus and thyroid disease. Specialist nurses are not always available.

McCune-Albright syndrome: growth hormone and prolactin hypersecretion

McCune-Albright syndrome (MAS) has a special interest for endocrinologists as its pathogenesis results in hypersecretion of hormones in peripheral endocrine tissues. This can be expressed as precocious puberty, mainly in girls, primary hyperthyroidism, growth hormone (GH) and/or prolactin excess, hyperparathyroidism and hypercortisolism. The incidence of GH excess among patients with MAS has been assessed as up to 21%. The pathogenesis of GH hypersecretion in MAS is not completely understood, whereas it seems to be different from the aetiology of acromegaly/gigantism in non-MAS patients. The clinical expression of GH excess can be masked because of precocious puberty or craniofacial fibrous dysplasia, indicating the necessity for screening. Medical treatment is usually the only option in MAS patients with GH excess, as transsphenoidal surgery is usually restricted due to massive thickening of the skull base, whereas radiotherapy is contraindicated due to probable higher predisposition to sarcomatous transformation. The use of bromocriptine, cabergoline and octreotide, or the combination of these, has shown variable results, whereas pegvisomant, a GH receptor antagonist, is a new promising option, although not yet used in patients with MAS.