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Guarda FJ, Yu X, Shiraliyeva N, Haines MS, Bradbury M, Saylor PJ, Nachtigall LB. GnRH agonist-associated pituitary apoplexy: a case series and review of the literature. Pituitary 2021; 24:681-689. [PMID: 33835355 DOI: 10.1007/s11102-021-01143-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To examine the clinical presentation and longitudinal outcome of Pituitary Apoplexy (PA) after gonadotropin-releasing hormone agonist (GnRHa) in a series of patients and compare to prior reports. METHODS A retrospective chart review was performed on seven patients receiving GnRHa who developed PA. Prior reported cases were analyzed. RESULTS Six men (median age 72 years) with prostate cancer and one woman (aged 22 years) undergoing oocyte donation presented with PA between 1990 and 2020. Most presented with within 24 h of the first dose, but two developed PA 1 to 5 months after GnRHa initiation. The main clinical manifestations were headache (100%), nausea and vomiting (86%). While no patients had a previously known pituitary tumor, all had imaging demonstrating sellar mass and/or hemorrhage at presentation. Among those surgically treated (5/7), 80% (4/5) of patients had pathologic specimens that stained positive for gonadotropins; the remaining patient's pathologic specimen was necrotic. At the time of PA, the most common pituitary dysfunction was hypocortisolism. Central adrenal insufficiency and central hypothyroidism were reversible in a subset. Pituitary imaging remained stable. CONCLUSIONS This is the first report of a case series with PA after GnRHa administration with longitudinal follow-up. Although infrequent, PA can be life-threatening and should be suspected among patients receiving GnRHa, with or without a known pituitary adenoma, who develop acute headache, nausea and/or vomiting. Since hypopituitarism was reversible in a subset, ongoing pituitary function testing may be indicated.
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Affiliation(s)
- Francisco J Guarda
- Department of Endocrinology and Center for Translational Endocrinology (CETREN-UC), School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Pituitary Tumor Program. Red de Salud UC-CHRISTUS, Santiago, Chile
| | - Xiaoling Yu
- Neuroendocrine Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, 100 Blossom Street, Cox140, Boston, MA, 02114, USA
| | - Naila Shiraliyeva
- Neuroendocrine Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, 100 Blossom Street, Cox140, Boston, MA, 02114, USA
| | - Melanie S Haines
- Neuroendocrine Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, 100 Blossom Street, Cox140, Boston, MA, 02114, USA
| | - Michael Bradbury
- Department of Ophthalmology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Philip J Saylor
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lisa B Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, 100 Blossom Street, Cox140, Boston, MA, 02114, USA.
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Raj R, Elshimy G, Jacob A, Arya PVA, Unnikrishnan DC, Correa R, Myint ZW. Pituitary apoplexy induced by gonadotropin-releasing hormone (GnRH) agonist administration for treatment of prostate cancer: a systematic review. J Cancer Res Clin Oncol 2021; 147:2337-2347. [PMID: 34156518 PMCID: PMC8236445 DOI: 10.1007/s00432-021-03697-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/14/2021] [Indexed: 11/07/2022]
Abstract
Objective We aimed to review of literature on the clinical presentation, management and outcomes of pituitary apoplexy following gonadotrophic release hormone (GnRH) agonist administration for the treatment of prostate cancer. Methods We used PRISMA guidelines for our systematic review and included all English language original articles on pituitary apoplexy following GnRH agonist administration among prostate cancer patients from Jan 1, 1995 to Dec 31, 2020. Data on patient demographics, prostate cancer type, Gleason score at diagnosis, history of pituitary adenoma, clinical presentation, GnRH agonist, interval to pituitary apoplexy, laboratory evaluation at admission, radiologic findings, treatment of pituitary apoplexy, time to surgery if performed, pathology findings, and clinical/hormonal outcomes were collected and analyzed. Results Twenty-one patients with pituitary apoplexy met our inclusion criteria. The mean age of patients was 70 (60–83) years. Leuprolide was the most common used GnRH agonist, used in 61.9% of patients. Median duration to symptom onset was 5 h (few minutes to 6 months). Headache was reported by all patients followed by ophthalmoplegia (85.7%) and nausea/vomiting (71.4%). Three patients had blindness at presentation. Only 8 cases reported complete anterior pituitary hormone evaluation on presentation and the most common endocrine abnormality was FSH elevation. Tumor size was described only in 15 cases and the mean tumor size was 26.26 mm (18–48 mm). Suprasellar extension was the most common imaging finding seen in 7 patients. 71.4% of patients underwent pituitary surgery, while 23.8% were managed conservatively. Interval between symptoms onset to pituitary surgery was 7 days (1–90 days). Gonadotroph adenoma was most common histopathologic finding. Clinical resolution was comparable, while endocrine outcomes were variable among patients with conservative vs surgical management. Conclusion Although the use of GnRH agonists is relatively safe, it can rarely lead to pituitary apoplexy especially in patients with pre-existing pituitary adenoma. Physicians should be aware of this complication as it can be life threatening. A multidisciplinary team approach is recommended in treating individuals with pituitary apoplexy.
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Affiliation(s)
- Rishi Raj
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Pikeville Medical Center, Pikeville, KY, 41501, USA
| | - Ghada Elshimy
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Augusta University, Augusta, GA, 39012, USA
| | - Aasems Jacob
- Department of Internal Medicine, University of Kentucky, 800 Rose Street, Room No. CC 402, Lexington, KY, 40536, USA.
| | - P V Akhila Arya
- Department of Medicine, Government Medical College, Calicut, Kerala, 673008, India
| | - Dileep C Unnikrishnan
- Department of Critical Care Medicine, Cloudphysician Healthcare, 7 Bellary Road, Ganganagar, Bengaluru, 560032, India
| | - Riccardo Correa
- Division of Endocrinology, Diabetes, and Metabolism, Phoenix VAMC and University of Arizona College of Medicine-Phoenix, Phoenix, AZ, 85012, USA
| | - Zin W Myint
- Division of Medical Oncology, Department of Internal Medicine, University of Kentucky, Lexington, KY, 40536, USA
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Barbosa M, Paredes S, Machado MJ, Almeida R, Marques O. Pituitary apoplexy induced by gonadotropin-releasing hormone agonist administration: a rare complication of prostate cancer treatment. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200018. [PMID: 32554827 PMCID: PMC7354737 DOI: 10.1530/edm-20-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/06/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Gonadotropin-releasing hormone (GnRH) agonists, currently used in the treatment of advanced prostate cancer, have been described as a rare cause of pituitary apoplexy, a potentially life-threatening clinical condition. We report the case of a 69-year-old man with a known pituitary macroadenoma who was diagnosed with prostate cancer and started treatment with GnRH agonist leuprorelin (other hormones were not tested before treatment). Few minutes after drug administration, the patient presented with acute-onset severe headache, followed by left eye ptosis, diplopia and vomiting. Pituitary MRI revealed tumor enlargement and T1-hyperintense signal, compatible with recent bleeding sellar content. Laboratory endocrine workup was significant for low total testosterone. The patient was managed conservatively with high-dose steroids, and symptoms significantly improved. This case describes a rare phenomenon, pituitary apoplexy induced by GnRH agonist. We review the literature regarding this condition: the pathophysiological mechanism involved is not clearly established and several hypotheses have been proposed. Although uncommon, healthcare professionals and patients should be aware of this complication and recognize the signs, preventing a delay in diagnosis and treatment. LEARNING POINTS Pituitary apoplexy (PA) is a potentially life-threatening complication that can be caused by gonadotropin-releasing hormone agonist (GnRHa) administration for the treatment of advanced prostate cancer. This complication is rare but should be taken into account when using GnRHa, particularly in the setting of a known pre-existing pituitary adenoma. PA presents with classic clinical signs and symptoms that should be promptly recognized. Patients should be instructed to seek medical care if suspicious symptoms occur. Healthcare professionals should be aware of this complication, enabling its early recognition, adequate treatment and favorable outcome.
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Affiliation(s)
- Mariana Barbosa
- Department of Endocrinology, Hospital de Braga, Braga, Portugal
| | - Sílvia Paredes
- Department of Endocrinology, Hospital de Braga, Braga, Portugal
| | | | - Rui Almeida
- Department of Neurosurgery, Hospital de Braga, Braga, Portugal
- Pituitary Consult, Hospital de Braga, Braga, Portugal
| | - Olinda Marques
- Department of Endocrinology, Hospital de Braga, Braga, Portugal
- Pituitary Consult, Hospital de Braga, Braga, Portugal
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Tanios G, Mungo NA, Kapila A, Bajaj K. Pituitary apoplexy: a rare complication of leuprolide therapy in prostate cancer treatment. BMJ Case Rep 2017; 2017:bcr-2016-218514. [PMID: 28710301 DOI: 10.1136/bcr-2016-218514] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Gonadotropin-releasing hormone agonists, used widely in the treatment of metastatic prostate cancer and hormone receptor-positive breast cancer, are associated with a rare but potentially fatal outcome of pituitary apoplexy (PA). An 85-year-old man presented with sudden onset of headache, left eye pain, sensitivity to light, nausea and vomiting. The symptoms started 4 hours after initiation of leuprolide therapy for treatment of recently diagnosed metastatic prostate carcinoma. Radiological imaging of the brain demonstrated a heterogeneously enlarged pituitary gland measuring 19×16×13 mm and T1-hyperintense signal compatible with pituitary haemorrhage. Hormone function tests were indicative of panhypopituitarism, confirming the diagnosis of PA. Due to age, the patient was started on hormonal replacement therapy and eventually symptoms improved.
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Affiliation(s)
- Georges Tanios
- Internal Medicine, East Tennessee State University, Johnson city, Tennessee, USA
| | | | - Aaysha Kapila
- Internal Medicine, East Tennessee State University, Johnson city, Tennessee, USA
| | - Kailash Bajaj
- Internal Medicine, East Tennessee State University, Johnson city, Tennessee, USA
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Abstract
Pituitary apoplexy, a rare clinical syndrome secondary to abrupt hemorrhage or infarction, complicates 2%-12% of pituitary adenomas, especially nonfunctioning tumors. Headache of sudden and severe onset is the main symptom, sometimes associated with visual disturbances or ocular palsy. Signs of meningeal irritation or altered consciousness may complicate the diagnosis. Precipitating factors (increase in intracranial pressure, arterial hypertension, major surgery, anticoagulant therapy or dynamic testing, etc) may be identified. Corticotropic deficiency with adrenal insufficiency may be life threatening if left untreated. Computed tomography or magnetic resonance imaging confirms the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. Formerly considered a neurosurgical emergency, pituitary apoplexy always used to be treated surgically. Nowadays, conservative management is increasingly used in selected patients (those without important visual acuity or field defects and with normal consciousness), because successive publications give converging evidence that a wait-and-see approach may also provide excellent outcomes in terms of oculomotor palsy, pituitary function and subsequent tumor growth. However, it must be kept in mind that studies comparing surgical approach and conservative management were retrospective and not controlled.
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Affiliation(s)
- Claire Briet
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Sylvie Salenave
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Jean-François Bonneville
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Edward R Laws
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Philippe Chanson
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
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Raverot G, Assié G, Cotton F, Cogne M, Boulin A, Dherbomez M, Bonneville JF, Massart C. Biological and radiological exploration and management of non-functioning pituitary adenoma. ANNALES D'ENDOCRINOLOGIE 2015; 76:201-9. [DOI: 10.1016/j.ando.2015.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 04/29/2015] [Indexed: 11/29/2022]
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7
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Sasagawa Y, Tachibana O, Nakagawa A, Koya D, Iizuka H. Pituitary apoplexy following gonadotropin-releasing hormone agonist administration with gonadotropin-secreting pituitary adenoma. J Clin Neurosci 2014; 22:601-3. [PMID: 25455737 DOI: 10.1016/j.jocn.2014.08.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 08/03/2014] [Indexed: 02/06/2023]
Abstract
Gonadotropin-releasing hormone (GnRH) agonists are widely used in hormone therapy for prostate cancer. We report a patient with pituitary apoplexy following this therapy as a rare complication and review the related literature. A 62-year-old man presented with elevated prostate specific antigen. Transrectal ultrasound guided biopsy of the prostate gland revealed adenocarcinoma. Whole-body (18)F-fluorodeoxyglucose (FDG) positron emission tomography/CT scan showed FDG-uptake in the pituitary region. MRI also demonstrated a pituitary tumor, diagnosed as an incidental non-functioning adenoma. The patient received his first dose of GnRH agonist (leuprolide 11.25mg) against prostate cancer. He complained of a severe headache 10 minutes after leuprolide administration and suffered from right third nerve palsy in the next 48 hours. MRI demonstrated a high intensity area on T1-weighted images, diagnosed as pituitary apoplexy. The patient underwent transsphenoidal surgery. Pathology revealed predominantly necrotic tissue and a gonadotropin secreting pituitary adenoma. Overall, 15 patients, including ours, have been reported with pituitary apoplexy after GnRH agonists with pathologic gonadotropin secreting adenoma. Fourteen of 15 patients were male. Pituitary apoplexy developed within 4 hours after administration of the agents in 8/15 patients. The combined data suggest that GnRH agonists have the potential to precipitate pituitary apoplexy in men with gonadotropin secreting adenoma. Therefore, prior to GnRH agonist therapy for prostate cancer, a known pituitary adenoma should be treated. Otherwise, the patients should be cautiously observed for any symptomatic change following drug administration.
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Affiliation(s)
- Yasuo Sasagawa
- Department of Neurosurgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada 920-0293, Ishikawa, Japan.
| | - Osamu Tachibana
- Department of Neurosurgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada 920-0293, Ishikawa, Japan
| | - Atsushi Nakagawa
- Department of Diabetology and Endocrinology, Kanazawa Medical University, 1-1 Daigaku, Uchinada 920-0293, Ishikawa, Japan
| | - Daisuke Koya
- Department of Diabetology and Endocrinology, Kanazawa Medical University, 1-1 Daigaku, Uchinada 920-0293, Ishikawa, Japan
| | - Hideaki Iizuka
- Department of Neurosurgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada 920-0293, Ishikawa, Japan
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Babbo A, Kalapurakal GT, Liu B, Bajramovic S, Chandler JP, Garnett J, Kalapurakal JA. The presence of a pituitary tumor in patients with prostate cancer is not a contraindication for leuprolide therapy. Int Urol Nephrol 2014; 46:1775-8. [DOI: 10.1007/s11255-014-0708-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
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9
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Huang TY, Lin JP, Lieu AS, Chen YT, Chen HS, Jang MY, Shen JT, Wu WJ, Huang SP, Juan YS. Pituitary apoplexy induced by Gonadotropin-releasing hormone agonists for treating prostate cancer-report of first Asian case. World J Surg Oncol 2013; 11:254. [PMID: 24088191 PMCID: PMC3851712 DOI: 10.1186/1477-7819-11-254] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 09/19/2013] [Indexed: 12/31/2022] Open
Abstract
We present the first Asian case of a 77-year-old man who developed pituitary apoplexy (PA) soon after gonadotropin-releasing hormone agonist (GnRHa) (leuprorelin) injection to treat prostate cancer. Headache, ophthalmoplegia, visual field deficit, nausea, and vomiting are the typical characteristics of pituitary apoplexy. Though the occurrence rate is rare, the consequence of this condition can vary from mild symptoms such as headache to life-threatening scenarios like conscious change. Magnetic resonance imaging is the best imaging modality to detect PA and sublabial trans-sphenoid pituitary tumor removal can resolve most of PA symptoms and is so far the best solution in consensus. We also review 11 previous reported cases receiving GnRHa for androgen deprivation therapy of prostate cancer, and hope to alert clinicians to use GnRHa with caution.
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Affiliation(s)
- Tsung-Yi Huang
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100 Tz-You 1st Road, Kaohsiung, Taiwan.
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10
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Ito Y. Unexpected enlargement of clinically silent pituitary gonadotroph adenoma induced by goserelin acetate given as treatment for prostate cancer. Int J Urol 2010; 18:83-4. [DOI: 10.1111/j.1442-2042.2010.02676.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sinnadurai M, Cherukuri R, Moses R, Nasser E. Delayed pituitary apoplexy in patient with advanced prostate cancer treated with gonadotrophin-releasing hormone agonists. J Clin Neurosci 2010; 17:1201-3. [DOI: 10.1016/j.jocn.2010.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 12/27/2009] [Accepted: 01/04/2010] [Indexed: 10/19/2022]
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12
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Guerra Y, Lacuesta E, Marquez F, Raksin PB, Utset M, Fogelfeld L. Apoplexy in non functioning pituitary adenoma after one dose of leuprolide as treatment for prostate cancer. Pituitary 2010; 13:54-9. [PMID: 19842040 DOI: 10.1007/s11102-009-0202-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We report the case of a 60 year old male who complained of headache and blurry vision--that progressed to left ophthalmoplegia and ptosis--after receiving a dose of leuprolide for Prostate cancer therapy. Imaging showed a hemorrhagic sellar mass. The patient underwent transsphenoidal debulking, and the tissue obtained demonstrated immunohistochemical staining for LH. A literature review revealed nine previously reported cases of pituitary apoplexy after GnRH agonist therapy for prostate cancer. In most cases, the sellar tissues stained for LH, consistent with a gonadotropinoma. The pathophysiology of these events is unclear, but recent animal models suggest possible explanations. The predominance of gonadotropinomas is important because they do not usually present with hypersecretory symptoms. Particular attention to clinical findings suggestive of a non functioning pituitary tumor in patients receiving GnRH agonist therapy is critical as routine screening with MRI is not practical.
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Affiliation(s)
- Yannis Guerra
- Hospital of Cook County/Rush University Medical Center, Chicago, IL, USA.
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13
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Burgos J, Cobos P, Vidaurrazaga N, Prieto B, Ocerin I, Matorras R. Ovarian hyperstimulation secondary to ectopic secretion of follicle-stimulating hormone. Literature review prompted by a case. Fertil Steril 2009; 92:1168.e5-1168.e8. [PMID: 19608176 DOI: 10.1016/j.fertnstert.2009.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Revised: 06/07/2009] [Accepted: 06/08/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To present an exceptional clinical case of functional follicle-stimulating gonadotropin secretion by a thorax neuroendocrine carcinoid tumor. DESIGN Case report. SETTING Department of Obstetrics and Gynecology, Cruces University Hospital, Vizcaya, Spain. PATIENT(S) A 26-year-old woman with ovarian hyperstimulation. INTERVENTION(S) Diagnosis algorithm. MAIN OUTCOME MEASURE(S) Successful management of ovarian hyperstimulation. RESULT(S) A 26-year-old woman seen with abdominal pain and swelling had bilateral multicystic ovaries. The diagnosis algorithm revealed the presence of ovarian hyperstimulation but with no due etiology. On the basis of the persistence of high levels of FSH a computed tomographic scan was taken looking for an FSH-producing neuroendocrine tumor. CONCLUSION(S) In idiopathic ovarian hyperstimulation secondary to supraphysiologic secretion of FSH, the presence of an FSH-producing neuroendocrine tumor should be considered. As far as we know, there are no similar cases with a confirmed diagnosis published in the literature.
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Affiliation(s)
- Jorge Burgos
- Human Reproduction Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain; School of Medicine, Universidad del País Vasco, Vizcaya, Spain.
| | - Patricia Cobos
- Human Reproduction Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain
| | - Nerea Vidaurrazaga
- School of Medicine, Universidad del País Vasco, Vizcaya, Spain; Department of Anatomopathology, Hospital de Cruces, Vizcaya, Spain
| | - Begoña Prieto
- Human Reproduction Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain
| | - Iratxe Ocerin
- School of Medicine, Universidad del País Vasco, Vizcaya, Spain; Endoscopy Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain
| | - Roberto Matorras
- Human Reproduction Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain; School of Medicine, Universidad del País Vasco, Vizcaya, Spain
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Semple PL, Jane JA, Laws ER. Clinical relevance of precipitating factors in pituitary apoplexy. Neurosurgery 2008; 61:956-61; discussion 961-2. [PMID: 18091272 DOI: 10.1227/01.neu.0000303191.57178.2a] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The pathogenesis of pituitary apoplexy and the role of precipitating factors in pituitary apoplexy are poorly understood. Most of the published cases are in the form of case reports. We assessed the presumed precipitating factors in a series of patients treated surgically for pituitary apoplexy and reviewed the contemporary published literature. METHOD Thirty-eight consecutive patients with pituitary apoplexy were treated surgically by the Department of Neurosurgery at the University of Virginia, Charlottesville, VA, between January 1996 and March 2006. Their medical records were retrospectively reviewed. Contemporary published cases from 1990 to 2006 were also reviewed. RESULTS Nine patients (24%) were identified as having precipitating factors for pituitary apoplexy. The factors identified were coronary artery surgery (two patients), other major surgery (two patients), pregnancy (two patients), gamma knife irradiation, anticoagulant therapy, and coagulopathy secondary to liver failure. The presentation, histology, and outcome were compared between those patients with a precipitating factor and those in whom none was identified. A review of the published literature showed that coronary artery surgery, pituitary stimulation, and coagulopathy were the most common precipitating factors. CONCLUSION A minority of patients with pituitary apoplexy will have precipitating factors. The majority of patients with precipitating factors will have histopathology showing hemorrhagic infarction or hemorrhage. The most common precipitating factors are pituitary stimulation, surgery, particularly coronary artery surgery, and coagulopathy. Caution in doing endocrine investigation, surgery, or anticoagulation in patients with a known pituitary tumor is advised. Patients with no diagnosed pituitary tumor but with a known precipitating factor who have neuro-ophthalmological deterioration or endocrine failure should undergo prompt magnetic resonance image scans and endocrine investigation and endocrine replacement as indicated.
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Affiliation(s)
- Patrick L Semple
- Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
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15
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Hands KE, Alvarez A, Bruder JM. Gonadotropin-releasing hormone agonist-induced pituitary apoplexy in treatment of prostate cancer: case report and review of literature. Endocr Pract 2008; 13:642-6. [PMID: 17954421 DOI: 10.4158/ep.13.6.642] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe a case and review the literature on the rare complication of pituitary apoplexy after administration of a gonadotropin-releasing hormone agonist (GnRHa) for treatment of patients with prostate cancer. METHODS We present a detailed case report of a patient with immediate signs of pituitary apoplexy after receiving a GnRHa and review the 6 previously reported cases in the literature. A 60-year-old man presented to a local hospital with severe headache, nausea, vomiting, and diplopia. Prostate cancer had recently been diagnosed, and he had received his first dose of a GnRHa 4 hours before this presentation. On physical examination, he was confused and had ptosis of the left eye. A head computed tomographic scan without contrast enhancement showed soft tissue filling the sella, without intracranial hemorrhage or mass effect. He was discharged with the diagnosis of viral meningitis. Three weeks later, he presented again with severe headache and diplopia. He had confusion, lethargy, disorientation, a blood pressure of 88/64 mm Hg, and left cranial nerve III, IV, and VI paralysis. Magnetic resonance imaging of the brain revealed an enhancing pituitary mass with hemorrhage extending to the optic chiasm, consistent with pituitary apoplexy. Laboratory results were consistent with panhypopituitarism. Surgical excision revealed a necrotic pituitary macroadenoma with hemorrhage. Tumor immunohistochemical staining was positive only for luteinizing hormone. CONCLUSION We describe a rare adverse effect of GnRHa therapy, which unmasked a gonadotropin-secreting pituitary macroadenoma. This case adds to the 6 previously reported cases of GnRHa administration inducing pituitary apoplexy in men with prostate cancer.
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Affiliation(s)
- Kathleen E Hands
- Department of Medicine, Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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16
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Dubuisson AS, Beckers A, Stevenaert A. Classical pituitary tumour apoplexy: clinical features, management and outcomes in a series of 24 patients. Clin Neurol Neurosurg 2006; 109:63-70. [PMID: 16488532 DOI: 10.1016/j.clineuro.2006.01.006] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Revised: 01/13/2006] [Accepted: 01/16/2006] [Indexed: 11/18/2022]
Abstract
We retrospectively analysed the incidence, clinical presentation, endocrinological and radiological findings, medical and surgical management of pituitary apoplexy in our department (single-centre study), having a large experience in pituitary surgery. Among 1540 pituitary lesions, 24 patients presented with pituitary apoplexy. Their charts were retrospectively reviewed. The symptoms included headache (92%), nausea and vomiting (54%), visual deficit (50%), oculomotor paresis (54%) and/or an altered mental state (42%). Skull X-rays (n = 14) demonstrated an enlarged sella turcica in all cases; CT-scan and/or MRI always revealed a sellar and suprasellar expanding lesion. Panhypopituitarism was present on admission in 70% of the patients. Urgent therapeutic management included high-dose cortisone treatment in all but one patients and CSF drainage in three. Three patients were treated conservatively. Nine patients were operated on rapidly, within hours or a few days because of severe visual deficit and/or altered level of consciousness. Nineteen patients were operated by the trans-sphenoidal approach; one of them required a second operation by craniotomy. There were two deaths related to the illness and one to an ill-defined reason at 4 months. Among the other patients 95% made a good recovery. All but two patients required a substitutive treatment with adrenal (83%), thyroid (68%), gonadal (42%) and/or growth (16%) hormones. The preoperative visual deficits recovered in all but one patients (92%) whereas the oculomotor pareses improved in all but two patients (85%). In conclusion, pituitary tumour apoplexy is a rare event, complicating in our series 1.6% of 1540 pituitary adenomas. Even in severe cases, complete recovery is possible if the diagnosis is rapidly obtained and adequate management is initiated in time. Surgical results after trans-sphenoidal approach are in the majority of cases very satisfactory.
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Affiliation(s)
- Annie S Dubuisson
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium.
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17
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Abstract
Clinically unsuspected pituitary adenomas are common among adults on autopsy and MRI survey. Acute pituitary hemorrhage is far more rare. We report a case of a 61-year-old male patient with locally advanced prostate cancer who presented with an acute picture of pituitary apoplexy after his first dose of leuprolide. He developed headache and neck pain within a few hours of treatment followed by nausea, vomiting, ptosis and diplopia. Pituitary apoplexy is a potentially life threatening medical emergency. Although the pathophysiology is poorly defined, various conditions and treatments have been reported to trigger apoplexy. Apoplexy has been reported in response to pituitary stimulation by GnRH or GnRH-agonists. Initial stimulatory effects of gonadotropin releasing hormone (GnRH) analogue may induce apoplexy in patients with asymptomatic gonadotroph adenomas.
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Affiliation(s)
- Anu Davis
- University of Texas Health Science Center - Houston, 6431 Fannin, MSB 4.202, Houston, TX 77030, USA.
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18
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Affiliation(s)
- Andy Levy
- University Research Centre for Neuroendorinology, Bristol Royal Infirmary, Division of Medicine, Bristol, UK.
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19
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Eaton HJ, Phillips PJ, Hanieh A, Cooper J, Bolt J, Torpy DJ. Rapid onset of pituitary apoplexy after goserelin implant for prostate cancer: need for heightened awareness. Intern Med J 2001; 31:313-4. [PMID: 11512605 DOI: 10.1046/j.1445-5994.2001.00065.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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20
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21
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Lahlou N, Carel JC, Chaussain JL, Roger M. Pharmacokinetics and pharmacodynamics of GnRH agonists: clinical implications in pediatrics. J Pediatr Endocrinol Metab 2000; 13 Suppl 1:723-37. [PMID: 10969915 DOI: 10.1515/jpem.2000.13.s1.723] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Since 1981, GnRH agonist administration has been the treatment of choice for central precocious puberty. Continuous administration of the agonist, instead of permanently stimulating gonadotropin secretion, deeply suppresses LH and FSH levels and induces a marked inhibition of gonadal activity and regression of clinical symptoms. This inhibitory effect is due both to specific kinetic parameters relative to natural GnRH, and to marked alterations of the biosynthetic pathways of gonadotropin subunits. The half disappearance time of infused agonists is 3-10 fold that of natural GnRH. This means that the residence time of GnRH agonists is significantly longer than that of GnRH. The resistance of agonist to enzymatic degradation, mainly due to the substitution of a hydrophobic D-amino acid for glycine 6, is one of the factors involved in the increased availability of GnRH superagonists. The paradoxical effects of GnRH superagonists are still incompletely understood. In children long-term treated with depot formulations of triptorelin or leuprorelin, alpha-subunit secretion is markedly increased, and remains sensitive to exogenous GnRH, which demonstrates that the gonadotrophs are not totally desensitized. Despite the sustained stimulation of a-subunit secretion, no deleterious side effects, either during therapy or during post-therapy follow-up, have been reported in children treated with GnRH agonists. It should be noted that alpha-subunit responsiveness to exogenous GnRH decreases progressively after several years of treatment, although it is never completely abolished. On the other hand, LH beta-subunit secretion is suppressed as evidenced by radioimmunoassay of LH beta-subunit in serum chromatographic fractions from children treated with triptorelin. This differential pattern of secretion parallels that of mRNA levels in rat pituitary after in vivo exposure to triptorelin. Both pharmacodynamic and pharmacokinetic data can help diagnose the situations of resistance or escape. The lack of clinical effect of GnRH in the treatment of precocious puberty can be due to true resistance, or to an inappropriate injection schedule, or to abnormal metabolism. Measurement of serum alpha-subunit level, and, if needed, of serum agonist level, generally provides the answer.
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Affiliation(s)
- N Lahlou
- Department of Biochemistry, Hôpital Saint-Vincent-de-Paul, Paris, France
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22
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Foppiani L, Piredda S, Guido R, Spaziante R, Giusti M. Gonadotropin-releasing hormone-induced partial empty sella clinically mimicking pituitary apoplexy in a woman with a suspected non-secreting macroadenoma. J Endocrinol Invest 2000; 23:118-21. [PMID: 10800766 DOI: 10.1007/bf03343690] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pituitary apoplexy has been reported as a rare complication of dynamic testing used for the study of pituitary functional reserve. In 1993, a diagnosis of non-secreting macroadenoma with moderate functional hyperprolactinaemia was made in a 43-year-old woman. Soon after the start of therapy with bromocriptine up to 5 mg/die, the patient complained of nausea and postural hypotension. As the symptoms persisted even when the dose was reduced to 2.5 mg/die, the patient was transferred to therapy with quinagolide at the dosage of 37.5 microg/die. PRL levels quickly normalized (range 1.4-5.7 ng/ml) as well as menstrual cycles, and no side-effect was reported. In 1995 a sellar magnetic resonance imaging (MRI) showed no shrinkage of the known macroadenoma. In 1996, few hours after a gonadotropin-releasing-hormone (GnRH) test, which showed normal LH and FSH response and with baseline PRL levels in the normal range, the patient started complaining of severe frontal headache, nausea and vomiting. No gross visual defects were present. An emergency computed tomography (CT) showed no evident hemorrhagic infarction in the macroadenoma. The symptoms completely resolved in few days with steroidal and antiemetic therapy. A new MRI performed in 1998 showed a partial empty sella and PRL levels were in the normal range under dopaminergic treatment. The pituitary functional reserve proved normal on dynamic testing. The temporal association between the onset of symptoms and the GnRH test strongly suggests an association between the two events. No evident signs of pituitary apoplexy (either on emergency CT or hormonal evaluation) were detected. The authors suggest that GnRH can cause severe side-effects that mimic pituitary apoplexy without related morphological evidence and that, in our particular case, it can have caused the gradual disappearance of the non-secreting macroadenoma. Moreover, a causal role of the chronic dopaminergic treatment cannot be completely ruled out.
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Affiliation(s)
- L Foppiani
- DiSEM, Cattedra di Endocrinologia, Università di Genova, Italy
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23
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Takai Y, Tsutsumi O, Momoeda M, Osuga Y, Sadatsuki M, Kaibara M, Taketani Y. Non-functioning pituitary tumour after long-term treatment with gonadotrophin-releasing hormone agonists in a patient with vaginal agenesis who underwent neovaginoplasty and cauterization of endometriosis under laparoscopy. Hum Reprod 1999; 14:2661-4. [PMID: 10528004 DOI: 10.1093/humrep/14.10.2661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Vaginal agenesis combined with a functional uterus is a rare condition in which treatment modalities that preserve reproductive function are controversial. A 21 year old female presented with congenital vaginal agenesis combined with cervical atresia. She was treated with gonadotrophin-releasing hormone (GnRH) agonists for a total period of over 5 years when a non-functioning pituitary tumour was detected by brain magnetic resonance imaging (MRI). A laparoscopically assisted reconstruction of a neovagina and neoendocervical canal was performed utilizing lyophilized porcine dermal skin to line the neovagina. Endometriosis of the pelvis was revealed and adhesiolysis and cauterization were also carried out under laparoscopy. The GnRH agonist was discontinued and the patient resumed cyclic menses with no abdominal pain. The pituitary tumour decreased in size 6 months after the cessation of GnRH agonists. We raise the question as to whether pituitary MRI should be performed for patients who need long-term administration of GnRH agonists.
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Affiliation(s)
- Y Takai
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
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