Symptomatic pituitary metastases from renal cell carcinoma

Pituitary metastases: a case series and scoping review

PURPOSE

To understand the natural history and optimal treatment strategy for pituitary gland metastasis.

METHODS

We performed both a retrospective chart review of patients treated at our institution and a scoping review of the topic.

RESULTS

The retrospective review identified seven patients with an average age of 59.6 years. Primary histologies included breast cancer (4), melanoma (1), renal cell carcinoma (1), and sarcoma (1). Two patients had anterior pituitary endocrine dysfunction, one of whom was the only patient with visual symptoms. All patients were treated with radiosurgery and two also underwent surgical resection. Overall survival ranged from 6.5 to 117 months. Literature review identified 166 patients from 71 studies. The most common primary cancer was lung (27.7%), followed by breast (18.7%) and renal (14.5%) cancer. 107 presented with endocrine dysfunction, including 41 cases of diabetes insipidus and 55 cases of hypopituitarism. 110 presented with visual compromise. 107 patients received radiotherapy, 96 underwent surgical resection and 44 received systemic chemotherapy/immunotherapy. Surgery was significantly associated with an increased likelihood of vision improvement and a decreased likelihood of endocrine normalization. Radiographic regression predicted visual improvement. Median overall survival was 9.9 months (range: 0.2-96).

CONCLUSIONS

This scoping review showed that both radiosurgery and surgical resection have been frequently used to treat pituitary metastases with good response. Vision improvement is more likely to happen following surgical resection, likely at the expense of endocrine dysfunction. Despite treatment and radiographic response, patient survival remains less than a year.

Endoscopic Endonasal Surgery for Uncommon Pathologies of the Sellar and Parasellar Regions

Endoscopic skull base surgery has become an integral part of the present neurosurgical armamentarium. The pioneering efforts in which the purely endoscopic transsphenoidal approach was introduced have triggered a growing tide of using the endoscopic endonasal procedures for a large variety of skull base lesions. Because of their anatomical peculiarities, lesions of the sellar and parasellar regions lend themselves very well to the endoscopic endonasal approaches. Apart from the common pathological entities, many other less frequent pathologies are encountered in the sellar and parasellar area. In this chapter, we review the surgical technique of the endoscopic endonasal transsphenoidal approach and its extensions applied to a variety of rare and uncommon pathological entities involving the sella turcica and clivus. An overview of these pathological entities is also presented and exemplified.

Isolated Pituitary Metastasis of Renal Cell Carcinoma: A Case Report and Systematic Review of the Literature

BACKGROUND

Isolated pituitary gland metastasis is an extremely rare event in renal cell carcinoma. We present a unique case of isolated pituitary metastasis of renal cell carcinoma and a systematic review of literature on it.

CASE REPORT

In this case, an abdominal ultrasound in an asymptomatic 51-year-old female patient showed a mass in her left kidney. Radical nephrectomy was performed and the tumor was diagnosed as a stage 1 clear cell carcinoma. Throughout the 3 months of the follow-up period, the patient started complaining of visual disturbances and headaches. A pituitary mass was found on brain magnetic resonance imaging and was suspected to be a macroadenoma. Surgical resection of the tumor was performed and the final pathological diagnosis was made as a pituitary metastasis of the renal cell carcinoma. After surgery, radiotherapy with sunitinib, a receptor tyrosine inhibitor, was performed.

CONCLUSION

The clinical symptoms are usually related to the mass effect of the tumor and anterior pituitary involvement. Most of the cases mimic pituitary macroadenoma on MRI. The most preferred treatment combination is surgery and radiotherapy. We recommend adding sunitinib to this combination. This illustrative case and those found in a systematic review of the literature highlight the importance of histopathologic diagnosis and appropriate management since isolated pituitary metastasis is challenging to preoperative diagnosis.

A tale of many tumors and one endocrine site: A case series of pituitary metastases

BACKGROUND

Metastases to the pituitary gland are extremely rare with an incidence rate reported from an autopsy series of 1.8%-12%, and only 20% was diagnosed clinically. Tumors that commonly metastasize are breast and lung tumors.

CASE SERIES

We present a series of five cases, including four female patients and one male patient with metastatic cancer. Two women had metastatic small lung cancer and presented with diabetes insipidus (DI). Two women had metastatic breast cancer, of which one presented with DI and the other with panhypopituitarism. The male patient had bronchogenic adenocarcinoma and presented with DI.

CONCLUSION

Our case series confirmed earlier reports that DI is the most common presentation of metastases to the pituitary gland.

Pituitary metastasis of a breast ductal adenocarcinoma

Pituitary metastases are rare, a primary tumor of the breasts or lungs are frequently found. The clinical picture is very variable, they can be accidental discovery or revealed by a pituitary dysfunction. The prognosis is generally poor and depends on the anatomopathological type.

We report the observation of a patient with a pituitary metastasis of a breast cancer evolving for 4 years, the diagnosis was suspected in front of pituitary macroadenoma images, a transphenoidal endoscopic biopsy and an anatomopathological confirmation revealing an infiltrating breast adenocarcinoma.

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Pituitary metastases are rare, a primary tumor of the breasts or lungs are frequently found.

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The prognosis of the pituitary metastases is generally poor and depends on the anatomopathological type.

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The clinical picture of the pituitary metastases is very variable, they can be accidental discovery or revealed by a pituitary dysfunction.

Slow-Growing Pituitary Metastasis from Renal Cell Carcinoma: Literature Review

BACKGROUND

Tumor metastasis to the pituitary is rare, most commonly reported with either breast or lung cancer metastasizing to the neurohypophysis. Pituitary metastases of renal cell carcinoma (RCC) are by contrast infrequently described even within this scarce literature. We present an illustrative case of RCC pituitary metastasis 15 years after radical nephrectomy for primary disease and a review of the published literature.

CASE DESCRIPTION

A 69-year-old female was diagnosed with a large sellar mass with suprasellar extension. The initial radiologic diagnosis was most in keeping with pituitary macroadenoma, although prominent vascular flow voids were noted. Endoscopic endonasal transsphenoidal adenectomy was challenging on account of significant intraoperative hemorrhage from an unusually vascular tumor. Pathologic examination supported a diagnosis of metastatic clear cell renal carcinoma. Literature review identified 41 cases of RCC pituitary metastasis since 1984. The mean age at time of diagnosis with pituitary metastasis was 59.5 years (range 35-81 years, 73% male). Pituitary metastasis was the initial presentation of RCC in 10 patients. The median time from RCC diagnosis to pituitary metastasis was 1 year (range 0-27 years). Surgical resection was performed for 30 patients, of which 47% reported a highly vascular tumor.

CONCLUSIONS

We highlight the potential for delayed metastasis to the pituitary to masquerade as a macroadenoma. Imaging consistent with rich vascularity should bring the diagnosis of RCC metastasis into the differential and is important to note when planning surgical resection in such cases.

Symptomatic Pituitary Metastasis as Initial Manifestation of Renal Cell Carcinoma: Case Report and Review of Literature

Metastasis to the pituitary gland is extremely rare (∼2% of sellar masses). Clinical, biochemical, and radiologic characteristics of pituitary metastasis are poorly defined and can be difficult to diagnose before surgery. We present an unusual case with pituitary metastasis as the first manifestation of renal cell carcinoma (RCC). A 70-year-old male presented with acute onset of weakness, dizziness, diplopia, and progressively worsening headache. The initial CT head revealed a heterogeneous sellar mass measuring 2.8 × 1.9 × 1.7 cm. A follow-up MRI showed the sellar mass invading the right cavernous sinus. The presumptive diagnosis was a pituitary macroadenoma. Physical examination revealed bilateral 6th cranial nerve palsy and episodes of intermittent binocular horizontal diplopia. Hormonal testing noted possible secondary adrenal insufficiency (AM serum cortisol: 3.3 mcg/dL, ACTH: 8 pg/mL), secondary hypothyroidism (TSH: <0.01 mIU/L, FT4: 0.7 ng/dL), secondary hypogonadism (testosterone: 47 ng/dL, LH: 1.3 mIU/mL, and FSH: 2.3 mIU/mL), and elevated serum prolactin (prolactin: 56.8 ng/ml, normal: 4.0-15.2 ng/ml). IGF-1 level was normal at 110 ng/mL (47-192 ng/mL). The patient was discharged on levothyroxine and hydrocortisone therapy with plans for close surveillance. However, his condition worsened over the next three months, and he was subsequently readmitted with nausea, vomiting, and hypernatremia secondary to diabetes insipidus. Repeat MRI pituitary showed an interval increase in the size of the sellar mass with suprasellar extension and a new mass effect on the optic chiasm. The sellar mass was urgently resected via a trans-sphenoidal approach. The tumor was negative for neuroendocrine markers and pituitary hormone panel, ruling out the diagnosis of pituitary adenoma and triggered workup for metastatic renal cell carcinoma, clear cell type. The diagnosis of renal cell carcinoma was confirmed by the diffuse and strong staining for renal cell carcinoma markers (Pax-8, RCC-1, and CD10). A follow-up CT scan noted large right renal mass measuring 11 × 10 × 11 cm. The patient underwent a cytoreductive robotic right radical nephrectomy for WHO/ISUP histologic grade II clear cell RCC, stage pT2b pNX pM1. He subsequently received fractionated stereotactic radiotherapy to the pituitary gland. He is presently stable with no radiological evidence of progression or new intracranial disease on subsequent imaging. Pituitary metastasis most commonly occurs from breast, lung, or gastrointestinal tumors but also rarely from renal cell carcinoma. Biochemical findings such as panhypopituitarism, acute clinical signs such as headache, visual symptoms, and diabetes insipidus and interval increase in sellar mass in a short time interval should raise suspicion for sellar metastasis.

Metastatic Lung Cancer Presenting as Monocular Blindness and Panhypopituitarism Secondary to a Pituitary Metastasis

Patient: Female, 52-year-old

Final Diagnosis: Metastatic lung adenocarcinoma

Symptoms: Fatigue • vision loss

Medication: —

Clinical Procedure: —

Specialty: Endocrinology and metabolic

Extended Survival After Surgical Resection for Pituitary Metastases: Clinical Features, Management, and Outcomes of Metastatic Disease to the Sella

BACKGROUND

Patients with pituitary metastasis (PM) have a relatively poor prognosis. We describe the presentation, management, and outcomes of patients with PM.

SUBJECTS, MATERIALS, AND METHODS

We performed a retrospective review of patients diagnosed with PM at a single institution from 1996 to 2015. Eighty-five patients diagnosed with metastasis to the pituitary or sella turcica by pathology or based on a combination of neuroimaging and clinical findings were included. Univariate and multivariable Cox regressions evaluated associations between clinical factors and overall survival.

RESULTS

The most frequent sites of primary malignancies resulting in PM were lung (26%) and breast (26%). Median age at diagnosis was 60 years (range, 18-95). The most common complaints at diagnosis included visual deficits (62%), headache (47%), and cranial nerve palsy (31%). Seventy percent of patients had pituitary insufficiency-adrenal insufficiency (59%), hypothyroidism (59%), or diabetes insipidus (28%). Management of PM included radiation therapy (76%), chemotherapy (68%), surgical resection (21%), or combination therapy (71%). Fifty percent and 52% of patients who received surgical treatment and irradiation, respectively, reported symptomatic improvement. Median overall survival (OS) was 16.5 months (95% confidence interval: 10.7-25.4). On multivariable analysis, a primary cancer site other than lung or breast (p = .020), age <60 years (p = .030), and surgical resection (p = .016) were associated with longer OS.

CONCLUSION

Patients <60 years of age, those with primary tumor sites other than lung or breast, and those who undergo surgical resection of the pituitary lesion may have prolonged survival. Surgical resection and radiation treatment resulted in symptomatic improvement in ~50% of patients.

IMPLICATIONS FOR PRACTICE

This study is the largest original series of patients with metastatic disease to the sella. In patients with pituitary metastasis, younger age, primary site other than lung or breast, and metastatic resection may prolong survival. Resection and radiation led to symptomatic improvement in ∼50% of patients. Seventy percent of patients had hypopituitarism. These hormonal deficiencies can be life threatening and can result in substantial morbidity if left untreated. Patients should be treated using a multimodality approach-including a potential role for surgery, radiation, chemotherapy, and hormone replacement-with the goal of improving survival and quality of life.

Machine learning defined diagnostic criteria for differentiating pituitary metastasis from autoimmune hypophysitis in patients undergoing immune checkpoint blockade therapy

PURPOSE

New-onset pituitary gland lesions are observed in up to 18% of cancer patients undergoing treatment with immune checkpoint blockers (ICB). We aimed to develop and validate an imaging-based decision-making algorithm for use by the clinician that helps differentiate pituitary metastasis (PM) from ICB-induced autoimmune hypophysitis (HP).

MATERIALS AND METHODS

A systematic search was performed in the MEDLINE and EMBASE databases up to October 2018 to identify studies concerning PM and HP in patients treated with cytotoxic T-lymphocyte-associated protein 4 and programmed cell death (ligand) 1. The reference standard for diagnosis was confirmation by histology or response on follow-up imaging. Patients from included studies were randomly assigned to the training set or the validation set. Using machine learning (random forest tree algorithm) with the most-described six imaging and three clinical features, a multivariable prediction model (the signature) was developed and validated for diagnosing PM. Signature performance was evaluated using area under a receiver operating characteristic curves (AUCs).

RESULTS

Out of 3174 screened articles, 65 were included totalising 122 patients (HP: 60 pts, PM: 62 pts). Complete radiological data were available in 82 pts (Training: 62 pts, Validation: 20 pts). The signature reached an AUC = 0.91 (0.82, 1.00), P < 10^-8 in the training set and AUC = 0.94 (0.80, 1.00), P = 0.001 in the validation set. The signature predicted PM in lesions either ≥ 2 cm in size or < 2 cm if associated with heterogeneous contrast enhancement and cavernous extension.

CONCLUSION

An image-based signature was developed with machine learning and validated for differentiating PM from HP. This tool could be used by clinicians for enhanced decision-making in cancer patients undergoing ICB treatment with new-onset, concerning lesions of the pituitary gland.

Clinical management of a pituitary gland metastasis from clear cell renal cell carcinoma

In very few years, several treatments have significantly improved the prognosis of patients with metastatic renal cell carcinoma (RCC). Despite this, the clinical outcomes of specific subgroups of patients including those with central nervous metastases still remain poor. In this population, a very infrequent and poorly described site of metastases is the pituitary gland. Because of the important endocrinal function and the anatomic site of this specific organ, clinical management of this complication requires several additional precautions compared with other central nervous metastases. Here, we describe a case of a single pituitary metastasis from clear cell RCC in a patient who showed a surprising progression-free survival and overall survival to sunitinib first-line treatment. Because of the uncommon clinical course of the disease of our patient and the atypical site of metastases, we want also to underline the importance of further investigation of molecular pathways associated with a favorable prognosis in patients with metastatic clear cell RCC.

Giant sellar metastasis from renal cell carcinoma: A case report and literature review

RATIONALE

Sellar metastasis is a rare and complex disease whose clinical features are strongly associated with the primary malignancy. Here, we present a rare case of giant sellar metastasis spread from renal cell carcinoma (RCC).

PATIENT CONCERNS

A 30-year-old Chinese woman was admitted to our Hospital, reporting headache, nasal congestion, nausea, vomiting, and a sharp decline in her right eye vision.

DIAGNOSES

Brain magnetic resonance imaging (MRI) revealed an invasive sellar mass with cavernous sinus and nasal cavity extension. Additionally, the patient had a medical history of right radical nephrectomy for clear-cell RCC.

INTERVENTIONS

The patient underwent a successful subtotal resection of the tumor. Final pathological diagnosis confirmed sellar metastasis from RCC. After surgery, the patient was referred to our medical oncology department and received further systemic therapy.

OUTCOMES

No light perception remained in her right eye even after prompt surgical decompression. Follow-up MRI showed subtotal resection of the giant sellar metastasis.

LESSON

Sellar metastasis, although rare, should be particularly considered for elderly patients with deteriorating visual function and medical histories of cancer.

Twelve cases of pituitary metastasis: a case series and review of the literature

PURPOSE

The pituitary gland is an unusual site for metastatic spread, but as patients with metastatic malignancy are living longer, it may become more prevalent. Compression of important anatomy adjacent to the sella may produce disabling symptoms and endocrine derangement, leading to significant morbidity.

METHODS

An ambispective review of patient records between 2013 and 2017 from three neurosurgical centres was performed. After identifying cases, further investigation was performed to evaluate patient demographic, symptoms at presentation, radiological and histological findings, management, and outcome.

RESULTS

Our investigation identified 12 patients with pituitary metastasis. The average age of the cases was 63.4 years, with breast (n = 4) and lung (n = 4) being the most common primary cancers. In half the cases there was a history of metastatic disease, while in one-quarter of cases, pituitary symptoms were the first sign of malignancy. Adenohypophyseal dysfunction (83%), diabetes insipidus (DI) (75%), headache (67%) and visual field defects (67%) were the most common findings at presentation. Glucocorticoid replacement increased the sensitivity for diagnosis of DI. All cases were contrast enhancing on MRI and the endoscopic trans-sphenoidal approach was preferred for biopsy and debulking.

CONCLUSIONS

The pituitary should not be overlooked as a site of metastasis and sellar symptoms may be the first presentation of neoplastic disease. Any biochemical or clinical sign of pituitary pathology in a patient with known cancer should raise suspicion for sellar metastasis. Moreover, the development of DI or ophthalmoplegia from any pituitary lesion is suggestive of metastatic disease even in patients with no known primary.

Pituitary metastasis: a rare condition

Tumor metastasis to the pituitary gland is a life-threatening condition associated with short life span. Pituitary metastasis is rare, however, and not well-documented. A better understanding of its clinical manifestations could lead to earlier diagnosis, appropriate therapy, and potentially improving quality of life. Therefore, we retrospectively studied the charts of patients with pituitary metastases who were treated at the City of Hope National Medical Center in Duarte, California, from 1984 to 2018. We reviewed and analyzed tumor origin, primary pituitary clinical manifestation, duration between primary tumor diagnosis and pituitary metastasis, type of treatment, and patient survival. A total 11 patients with a mean age of 59.2 years and median survival of 50.33 months were identified. Breast cancer and lymphoma were the most common primary origins in these cases, and diabetes insipidus and panhypopituitarism were the most common primary manifestations of their metastasis. We also compared our results with reports in the literature published between 1957 and 2018. A total 289 patients with pituitary metastasis have been reported in the literature. Breast cancer was the most frequent primary origin of the metastasis, and visual involvement was the most common primary manifestation. The posterior part of the pituitary is more susceptible than the anterior to metastasis. Pituitary metastasis may occur as a consequence of successful primary tumor treatment prolonging the chance of seeding. Future studies are needed to determine the molecular mechanism of metastasis to the pituitary.

Newly Diagnosed Sellar Tumors in Patients with Cancer: A Diagnostic Challenge and Management Dilemma

BACKGROUND

The use of combined positron emission tomography/computed tomography for staging in patients with cancer and the widespread use of magnetic resonance imaging has led to increased detection of incidental sellar masses. The imaging findings can be suggestive of a benign pituitary tumor, but metastasis can never be completely ruled out with noninvasive work-up. Appropriate diagnosis of sellar masses is critical, as the treatment paradigm might change in the presence of a pituitary metastasis. Definitive tissue diagnosis might prevent unnecessary radiotherapy to the skull base or the need for systemic treatment when benign pituitary disease is confirmed.

METHODS

A retrospective chart review from 2010 to 2015 of all patients with recently diagnosed cancer and undergoing surgery for sellar region masses was performed.

RESULTS

There were 9 patients (3 female and 6 male) identified. Lung cancer was the primary condition in 4 patients; the remaining 5 patients had breast cancer, follicular thyroid cancer, cutaneous melanoma, colorectal carcinoma, and renal cell carcinoma. On final pathology, the sellar mass was a benign pituitary adenoma in 5 patients, metastatic cancer in 3 patients, and a granular cell tumor in 1 patient.

CONCLUSIONS

Surgical resection of a sellar mass in patients with known cancer helps in the definitive diagnosis, relieves compressive symptoms, and avoids unnecessary empiric radiotherapy in cases of confirmed benign pituitary disease.

Pituitary Metastasis from Renal Cell Carcinoma: Description of a Case Report

BACKGROUND Pituitary metastasis is uncommon, breast and lung cancers being the most frequent primary tumors. Renal cell carcinoma (RCC) is a rare cause of pituitary metastases, with only a few cases described to date. CASE REPORT We report a case of a 61-year-old man who presented with a progressive deterioration of visual acuity and field associated with a bitemporal hemianopsia. Two years ago, he underwent radical right nephrectomy for a clear cell RCC (ccRCC). The biological tests showed pan-hypopituitarism and diabetes insipidus. Brain MRI revealed a large sellar tumor lesion bilaterally infiltrating the cavernous sinuses, which was surgically resected. Histology confirmed a ccRCC pituitary metastasis. The patient received post-surgical radiotherapy. Considering the presence of concomitant extra-pituitary metastases, treatment with sunitinib was started, followed by several lines of therapy with axitinib, everolimus, and sorafenib because of tumor progression. The patient also presented with a pituitary tumor recurrence, which was treated by stereotaxic radiotherapy. He died five years after the initial diagnosis of RCC and 30 months after the diagnosis of the pituitary metastasis.  CONCLUSIONS There are no standardized treatment guidelines for management of pituitary metastases. Pituitary surgery plays a role in symptom palliation, and it does not have any relevant impact on survival. Exclusive radiotherapy or stereotaxic radiotherapy could be an alternative to surgery in patients whose general condition is poor or who have concomitant extra-pituitary metastases.

Acanthosis Nigricans associated with clear-cell renal cell carcinoma

Acanthosis nigricans (AN), an entity recognized since the 19th century, is a dermatopathy associated with insulin-resistant conditions, endocrinopathies, drugs, chromosome abnormalities and neoplasia. The latter, also known as malignant AN, is mostly related to abdominal neoplasms. Malignant AN occurs frequently among elderly patients. In these cases, the onset is subtle, and spreading involves the flexural regions of the body, particularly the axillae, palms, soles, and mucosa. Gastric adenocarcinoma is the most frequent associated neoplasia, but many others have been reported. Renal cell carcinoma (RCC), although already reported, is rarely associated with malignant AN. The authors report the case of a woman who was being treated for depression but presented a long-standing and marked weight loss, followed by darkening of the neck and the axillary regions. Physical examination disclosed a tumoral mass in the left flank and symmetrical, pigmented, velvety, verrucous plaques on both axillae, which is classical for AN. The diagnostic work-up disclosed a huge renal mass, which was resected and further diagnosed as a RCC. The post-operative period was uneventful and the skin alteration was evanescent at the first follow-up consultation. The authors call attention to the association of AN with RCC.

Endoscopic Endonasal Management of Metastatic Lesions of the Anterior Skull Base: Case Series and Literature Review

BACKGROUND

The anterior skull base is an uncommon site for brain metastases. A limited number of cases have been reported where a region of the skull base is accessed through an expanded/extended transsphenoidal route. In addition, reports of overall and progression-free survival rates are lacking.

OBJECTIVE

To report progression-free and overall survival rates for skull base metastases treated with aggressive endoscopic endonasal surgery and radiation therapy.

METHODS

We retrospectively review a prospective database of patients at New York Presbyterian Hospital undergoing expanded endoscopic endonasal surgery from 2004 to 2014. From this database, we identified all patients whose final pathology revealed a metastatic lesion in the midline skull base.

RESULTS

Seven hundred forty-nine patients underwent endonasal endoscopic surgery. Final pathology in 12 patients (1.6%) revealed metastasis to the sellar or parasellar region. Tumors were located in the sella, suprasellar cistern, clivus, ethmoid sinuses, sphenoid sinus, cavernous sinus, and craniovertebral junction. Breast and lung cancers were the most common primary diagnoses. Gross total resection was achieved in 41.6% of patients. There were no postoperative cerebrospinal fluid leaks. Adjuvant radiation therapy was used in 92% of cases. Median follow-up was 14 months (range, 1-55). Median progression-free and overall survival were 18 and 16 months, respectively.

CONCLUSIONS

The range of anterior skull base metastatic lesions that can be managed endonasally has increased with the advent of extended endonasal endoscopic surgical approaches. Favorable results can be obtained with this surgical approach as part of the overall management paradigm for patients with skull base metastases.

Metastatic involvement of the pituitary gland: a systematic review with pooled individual patient data analysis

PURPOSE

To report a rare case of pituitary metastasis (PM) from hepatocellular carcinoma (HCC) and help better understand the incidence of PM and its most common presenting symptoms through a pooled individual patient data analysis.

METHODS

Literature regarding PM was systematically reviewed with a pooled individual patient data analysis conducted. Pooled individual data analysis result is also compared with the result in a most recent systematic review.

RESULTS

Our results demonstrate that the incidence of PM among all intracranial metastases is 0.87% (95% CI 0.56, 1.18); it is 1.9% (95% CI 1.46, 2.34) among all autopsied cancer cases; it is 11.56% (95% CI 7.08, 16.04) among all breast cancer patients who had hypophysectomies and 12.83% (95% CI 10.5, 15.16) among all autopsied breast cancer patients. The fixed effect model showed that the incidence of PM in breast cancer patients group is significantly higher (p < 0.001) with an odds ratio of 6.71 (95% CI 4.24, 10.61). Breast and lung cancer are the most common primary cancer of PM with a percentage of 37.2 and 24.2 respectively. The next most common primary sites are prostate and kidney respectively, although the percentages for each are only about 5. Diabetes insipidus (DI) remains the most common symptom among all reported PM cases with a pooled incidence of 42.34% (95% CI 36.15, 48.53). Although not significant (χ(2) = 2.846, df = 1, p = 0.061), it is less common in the most recent reported cases which has a pooled incidence of 32.76% (95% CI 20.31, 45.21). DI is extremely rare in the reported PM cases from HCC (none of the eight cases presented with DI). The symptoms of anterior hypopituitarism (23.68 vs 39.66%, p = 0.015), visual deterioration (27.89 vs 41.38%, p = 0.039), cranial nerve palsies (21.58 vs 41.38%, p = 0.003) and headaches (15.79 vs 32.76%, p = 0.005) were reported significantly higher than previously described in the literature.

CONCLUSIONS

Pituitary metastasis is rare in patients with cancer, and the pituitary gland is an uncommonly involved location in patients with intracranial metastases. With advanced diagnostic imaging techniques and increased awareness about the manifestation of sellar lesions, the incidence of cranial nerve palsies and anterior pituitarism are higher than reported. This information may allow earlier diagnosis of PM.

Renal cell carcinoma metastatic to a pituitary FSH/LH adenoma: case report and review of the literature

Abstract Metastases to the pituitary occur more frequently in patients with widespread cancer and mainly involve the posterior lobe. A few cases of metastatic carcinoma to a pituitary adenoma have been described so far. Here, the authors present an additional case of a clear cell renal cell carcinoma (CCRCC) metastatic to a FSH/LH/α-subunit pituitary adenoma and systematically review the literature. Immunohistochemistry and electron microscopy were performed to characterize both neoplastic components at the morphological level. Moreover, it was hypothesized that expression of VEGF and of the corresponding receptor VEGFR1 could be implicated in the development of the carcinomatous metastasis within the adenoma.

Differential diagnosis and management of a pituitary mass with renal cell carcinoma

The small pituitary mass was incidentally found in 40-years-old women with renal cell carcinoma. The endocrinological and ophthalmological evaluation revealed no deficit and the short-term follow-up was recommended. In 6 months later, the visual disturbance was reported and the size of mass was increased. The tumor was removed totally via the trans-sphenoid approach. The post-operative endocrinological insufficiency was not noticed. During one year of follow-up period, there was no evidence of recurrence without adjuvant radiotherapy. The clinical features of pituitary metastasis from renal cell carcinoma were similar to those of pituitary adenoma. The possibility of pituitary metastasis should be kept in mind in patients with sellar mass and renal cell carcinoma.

Pituitary metastasis from a renal cell carcinoma progressed after sorafenib treatment

Pituitary metastasis from renal cell carcinoma is rare and has never been reported for renal cell carcinoma primarily treated with sorafenib. Herein, we present a case of an advanced clear-cell renal cell carcinoma in which pituitary metastasis progressed but extracerebral metastases showed partial response to sorafenib treatment.

Pituitary incidentaloma

Pituitary incidentalomas (PIs) are commonly encountered in clinical practice. While most are microincidentalomas (<1 cm) and not functional, in some cases their identification may lead to discovery of unrecognized abnormalities such as pituitary hormonal deficiencies, excess hormone secretion or visual field defects. Although the majority are pituitary adenomas, the potential list of differential diagnosis is extensive. A limited biochemical work up for asymptomatic patients with microincidentalomas, to include measurement of prolactin and IGF-1, is reasonable, with further studies to be tailored based on the clinical picture. All patients with macroincidentalomas (≥1 cm) should be evaluated for hypopituitarism and undergo visual field testing if the sellar mass abuts or compresses the optic chiasm. Most PIs can be followed, closely without surgery over time, but some may require surgical removal, especially if they are found to be macroincidentalomas at presentation, encroaching on or abutting the optic chiasm, or are found to be functional, excluding prolactinomas. Recovery of pituitary function may be seen in some patients with mass effect following resection of a sellar mass. The association of headache and pituitary incidentalomas remains a diagnostic challenge. There are no randomized controlled studies to guide the follow up approach when surgery is not indicated; most of the follow up algorithms in the literature are based on personal experience. Most retrospective series on natural history indicate that microincidentalomas tend not to grow; without a need for long-term follow up unless the patient becomes symptomatic. Macroincidentalomas, on the other hand, have a propensity to grow and need a more aggressive follow up approach to minimize morbidity.

Pituitary gland metastasis from renal cell carcinoma presented as a non-functioning macroadenoma

Metastatic tumors involving the pituitary gland are an uncommon finding and occur in up to 1% of all pituitary tumor resections. A 74-year-old man had progressive vision deterioration, over the 30 days prior to consultation. He did not complain of headache or polyuria, but referred to intestinal constipation. Five years ago, he underwent a right radical nephrectomy for renal cell carcinoma, followed by chemotherapy and radiotherapy for lung and parotid metastases. On ophthalmologic examination, there was a left abducens nerve palsy and bitemporal hemianopia. Magnetic resonance imaging demonstrated a sellar mass with suprasellar cistern extension compressing the optic chiasm. Endocrinological evaluation revealed central adrenal and gonadal insufficiencies. The patient underwent a transsphenoidal tumor resection that revealed renal cell carcinoma. This case illustrates that metastatic pituitary lesions can mimic typical symptoms and signs of pituitary macroadenoma. Furthermore, clinical diabetes insipidus, a common finding of pituitary metastases, can be absent.

[Diagnostic significance of T2W hypointensity of the sella]

Normal anatomical structures and lesions characterized by low T2W signal intensity are reviewed in this pictorial essay. The purpose is to demonstrate how evaluation of the appearance, shape and exact anatomical location of the T2W hypointense sellar region structure, correlated with its T1W signal intensity, can based on the clinical context lead to an appropriate differential diagnosis.