Triple jeopardy in the pituitary

Pituitary apoplexy in cushing's disease: a single center study and systematic literature review

INTRODUCTION

Pituitary apoplexy (PA) in Cushing's disease (CD) is rare with data limited to case reports/series.

METHODS

We retrospectively reviewed case records of PA in CD managed at our center from 1987 to 2023 and performed a systematic literature review.

RESULTS

We identified 58 patients (44 females), including twelve from our center (12/315 CD, yielding a PA prevalence in CD of 3.8%) and forty six from systematic review. The median age at PA diagnosis was 35 years. The most common presentation was type A (79.3%) and symptom was headache (89.6%), with a median Pituitary Apoplexy Score (PAS) of 2. Median cortisol and ACTH levels were 24.9 µg/dl and 94.1 pg/ml, respectively. Apoplexy was the first manifestation of underlying CD in 55.2% of cases, with 31.1% (14/45) presenting with hypocortisolemia (serum cortisol ≤ 5.0 µg/dl), underscoring the importance of recognizing clinical signs/symptoms of hypercortisolism. The median largest tumor dimension was 1.7 cm (53/58 were macroadenomas). PA was managed surgically in 57.8% of cases, with the remainder conservatively managed. All five PA cases in CD with microadenoma achieved remission through conservative management, though two later relapsed. Among treatment-naïve CD patients with macroadenoma, PA-related neuro-deficit improvement was comparable between surgical and conservative groups. However, a greater proportion of surgically managed patients remained in remission longer (70% vs. 38.5%; p = 0.07), for an average of 31 vs. 10.5 months.

CONCLUSION

PA in CD is more commonly associated with macroadenomas, may present with hypocortisolemia, and surgical treatment tends towards higher and longer-lasting remission rates.

Non-functioning pituitary carcinoma: Case report and literature review

INTRODUCTION AND IMPORTANCE

Non-functional pituitary carcinoma is a rare neuroendocrine tumor. It is characterized by the presence of cerebrospinal or distant metastasis of an adenohypophysis tumor without any hypersecretion. Only a few cases of non-functional pituitary carcinomas have been reported in the literature.

CASE PRESENTATION

In this paper, we report the case of a 48-year-old female patient who presented with spinal pain and a mass facing the second thoracic vertebrae. Spinal magnetic resonance imaging (MRI) revealed the presence of pituitary and bilateral adrenal incidentalomas. The patient was operated and the histopathological examination of the specimen revealed a non-functional pituitary carcinoma variety "Null Cell".

DISCUSSION AND CONCLUSION

There are no clinical, biological, or radiological characteristics that reliably differentiate between non-functional pituitary adenoma and non-functional pituitary carcinoma. Management remains a challenge for clinicians and neurosurgeons. A combination of surgery, chemotherapy, and radiotherapy seems necessary to achieve tumor control.

Corticotrophic pituitary carcinoma with cervical metastases: case series and literature review

PURPOSE

Pituitary tumors are the second most common intracranial tumors, however, pituitary carcinoma is a rare clinical entity which represents only 0.1-0.2% of all pituitary tumors. Diagnosis of pituitary carcinoma requires the presence of metastasis. Early identification of pituitary carcinoma is difficult, and only recently have guidelines been published for the treatment of aggressive pituitary tumors. We present two cases from our institution, with a review of other cases available in literature in order to better characterize this rare disease.

METHODS

A retrospective review of two patients with pituitary carcinoma treated at a tertiary medical center was performed. The MEDLINE database was searched for all cases of pituitary carcinoma. Information for age at diagnosis, sex, pituitary tumor type, latency period from pituitary tumor to presentation of carcinoma, sites of metastasis, number of surgical therapies, radiation and chemotherapy, and survival after diagnosis were collected.

RESULTS

A total of 69 studies were available for review for a total of 72 unique cases. The average age at diagnosis was 46.3 years. The most common tumors were ACTH-secreting (34.7%), Prolactin-secreting (23.6%), and Null Cell (15.3%). The average latency period from pituitary tumor diagnosis to metastasis was 9 years. All patients underwent surgical therapy during their treatment, with an average of 2.76 procedures. The mortality rate was 54.8% with average time to death after diagnosis of approximately 10 months.

CONCLUSIONS

Pituitary carcinoma is a rare disease with high mortality rate and is a diagnostic and treatment challenge. Further study is required but is difficult due to its low incidence.

Recurrent pituitary apoplexy due to two successive neoplasms presenting with ocular paresis and epistaxis

A case of recurrent pituitary apoplexy is described in a 72-year-old man who initially presented with haemorrhage in a non-functioning pituitary adenoma. Five years later, he re-presented with a severe pituitary haemorrhage in an enlarging sellar mass invading both cavernous sinuses causing epistaxis and bilateral ocular paresis. Subsequent histology was consistent with a sellar malignant spindle and round cell neoplasm. Multiple pituitary tumours have previously been reported to coexist in the same individual, but to our knowledge this is the only case where two pathologically distinct pituitary neoplasms have sequentially arisen in a single patient. This case is also notable with respect to the progressive ocular paresis, including bilateral abducens nerve palsies, and the presentation with epistaxis.

LEARNING POINTS

Ocular paresis in pituitary apoplexy can result from tumour infiltration of nerves, or by indirect compression via increased intrasellar pressure.Epistaxis is a very rare presentation of a pituitary lesion.Epistaxis more commonly occurs following trans-sphenoidal surgery, and can be delayed.

Clival invasion on multi-detector CT in 390 pituitary macroadenomas: correlation with sex, subtype and rates of operative complication and recurrence

BACKGROUND AND PURPOSE

Clival invasion, a rare but potentially significant complication of pituitary adenoma, is difficult to detect on MR imaging. Because CT is widely used in adjunct guidance of pituitary surgery and it has recently been suggested that preoperative CT may add useful diagnostic information in addition to pituitary MR imaging, we performed the first large cross-sectional imaging study to define the image attributes, clinical correlates, and prognostic implications of clival invasion on CT for pituitary adenoma surgical guidance.

MATERIALS AND METHODS

Preoperative CT images from 390 patients with histopathologically diagnosed pituitary macroadenoma were reviewed retrospectively and classified by the presence and degree of clival invasion. Tumor volume, tumor subtype, patient sex, operative complication, and recurrence rates were compared between groups.

RESULTS

After we corrected for multiple correlations, the most significant independent risk factor for clival invasion was female sex (OR=3.62, P=.014, multinomial logistic regression), followed by large tumor volume (OR=1.08, P<.001), and null-cell subtype (OR=5.47, P<.001). Larger tumor volume correlated with null-cell subtype (Mann-Whitney U test, P=.006), incidence of clival invasion (P<.001), and extent of clival invasion (P=.038). Clival invasion was associated with a significantly higher ratio of operative complications (15.63%, χ(2)=7.067, P=.008) and recurrence (57.14%, χ(2)=10.739, P=.001).

CONCLUSIONS

CT detection of clival invasion by pituitary macroadenoma is significantly more common in women, in patients with large tumors, and in patients with null-cell tumors, and it is associated with a higher rate of operative complications and recurrences. Attention to the presence of clival invasion on preoperative CT and prospective investigation of its prognostic significance are indicated. Attention to this finding on pituitary guidance CT is warranted.