Primary central nervous system lymphoma mimicking pituitary apoplexy: case report

Treatment Response to Acute Total Ophthalmoplegia in Primary Pituitary Lymphoma: A Case Report and Review of the Literature

Primary pituitary lymphoma (PPL) is an extremely rare localized lymphoma without systemic involvement. The most common clinical presentations of PPL are hypopituitarism, headaches, and ophthalmoplegia. Diagnosing PPL without a biopsy is almost impossible. There is no study that has specifically investigated and reviewed treatment responses to the ophthalmological symptoms of PPL patients. Herein, we present a 66-year-old female patient who had acute-onset total ophthalmoplegia and headache as admission symptoms, which was diagnosed as PPL after subtotal resection. In the present study, we discussed the response of ophthalmological symptoms to treatment with a review of the literature. Only 18 reported cases had postoperative ophthalmological examination, and in 94.4% of these cases, ophthalmoplegia resolves after surgery and chemotherapy. The complete resection rate of the PPL in the literature was found to be as low as 12.3% in this region because of the hard and adhesive nature of the tumor. Our review unveiled that complete recovery of ophthalmoplegia can be achieved even in the late phase of the symptoms. In the present case, ophthalmoplegia resolved completely following subtotal resection and rituximab, high-dose methotrexate, and cytarabine treatment.

HIV and the Pituitary Gland: Clinical and Biochemical Presentations

Human immunodeficiency virus (HIV) can have profound impact on the function of the pituitary gland. We have performed an electronic literature search using the following database: PubMed, Medline, Scopus, and Google Scholar. These databases were searched using the keywords HIV, pituitary glands, cancer, pituitary apoplexy, and infertility. HIV can cause hypopituitarism and also can lead to diabetes insipidus. The impact can be slow and insidious, and diagnosis depends on high index of clinical suspicion. The effect on anterior pituitary gland can be associated with growth hormone deficiency, hypothyroidism, adrenal insufficiency, premature menopause, erectile dysfunction, and infertility. HIV can cause pituitary apoplexy, and this should be treated as an endocrine emergency. Importantly, HIV can be associated with pituitary lymphoma and pituitary cancer. Therefore, joined management between HIV physicians, clinical biochemists and endocrinologists may help in establishing pituitary dysfunction.

Primary Pituitary Lymphoma As Rare Cause Of A Pituitary Mass And Hypopituitarism In Adulthood

OBJECTIVE

Differential diagnosis of nonadenomatous sellar masses causing hypopituitarism is still a challenge. Among these masses, growing evidence has demonstrated that primary pituitary lymphoma is a specific and emerging entity. The aim of our study was to describe our experience with a case of primary pituitary lymphoma and to perform a review of the available literature.

METHODS

We searched relevant databases up to March 2020, identifying 36 suitable articles basing on inclusion criteria (primary pituitary lymphoma in adult immunocompetent subjects). Overall, 43 cases were included in the review, adding a new case diagnosed and treated in our hospital. Epidemiologic data, clinical presentation, hormonal status, radiologic findings, pathology, treatment, and outcome were extracted.

RESULTS

Mean age at diagnosis was 58.9 years, without gender difference. Symptoms related to mass were common (52.3%), in particular cranial nerve palsy (70.5%), headache (56.8%), and alteration in visual field (40.9%). Impaired hormonal status was detected in 89.7% of patients; of them, 58.9% presented with anterior pituitary failure (partial or total), while 25.6% presented with panhypopituitarism. Overall, diabetes insipidus was present in 30.8% and hyperprolactinemia in 41.0% of patients. The majority of patients presented a radiologically invasive mass in the suprasellar region and cavernous sinus (65.9% and 40.9%, respectively) and histologic diagnosis of diffuse B-cell lymphoma (54.5%).

CONCLUSION

The differential diagnosis of sellar and parasellar masses causing hypopituitarism should include primary pituitary lymphoma, even in absence of systemic symptoms or posterior pituitary dysfunction. The disease has a heterogeneous pattern, so a collaboration between endocrinologists, neuroradiologists, neurosurgeons, and hematologists is desirable.

Primary central nervous system lymphoma involving the hypothalamic-pituitary axis: a case series and pooled analysis

PURPOSE

Primary central nervous system lymphoma (PCNSL) involving the hypothalamic-pituitary axis (H-P axis) is a rare intracranial neoplasm. We aimed to determine the unique characteristics and treatment outcomes of patients with PCNSL at the H-P axis and review the literature.

METHODS

We retrospectively reviewed the electronic medical records of patients with PCNSL in our institute from 2000 to 2017. We analyzed patient characteristics, clinicopathologic features, imaging results, and treatment outcomes. Furthermore, we searched the PubMed database and gathered more cases from published studies to analyze patient treatment outcomes.

RESULTS

A total of 488 patients were diagnosed with central nervous system lymphoma at our institute. Seven (1.4%) patients had H-P axis involvement, five had diffuse large B-cell lymphoma, and two had mucosa-associated lymphoid tissue lymphoma. All patients had anterior pituitary lobe dysfunction, and two had posterior lobe dysfunction. The median progression-free survival (PFS) for seven patients was 29.0 (range: 0.9-48.1) months, and the 3-year survival rate was 42.9%. Pooled analysis included 45 patients. The median PFS for these patients was 7.0 months (0.9-52.0), and the 2-year survival rate was 20%. Univariate and multivariate analyses revealed that the patients with visual field defects had better prognosis (p = 0.0153 and 0.043, respectively).

CONCLUSION

PCNSL at the H-P axis is associated with a higher rate of pituitary dysfunction than other parasellar pathologies. PCNSL at the H-P axis has a worse treatment outcome than PCNSL at other sites. However, visual field defect is related to a favorable prognosis in these patients.

Primary Pituitary Lymphoma in Immunocompetent Patients: A Report on Two Case Studies and the Review of Literature

Primary pituitary lymphoma (PPL) represents an extremely rare entity. Here, we have reported two recently identified cases of immunocompetent PPL having diffuse large B-cell lymphoma by surgical biopsy. Both patients had hypopituitarism, with one patient developing right ptosis. In both patients, MRI and FDG-PET/CT depicted sellar mass that extended into the cavernous sinus with the right sphenoid also present in one of the patients. No systemic disease was found in these two patients. Surprisingly, we found that both patients had infiltrative lesions in sphenoid sinus mucosa pathologically, but the sphenoid bones that composed the sellar base were visually intact during the biopsy procedure. Chemotherapy was administered to both patients, where one patient achieved remission at the recent follow-up, whereas the other one did not respond to the treatment. The diagnosis of PPL is usually difficult if solely dependent on history, clinical presentation, biochemical indexes, and radiographic findings. We have also updated and reviewed the epidemiologic features, clinical presentations, pathological characteristics, potential mechanisms, therapeutic orientation, and prognostic advances of PPL. A total of 40 cases (including ours and four pediatric patients), histologically diagnosed, were analyzed in terms of clinical presentation, endocrine abnormality, radiological features, pathology, treatment, and follow-up. Hypopituitarism and headache were the most common presentation of PPL, while diabetes insipidus was reported in 13 patients (43.3%). B cell lymphoma was the most common type of pathology, followed by T-cell and NK/T cell. PPL was more invasive in nature at the suprasellar region (72.5%), cavernous sinus (52.5%), and sphenoidal sinus (27.5%) in 29, 21, and 11 patients, respectively. Pediatric patients with PPL seem to be different compared to their adult counterparts in terms of pathogenesis, clinical presentation, and radiological features. The management of PPL usually follows the treatment protocols for PCNSL but has a poor prognosis compared to the pituitary involvement of systemic lymphoma.

Methotrexate-associated lymphoproliferative disorder with hypopituitarism and central diabetes insipidus

SUMMARY

Patients treated with immunosuppressive drugs, especially methotrexate (MTX), rarely develop lymphoproliferative disorders (LPDs), known as MTX-related LPD (MTX-LPD). The primary site of MTX-LPD is often extranodal. This is the first reported case of MTX-LPD in the pituitary. A 65-year-old woman was admitted to our hospital with symptoms of oculomotor nerve palsy and multiple subcutaneous nodules. She had been treated with MTX for 11 years for rheumatoid arthritis. Computed tomography showed multiple masses in the orbit, sinuses, lung fields, anterior mediastinum, kidney, and subcutaneous tissue. Brain magnetic resonance imaging revealed a sellar mass. She was diagnosed with hypopituitarism and central diabetes insipidus based on endocrine examination. Although pituitary biopsy could not be performed, we concluded that the pituitary lesion was from MTX-LPD, similar to the lesions in the sinuses, anterior mediastinum, and subcutaneous tissue, which showed polymorphic LPD on biopsy. MTX was discontinued, and methylprednisolone was administered to improve the neurologic symptoms. After several weeks, there was marked improvement of all lesions, including the pituitary lesion, but the pituitary function did not improve. When pituitary lesions are caused by MTX-LPD, the possibility of anterior hypopituitarism and central diabetes insipidus needs to be considered. Further studies are needed to investigate the effectiveness of early diagnosis and treatment of MTX-LPD in restoring pituitary dysfunction.

LEARNING POINTS

Pituitary lesions from MTX-LPD may cause hypopituitarism and central diabetes insipidus. Pituitary metastasis of malignant lymphoma and primary pituitary lymphoma, which have the same tissue types with MTX-LPD, have poor prognosis, but the lesions of MTX-LPD can regress only after MTX discontinuation. In cases of pituitary lesions alone, a diagnosis of MTX-LPD may be difficult, unless pituitary biopsy is performed. This possibility should be considered in patients treated with immunosuppressive drugs. Pituitary hypofunction and diabetes insipidus may persist, even after regression of the lesions on imaging due to MTX discontinuation.

Sex hormone Profile in Human Immunodeficiency Virus-Infected Men and It's Correlation with CD4 Cell Counts

BACKGROUND

In human immunodeficiency virus (HIV)-infected men, hypogonadism is the most common endocrinological disorder, and most cases of hypogonadism are secondary. The aim of this study was to find out the hormonal abnormalities in HIV-infected males and it's correlation with CD4 cell counts.

MATERIALS AND METHODS

One hundred HIV-infected male patients were evaluated in the Department of Medicine, Postgraduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, India, over a period of 12 months from September 2014 to August 2015 using history, physical examination, routine baseline investigations, and CD4 counts. Free testosterone, dehydroepiandrosterone sulfate (DHEAS), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin were measured using an overnight fasting sample. Patients were divided into three groups on the basis of CD4 counts (Group A: CD4 counts ≥350/mm³, Group B: CD4 counts between 200 and 349/mm³, and Group C: CD4 counts <200/mm³). Data were analyzed using Student's t-test, ANOVA test, Chi-square test, and Pearson's test and P ≤ 0.05 was considered statistically significant.

RESULTS

In 100 HIV-infected males, overall prevalence of hypogonadism was found to be 66%, and 30%-35% patients had symptoms of hypoandrogenemia. Hypogonadotropic hypogonadism was found in 42% of patients. A significant association (P = 0.027) was found between prevalence of hypogonadism and the level of immunodeficiency with an increase in the prevalence of hypogonadism as CD4 counts decreased. Lower levels of free testosterone and DHEAS were found in cases of severe immunosuppression with a statistically significant correlation with CD4 counts. Correlation of other sex hormones (LH, FSH, and prolactin) with CD4 counts not statistically significant. Mean free testosterone and FSH were found to be significantly higher in patients on antiretroviral therapy (ART) than in those not on ART (P = 0.028 and P = 0.045, respectively), but no specific ART drug or their drug combination was found to have a significant correlation with levels of any sex hormone.

CONCLUSION

Hypogonadism (hypogonadotropic hypogonadism) was found to be a common endocrinological disorder in HIV-infected male population, seen more commonly in association with low CD4 counts.

Hypogonadism in the HIV-Infected Man

Low testosterone levels are frequently observed among men with treated and untreated HIV infection. However, the interpretations of biochemical measurements of testicular function are challenging and need to be considered in the context of the clinical presentation and scenario. The distinction between primary and secondary hypogonadism and determination of the underlying clinical pathophysiology are not always straightforward. Early recognition of clinical hypogonadism and appropriate treatment may improve clinical outcomes and quality of life for affected individuals. A principal aim of testosterone replacement is to maintain serum testosterone concentrations in the normal physiological range and should be considered in clinically symptomatic patients.

Primary pituitary lymphoma: an update of the literature

Primary intracranial lymphomas (Weller et al. in Neuro Oncol 14(12):1481-1484, 2012) are an emerging disease and an isolated localization in the pituitary gland i.e. primary pituitary lymphoma (PPL) represents a rare condition. We present an update of the most recent evidence for PPL through a systematic review of the literature. A systematic literature review was conducted using PubMed database up to October 2015. The population was defined as immunocompetent patients with a pathologically confirmed diagnosis of PPL. Patients' characteristics, clinical presentation, radiological features, pathology reports, adjuvant treatment and follow-up data were analyzed. We reported one case of PPL and included our data in this analysis. A total of 33 cases of PPL were identified, including ours. A slight not significant female prevalence was evident, with a mean age of 59 years at diagnosis. Visual troubles and headaches were the most common presenting symptoms. About 80 % of patients presented a cranial nerve (CN) deficit. The most frequently involved were the II and III CN. Anterior hypopituitarism was present in 70 % of cases and a diabetes insipidus in 36 % of cases. PPL was rarely limited to the sella and most often extended to the suprasellar and parasellar space. 70 % of cases underwent resection, 21 % a biopsy. A B-cell lymphoma was isolated in 82 % of cases, a T-cell lymphoma in 15 % and a NK/T cell lymphoma in one case. Overall mean survival rate was 14.4 months (95 % confidence interval 9.0-19.8 months) and there was no difference in terms of survival rates when patients were stratified according to the treatment they received. PPL is an emerging clinical entity. Literature data are too scarce to allow the definition of specific protocols of treatment and the management is based on the guidelines present for PCNSL. The role of surgery aiming at a complete resection of PPL should be reevaluated in wider studies including only this category of patients, to establish the real role of each therapeutic strategy.

Encephalopathy, Chiasmal Compression, Ophthalmoplegia, and Diabetes Insipidus in Pituitary Apoplexy

Pituitary apoplexy with haemorrhage is a potentially life-threatening condition, and a rare cause of third nerve palsies. The range of vision loss and ophthalmoplegia seen in cases of apoplexy reflects the variability of cranial structures compressed by mass effect. The pathophysiology of extraocular muscle limitation and facial paraesthesia occurs with compression of the cavernous sinus, which contains cranial nerves III, IV, VI, and the ophthalmic branch of V. Blood supply to adjacent structures may be also compromised, causing additional loss of function. This case report of a patient with diabetes insipidus and a third nerve palsy illustrates the anatomic basis of the presenting signs of pituitary apoplexy, and the necessity for prompt neuroimaging if it is suspected.

Pituitary and adrenal involvement in diffuse large B-cell lymphoma, with recovery of their function after chemotherapy

BACKGROUND

Diffuse large B-cell lymphoma sometimes involves the endocrine organs, but involvement of both the pituitary and adrenal glands is extremely rare. Involvement of these structures can lead to hypopituitarism and adrenal insufficiency, and subsequent recovery of their function is rarely seen. The present report describes an extremely rare case of pituitary and adrenal diffuse large B-cell lymphoma presenting with hypopituitarism and adrenal insufficiency with subsequent recovery of pituitary and adrenal function after successful treatment of the lymphoma.

CASE PRESENTATION

A 63-year-old Japanese man was referred to our hospital due to miosis, ptosis, hypohidrosis of his left face, polydipsia and polyuria. 18F-fluorodeoxy glucose positron emission tomography / computed tomography revealed hotspots in the pituitary gland, bilateral adrenal glands and the apex of his left lung. Surgical biopsy from the pituitary lesion confirmed the diagnosis of diffuse large B-cell lymphoma, with lymphoma cells replacing normal pituitary tissue. Endocrine function tests revealed adrenal insufficiency and panhypopituitarism, including a possible affection of the posterior pituitary. Hormone replacement therapy with desmopressin and hydrocortisone was started. Chemotherapy consisted of six courses of R-CHOP (rituximab, cyclophosphamide, vincristine, doxorubicin and prednisolone) and two courses of high-dose methotrexate followed by autologous hematopoietic stem cell transplantation. Subsequently, his pituitary and bilateral adrenal lesions resolved, and serial endocrine function tests showed gradual improvement in pituitary and adrenal function.

CONCLUSIONS

The present report describes an extremely rare case of diffuse large B-cell lymphoma with involvement of both the pituitary and bilateral adrenal glands. R-CHOP and high-dose methotrexate therapy followed by autologous hematopoietic stem cell transplantation was quite effective, and panhypopituitarism and adrenal insufficiency improved to almost normal values after successful treatment of the lymphoma with chemotherapy.

Primary pituitary lymphoma in immunocompetent patient: diagnostic problems and prolonged follow-up

Primary pituitary lymphoma in immunocompetent patients is a rare disease and has been described in less than 20 cases. Moreover, low-grade lymphomas constitute only 3% of all primary central nervous system lymphoma. The objective of this report is to report a low-grade primary pituitary lymphoma, diagnostic problems and to give more evidence about the evolution of this rare disease. A 49 y.o. woman was referred to our clinic with symptoms of hypopituitarism. A diagnostic work-up showed mild anemia, an erythrocyte sedimentation rate of 122 mm/h and a negative Elisa test for HIV. Panhypopituitarism was confirmed and the MRI showed a 20 mm sellar and suprasellar enhancing mass with a thickening of the pituitary stalk, chiasmal compression and bitemporal hemianopsia. She underwent transsphenoidal resection only 10 months later for non medical reasons. During this period she was clinically asymptomatic on hormonal replacement therapy. A new MRI showed regression of the suprasellar extension and invasion to the left cavernous sinus. A firm and infiltrative mass was found during transsphenoidal surgery, and only partial resection was performed. Biopsy showed a low-grade lymphoplasmacytic lymphoma. Staging was negative for other localizations. She was given chemotherapy and localized radiotherapy. Four years after surgery, the sellar MRI showed a 10 mm residual sellar mass with the persistence of a cavernous sinus invasion and she is considered to be in remission. The neurosurgeon and clinician should consider primary pituitary lymphoma as a potential cause of a sellar mass, especially in the presence of diabetes insipidus and an enhancing invasive mass. Neurosurgical biopsy is crucial for a correct diagnosis and prognosis could be better than classic CNS primary lymphomas.

Diffuse large B-cell non Hodgkin's lymphoma in a 65-year-old woman presenting with hypopituitarism and recovering after chemotherapy: a case report

INTRODUCTION

Diffuse large B-cell non Hodgkin's lymphoma may involve the pituitary either as a primary central nervous system lymphoma or, more frequently, as metastasis from systemic lymphoma leading to hypopituitarism. A partial recovery of pituitary function after treatment with chemotherapy has previously been described but complete recovery with cessation of all hormone supplements is excessively rare. We report a patient presenting with anterior hypopituitarism with subsequent complete and sustained recovery of pituitary function after successful treatment of the lymphoma.

CASE PRESENTATION

A 65-year-old Caucasian woman with lethargy, loss of appetite and peripheral edema was found to have anterior hypopituitarism. Magnetic resonance imaging showed no mass lesions in the pituitary although a positron emission tomography scan showed abnormal pituitary activity. An abdominal computed tomography scan revealed multiple intra-abdominal lymph nodes, which on histology proved diagnostic of diffuse large B-cell non Hodgkin's lymphoma. She received six cycles of R-CHOP chemotherapy, after which she achieved a complete metabolic response at all known previous sites of the disease, confirmed by positron emission tomography scanning. Concomitant with the tumor response, there was full recovery of adrenal, thyroid and gonadal axes which has persisted at 10 months follow-up.

CONCLUSION

Although rare, it is important to recognize lymphomatous infiltration of the pituitary as a potentially reversible cause of hypopituitarism.

Primary pituitary lymphoma in an immunocompetent patient: a rare clinical entity

Primary pituitary lymphoma in immunocompetent patients is an exceedingly rare clinical entity. We report the case of a 41-year-old woman with initial polydipsia and polyuria. When laboratory evaluation revealed panhypopituitarism, a pituitary enhanced MRI was performed and was suggestive of a pituitary adenoma. Obstructive hydrocephalus provoked by enlarged sellar mass was also demonstrated during observation, and a shunt procedure following lesion resection was carried out. Histopathological examination and immunophenotyping verified diffuse large B-cell non-Hodgkin's lymphoma. No systemic disease was found on staging of the patient. We will also review the clinical, radiological features and outcomes of 28 cases that have been reported since 1993.

Primary CNS lymphoma with bilateral symmetric hypothalamic lesions presenting with panhypopituitarism and diabetes insipidus

We present an unusual case of primary central nervous system (CNS) lymphoma presenting with bilateral symmetric hypothalamic lesions causing diabetes insipidus and hypopituitarism. A 50-year-old male presented initially with mental status changes, polyuria and polydipsia. The patient was determined to have diabetes insipidus (DI) and significant anterior pituitary deficiencies resulting in symptomatic pleural and pericardial effusions. Brain MRI with contrast demonstrated bilateral enhancement of his hypothalamus extending to the optic tract. The extensive diagnostic workup that ensued on his initial presentation was non-diagnostic as he had no obvious site of involvement that was easily accessible to biopsy. With close follow-up, the patient had rapid radiographic progression of his disease to his cerebral hemispheres. He therefore underwent brain biopsy and was diagnosed with primary CNS large B cell lymphoma. Chemotherapy has resulted in disease remission with resolution of MRI findings, but the patient has not had resolution of the hypopituitarism or DI. This case highlights the unique diagnostic challenge of patients with isolated hypothalamic lesions.

Primary sellar lymphoma: intravascular large B-cell lymphoma diagnosed as a double cancer and improved with chemotherapy, and literature review of primary parasellar lymphoma

Lymphoma is one of the causative factors of hypothalamus-pituitary dysfunction, and intravascular large B-cell lymphoma (IVLBCL) is a subtype of primary extranodal neoplasm. A 69-year-old woman visited our hospital because of general fatigue. We diagnosed her with presumable non-functional primary pituitary adenoma and subsequent dysfunction. Eight months after, the patient revisited our hospital because of dyspnea. Though we conducted systemic investigations including chest and abdomen enhanced computer tomography, transbronchial lung biopsy, and bone marrow biopsy, the diagnosis was not confirmed. Inadvertently, a breast cancer was found, and the surgical specimen proved that the patient had double cancer-adenocarcinoma and IVLBCL. Rituximab, cyclophosphamide, adriamycin, vincristine, and prednisolone regimen was initiated, and complete remission was achieved. Notably, the sellar mass returned to normal size with improved function. We reviewed 32 patients with primary parasellar lymphoma. In affected sites, both sellar and pituitary stalk (6.7%), both hypothalamus and pituitary stalk (6.7%), only sellar (63.3%), only pituitary stalk (6.7%), only hypothalamus (13.3%), and only clivus (3.3%) were observed. In hypothalamus-pituitary dysfunction, both anterior and posterior dysfunction (20.7%), only anterior dysfunction (58.6%), only posterior dysfunction (3.4%), and no dysfunction (17.2%) were observed. It seemed that hypothalamic lesion is related to both anterior and posterior dysfunction, while sellar lesion is related to mainly anterior dysfunction. In cranial nerve dysfunction, 2nd nerve dysfunction (45.2%) and 6th nerve dysfunction (35.5%) were frequently observed. It seemed that sellar lesion is related to both 2nd and 6th nerve dysfunction, while hypothalamic lesion is related to mainly 2nd nerve dysfunction.

[Lymphoma of the pituitary stalk]

INTRODUCTION

Tumors of the pituitary stalk are rare and their diagnosis is sometimes difficult.

CASE REPORT

We report a case of a primary lymphoma of the pituitary stalk in a 78-year-old patient. To our knowledge, only seven similar cases have been previously published: prominent symptoms were headache, fatigue and diplopia; biologically, anterior pituitary low secretion or hyperprolactinemia were found in the majority of cases; regarding the imaging, only three patients presented an initial and isolated lesion of the stalk; histological evidence was obtained by a trans-sphenoidal biopsy in case of hypothalamic or pituitary associated lesion or by a trans-cranial biopsy in the event of an isolated lesion. As an alternative, a lumbar puncture could be performed; although less invasive, its diagnostic performance is lower.

CONCLUSION

Current treatment relies on chemotherapy with intravenous methotrexate associated with intrathecal methotrexate infusion if cerebrospinal showed abnormal cells. Unfortunately, the results remain poor with a median survival of 9 months.