Orbital invasion by a pituitary macroadenoma without visual loss: case report and review of the literature

Lost to Follow-Up: Complications of an Invasive Giant Prolactinoma

Invasive giant prolactinomas are a rare type of prolactin-secreting tumors. Most lactotroph adenomas, including giant prolactinomas, consist of the sparsely granulated subtype and respond well to medical therapy with dopamine agonists. Proptosis due to intra-orbital tumor extension and ischemic infarction are two rare complications associated with these tumors.

We report a case of a 51-year-old woman with a 30-year history of a macroprolactinoma who was lost to follow-up and returned with severe proptosis, a 10-cm invasive sellar mass on imaging, and markedly elevated serum prolactin levels, consistent with invasive giant prolactinoma. She was initially managed with dopamine agonists followed by palliative debulking of the tumor, which microscopically demonstrated a highly proliferative neoplasm predominantly consisting of sparsely granulated lactotroph adenoma with a minor component of the rare and aggressive acidophil stem cell adenoma subtype. Postoperatively, she developed a large left middle cerebral artery infarct and ultimately died.

This case is notable in that it demonstrates the aggressive nature of invasive giant prolactinomas when not treated and highlights two rare findings in patients with this tumor: orbital invasion and ischemic infarct.

Pituitary Adenoma Apoplexy of the Orbit, Diagnosis, and Management With Presurgical Embolization

Orbital invasion of pituitary adenomas has been previously reported. In this report, the authors describe a 71-year-old female with a prolactinoma that presented with invasion of and apoplexy within the orbit. The patient underwent exenteration, followed by rapid tumor recurrence and growth. Given the hemorrhagic nature of the tumor, she subsequently underwent preoperative embolization and surgical resection. This case is notable in that it illustrates both apoplexy of a pituitary tumor within the orbit and the benefit of presurgical embolization.

A review of nasal, paranasal, and skull base tumors invading the orbit

Tumors that invade the orbit are uncommon. The majority are meningiomas arising from the sphenoid ridge (66%). Others are bone and cartilage tumors arising from the surrounding bones of the orbit, pituitary adenomas, and epithelial tumors arising from the paranasal sinuses and nasal cavity. Meningiomas occur more often in women, whereas epithelial tumors have a predilection for men. Meningiomas and epithelial tumors typically present in the sixth decade of life, whereas bone tumors tend to affect individuals in their third decade of life. Patients often present with a combination of ophthalmological and otorhinolaryngological symptoms, including proptosis, pain, decreased visual acuity, restrictions in motility of the eye, epistaxis, and nasal obstruction. Sarcomas and benign bone and cartilage tumors arise from surrounding structures, whereas carcinomas usually arise from the paranasal sinuses. Surgery is the mainstay of treatment. Depending on the aggressiveness and histology of the tumor, surgery may be combined with radiation and chemotherapy. The prognosis is generally poor, but varies depending on histology and cell origin, size of the tumor, and degree of invasion. Meningiomas and benign bone tumors have the best prognoses. Sinonasal undifferentiated carcinomas, small-cell neuroendocrine carcinomas, osteosarcomas, and rhabdomyosarcomas have poorer prognoses.

Atypical pituitary adenoma with orbital invasion: Case report and review of the literature

Pituitary adenoma invasion into the orbit is a rare phenomenon with only 22 cases, including the present case, in the literature. Our case is a 31-year-old man who presented with biopsy-proven atypical pituitary adenoma invading the right orbit after a prior resection. We compare his clinical course with previous cases and discuss clinical features, radiological features, management considerations, histologic features, and prognosis. Cases are organized by specific pituitary tumor type to aid in determining appropriate management. Early surgical intervention is the key, especially in the setting of pathologic features indicating aggressive tumor behavior or worsening visual function but is generally not indicated in prolactin-secreting adenomas that may respond to medical therapy. The role of radiation therapy is not fully established; however, it should be strongly considered in conjunction with or after surgery, especially in cases where complete resection is not achieved or histological and molecular analyses indicate a high likelihood of recurrence. More uniform and comprehensive data about management and outcomes are needed to determine the optimal treatment approach for this rare entity.

Preserved visual function with an orbital invasion of pituitary adenoma

Pituitary adenomas rarely extend to the orbit through the optic foramen and superior orbital fissure. Compressive optic neuropathy could be caused by orbital invasion of the mass showing variable visual prognosis. We are reporting a patient with intact visual acuity after 3 years of a profound orbital invasion of pituitary adenoma.

[Macroprolactinoma revealed by an exophthalmos]

With the purpose of illustrating a particular circumstance of giant macroprolactinoma diagnosis, we report the case of a 54-year-old woman who was seen in the Endocrinology department with the suspected diagnosis of hyperthyroidism in presence of unilateral exophthalmos. The patient reported headaches during the last year and secondary amenorrhea since she was 38 years old. The ophthalmologic examination confirmed the unilateral left exophthalmos, which was associated with oculomotor paralysis and vision loss. The computed tomography demonstrated a great mass of the sella extending in all directions and destroying the bone. The hormonal investigation confirmed the diagnosis of prolactinoma, with a level of 8723 ng/ml, and revealed hypopituitarism. The start of bromocriptin treatment was followed by a fall in the prolactin level to less then 200 ng/ml in 1 month. This case is particular regarding the giant macroprolactinoma in a woman discovered by an unusual visual complication.