A 52-year-old male with visual changes

Crooke Cell Adenoma Confers Poorer Endocrinological Outcomes Compared with Corticotroph Adenoma: Results of a Multicenter, International Analysis

BACKGROUND

Crooke cell adenomas (CCAs) are a rare, aggressive subset of secretory pituitary corticotroph adenomas (sCTAs) found in 5%-10% of patients with Cushing disease. Multiple studies support worse outcomes in CCAs but are limited by small sample size and single-institution databases. We compared outcomes in CCA and sCTA using a multicenter, international retrospective database of high-volume skull base centers.

METHODS

Patients surgically treated for pituitary adenoma from January 2017 through December 2020 were included.

RESULTS

Among 2826 patients from 12 international centers, 20 patients with CCA and 480 patients with sCTA were identified. No difference in baseline demographics, tumor characteristics, or postoperative complications was seen. Microsurgical approaches (60% CCA vs. 62.3% sCTA) were most common. Gross total resection was higher in CCA patients (100% vs. 83%, P = 0.05). Among patients with gross total resection according to intraoperative findings, fewer CCA patients had postoperative hormone normalization of pituitary function (50% vs. 77.8%, P < 0.01) and remission of hypersecretion by 3-6 months (75% vs. 84.3%, P < 0.01). This was the case despite CCA having better local control rates (100% vs. 96%, P < 0.01) and fewer patients with remnant on magnetic resonance imaging (0% vs. 7.2%, P < 0.01). A systematic literature review of 35 studies reporting on various treatment strategies reiterated the high rate of residual tumor, persistent hypercortisolism, and tumor-related mortality in CCA patients.

CONCLUSIONS

This modern, multicenter series of patients with CCA reflects their poor prognosis and reduced postsurgical hormonal normalization. Further work is necessary to better understand the pathophysiology of CCA to devise more targeted treatment approaches.

Prevalence and clinical characteristics of Crooke's cell adenomas in 101 patients with T-PIT-positive pituitary adenomas: Case series and literature review

PURPOSE

We aimed to perform a retrospective analysis of a rare subtype of corticotroph adenoma, Crooke's cell adenoma, to better understand its clinical features.

METHODS

We collected T-PIT-positive pituitary adenomas and screened Crooke's cell adenomas from January 2020 to December 2021 in our center. Case reports of such tumors were also collected through a literature search. Clinical data such as biochemical tests, imaging examinations, and pathological data of the above cases were analyzed.

RESULTS

A total of 101 T-PIT-positive patients were treated in our center in the last 2 years, and 4 were finally pathologically diagnosed with Crooke's cell adenomas. All of these patients were male with elevated adrenocorticotropic hormone levels, and 50.0% presented with hypercortisolemia, Cushing's syndrome, visual impairment, and headache. The tumor diameter was significantly larger in these 4 patients (37.0 mm) than in the other patients (26.0 mm), and their tumor invasive behavior was more pronounced. Cases reported in the literature were mainly female (72.8%), and the clinical presentation was also dominated by Cushing's syndrome (65.1%) and hormonal dysfunction. Tumors were more common as macroadenomas (33.2 mm) and suprasellar growths (63.8%). The tumor recurrence rate was as high as 55.6%, with 6 cases progressing to pituitary carcinomas and 7.7% of tumor-related deaths. Our further integrated analysis of our center and reported cases revealed that gender, Cushing's syndrome, visual dysfunction, hormonal disorders, and tumor growth characteristics were statistically different in different tumor categories.

CONCLUSION

Crooke's cell adenoma is a tumor subtype with obvious clinical aggressive behavior, and an in-depth analysis of its clinical characteristics may assist in developing a comprehensive treatment plan.

Functioning Crooke Cell Adenomas: Case Series and Literature Review

BACKGROUND

Crooke cell adenomas (CCA) are rare potentially aggressive pituitary adenomas. Data regarding prevalence and clinical course is sparse.

METHODS

Methods consisted of a retrospective review of 59 consecutive functioning corticotroph adenomas (FCA) operated between October 2017-November 2020, and a literature review of CCA publications since 1991.

RESULTS

The prevalence of CCA among FCA at our institution was 8.5% (5/59). In the 4 other surgical cases series, prevalence of CCA ranged between 0%-6.8%. Our patients, 4 women and 1 man, mean age 46±11 years, presented with hypercortisolism (3/5), vision loss (1/5) and incidentally (1/5). All patients had elevated ACTH (151±54 pg/ml) and urinary free cortisol (830±796.5 μg/day) levels. Radiologically, 3 tumors were macroadenomas and 2 had cavernous sinus invasion. All patients achieved biochemical remission at 3 months postoperatively. One patient with a giant pituitary adenoma underwent fractionated radiation for residual tumor. During follow-up (range: 3.1-31.0 months), no patients had evidence of radiological or biochemical recurrence. The literature review (3 case series) and 21 case reports identified 22 FCA with outcome data. Additional treatments included reoperation (50%), radiation (59%), bilateral adrenalectomy (23%) and Temozolomide (36%).

CONCLUSION

We report a higher CCA prevalence among functioning ACTH-adenomas after the implementation of 2017 WHO classification. In our series and the literature, most CCAs were macroadenomas with high ACTH levels. Postoperative outcomes were excellent in our series, while some cases from the literature were refractory to standard treatments. Larger clinical and molecular studies are needed to identify patients at risk.

Crooke's cell tumors of the pituitary

Crooke's cell adenomas are a rare type of pituitary neoplasm. They produce adrenocorticotropic hormone causing Cushing's disease or may be endocrinologically silent. These tumors are usually invasive, may exhibit aggressive clinical behavior, and often recur with a low success of cure after reoperation and/or radiotherapy. Due to their rarity, they present great difficulties in assessing prognosis, treatment, and clinical management. Neurosurgeons and physicians dealing with pituitary adenomas diagnosed as Crooke's cell adenomas have to be aware of their potential clinical aggressiveness to plan strict follow-up of patients and eventual multimodality treatment. We review here the published cases of Crooke's cell tumors, as well as the clinical and histopathological characteristics of these unusual neoplasms.