Early surgical intervention for patients with possible clinically silent somatotroph adenoma: a case series

Silent Corticotroph and Somatotroph Double Pituitary Adenoma: A Case Report and Review of Literature

Clinically silent double pituitary adenomas consisting of corticotroph and somatotroph cells are an exceedingly rare clinical finding. In this report, we present the case of a 28-year-old man with a 1-year history of recurrent headaches. Imaging revealed a 2.1 (anterior-posterior) × 2.2 (transverse) × 1.3 (craniocaudal) cm pituitary adenoma invading into the left cavernous sinus and encasing the left internal carotid artery. Endoscopic transnasal resection was performed without complications. Immunohistochemical staining revealed a double adenoma consisting of distinct sparsely granulated somatotroph and densely granulated corticotroph cells that were positive for growth hormone and adrenocorticotropic hormone, respectively. K _i -67 index labeling revealed a level of 6% within the corticotroph adenoma. No increase in serum growth hormone or adrenocorticotropic hormone was found, indicating a clinically silent double adenoma. While transsphenoidal surgery remains a first-line approach for silent adenomas presenting with mass effects, increased rates of proliferative markers, such as the K _i -67 index, provide useful insight into the clinical course of such tumors. Determining the K _i -67 index of silent pituitary adenomas could be valuable in predicting recurrence after initial surgical resection and identifying tumors that are at an increased risk of needing additional therapeutic interventions or more frequent surveillance imaging.

Metachronous Double Pituitary Adenoma with Altered Transcriptional Factor Profile: A Case Report and Literature Review

Double pituitary adenomas (DPAs), especially metachronous DPAs, are extremely rare and there has been no report about DPAs with altered transcriptional factors. We describe the case of a 25-year-old man who presented with acromegaly 7 years after surgery for a non-functioning pituitary adenoma (NFPA). Before the initial surgery, endocrine evaluation confirmed NFPA or silent somatotroph pituitary adenoma (SPA) because of normal serum levels of insulin-like growth factor-1 (IGF-1) and insufficient suppression of growth hormone (GH) levels in the oral glucose tolerance test (OGTT). Immunohistochemistry of resected tissue obtained from gross total resection (GTR) with transsphenoidal surgery (TSS) was negative for follicle-stimulating hormone, luteinizing hormone, GH, and Pit-1 but positive for GATA3, which confirmed the gonadotroph pituitary adenoma (GPA) diagnosis. Seven years later, follow-up brain MRI revealed a 13.3 × 5.6 × 4.7 mm tumor within the sellar turcica. The endocrine evaluation confirmed acromegaly because of high serum levels of IGF-1 and insufficient suppression of GH levels upon OGTT. GTR with TSS was again performed, and immunohistochemistry was negative for GATA3 but positive for GH and Pit-1. Surprisingly, he showed altered transcription factor expressions between initial and recurrent surgery. Based on the overall clinical course and hormonal secretion findings, we speculated metachronous development of a DPA, i.e., SPA followed by GPA, wherein a few remaining cells of the SPA might have regrown after the initial surgery. We conducted a literature review of cases that documented altered hormone secretion at recurrence and emphasized the necessity of identifying a small adenoma when there is a discrepancy between pathological findings and hormone secretion tests.

Clinico-Radiological Features of Tumor-like Lesions of the Upper Limbs: don't worry about those lumps

Tumor-like lesions of the upper limb are more frequent than malignant neoplastic lesions and they represent a wide and heterogeneous group of disorders. The combination of clinical evaluation and imaging is the first pivotal step to attempt a distinction between benign and malignant masses, since there are important implications for further management, such as the requirement for conservative or interventional treatment. The classification of these pseudo tumoral lumps remains arbitrary and is still a matter of debate, currently based on a conjunct clinico-radiologic approach. In this article, we review various types of tumor-like lesions of the upper limb in terms of imaging approach and related clinic features, proponing a descriptive classification, useful in clinical practice to recognize these disorders, and to avoid unnecessary or potentially harmful procedures.

A single- center experience of prolactin-producing pituitary adenomas without hyperprolactinemia: Its incidence and clinical management

OBJECTIVE

This study clarifies the incidence of prolactin-producing pituitary adenomas without hyperprolactinemia and determines the appropriate treatment strategy for these tumors.

PATIENTS AND METHODS

This retrospective analysis focused on prolactin-producing adenomas without hyperprolactinemia, which were initially treated by surgery as nonfunctioning pituitary adenomas. Among 942 patients with histologically confirmed pituitary adenoma, 114 (12.1 %) patients, consisting of 68 men and 46 women, who had prolactin-producing adenomas without hyperprolactinemia were identified between April 2005 and March 2019.

RESULTS

Of the 114 patients identified, 13 (11.4 %) had prolactin mono-expressions, 18 (15.8 %) had pit-1 lineage hormonal expressions, and 83 (72.8 %) had paradoxical immunoexpression out of the pituitary differentiation lineage, including prolactin. During the follow-up period, 19 patients suffered tumor progression, and 14 required salvage treatment. Of the 19 patients, 11 underwent gamma knife radiosurgery, and none of them experienced further tumor progression. Cabergoline was administered of them to six patients, and one achieved tumor shrinkage. However, the remaining five patients who were treated with cabergoline suffered further tumor progression and required another salvage treatment. Among the patients in the prolactin mono-expression group, one experienced tumor regrowth and underwent gamma knife radiosurgery. In the pit-1 lineage group, two patients experienced tumor regrowth. One had further tumor progression after treatment with cabergoline and underwent gamma knife radiosurgery. Among the patients in the paradoxical immunoexpression group, 16 suffered tumor progression. Four patients underwent further surgery, seven patients were treated with gamma knife radiosurgery, and one patient received fractionated irradiation. None of the eight patients who were treated with gamma knife radiosurgery and fractionated irradiation showed further tumor progression. Four patients in this group were treated with cabergoline, but they all suffered further tumor progression and underwent additional salvage treatments.

CONCLUSIONS

Out of the pituitary differentiation lineage, paradoxical hormonal expression occurred in three-quarters of the patients identified. Further surgery or gamma knife radiosurgery should be given priority in times of tumor progression because most patients were resistant to dopamine agonists.