Metastasis of lung adenocarcinoma to the pituitary gland

Pituitary metastasis (PM) is rare occurrence and accounts for <1% of all intracranial metastatic lesions. In this study, we highlight the importance of considering atypical sites for lung adenocarcinoma metastasis by presenting a case of a 54-year-old male who was diagnosed with PM 15 months after being diagnosed with stage IV lung adenocarcinoma with metastasis to the spine, pelvis, left frontal lobe, and right occipital lobe. He was on a prolonged course of chemotherapy during those 15 months and received palliative radiation for his brain metastasis with subsequent remission after 5 months following his initial diagnosis. The pituitary lesion was picked up as an incidental finding on a routine staging magnetic resonance imaging (MRI) 10 months after his brain metastasis remission. The patient successfully underwent trans-sphenoidal pituitary lesion resection. This case emphasizes the importance of routine surveillance and examination of atypical sites of metastasis even in patients undergoing a prolonged course of chemotherapy.

Pituitary metastasis of hepatocellular carcinoma as the initial presentations: a case report and review of the literature

Background

Extrahepatic metastasis of hepatocellular carcinoma (HCC) is common. However, pituitary metastasis of HCC is extremely rare. Our case may be helpful to extend the understanding of the disease.

Case presentation

A 65-year-old man presented to the outpatient department for unexplained headache and ptosis for 1 month. Brain imaging showed a slight enhancement tumor in the pituitary fossa, and the endocrinological assessment showed normal results. We considered the tumor as a non-functioning pituitary adenoma before surgery. Then, the tumor was resected by an endonasal endoscopic transsphenoidal approach. The histopathological examination results revealed the pituitary metastasis of HCC. Additional abdominal imaging revealed tumors were located in the left and right liver lobes with portal vein invasion and bilateral ilium metastases. After multidisciplinary cooperation, the patient chose chemotherapy.

Conclusion

We report a case of HCC metastasis to the pituitary gland that initially presented with neurological symptoms. We should consider the possibility of pituitary metastasis in HCC patients.

Metastatic Pleomorphic Lobular Carcinoma of the Breast to the Hypothalamus Presenting as a Primary Pituitary Lesion Presenting 17 Years Later-Report of a Case and Review of the Literature

Carcinomas metastatic to the brain are common, however, metastatic disease to the hypothalamic- pituitary region is uncommon and account for less than 3.6% of all resected malignant pituitary tumors. Most metastatic disease in that region derives from a lung or breast primary, with both ductal and lobular carcinoma reported. We report what we believe is the first case of pleomorphic lobular carcinoma metastatic to the hypothalamus. This case is also reaffirms that late metastasis from breast cancer should be considered in the differential diagnosis. It is important for the clinician to consider the clinical history of breast cancer, even when remote, in the differential diagnosis.

Sellar Metastases: Diagnosis and Management

Sellar metastases account for 0.87% of all intracranial metastases. They are usually asymptomatic and can be the first manifestations of some occult malignancy. The diagnosis is made mainly during the screening of patients with known primary lesions or can present with neurologic or hormonal changes related to compression or invasion of surrounding structures. Differentiating these lesions from other more common lesions such as pituitary adenoma maybe difficult. Management is mainly aimed at the primary lesion and is palliative to improve quality of life or for pathologic confirmation.

Machine learning defined diagnostic criteria for differentiating pituitary metastasis from autoimmune hypophysitis in patients undergoing immune checkpoint blockade therapy

PURPOSE

New-onset pituitary gland lesions are observed in up to 18% of cancer patients undergoing treatment with immune checkpoint blockers (ICB). We aimed to develop and validate an imaging-based decision-making algorithm for use by the clinician that helps differentiate pituitary metastasis (PM) from ICB-induced autoimmune hypophysitis (HP).

MATERIALS AND METHODS

A systematic search was performed in the MEDLINE and EMBASE databases up to October 2018 to identify studies concerning PM and HP in patients treated with cytotoxic T-lymphocyte-associated protein 4 and programmed cell death (ligand) 1. The reference standard for diagnosis was confirmation by histology or response on follow-up imaging. Patients from included studies were randomly assigned to the training set or the validation set. Using machine learning (random forest tree algorithm) with the most-described six imaging and three clinical features, a multivariable prediction model (the signature) was developed and validated for diagnosing PM. Signature performance was evaluated using area under a receiver operating characteristic curves (AUCs).

RESULTS

Out of 3174 screened articles, 65 were included totalising 122 patients (HP: 60 pts, PM: 62 pts). Complete radiological data were available in 82 pts (Training: 62 pts, Validation: 20 pts). The signature reached an AUC = 0.91 (0.82, 1.00), P < 10^-8 in the training set and AUC = 0.94 (0.80, 1.00), P = 0.001 in the validation set. The signature predicted PM in lesions either ≥ 2 cm in size or < 2 cm if associated with heterogeneous contrast enhancement and cavernous extension.

CONCLUSION

An image-based signature was developed with machine learning and validated for differentiating PM from HP. This tool could be used by clinicians for enhanced decision-making in cancer patients undergoing ICB treatment with new-onset, concerning lesions of the pituitary gland.

Pituitary Metastases: A Nationwide Study on Current Characteristics With Special Reference to Breast Cancer

OBJECTIVE

To investigate the contemporary presentation of pituitary metastases.

PATIENTS

Thirty-eight patients diagnosed with pituitary metastases from 1996 to 2018 in Sweden.

METHODS

Pituitary metastases were confirmed by histopathology (n = 27) or considered highly likely according to radiological findings, including rapid tumor progression (n = 11). Medical records were reviewed and sellar images reexamined centrally.

RESULTS

Breast and lung cancers were the most common primary tumors, in 45% and 21% of patients, respectively. Sixty-seven percent of breast cancers overexpressed human epidermal growth factor receptor 2 (HER2); 53% of pituitary metastases from breast cancers appeared ≥10 years after diagnosis of the primary tumor. At presentation, 71% appeared to have ACTH deficiency, 65% had TSH deficiency, and 26% had diabetes insipidus. Fatigue, nausea/vomiting, loss of appetite, weight loss, myalgia, and/or arthralgia were reported in 47% of patients with morning cortisol <100 nmol/L vs 23% with cortisol ≥200 nmol/L. Sixteen patients had visual field defects, and eight had diplopia. Intrasellar and suprasellar tumor growth was the most frequent finding. Initially, a pituitary adenoma was considered the etiology in 18% of patients.Radiotherapy, pituitary surgery, and chemotherapy were used in 68%, 68%, and 11% of patients, respectively. One and 2 years after diagnosis of pituitary metastases, 50% and 26% of patients were alive.

CONCLUSION

Pituitary metastases may be mistaken for pituitary adenomas and can appear late, especially in breast cancer. Breast cancers overexpressing HER2 seem prone to metastasize to the pituitary. Hypocortisolism may be misdiagnosed as cancer-related malaise. An increased awareness of pituitary metastases and undiagnosed pituitary failure can improve management in these patients.

Clinical Presentation and Pathologic Characteristics of Pituitary Metastasis from Breast Carcinoma: Cases and a Systematic Review of the Literature

BACKGROUND

It is rare for breast carcinoma to metastasize to the pituitary gland; this finding indicates extensive metastasis of the primary tumor.

CASE DESCRIPTION

Herein, we present a 57-year-old patient with pituitary gland metastasis from breast cancer that was treated with extensive radical mastectomy 16 years prior. The pituitary was the sole site of metastasis. The patient was admitted with the chief complaint of blurred vision for 1 year and episodic headaches for 1 month. Magnetic resonance imaging revealed a solid mass in the sellar region with heterogenous contrast enhancement. The preoperative diagnosis was a pituitary adenoma. Neuroendoscopy-assisted tumor resection was conducted through a single-nostril sphenoid sinus approach. A pinkish-white, firm neoplasm was found, with an abundant blood supply and an indistinct boundary between the neoplasm and normal pituitary tissue; complete resection was achieved. The results of immunohistochemical analysis were positive for cytokeratin, Ki-67antigen, estrogen receptors, progesterone receptors, and prolactin-induced protein. The neoplasm was negative for spalt-like transcription factor 4, mammaglobin, and the alpha subunit of the glycoprotein hormones. These results were used to reach a final diagnosis of pituitary gland metastasis from a primary breast carcinoma. The patient's vision improved significantly after surgery, and no recurrence was detected during 1 year of follow-up.

CONCLUSIONS

Pituitary gland metastasis is rare and difficult to differentiate from a pituitary adenoma without a pathologic diagnosis. Surgery is the first choice for treatment. Surgery, radiotherapy, and chemotherapy are combined with endocrine therapy to tailor treatment to the results of immunohistochemistry.

Pituitary metastasis: a rare condition

Tumor metastasis to the pituitary gland is a life-threatening condition associated with short life span. Pituitary metastasis is rare, however, and not well-documented. A better understanding of its clinical manifestations could lead to earlier diagnosis, appropriate therapy, and potentially improving quality of life. Therefore, we retrospectively studied the charts of patients with pituitary metastases who were treated at the City of Hope National Medical Center in Duarte, California, from 1984 to 2018. We reviewed and analyzed tumor origin, primary pituitary clinical manifestation, duration between primary tumor diagnosis and pituitary metastasis, type of treatment, and patient survival. A total 11 patients with a mean age of 59.2 years and median survival of 50.33 months were identified. Breast cancer and lymphoma were the most common primary origins in these cases, and diabetes insipidus and panhypopituitarism were the most common primary manifestations of their metastasis. We also compared our results with reports in the literature published between 1957 and 2018. A total 289 patients with pituitary metastasis have been reported in the literature. Breast cancer was the most frequent primary origin of the metastasis, and visual involvement was the most common primary manifestation. The posterior part of the pituitary is more susceptible than the anterior to metastasis. Pituitary metastasis may occur as a consequence of successful primary tumor treatment prolonging the chance of seeding. Future studies are needed to determine the molecular mechanism of metastasis to the pituitary.

Pituitary metastasis of hepatocellular carcinoma presenting with panhypopituitarism: a case report

Background

Metastasis to the pituitary gland is extremely rare and is often detected incidentally by symptoms associated with endocrine dysfunction. Breast and lung cancer are the most common primary metastasizing to pituitary gland. Metastasis from hepatocellular carcinoma to the pituitary gland is extremely rare, with only 10 cases having been previously reported. We present here the first case of pituitary metastasis of hepatocellular carcinoma presenting with panhypopituitarism diagnosed by magnetic resonance imaging.

Case presentation

We report the case of an 80-year-old Japanese woman who presented with the sudden onset of hypotension and bradycardia after having previously been diagnosed with hepatocellular carcinoma. Based on low levels of pituitary hormones, she was diagnosed with panhypopituitarism caused by metastasis of the hepatocellular carcinoma to the pituitary gland. Magnetic resonance imaging with arterial spin-labeling was effective in the differential diagnosis of the intrasellar tumor. The patient died despite hormone replacement therapy because of hypovolemic shock.

Conclusion

Metastasis to the pituitary gland causes various non-specific symptoms, so it is difficult to diagnose. The present case emphasizes the importance of diagnostic imaging in identifying these metastases. Clinicians should consider the possibility of pituitary metastasis in patients with malignant tumors who demonstrate hypopituitarism.

Metastatic involvement of the pituitary gland: a systematic review with pooled individual patient data analysis

PURPOSE

To report a rare case of pituitary metastasis (PM) from hepatocellular carcinoma (HCC) and help better understand the incidence of PM and its most common presenting symptoms through a pooled individual patient data analysis.

METHODS

Literature regarding PM was systematically reviewed with a pooled individual patient data analysis conducted. Pooled individual data analysis result is also compared with the result in a most recent systematic review.

RESULTS

Our results demonstrate that the incidence of PM among all intracranial metastases is 0.87% (95% CI 0.56, 1.18); it is 1.9% (95% CI 1.46, 2.34) among all autopsied cancer cases; it is 11.56% (95% CI 7.08, 16.04) among all breast cancer patients who had hypophysectomies and 12.83% (95% CI 10.5, 15.16) among all autopsied breast cancer patients. The fixed effect model showed that the incidence of PM in breast cancer patients group is significantly higher (p < 0.001) with an odds ratio of 6.71 (95% CI 4.24, 10.61). Breast and lung cancer are the most common primary cancer of PM with a percentage of 37.2 and 24.2 respectively. The next most common primary sites are prostate and kidney respectively, although the percentages for each are only about 5. Diabetes insipidus (DI) remains the most common symptom among all reported PM cases with a pooled incidence of 42.34% (95% CI 36.15, 48.53). Although not significant (χ(2) = 2.846, df = 1, p = 0.061), it is less common in the most recent reported cases which has a pooled incidence of 32.76% (95% CI 20.31, 45.21). DI is extremely rare in the reported PM cases from HCC (none of the eight cases presented with DI). The symptoms of anterior hypopituitarism (23.68 vs 39.66%, p = 0.015), visual deterioration (27.89 vs 41.38%, p = 0.039), cranial nerve palsies (21.58 vs 41.38%, p = 0.003) and headaches (15.79 vs 32.76%, p = 0.005) were reported significantly higher than previously described in the literature.

CONCLUSIONS

Pituitary metastasis is rare in patients with cancer, and the pituitary gland is an uncommonly involved location in patients with intracranial metastases. With advanced diagnostic imaging techniques and increased awareness about the manifestation of sellar lesions, the incidence of cranial nerve palsies and anterior pituitarism are higher than reported. This information may allow earlier diagnosis of PM.

Clinical and biochemical characteristic features of metastatic cancer to the sella turcica: an analytical review

BACKGROUND AND OBJECTIVES

Sellar metastasis is uncommon and poorly characterized as published data include small series of subjects. This study's goal is to identify unique features that differentiate this entity from other sellar masses such as pituitary macroadenomas.

METHODS

Published cases of pathologically-confirmed sellar metastasis along with our experience in such patients over a 6-years period were reviewed (total = 129). As a control group, we reviewed similar data on 55 patients with pituitary macroadenomas managed over the same time-period. Presenting symptoms, pituitary dysfunction were analyzed using univariate, multivariate and receiver operating characteristic (ROC) analyses.

RESULTS

Sellar metastasis has equal gender distribution with a median patient-age of 56 years. The most common primary malignancy was breast cancer (29%) in women and lung cancer (30%) in men. Sellar metastasis was the first manifestation of cancer in over 40% of patients. Common presenting symptoms included headaches, visual field deficits, abnormal eye motility and diabetes insipidus. These symptoms were less frequent among patients with pituitary macroadenomas. Univariate regression analyses showed that headaches, abnormal eye motility, visual field deficits and diabetes insipidus were each predictive of metastatic disease. ROC analysis combining all 4 features revealed an AUC of 0.953 with a sensitivity of 0.818 and a specificity of 0.935. Using the multivariate regression, abnormal eye motility and/or diabetes insipidus independently predicted metastatic disease.

CONCLUSIONS

Sellar metastasis should be suspected in patients presenting with sellar masses, abnormal eye motility and/or diabetes insipidus even those without known malignancy since pituitary metastasis can often be the first manifestation of cancer.

Endocrine side effects induced by immune checkpoint inhibitors

CONTEXT

In recent years, progress has been made in cancer immunotherapy by the development of drugs acting as modulators of immune checkpoint proteins, such as the cytotoxic T-lymphocyte antigen-4 (CTLA4) and programmed death-1 (PD-1), two co-inhibitory receptors that are expressed on T cells upon activation. These molecules play crucial roles in maintaining immune homeostasis by down-regulating T-cell signaling, thereby preventing unbridled T-cell proliferation while maintaining tolerance to self-antigens, such as tumor-associated antigens. CTLA4 blockade through systemic administration of the CTLA4-blocking antibody ipilimumab was shown to confer significant survival benefit and prolonged stable disease in patients affected by advanced cutaneous melanoma. Other immune checkpoint inhibitors are under clinical evaluation. However, immune checkpoint blockade can lead to the breaking of immune self-tolerance, thereby inducing a novel syndrome of autoimmune/autoinflammatory side effects, designated as "immune-related adverse events," mainly including rash, colitis, hepatitis, and endocrinopathies.

DATA ACQUISITION

We searched the medical literature using the words "hypophysitis," "hypopituitarism," "thyroid," "adrenal insufficiency," and "endocrine adverse events" in association with "immune checkpoint inhibitors," "ipilimumab," "tremelimumab," "PD-1," and "PD-1-L."

EVIDENCE SYNTHESIS

The spectrum of endocrine disease experienced by patients treated with ipilimumab includes most commonly hypophysitis, more rarely thyroid disease or abnormalities in thyroid function tests, and occasionally primary adrenal insufficiency. Hypophysitis has emerged as a distinctive side effect of CTLA4-blocking antibodies, establishing a new form of autoimmune pituitary disease. This condition, if not promptly recognized, may be life-threatening (due to secondary hypoadrenalism). Hypopituitarism caused by these agents is rarely reversible, and prolonged or lifelong substitutive hormonal treatment is often required. The precise mechanism of injury to the endocrine system triggered by these drugs is yet to be fully elucidated.

CONCLUSIONS

Although reports of endocrine side effects caused by cancer immune therapy are abundant, their exact prevalence and mechanism are unclear. Well-designed correlative studies oriented to finding and validating predictive factors of autoimmune toxicity are urgently needed.

A lifelong smoker with hypopituitarism: rethinking the hypothesis of a tumor in the hypophysis

Pituitary adenomas are the most common cause of a sellar mass. Metastases to the pituitary gland, a rare occurrence, may mimic benign pituitary adenomas. We report here a case of a 61-year-old woman with an 80-pack-year smoking history who presented with headache and diplopia. Visual field testing demonstrated bitemporal hemianopsia. Pituitary MRI revealed a 2.0 cm sellar mass impinging upon the optic chiasm. Hypopituitarism was present, with no evidence of diabetes insipidus. The patient was referred to our service for transsphenoidal resection of a presumed pituitary macroadenoma. As part of her preoperative evaluation, a chest radiograph was obtained, which showed a large hilar mass. In light of the patient's extensive smoking history, the differential diagnosis was expanded to include metastatic lesion to the sella. Transsphenoidal resection of the tumor was performed and histopathology revealed small cell carcinoma. The patient received chemotherapy, but died 18 months later due to widespread brain metastases. Although the presence of diabetes insipidus may help to discriminate between pituitary adenomas and metastatic lesions, this is not a sensitive finding. This case illustrates the need for maintaining a high index of suspicion for pituitary metastasis in patients with known risk factors for malignancy.