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Zhang Y, Gong X, Pu J, Liu J, Ye Z, Zhu H, Lu L, Pan H, Deng K, Yao Y. Double pituitary adenomas: report of two cases and systematic review of the literature. Front Endocrinol (Lausanne) 2024; 15:1373869. [PMID: 38628582 PMCID: PMC11018951 DOI: 10.3389/fendo.2024.1373869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Objective Double pituitary adenomas (DPA) are a rare clinical condition, and our knowledge of them is limited. Missing the second lesion leading to incomplete biochemical remission after surgery is an important challenge in DPA management. This study aims to analyze independent prognostic factors in DPA patients and summarize clinical experiences to prevent surgical failure. Methods Two cases of DPA patients with Cushing's disease diagnosed and surgically treated at Peking Union Medical College Hospital are reported. A literature review was performed on the online database Pubmed, and 57 DPA patients from 22 retrieved articles were included. Demographic characteristics, endocrine manifestations, diagnostic methods, tumor size, and immunohistochemical features of 59 patients were analyzed. Binary logistic regression models were used to identify independent prognostic factors affecting postoperative biochemical remission. Results Among 59 DPA patients, the mean ± SD age was 43.64 ± 14.42 years, with 61.02% being female (n = 36). The most common endocrine manifestations were Cushing's syndrome (23/59, 38.98%) and acromegaly (20/59, 33.90%). The most prevalent immunohistochemical types were ACTH-immunopositive (31/118, 26.27%) and GH-immunopositive (31/118, 26.27%) tumors. Microadenomas (<1cm) were the most frequent in terms of tumor size (62/92, 67.39%). The detection rate for double lesions on 3.0T MRI was 50.00% (14/28), which significantly higher than 1.5T MRI (P = 0.034). Univariate analysis revealed that female, Cushing's syndrome and only single lesion detected by surgical exploration were associated with significantly worse prognosis (P<0.05). Multivariate analysis identified double lesion detected by surgical exploration (OR = 0.08, P = 0.003) and contiguous type tumor (OR = 0.06, P = 0.017) as independent protective factors for DPA patients. Conclusions The double lesion detected by surgical exploration is independently associated with a better prognosis for DPA patients. Comprehensive intraoperative exploration are crucial measures to avoid missing causative lesions.
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Affiliation(s)
- Yi Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xinyue Gong
- Eight-Year Program of Clinical Medicine, Peking Union Medical College, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Jun Pu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jifang Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhang Ye
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hui Pan
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Voznyak O, Hryniv N, Lytvynenko A, Zinkevych Y. Double Pituitary Adenomas in Patients With Cushing's Disease. Cureus 2023; 15:e38923. [PMID: 37188065 PMCID: PMC10176272 DOI: 10.7759/cureus.38923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 05/17/2023] Open
Abstract
Background and objective Double and multiple pituitary adenomas (PAs) are discovered in 2.6-3.3% of patients with Cushing's disease and in approximately 1% of autopsies. Undiagnosed and unremoved second PA may be the cause of unsuccessful surgical treatment of Cushing's disease. In this study, we aimed to describe our experience with the detection and treatment of patients with double PAs. Methods All patients in our series underwent transsphenoidal surgery (TSS) with endoscopic and neuronavigation assistance. Before 2017, we completely relied on MRI findings while planning surgery. From 2017 onwards, a broad revision of the sella turcica was conducted during surgeries regardless of the MRI data. Results Overall, 81 patients were included in the study: 51 before 2017 and 30 in 2017 after. In the pre-2017 group of patients, three out of 51 had double adenomas, and all of them were seen on MRI images. We encountered four more double PAs during the next period. Only two of them had been predicted by MRI. The remission rate was higher after 2017 and amounted to 90% (27 out of 30 patients). In contrast, before the implementation of total revision (pre-2017), our success rate was 82% (42 out of 51 cases). Both neoplasms in cases of double PAs yielded similar histological and immunohistochemical (IHC) features but were consistent with multiple PAs. Conclusions Although the improvement in our results in recent years cannot be clearly attributed to a targeted search for the second microadenoma, we still recommend performing a broad inspection of the sella turcica after the excision of the pituitary microadenoma regardless of preoperative MRI data.
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Affiliation(s)
| | - Nazarii Hryniv
- Centre of Neurosurgery, Clinical Hospital "Feofaniya", Kyiv, UKR
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Demirci H, Kahraman D, Kuzucu P, Şenol Ö, Uğur KŞ, Ergün MA, Keskil S, Akdemir Özışık P. Growth hormone-releasing pituitary microadenoma overshaded by a macroadenoma: a case of double pituitary adenomas and review of the literature. Br J Neurosurg 2022:1-7. [PMID: 35657108 DOI: 10.1080/02688697.2022.2076806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 03/21/2022] [Accepted: 05/09/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVES Double pituitary adenoma is a rare entity that can pose a significant challenge. The incidence of double or multiple pituitary adenomas is ∼1% in autopsy cases and 0.4-1.3% in surgical series. Its definition varies, including 'double adenomas' in the literature in contrast to 'multiple adenomas', which is more specific and suitable. While some authors require separating topographically unique tumours, others have used a looser definition of separate immunohistochemistry. CASE PRESENTATION We presented the case of a 26-year-old patient with recurrent carpal tunnel syndrome symptoms, with double pituitary adenomas secreting growth hormone (GH) and thyroid-stimulating hormone (TSH). To date, 89 patients have been reported in the literature with symptomatic carpal tunnel syndrome, but only five had GH-TSH secretion. CONCLUSIONS Double adenoma resection is of great importance for ensuring successful biochemical treatment. To ensure a successful operation, a careful preoperative 3T MRI examination is of great importance.
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Affiliation(s)
- Harun Demirci
- Department of Neurosurgery, Faculty of Medicine, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Devrim Kahraman
- Department of Pathology, Faculty of Medicine Hospital, TOBB University of Economics and Technology, Ankara, Turkey
| | - Pelin Kuzucu
- Department of Neurosurgery, Gülhane Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Özde Şenol
- Department of Neurosurgery, Ege University Faculty of Medicine, İzmir, Turkey
| | - Kadriye Şerife Uğur
- Department of ENT, Faculty of Medicine Hospital, TOBB University of Economics and Technology, Ankara, Turkey
| | - Mehmet Ali Ergün
- Department of Genetics, School of Medicine, Gazi University, Ankara, Turkey
| | | | - Pınar Akdemir Özışık
- Department of Neurosurgery, Faculty of Medicine, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Collazo-Gutiérrez N, de Jesús O, Villamil-Jarauta M, Alvarado M, González L, Ramírez M, Carlo-Chevere VJ. Double Pituitary Adenomas with Synchronous Somatotroph and Corticotroph Clinical Presentation of Acromegaly and Cushing's Disease. World Neurosurg 2019; 132:161-164. [PMID: 31505284 DOI: 10.1016/j.wneu.2019.08.224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Double pituitary adenomas are a rare occurrence. Synchronous clinical manifestation is extremely rare. CASE DESCRIPTION We report a case of a 51-year-old female with symptoms of both hypercortisolism and acromegaly during the past 2 years. Endocrine evaluation confirmed active acromegaly and revealed adrenocorticotropin hormone-dependent hypercortisolemia. Preoperative magnetic resonance imaging of the pituitary demonstrated separated double microadenomas with different intensity. Immunohistochemical analysis of each separate adenoma confirmed an exact diagnosis. The diagnosis of acromegaly and adrenocorticotropin hormone-dependent Cushing's disease was confirmed. CONCLUSIONS This is the third reported case in the literature of synchronous clinical manifestation of acromegaly and Cushing's disease. Extensive surgical exploration of the sella must be performed to avoid surgical failures from residual tumor. Immunohistochemical analysis is required to confirm an exact diagnosis for each of the double pituitary adenomas.
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Affiliation(s)
| | - Orlando de Jesús
- Section of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico.
| | | | - Milliette Alvarado
- Section of Endocrinology, University of Puerto Rico, San Juan, Puerto Rico
| | - Loida González
- Section of Endocrinology, University of Puerto Rico, San Juan, Puerto Rico
| | - Margarita Ramírez
- Section of Endocrinology, University of Puerto Rico, San Juan, Puerto Rico
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Kontogeorgos G, Thodou E. Double adenomas of the pituitary: an imaging, pathological, and clinical diagnostic challenge. Hormones (Athens) 2019; 18:251-254. [PMID: 31388898 DOI: 10.1007/s42000-019-00126-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/24/2019] [Indexed: 12/14/2022]
Abstract
Double and multiple adenomas of the pituitary are composed of two or more distinct tumors located in the same gland. They represent uncommon lesions measuring less than 1 cm, reported as having a low incidence in autopsies and occurring even more infrequently in surgical series. The histological diagnosis of double adenomas in surgical material is often extremely difficult, and confirmation requires immunohistochemistry and, occasionally, electron microscopy. Fragmented tissue material submitted for histology after transsphenoidal resection complicates the diagnosis. Difficulties in demonstrating double or multiple adenomas by imaging techniques contribute to diagnostic failure. Magnetic resonance imaging (MRI) techniques may disclose two separate adenomas located in the same pituitary gland. Intraoperative MRI and imaging ultrasonography, together with positron emission computed tomography, more accurately identify sites of residual tumors. These techniques might also detect postoperatively a residual tumor belonging to the second component of double adenoma. Double adenomas may also create extreme clinical diagnostic challenges. It is almost impossible to suspect functioning double adenomas with combined hormone secretion, each one secreting a different hormone, and distinguish them from an isolated plurihormonal adenoma, simultaneously secreting more than one hormone. Double adenomas may underlie surgical failure when one adenoma is removed while the other is left behind. Despite the low frequency of double adenomas, identification and resection of both of them is of major importance for the achievement of biochemical cure.
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Affiliation(s)
| | - Eleni Thodou
- Department of Pathology, University of Thessaly, Larissa, Greece
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Baig MZ, Laghari AA, Darbar A, Abdullah UEH, Abbasi S. Endoscopic Transsphenoidal Surgery for Cushing's Disease: A Review. Cureus 2019; 11:e5254. [PMID: 31572639 PMCID: PMC6760885 DOI: 10.7759/cureus.5254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/26/2019] [Indexed: 11/12/2022] Open
Abstract
Ever since the 1960s, transsphenoidal surgery has been the modality of choice for treating Cushing's disease. Subsequent visualization of the pituitary fossa and sphenoid sinus may be done either with the operating microscope or with the relatively new endoscope. The endoscope due to its panoramic view allows greater visualization as compared to the operating microscope. It confers greater access to the cavernous sinus, sella, suprasellar, and parasellar regions and accommodates higher magnifications. It is bi-dimensional, however as opposed to the operating microscope that provides a three-dimensional view and allows greater depth perception. This article provides a comprehensive review of the advantages and disadvantages of the endoscope and compares it to the operating microscope. We hope this article will prove useful to both clinicians and academicians alike in their approach and management of Cushing's disease.
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Affiliation(s)
- Mirza Zain Baig
- Surgical Oncology, Rudy L. Ruggles Biomedical Research Institute, Danbury, USA
| | | | - Aneela Darbar
- Neurosurgery, Aga Khan University Hospital, Karachi, PAK
| | | | - Sumiya Abbasi
- Epidemiology, Liaquat College of Medicine & Dentistry, Karachi, PAK
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Marques P, Barry S, Ronaldson A, Ogilvie A, Storr HL, Goadsby PJ, Powell M, Dang MN, Chahal HS, Evanson J, Kumar AV, Grieve J, Korbonits M. Emergence of Pituitary Adenoma in a Child during Surveillance: Clinical Challenges and the Family Members' View in an AIP Mutation-Positive Family. Int J Endocrinol 2018; 2018:8581626. [PMID: 29849625 PMCID: PMC5904812 DOI: 10.1155/2018/8581626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 01/30/2018] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Germline aryl hydrocarbon receptor-interacting protein (AIP) mutations are responsible for 15-30% of familial isolated pituitary adenomas (FIPAs). We report a FIPA kindred with a heterozygous deletion in AIP, aiming to highlight the indications and benefits of genetic screening, variability in clinical presentations, and management challenges in this setting. PATIENTS An 18-year-old male was diagnosed with a clinically nonfunctioning pituitary adenoma (NFPA). Two years later, his brother was diagnosed with a somatolactotrophinoma, and a small Rathke's cleft cyst and a microadenoma were detected on screening in their 17-year-old sister. Following amenorrhoea, their maternal cousin was diagnosed with hyperprolactinaemia and two distinct pituitary microadenomas. A 12-year-old niece developed headache and her MRI showed a microadenoma, not seen on a pituitary MRI scan 3 years earlier. DISCUSSION Out of the 14 members harbouring germline AIP mutations in this kindred, 5 have pituitary adenoma. Affected members had different features and courses of disease. Bulky pituitary and not fully suppressed GH on OGTT can be challenging in the evaluation of females in teenage years. Multiple pituitary adenomas with different secretory profiles may arise in the pituitary of these patients. Small, stable NFPAs can be present in mutation carriers, similar to incidentalomas in the general population. Genetic screening and baseline review, with follow-up of younger subjects, are recommended in AIP mutation-positive families.
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Affiliation(s)
- Pedro Marques
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sayka Barry
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Amy Ronaldson
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Arla Ogilvie
- West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Helen L. Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Peter J. Goadsby
- Basic & Clinical Neuroscience and NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK
| | - Michael Powell
- The National Hospital for Neurology and Neurosurgery, UCLH, NHS Trust, London, UK
| | - Mary N. Dang
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Harvinder S. Chahal
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Jane Evanson
- Department of Radiology, Barts and the London School of Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - Ajith V. Kumar
- North East Thames Regional Genetics Service, Great Ormond Street Hospital, London, UK
| | - Joan Grieve
- The National Hospital for Neurology and Neurosurgery, UCLH, NHS Trust, London, UK
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Song JY, Mun SJ, Sung SK, Hwang JY, Baik SK, Kim JY, Cheon CK, Kim SY, Kim YM. A rare case of multiple pituitary adenomas in an adolescent Cushing disease presenting as a vertebral compression fracture. Ann Pediatr Endocrinol Metab 2017; 22:197-202. [PMID: 29025207 PMCID: PMC5642078 DOI: 10.6065/apem.2017.22.3.197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/16/2017] [Accepted: 03/27/2017] [Indexed: 12/03/2022] Open
Abstract
Cushing disease in children and adolescents, especially with multiple pituitary adenomas (MPAs), is very rare. We report 17-year-old boy with MPAs. He presented with a vertebral compression fracture, weight gain, short stature, headache, and hypertension. On magnetic resonance imaging (MRI), only a left pituitary microadenoma was found. After surgery, transient clinical improvement was observed but headache and hypertension were observed again after 3 months later. Follow-up MRI showed a newly developed right pituitary microadenoma 6 months after the surgery. The need for careful clinical and radiographic follow-up should be emphasized in the search for potential MPAs in patients with persistent Cushing disease.
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Affiliation(s)
- Ji-Yeon Song
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
| | - Sue-Jean Mun
- Departments of Otorhinolaryngology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soon-Ki Sung
- Departments of Neurosergery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jae-Yeon Hwang
- Departments of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seung-Kug Baik
- Departments of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jee Yeon Kim
- Departments of Pathology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chong-Kun Cheon
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
| | - Su-Young Kim
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
| | - Yoo-Mi Kim
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea,Address for correspondence: Yoo-Mi Kim, MD, PhD https://orcid.org/0000-0002-8440-5069 Department of Pediatrics, Pusan National University Children’s Hospital, 20 Geumo-ro, Mulgeumeup, Yangsan 50612, Korea Tel: +82-55-360-3173 Fax: +82-55-360-2181 E-mail:
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