Follicular thyroid carcinoma with metastases to the pituitary causing pituitary insufficiency

Pituitary metastases: a case series and scoping review

PURPOSE

To understand the natural history and optimal treatment strategy for pituitary gland metastasis.

METHODS

We performed both a retrospective chart review of patients treated at our institution and a scoping review of the topic.

RESULTS

The retrospective review identified seven patients with an average age of 59.6 years. Primary histologies included breast cancer (4), melanoma (1), renal cell carcinoma (1), and sarcoma (1). Two patients had anterior pituitary endocrine dysfunction, one of whom was the only patient with visual symptoms. All patients were treated with radiosurgery and two also underwent surgical resection. Overall survival ranged from 6.5 to 117 months. Literature review identified 166 patients from 71 studies. The most common primary cancer was lung (27.7%), followed by breast (18.7%) and renal (14.5%) cancer. 107 presented with endocrine dysfunction, including 41 cases of diabetes insipidus and 55 cases of hypopituitarism. 110 presented with visual compromise. 107 patients received radiotherapy, 96 underwent surgical resection and 44 received systemic chemotherapy/immunotherapy. Surgery was significantly associated with an increased likelihood of vision improvement and a decreased likelihood of endocrine normalization. Radiographic regression predicted visual improvement. Median overall survival was 9.9 months (range: 0.2-96).

CONCLUSIONS

This scoping review showed that both radiosurgery and surgical resection have been frequently used to treat pituitary metastases with good response. Vision improvement is more likely to happen following surgical resection, likely at the expense of endocrine dysfunction. Despite treatment and radiographic response, patient survival remains less than a year.

Pituitary Metastases From Differentiated Thyroid Cancers: A Systematic Review

Background

Pituitary metastasis (PM) from differentiated thyroid cancer (DTC) is extremely rare and may adversely affect outcomes. We aimed to assess the characteristics and outcomes of patients with PM from DTC.

Methods

We systematically reviewed the literature on publications on PM and the different DTC histologic types (papillary, follicular, and Hurthle cell cancers). Three databases (PubMed, Embase, and Scopus) were searched for articles published from 1967 to 2022. Survival time was estimated as the period from the first treatment of PM to the time of death or last follow-up.

Results

Twenty-five articles comprising 27 cases that met the eligibility criteria were identified using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The median age of the patients was 60 years (23 - 86). A preponderance of females (66.7%) with PM most commonly reported papillary thyroid cancer (55.6%). This was followed by follicular thyroid cancer (37.0%) and Hurthle cell cancer (7.4%). The most common presentations were headache, nausea, and vomiting, with visual symptoms in 44.4%. Diabetes insipidus was an infrequent finding (7.4%). The median time from diagnosis or first treatment of DTC to the diagnosis of PM was 3 years (0 - 25). The most common endocrine abnormality was hyperprolactinemia (63.2%), while the most frequently deficient hormone was luteinizing hormone (50%). The most common treatment modality for PM was a combination of radiotherapy and surgery with or without radio-iodine. At the end of the follow-up, 30% of the patients died. Only 33.3% of the patients achieved complete resolution of symptoms. The overall median survival time was 12 months (3 - 108). There was a moderate inverse correlation between the age of patients and survival, which was, however, not statistically significant (rs = -0.45, P = 0.103).

Conclusion

PM from DTC is extremely rare, and Hurtle cell cancer appears to be the least associated with PM. Diabetes insipidus is a rare initial manifestation of PM from DTC. Complete resolution of symptoms is less likely to be achieved in PM from DTC. Older age may confer an increased survival tendency, probably due to more intracranial space volume in older people compared to the younger population. Larger studies are needed to examine the relationship between age and survival in PM from DTC. Also, more observational data are required to determine the predictors of survival and compare the efficacy of the different treatment modalities in patients with PM from DTC.

A tale of many tumors and one endocrine site: A case series of pituitary metastases

BACKGROUND

Metastases to the pituitary gland are extremely rare with an incidence rate reported from an autopsy series of 1.8%-12%, and only 20% was diagnosed clinically. Tumors that commonly metastasize are breast and lung tumors.

CASE SERIES

We present a series of five cases, including four female patients and one male patient with metastatic cancer. Two women had metastatic small lung cancer and presented with diabetes insipidus (DI). Two women had metastatic breast cancer, of which one presented with DI and the other with panhypopituitarism. The male patient had bronchogenic adenocarcinoma and presented with DI.

CONCLUSION

Our case series confirmed earlier reports that DI is the most common presentation of metastases to the pituitary gland.

Thyroid carcinoma with atypical metastasis to the pituitary gland and unexpected postmortal diagnosis

SUMMARY

Papillary thyroid gland carcinoma is the most common type of malignancy of the endocrine system. Metastases to the pituitary gland have been described as a complication of papillary thyroid cancer in few reported cases since 1965. We report the case of a 68-year-old female patient with a well-differentiated form of thyroid gland cancer. Despite it being the most common malignant cancer of the endocrine system, with its papillary form being one of the two most frequently diagnosed thyroid cancers, the case we present is extremely rare. Sudden cardiac arrest during ventricular fibrillation occurred during hospitalization. Autopsy of the patient revealed papillary carcinoma of the thyroid, follicular variant, with metastasis to the sella turcica, and concomitant sarcoidosis of heart, lung, and mediastinal and hilar lymph nodes. Not only does atypical metastasis make our patient's case most remarkable, but also the postmortem diagnosis of sarcoidosis makes her case particularly unusual.

LEARNING POINTS

The goal of presenting this case is to raise awareness of the clinical heterogeneity of papillary cancer and promote early diagnosis of unexpected metastasis and coexisting diseases to improve clinical outcomes. Clinicians must be skeptical. They should not fall into the trap of diagnostic momentum or accept diagnostic labels at face value. Regardless of the potential mechanisms, clinicians should be aware of the possibility of the coexistence of thyroid cancer and sarcoidosis as a differential diagnosis of lymphadenopathy. This case highlights the importance of the diagnostic and therapeutic planning process and raises awareness of the fact that one uncommon disease could be masked by another extremely rare disorder.

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.

Twelve cases of pituitary metastasis: a case series and review of the literature

PURPOSE

The pituitary gland is an unusual site for metastatic spread, but as patients with metastatic malignancy are living longer, it may become more prevalent. Compression of important anatomy adjacent to the sella may produce disabling symptoms and endocrine derangement, leading to significant morbidity.

METHODS

An ambispective review of patient records between 2013 and 2017 from three neurosurgical centres was performed. After identifying cases, further investigation was performed to evaluate patient demographic, symptoms at presentation, radiological and histological findings, management, and outcome.

RESULTS

Our investigation identified 12 patients with pituitary metastasis. The average age of the cases was 63.4 years, with breast (n = 4) and lung (n = 4) being the most common primary cancers. In half the cases there was a history of metastatic disease, while in one-quarter of cases, pituitary symptoms were the first sign of malignancy. Adenohypophyseal dysfunction (83%), diabetes insipidus (DI) (75%), headache (67%) and visual field defects (67%) were the most common findings at presentation. Glucocorticoid replacement increased the sensitivity for diagnosis of DI. All cases were contrast enhancing on MRI and the endoscopic trans-sphenoidal approach was preferred for biopsy and debulking.

CONCLUSIONS

The pituitary should not be overlooked as a site of metastasis and sellar symptoms may be the first presentation of neoplastic disease. Any biochemical or clinical sign of pituitary pathology in a patient with known cancer should raise suspicion for sellar metastasis. Moreover, the development of DI or ophthalmoplegia from any pituitary lesion is suggestive of metastatic disease even in patients with no known primary.

Pituitary metastasis: a rare condition

Tumor metastasis to the pituitary gland is a rare, not well-documented and life-threatening condition associated with a shortened life span. 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 (Duarte, CA) 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 of 11 patients were identified with a mean age of 59.2 years and median survival following the diagnosis of metastasis of 10 months. Breast cancer and lymphoma were the most common primary origins in these cases, and diabetes insipidus and panhypopituitarism were the most common clinical 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 symptoms were 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 Thyroid Carcinoma: A Case Report

BACKGROUND Pituitary metastasis of thyroid carcinoma is a rare entity. Differential diagnosis with other lesions in the sellar/parasellar region, through clinical, histopathological, immunohistochemical, and imaging is challenging but essential for adequate treatment. CASE REPORT This case report describes a 58-year-old patient with the previous diagnosis of follicular thyroid carcinoma, with metastasis to cervical lymph nodes, bone, and lung, initially evolving to left palpebral ptosis. In the investigation, laboratory tests showed hypopituitarism, and magnetic resonance imaging of the skull showed a suprasellar formation measuring 2.2×3.5×2.5 cm, which increased in size in a few months. The patient underwent transcranial neurosurgery and subsequent immunohistochemical analysis, which confirmed pituitary metastasis of follicular thyroid carcinoma. The patient underwent chemotherapy and radiotherapy but died 26 months after the onset of symptoms. CONCLUSIONS The differential diagnosis of pituitary metastasis from a benign lesion is difficult. Therefore, a careful analysis of the history and clinical evolution, use of complementary imaging tests, and, where possible, the histopathological and immunohistochemical analysis of the lesion for diagnostic elucidation are necessary.

Radioiodine therapy under rhTSH for follicular thyroid carcinoma with sellar metastasis and non-rising TSH

Metastasis to the pituitary gland/sella turcica is an uncommon complication of thyroid cancer. Treating this condition is a challenge in the setting of pituitary insufficiency due to this lesion, and recombinant human thyroid-stimulating hormone (rhTSH) stimulation becomes critically essential. We present a rare case of an 82-year-old female patient with follicular carcinoma of the thyroid with metastasis to the sella turcica in addition to multiple skeletal and lung metastases. MRI of the brain showed a hypointense suprasellar lesion on T ₁ weighted images. The thyroid-stimulating hormone level remained persistently low even 4 weeks after thyroidectomy. A whole-body pertechnetate scan could not localize any abnormal tracer uptake and radioactive iodine uptake was also persistently low. The patient did not have symptoms related to pituitary involvement but TSH and early morning adrenocorticotrophic hormone levels were low. After thorough discussion with the neurosurgeon and radiotherapist, it was decided to start the patient on high-dose radioiodine treatment. Persistently low TSH level was a concern for starting radioiodine therapy. In view of this clinical context, rhTSH stimulation was used to achieve adequate TSH levels prior to radioiodine therapy. Subsequently, the patient was treated with 3.7 GBq (100 mci) of high-dose radioiodine. A post-therapy scan demonstrated radioiodine concentration in the thyroid bed remnant, multiple skeletal lesions and the sellar region. Thus, the use of rhTSH was critical in the management of this patient. It helped in radioiodine treatment by stimulating radioiodine uptake in the remnant and at the metastatic sites.

Thyroid carcinoma with pituitary metastases: 2 case reports and literature review

We present 2 patients with pituitary metastases from thyroid carcinoma-the first from anaplastic thyroid carcinoma and the second from follicular thyroid carcinoma. The first patient, a 50-year-old lady, presented with 2-week history of hoarseness of voice, dysphagia, dyspnoea, and neck swelling. Imaging revealed metastatic thyroid cancer to lymph nodes and bone. Histology from surgery confirmed anaplastic thyroid cancer. She was found to have pituitary metastases postoperatively when she presented with nonvertiginous dizziness. She subsequently underwent radiotherapy and radioiodine treatment but passed away from complications. The second patient, a 65-year-old lady, presented with loss of appetite and weight with increased goitre size and dyspnoea. Surgery was performed in view of compressive symptoms and histology confirmed follicular thyroid carcinoma. Imaging revealed metastases to bone, lung, and pituitary. She also had panhypopituitarism with hyperprolactinemia and diabetes insipidus. She received radioiodine therapy but eventually passed away from complications.

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.

Pituitary metastasis of thyroid cancer

Pituitary metastases (PM) from thyroid cancer are rare, but their management can represent a difficult challenge for the endocrinologist. Our aim was to review all reported cases of PM from thyroid cancer. PubMed was consulted and 19 papers reporting 20 cases were found. We moreover discuss two of our own cases, which had come to our attention within a few months of one another. Eleven cases were follicular cancer, eight cases were papillary cancer, two cases were medullary cancer, and one case was an insular cancer. In nine cases, PM was the first sign of the disease. Cranial nerve involvement was the most common sign of its presence, and no neuroradiological imaging could lead to a sure diagnosis of PM. Neurosurgical intervention was performed in almost all cases, and post-surgical treatment comprised radioiodine, external beam radiotherapy, and radiosurgery. Prognosis was poor for larger metastases, cranial nerve palsy disappeared in only one case, and in only one case of intrasellar metastasis was the disease cured. PM from thyroid cancer are rare, but are burdened by a poor prognosis. An early diagnosis appears important, and a comprehensive strategy for treatment (neurosurgery, radioiodine, external radiotherapy, and radiosurgery) appears advisable.

Hypopituitarism in the elderly

Pituitary dysfunction in elderly can represent a true diagnostic and therapeutic challenge to clinicians caring for these patients. Symptoms associated with partial or total hypopituitarism, such as fatigue, lower muscle strength and decreased libido, are nonspecific and can be often attributed to normal aging. Gold standard pituitary diagnostic testing carries higher risks in elderly and is classically replaced by alternative testing. Furthermore, the benefits and safety of selective pituitary hormonal replacement, specifically sexual and growth hormone replacement, remain subject of controversy in this group of patients. Recognizing and appropriately treating hypopituitarism in elderly is crucial for the survival and well being of the older patients with this disease.