Bronchioloalveolar carcinoma with metastasis to the pituitary gland: a case report

Pituitary Metastasis From Urothelial Carcinoma: A Case Report and Review of the Diagnosis and Treatment of Pituitary Metastases

The sellar and parasellar regions are a rare site of brain metastasis, most commonly from breast and lung cancer. Pituitary metastasis (PM) often presents as the first sign of metastatic disease but may herald early disseminated cancer. The diagnosis of PM requires differentiation from a benign pituitary adenoma. Although this may be proven definitively via surgical biopsy, a constellation of clinical findings including oculomotor palsy, visual disturbances, retroorbital pain, and diabetes insipidus is more suggestive of PM. Imaging is neither sensitive nor specific for differentiation but may inform the broader clinical picture. Due to its rarity, treatment guidelines for PM lack consensus, often including a mixture of radiation and surgery. Gross resection is challenging because of the vascular, invasive nature of these lesions. Stereotactic radiosurgery may be used to good effect either alone or in addition to resection. Even with treatment, the prognosis is poor. In this article, we present the third reported case of urothelial carcinoma metastasis to the pituitary. In addition, we review the clinical presentation, diagnosis, and treatment options including surgical resection and radiosurgery.

Diabetes insipidus and panhypopituitarism as a first presentation of silent adenocarcinoma of lung: a case report and literature review

BACKGROUND

Pituitary metastasis is a rare condition with a poor prognosis. Very few patients with pituitary metastasis are symptomatic. It is often associated with presence of co-existing metastases to other organs. Isolated pituitary metastasis as the first presentation of primary malignancy is uncommon.

CASE PRESENTATION

A 72-year-old woman presented with a 2-month history of polyuria, increasing thirst and unexplained weight loss. Esophagogastroduodenoscopy (EGD) was scheduled as part of the investigation. She was kept nil per os for 10 h prior to EGD, after which she developed alteration of consciousness. Further investigation revealed hypernatremia with sodium level of 161 mmol/L and low urine osmolality of 62 mOsm/kg. Her urine output was 300 mL per hour. Diabetes insipidus (DI) was diagnosed based on evidence of polyuria, hypernatremia, and low urine osmolality. Her urine output decreased and urine osmolality increased to 570 mOsm/kg in response to subcutaneous desmopressin acetate, confirming central DI. Pituitary magnetic resonance imaging showed a heterogeneous gadolinium enhancing lesion at the sellar and suprasellar regions, measuring 2.4 × 2.6 × 3.9 cm compressing both the hypothalamus bilaterally and the inferior aspect of optic chiasm as well as displacing the residual pituitary gland anteriorly. The posterior pituitary bright spot was absent. These MRI findings suggested pituitary macroadenoma. There were also multiple small gadolinium-enhancing lesions up to 0.7 cm in size with adjacent vasogenic brain edema at the subcortical and subpial regions of the left frontal and parietal areas, raising the concern of brain metastases. Pituitary hormonal evaluation was consistent with panhypopituitarism. Histopathological and immunohistochemical studies of the pituitary tissue revealed an adenocarcinoma, originating from the lung. Computed tomography of the chest and abdomen was subsequently performed, showing a 2.2-cm soft tissue mass at the proximal part of right bronchus. There was no evidence of distant metastases elsewhere. The final diagnosis was adenocarcinoma of the lung with pituitary metastasis manifesting as panhypopituitarism and central DI. Palliative care along with hormonal replacement therapy was offered to the patient. She died 4 months after diagnosis.

CONCLUSION

Diagnosis of pituitary metastasis is challenging, especially in patients with previously undiagnosed primary cancer. It should be considered in the elderly patients presenting with new-onset central DI with or without anterior pituitary dysfunction.

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.

Joint approach based on clinical and imaging features to distinguish non-neoplastic from neoplastic pituitary stalk lesions

Purpose

Distinguishing non-neoplastic pituitary stalk lesions (non-NPSLs) from neoplastic pituitary stalk lesions (NPSLs) is a major concern in guiding treatment for a thickened pituitary stalk. Our study aimed to aid provide preoperative diagnostic assistance by combining clinical and magnetic resonance imaging (MRI) findings to distinguish non-NPSLs from NPSLs.

Materials and methods

We recruited 158 patients with thickened pituitary stalk lesions visible on MRI. Laboratory findings included hypopituitarism, diabetes insipidus (DI), and hyperprolactinemia. MR images were assessed for anterior–posterior thickness (mm), diffuse pituitary stalk thickening, cystic changes, a high T1 signal, and glandular or extrasellar involvement. A diagnostic model was developed using a recursive partitioning logistic regression analysis. The model was validated in an independent dataset comprising 63 patients, and its diagnostic performance was compared with that of the original radiological reports.

Results

A univariate analysis found significant associations of DI (P = 0.006), absence of extrasellar involvement (P = 0.002), and lower stalk thickness (P = 0.031) with non-NPSLs. A diagnostic model was created using the following parameters (in order of priority): 1) lack of extrasellar involvement, 2) stalk thickness < 5.3 mm, and 3) presence of DI. The diagnostic performance (area under the curve; AUC) of this model in the independent set was 0.813, representing a significant improvement over the original radiological reports (AUC: 0.713, P = 0.029).

Conclusion

The joint diagnostic approach based on clinical and imaging-based factors robustly distinguished non-NPSLs from NPSLs. This approach could guide treatment strategies and prevent unnecessary surgery in patients with non-NPSL.

Pituitary metastasis: is there still a place for neurosurgical treatment?

Pituitary metastases are uncommon, ranging from 1 to 5 % of all metastases. Between 10 and 30 % of pituitary lesions are symptomatic responsible for diabetes insipidus, visual field defect or cranial nerve palsy. Primary sites are lung or breast in two-thirds of cases. There is no current reference concerning treatment of such lesions. Overall survival is poor and depends on primary site. Although the role of surgery is currently limited, discussion is warranted in several indications for diagnostic or symptomatic purposes. We report two cases of symptomatic pituitary metastases in a context of breast cancer and review the litterature concerning the role of surgery and other treatment modalities.

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.

Lung cancer presents as Addisonian crisis secondary to a solitary pituitary metastasis

We present the case of 68-year-old white man who presented with lung cancer in Addisonian crisis due to a pituitary metastasis. He was successfully treated with radiotherapy which reversed his visual field deficits. Pituitary metastasis as the first manifestation of malignancy is rare but, should be considered in the differential diagnosis of patients presenting with endocrine disturbances and visual problems.

[Pituitary metastases in patients with prior neoplasms]

The pituitary is an uncommon site for metastases. We report three cases of patients with a history of cancer (breast and lung) who presented with symptoms of headache, ophthalmoplegia, fatigue, diabetes insipidus, nausea, and vomiting. Cranial magnetic resonance imaging was performed, revealing sellar masses with infiltration of the adjacent tissues compatible with pituitary metastases in all three patients. In two of the patients, hormonal analyses were performed, which showed anterior pituitary insufficiency (thyroid-stimulating hormone and adrenocorticotropic hormone deficiency), symptoms which improved with hormone replacement therapy. Other treatments applied were surgery, radiotherapy and chemotherapy, which show no association with increased survival rates but are able to improve symptoms. The prognosis in all patients was poor. The patients developed further metastases and two died soon after diagnosis. Pituitary function study should be performed in patients with a previous neoplasm and symptoms compatible with hormonal dysfunction or local compressive symptoms.

[Pituitary metastases from lung cancer. Five cases]

Pituitary metastases are rare and generally asymptomatic. We studied 5 patients with pituitary metastases from lung cancer, illustrating the different clinical features. These metastases were in these cases symptomatic with the manifestation being diabetes insipidus or visual field defect. Histological subtypes from our five patients were as well small cell or non small cell lung cancer. After diagnosis of pituitary metastasis, prognosis seems to be linked to the histological subtype and the stage of lung cancer, rather than to the presence of such metastases.

Diabetes insipidus and panhypopituitarism revealing pituitary metastasis of small cell lung carcinoma: a case report

Metastatic tumors of the pituitary gland are not commonly diagnosed during life in cancer patients. The occurrence of symptomatic lesions is also very unusual and difficult to differentiate clinically and radiologically from pituitary adenomas. We report a case of pituitary metastasis which was the prime manifestation of a small cell lung carcinoma in a 40-year-old man. This cancer was revealed by diabetes insipidus and a hypopituitarism.

Hepatocellular carcinoma metastasis in the pituitary gland: case report and review of the literature

Symptomatic pituitary metastases are uncommon and have been reported mainly in autopsy series. Although all types of malignancies can metastasize to the pituitary gland, a review of the literature has indicated that lung and breast carcinomas are the most frequent primary tumors while hepatocellular carcinoma metastasis has only recently been described. A 59-year-old man with abdominal pain and fever was admitted to our hospital. Hepatosplenomegaly was present without signs of ascites. Laboratory tests showed only abnormal hepatic biochemistry while the radiological studies revealed a solid mass occupying the left hepatic lobe. The patient underwent excision of the left hepatic lobe and was closely followed-up. Six months later he readmitted with headache and visual disturbances. MRI revealed a solid mass in the sella region pressing the optic chiasma. Transsphenoidal excision of the pituitary mass was followed and the histological examination of the tumor was compatible with hepatocellular carcinoma. Symptomatic pituitary metastases are uncommon and may be difficult to differentiate from pituitary adenomas. The present case emphasizes on the capricious nature of hepatocellular carcinoma and on the importance of the individualized therapeutic approach.