Pituitary carcinoma with a single metastasis causing cervical spinal cord compression. Case report

Clinical features of pituitary carcinoma: analysis based on a case report and literature review

Introduction

Pituitary carcinoma (PC) is an extremely rare tumor of the adenohypophysis, which manifests as craniospinal dissemination and/or systemic metastasis. The diagnosis of PC is particularly difficult, as the clinical diagnosis only can be made after the metastasis is found. Owing to the complex diagnostic process and less effective treatments, the clinical prognosis of PC is usually very poor. Hence, it is of great significance to illustrate the diagnosis and treatment course of PC.

Methods

In this case report, we described a 48-year-old male patient who was diagnosed with pituitary adenoma (PA) initially and then was diagnosed with PC eventually after spinal cord metastasis was found, and we illustrated the treatment course as well. Furthermore, we summarized all the published case reports until now and provided a comprehensive review of the diagnosis, treatment, prediction, and clinical outcome of PC.

Results and Conclusions

We found that most PC patients had adrenocorticotropic hormone/prolactin (ACTH/PRL)-secreting tumors, Ki-67 ≥ 10%, and P53 positivity, which may have the potential to predict the transformation from PA to PC; surgery excision combined with temozolomide (TMZ) and radiotherapy is helpful to prolong the survival of PC patients.

A Rare Prolactin-secreting Pituitary Carcinoma With Epidural and Thecal Metastases

Pituitary carcinomas are rare but associated with significant morbidity and mortality. They remain challenging to diagnose and manage. In this case, we describe a 56-year-old man who presented with erectile dysfunction and binocular vertical diplopia. He had central hypogonadism, secondary adrenal insufficiency, and central hypothyroidism on biochemical testing. His serum prolactin was 1517 mcg/L (1517 ng/mL; reference range 4-15 mcg/L), and his sellar magnetic resonance imaging showed a 2.0 × 2.2 × 3.1 cm pituitary tumor. Pathology revealed a prolactin-secreting carcinoma. Despite treatment with a high-dose dopaminergic, 2 transsphenoidal resections, and 1 course of radiation, prolactin levels continued to rise. He developed metastases to the epidural space and thecal sac from the thoracic to sacral spine, for which he received 12 cycles of temozolomide chemotherapy with initial clinical and biochemical response. This was followed by disease escape and progression. We discuss the clinical and imaging features that warrant a high index of suspicion for pituitary carcinoma and review contemporary treatment.

Natural history of pituitary carcinoma with metastasis to the cervical spine: illustrative case

BACKGROUND

Pituitary carcinoma is a rare tumor of the adenohypophysis with noncontiguous craniospinal dissemination and/or systemic metastases. Given the rarity of this malignancy, there is limited knowledge and consensus regarding its natural history, prognosis, and optimal treatment.

OBSERVATIONS

The authors present the case of a 46-year-old woman initially treated with invasive prolactin-secreting pituitary macroadenoma who developed metastatic disease of the cervical spine 6 years later. The patient presented with acutely worsening compressive cervical myelopathy and required posterior cervical decompression, tumor resection, and instrumented arthrodesis for posterolateral fusion.

LESSONS

This case underscores the importance of long-term monitoring of hormone levels and having a high clinical suspicion for metastatic disease to the spine in patients presenting with acute myelopathy or radiculopathy in the setting of previously treated invasive secreting pituitary adenoma.

Corticotrophic pituitary carcinoma with cervical metastases: case series and literature review

PURPOSE

Pituitary tumors are the second most common intracranial tumors, however, pituitary carcinoma is a rare clinical entity which represents only 0.1-0.2% of all pituitary tumors. Diagnosis of pituitary carcinoma requires the presence of metastasis. Early identification of pituitary carcinoma is difficult, and only recently have guidelines been published for the treatment of aggressive pituitary tumors. We present two cases from our institution, with a review of other cases available in literature in order to better characterize this rare disease.

METHODS

A retrospective review of two patients with pituitary carcinoma treated at a tertiary medical center was performed. The MEDLINE database was searched for all cases of pituitary carcinoma. Information for age at diagnosis, sex, pituitary tumor type, latency period from pituitary tumor to presentation of carcinoma, sites of metastasis, number of surgical therapies, radiation and chemotherapy, and survival after diagnosis were collected.

RESULTS

A total of 69 studies were available for review for a total of 72 unique cases. The average age at diagnosis was 46.3 years. The most common tumors were ACTH-secreting (34.7%), Prolactin-secreting (23.6%), and Null Cell (15.3%). The average latency period from pituitary tumor diagnosis to metastasis was 9 years. All patients underwent surgical therapy during their treatment, with an average of 2.76 procedures. The mortality rate was 54.8% with average time to death after diagnosis of approximately 10 months.

CONCLUSIONS

Pituitary carcinoma is a rare disease with high mortality rate and is a diagnostic and treatment challenge. Further study is required but is difficult due to its low incidence.

Pituitary carcinoma with fourth ventricle metastasis: treatment by excision and Gamma-knife radiosurgery

Pituitary carcinomas, which are rare, generally present with craniospinal and systemic metastases. Although several treatments exist, the prognoses of patients with pituitary carcinomas are extremely poor to date. In this report, the authors describe the case of a 23-year-old male who had undergone trans-sphenoidal surgery and radiotherapy for an invasive prolactinoma. Seven years later, he presented with a new 4th ventricle metastasis from the pituitary lesion, and it was diagnosed with a pituitary carcinoma. He underwent resection and Gamma-knife radiosurgery (GKRS). The tumor has been well controlled for over 3 years. To our knowledge, there have been no reports of the effects of GKRS in patients with pituitary carcinomas. GKRS might have considerable effects in the treatment of pituitary carcinomas.

Long-term follow-up of growth hormone-producing pituitary carcinoma with multiple spinal metastases following multiple surgeries: case report

This report describes a rare case of a patient with growth hormone (GH)-secreting pituitary adenoma with malignant transformation resulting in multiple metastases to the dura mater of the cerebral convexity and high cervical spine. The patient was a 60-year-old man with a previous history of pituitary adenoma with suprasellar extension who had undergone transsphenoidal surgery, craniotomy for a convexity tumor, and suboccipital craniotomy for a cerebellar tumor. Thirteen years after the initial surgery, suboccipital craniotomy for a cervicomedullary junction tumor and cervicospinal surgery for a metastatic tumor was performed. Histologic findings of resected specimens demonstrated that the primary pituitary tumor was typical adenoma (similar to specimens from the initial surgery) but that the cerebellar and the dural tumor from the high cervical spine had a high incidence of mitotic figures, and cellular anaplasia with nuclear polymorphism and necrosis. In addition, the serum levels of GH were noted to have decreased with recurrence of the tumor. It was concluded that patients with pituitary adenoma, even when benign, must be carefully followed for signs of malignant transformation, and spinal or distant metastases.

Orbital metastasis of pituitary growth hormone secreting carcinoma causing lateral gaze palsy

Background:

Although pituitary adenoma is one of the most common intracranial tumors, it rarely progresses secondarily into a metastatic carcinoma. Commonalities in reported cases include subtotal resection at presentation, treatment with radiation therapy, and delayed metastatic progression. Pathologic descriptions of these lesions are varying and inconsistent.

Case Description:

A 52-year-old male was diagnosed with acromegaly and pituitary tumor in 1996. He underwent four subtotal resections and five courses of stereotactic radiosurgery over 14 years. He developed left eye lateral gaze palsy, and was found to have a distant orbital metastasis with involvement of the left lateral rectus and lateral orbital wall. He underwent left orbital craniotomy via eyebrow incision for resection of this lesion. Pathologic evaluation showed a markedly elevated Ki67 level of 30%.

Conclusion:

While overall incidence of metastatic progression of pituitary adenoma after radiotherapy appears to be low, it appears to be a possible complication, and could be more likely in patients receiving multiple doses of radiotherapy. Our review of reported cases showed that 45/46 (97.8%) of patients developing carcinoma had prior radiation exposure. These patients may also have more aggressive pathologic characteristics of their lesions.

Pituitary carcinoma recurrent to the lumbar intradural extramedullary space: case report

CONTEXT

Pituitary tumors are rare, and pituitary carcinomas are rarer still. Prognosis is poor, with less than 50% of patients surviving past 1 year after diagnosis. In this case of spinal metastasis from an adrenocorticotropic hormone-secreting pituitary carcinoma, the intradural extramedullary metastases recurred in the same lumbar area 6 years apart.

FINDINGS

Fourteen years prior to presentation in our clinic, a 48-year-old woman was diagnosed with pituitary adenoma which was treated with resection followed by radiation. Eight years later, an intradural extramedullary spinal drop metastasis at L2-L3 was again treated with resection and radiation. Three years later, magnetic resonance imaging (MRI) revealed a mass encasing the right carotid artery, which was treated for 1 year with chemotherapy using temozolomide (Temodar). Three years later, MRI showed intradural extramedullary metastases at the L3-L4 intervertebral disc space and behind the L3 vertebral body; treatment was again resection followed by radiation. Back pain and weakness resolved after surgery and her neurological examination returned to baseline. There was no evidence of recurrence 1 year after surgery.

CONCLUSION/CLINICAL RELEVANCE

In this unusual case, this pituitary carcinoma metastasized twice in 6 years to virtually the same intradural extramedullary lumbar region. Surgical resection of these masses aided in relieving neurological symptoms and prolonging life.

Clinical review: Pituitary carcinoma: difficult diagnosis and treatment

CONTEXT

Although pituitary tumors are common, pituitary carcinoma is very rare and is only diagnosed when pituitary tumor noncontiguous with the sellar region is demonstrated. Diagnosis is difficult, resulting in delays that may adversely effect outcome that is traditionally poor. Barriers to earlier diagnosis and management strategies for pituitary carcinoma are discussed.

EVIDENCE ACQUISITION

PubMed was employed to identify relevant studies, a review of the literature was conducted, and data were summarized and integrated from the author's perspective.

EVIDENCE SYNTHESIS

The available data highlight the difficulties in diagnosis and management and practical challenges in conducting clinical trials in this rare condition. They suggest that earlier diagnosis with aggressive multimodal therapy may be advantageous in some cases.

CONCLUSIONS

Although pituitary carcinoma remains difficult to diagnose and treat, recent developments have led to improved outcomes in selected cases. With broader use of molecular markers, efforts to modify current histopathological criteria for pituitary carcinoma diagnosis may now be possible. This would assist earlier diagnosis and, in combination with targeted therapies, potentially improve long-term survival.

Pituitary adenomas

Pituitary adenomas are by far the most common sellar tumor and magnetic resonance imaging is the modality of choice for their detection and characterization. However, most of these neoplasms are asymptomatic and frequently incidentally visualized. One also has to be aware of common other incidental findings and normal age-related changes in the appearance of the gland. By convention, 10 mm is used as the size threshold to separate macroadenomas from microadenomas. For microadenomas, imaging is primarily used for lesion detection and localization, whereas with macroadenomas, the goal is to establish whether the mass represents a pituitary tumor or some other lesion and to precisely delineate its extent.