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Pituitary metastasis of solid tumors: 2 cases of different presentation
Metástasis hipofisarias de tumores sólidos: 2 casos de diferente presentación
Maria Gràcia Cardona-Roviraa,
Corresponding author
, Rosa Casañ-Fernándezb, Javier Sanz-Gallurb, Elena Almonacid-Folchb, Alba Nadal-Máñeza
a Hospital Lluís Alcanyís, Xàtiva, Universitat de València, València, Spain
b Unidad de Diabetes y Endocrinología, Servicio de Medicina Interna, Hospital Lluís Alcanyís, Xàtiva, València, Spain
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and free T4 levels &#40;0&#46;4<span class="elsevierStyleHsp" style=""></span>ng&#47;dl&#41;&#46; He reported fatigue and drowsiness&#44; xerosis&#44; polydipsia and polyuria over the previous month&#46; Expanded laboratory testing confirmed secondary hypothyroidism&#44; with the detection of decreased testosterone &#40;0&#46;03<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; and cortisol &#40;2&#46;3<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dl&#41;&#44; as well as increased urine output &#40;7000<span class="elsevierStyleHsp" style=""></span>ml&#47;day&#41; with low urine osmolality &#40;124<span class="elsevierStyleHsp" style=""></span>mOsm&#47;kg&#41;&#46; A diagnosis of adrenal insufficiency&#44; hypogonadotropic hypogonadism&#44; and diabetes insipidus was established&#46; Replacement therapy was started with hydrocortisone&#44; levothyroxine and desmopressin&#44; followed by a considerable clinical improvement and weight recovery&#46; Magnetic resonance imaging &#40;MRI&#41; revealed a pituitary gland tumor measuring 24<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>mm in size&#44; with heterogeneous contrast uptake &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; The campimetric findings were normal&#46; The patient was referred to neurosurgery for removal of the tumor&#46; In order to better plan surgery&#44; upon admission MRI was repeated&#44; which revealed that the pituitary tumor had grown considerably in size in one month&#44; with diameters of 32<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>32<span class="elsevierStyleHsp" style=""></span>mm&#44; compressing the optic chiasm&#46; Campimetry showed bitemporal hemianopsia&#46; Following transsphenoidal surgery&#44; the pathology study showed the lesion to correspond to metastatic tissue&#46; A computed tomography &#40;CT&#41; study of disease spread was performed&#44; and lung adenocarcinoma was identified as the primary tumor&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Case 2&#58;</span> A 51-year-old woman was referred due to pituitary macroadenoma&#46; The patient history included infiltrating ductal carcinoma of the breast with lymph node and bone metastases at diagnosis&#46; Treatment was thus provided with tamoxifen&#44; goserelin&#44; surgical castration and palliative radiotherapy&#44; after which stable disease was observed with tamoxifen alone&#46; Prior to cancer treatment she had regular menstrual periods&#44; and after castration showed amenorrhea&#46; The patient reported to Ophthalmology due to diminished visual acuity&#44; and after showing bitemporal hemianopsia&#44; she was sent to the emergency room&#46; She reported headache&#44; asthenia and weight loss&#44; with no galactorrhea or polyuria or polydipsia&#46; Upon admission&#44; MRI revealed a pituitary tumor measuring 22<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>19<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>mm in size&#44; displacing the optic chiasm and consistent with pituitary macroadenoma &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Laboratory tests revealed marked hyperprolactinemia &#40;prolactin &#91;PRL&#93; 228 and 211<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; and low cortisol &#40;4&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dl&#41;&#44; TSH &#40;0&#46;29<span class="elsevierStyleHsp" style=""></span>mIU&#47;l&#41;&#44; free T4 &#40;0&#46;52<span class="elsevierStyleHsp" style=""></span>ng&#47;dl&#41;&#44; FSH &#40;2&#46;2<span class="elsevierStyleHsp" style=""></span>mIU&#47;ml&#41; and LH &#40;0&#46;8<span class="elsevierStyleHsp" style=""></span>mIU&#47;ml&#41;&#46; A differential diagnosis between macroprolactinoma and metastasis was therefore considered&#46; The deficits were corrected&#44; and treatment was started with cabergoline&#46; The patient showed a considerable improvement of her asthenia and gained weight&#46; The MRI study was repeated&#44; with no changes in the lesion&#46; The patient was therefore referred to neurosurgery for surgical removal&#44; followed by a clear improvement of her problems with vision&#46; The pathology study showed the excised tissue to correspond to metastatic breast carcinoma&#46; Radiotherapy was subsequently provided &#40;21<span class="elsevierStyleHsp" style=""></span>Gy&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Pituitary gland metastases account for 3&#8211;5&#37; of all intracranial metastases&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> The most common origin is the breast &#40;20&#8211;30&#37;&#41; and lung &#40;30&#8211;50&#37;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3&#44;4&#44;6</span></a> and such lesions may constitute the first presentation of the underlying primary tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Only 2&#46;5&#8211;18&#46;2&#37; of all pituitary metastases are symptomatic&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> the most common manifestation being central diabetes insipidus &#40;case 1&#41;&#44; though they may also manifest as headache&#44; visual field abnormalities&#44; anterior pituitary dysfunction and hyperprolactinemia<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;3&#44;7</span></a> &#40;case 2&#41;&#46; Clinically&#44; and as in our first case&#44; disease progression is typically much faster for metastases than for adenomas&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Determining whether a pituitary tumor is primary or secondary is important for treatment&#44; but it is difficult to do so without pathological confirmation&#46; Since diabetes insipidus is a very rare symptom in pituitary adenoma &#40;&#60;1&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and is more common in metastatic forms &#40;42&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> it is the most important clinical manifestation differentiating metastasis from adenoma&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> as occurred in case 1&#46; However&#44; in case 2 there were no clinical signs of diabetes insipidus&#44; and the prolactin levels were so high that a differential diagnosis between prolactinoma and metastasis was considered&#46; On the one hand&#44; treatment with tamoxifen should cause a decrease in prolactin and an increase in LH and FSH&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> in contrast to what was seen in the laboratory tests in case 2&#46; On the other hand&#44; previous studies report that hyperprolactinemia is present in 6&#46;3&#37; of all pituitary metastases&#44; with a mean value of &#60;160<span class="elsevierStyleHsp" style=""></span>ng&#47;ml due to stem compression&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> while levels of &#62;200<span class="elsevierStyleHsp" style=""></span>ng&#47;ml are more suggestive of prolactinoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;10</span></a> The cases reported in the reviewed literature confirm this pattern&#44; with prolactin between 35 and 152<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;8&#44;10</span></a> By contrast&#44; in our case the prolactin concentration was 228<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; which complicated the diagnosis&#46; Finally&#44; visual field changes are not useful for distinguishing between adenoma and metastasis&#44; though rapid vision impairment and its association with weight loss or diabetes insipidus may be an interesting differentiating factor&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> as occurred in case 1&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Once the pituitary tumor is confirmed to be of metastatic origin&#44; treatment should be decided upon&#46; This is usually palliative and dependent upon the extent of the disease and the symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Exploration and surgical decompression alone or in combination with radiotherapy are essential if the pathological diagnosis guides treatment&#44; or for providing relief from symptoms and improved quality of life if the spread of the tumor toward the suprasellar region is causing compressive clinical signs or vision problems&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4&#44;10</span></a> as in case 2 at onset and in case 1 prior to surgery&#46; The pituitary lesion is the cause of death in only 13&#37; of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Pituitary gland metastases are uncommon&#46; However&#44; the diagnosis of metastasis should be suspected in the presence of rapid onset diabetes insipidus&#44; ocular disease&#44; headache and hyperprolactinemia&#44; as well as in rapidly progressing adenomas&#44; with a view to establishing an early diagnosis and appropriate treatment&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cardona-Rovira MG&#44; Casa&#241;-Fern&#225;ndez R&#44; Sanz-Gallur J&#44; Almonacid-Folch E&#44; Nadal-M&#225;&#241;ez A&#46; Met&#225;stasis hipofisarias de tumores s&#243;lidos&#58; 2 casos de diferente presentaci&#243;n&#46; Endocrinol Diabetes Nutr&#46; 2019&#59;66&#58;202&#8211;203&#46;</p>"
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Article information
ISSN: 25300180
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos