P-50 Plurihormonal cystic pituitary adenoma: Case report

Abstract

Abstract Introduction Pituitary adenomas account for 10-15% of all intracranial neoplasms. Around 1/3 of cases are cystic pituitary adenomas presented by non-staining tumors, usually being prolactinomas and rarely – somatotropinomas. Combined prolactin and growth hormone-secreting adenomas are uncommon and clinical diagnosis can be deferred due to symptoms specific for only one of the excess secreted hormones. Clinical Case A 47-years-old woman was referred to our clinic in November 2022, her only complaint being headaches in the occipital region that persisted for the last 7 years. The patient had a history of taking various SSRI/SNRI antidepressants and benzodiazepines continuously for the same period of time (7 years). She presented outpatient prolactin test results from August 2022 showing a level of 3180 µUI/ml [N 17-637 µUI/ml], 10 fold dilution - 2947 µUI/ml and a pituitary scan that revealed a 13.3×9.6×11.1 mm tumor with a cystic component, invading the suprasellar cistern and the left cavernous sinus. Anamnesis determined that she had two children, a regular menstrual cycle and no heredocolateral antecedents. Clinical examination revealed milky white breast discharge and mild changes in the face, hands, and feet structure that were suggestive of acromegaly. Before admission the patient was started on 0.5 mg cabergoline weekly. On admission, prolactin levels were still elevated, and the cabergoline dose was increased. Of all the pituitary axes the only out-of-range value was IGF-1 – which was elevated to 53.1 nmol/l [N 10.3-28.57]. The patient refused surgery for the moment, and no pharmacological treatment options were available in the country. The patient was lost to follow up and had returned in August 2023 with complaints of general fatigue and malaise. History revealed that in May 2023 she suffered from severe headaches and was admitted to the neurosurgery department of a local hospital, where she underwent transsphenoidal surgery for the pituitary adenoma. The histology showed chromophobe adenoma tissue, no follow-up immunohistology was done. After the surgery, cabergoline was stopped. During our exploration of the pituitary function – there were no deficits or excesses registered. Considering that co-secreting pituitary adenomas are common for MEN syndromes, she was tested for presence of thyroid, parathyroid, adrenal tumors, but no imagistic or laboratory findings were detected. Conclusion In the light of global increased use of antidepressant and anxiety relieving medication, this clinical case underlines the importance of a thorough assessment in these patients, before and during treatment. Additionally, prolactin and growth hormone co-secreting pituitary adenomas often have a silent clinical presentation and may be challenging in diagnosis. A multimodal management is necessary as plurihormonal adenomas require both control of hormone excess and tumor growth.