Progressive headache and lethargy in a middle-age female patient: answer

Abstract

D. Metastasis Following MRI and pre-operative workup, the patient underwent an endoscopic transnasal/transsphenoidal biopsy of the sella lesion with formal histopathology demonstrating malignant tumour cells which were strongly CK7 and thyroid transcription factor-1 positive and GCDFP-15, PR, HER2, CK20, CDX-2 and WT1 negative consistent with a metastasis from a lung primary cancer. The patient underwent staging CT scanning, which demonstrated a right upper lobe lung lesion associated with right hilar adenopathy and a bulky adrenal gland. The patient has commenced stereotactic radiosurgery for the pituitary metastasis and is currently on hormone replacement. Pituitary metastasis is uncommon, comprising of 0.14 to 28.1% of all brain metastases in an autopsy series [[1]Nelson P.B. Robinson A.G. Martinez A.J. Metastatic tumor of the pituitary gland.Neurosurgery. 1987; 21: 941-944Crossref PubMed Scopus (64) Google Scholar]. The most common primary disease is breast cancer in women and lung cancer in men [[2]Rajput R. Bhansali A. Dutta P. et al.Pituitary metastasis masquerading as non-functioning pituitary adenoma in a woman with adenocarcinoma lung.Pituitary. 2006; 9: 155-157Crossref PubMed Scopus (20) Google Scholar], however, it is rare that a pituitary metastasis is the first manifestation of disease [[3]Ruelle A. Palladino M. Andrioli G.C. Pituitary metastases as presenting lesions of malignancy.J Neurosurg Sci. 1992; 36: 51-54PubMed Google Scholar]. Patients present with visual disturbance, particularly hemianopia, which can be explained by suprasellar extension of the tumour compressing the optic apparatus. Other cranial nerve deficits are less common but can be seen with tumour extension to the parasellar region and cavernous sinus. In a case series by McCormack et al. 70% of patients presented with diabetes insipidus. This can be attributed to posterior pituitary involvement [[4]McCormick P.C. Post K.D. Kandji A.D. et al.Metastatic carcinoma to the pituitary gland.Br J Neurosurg. 1989; 3: 71-79Crossref PubMed Scopus (166) Google Scholar]. In comparison, in the more common pituitary adenoma, diabetes insipidus is reported in only 1% of cases [[5]Max M.B. Deck M.D. Rottenberg D.A. Pituitary metastasis: incidence in cancer patients and clinical differentiation from pituitary adenoma.Neurology. 1981; 31: 998-1002Crossref PubMed Google Scholar]. This also suggests the importance of the inferior hypophyseal artery as the blood supply to the posterior pituitary from the systemic circulation. MRI is a powerful diagnostic tool to determine size and location of pituitary tumours, however, there are no single or collection of hallmark radiological features that can accurately determine tumour types that can be found in the sellar as metastases [[6]Koshimoto Y. Maeda M. Nakiki H. et al.MR of pituitary metastasis in a patient with diabetes insipidus.AJNR Am J Neuroradiol. 1995; 16: 971-974PubMed Google Scholar]. The features that are atypical in this case include the relatively small/normal sized sella and the involvement of the pituitary stalk. Other features that may be helpful to distinguish a macroadenoma from a metastasis can also include irregular edges, dural thickening, bony destruction and invasion rather than remodeling of the sella [7Rupp D. Molitch M. Pituitary stalk lesions.Curr Opin Endocrinol Diabetes Obes. 2008; 15: 339-345Crossref PubMed Scopus (39) Google Scholar, 8Hamilton B.E. Salzman K.L. Osborn A.G. Anatomic and pathologic spectrum of pituitary infundibulum lesions.AJR Am J Roentgenol. 2007; 188: W223-32Crossref PubMed Scopus (59) Google Scholar]. A high T1 signal spot of the posterior pituitary is demonstrated in a normal patient, however, a loss of this radiological feature may indicate tumour infiltration into the infundibulum as well as the posterior pituitary [[9]Cote M. Salzman K.L. Sorour M. et al.Normal dimensions of the posterior pituitary bright spot on magnetic resonance imaging.J Neurosurg. 2014; 120: 357-362Crossref PubMed Scopus (48) Google Scholar]. Pituitary metastasis presenting as the first manifestation of remote metastatic disease is rare, however, should be considered in patients presenting with diabetes insipidus. Progressive headache and lethargy in a middle-age female patient: questionJournal of Clinical NeuroscienceVol. 26PreviewA 63-year-old woman with a background of depression, uterine fibroids, fibrocystic disease of the breast and smoking presented with progressive intermittent severe headaches and lethargy associated with blurred vision and loss of peripheral vision. On examination, the patient had a bi-temporal hemianopia on confrontation, which was confirmed with formal Humphrey field testing (Fig. 1) along with a visual acuity on Snellen chart of 6/6 and 6/7.5 and Ishihara plate tests of 7/13 and 3/13 in the right and left eye, respectively. Full-Text PDF