Abstract
Objective and importance: Symptomatic metastases to the pituitary gland are rare and often herald advanced systemic malignant disease. Distinguishing them from benign pituitary adenomas is challenging. The clinicoradiological features of three patients with pituitary metastases are presented. We also review the literature from 1970 to 2015 to formulate a diagnostic strategy. Clinical presentation: All patients were elderly with ages ranging from 65 to 82 years old. One had a previously undiagnosed prostatic carcinoma and two had known histories of primary gastric or parotid salivary gland carcinoma. Rapid visual deterioration was the most common symptom followed by ophthalmoplegia. Cranial diabetes insipidus (CDI) was observed after administrating hydrocortisone replacement in one patient. All patients had evidence of a solitary pituitary tumor on magnetic resonance imaging (MRI) of which two had discernible posterior pituitary signal changes. Trans-sphenoidal excision was performed for all patients with no procedure related complications. Two patients had visual improvement, but due to advanced systemic disease all succumbed within two months. A literature review of 475 pituitary metastases revealed that breast (37.1%) and bronchogenic carcinomas (22.1%) were the most frequently encountered primary malignancies. Among 290 symptomatic patients (22.1%) were the most frequently encountered primary malignancies. Among 290 symptomatic patients the commonest presentation was CDI (19.9%) and 12.1% had ophthalmoplegia. Of the 166 tumors with documented neuroimaging features, 31.3% had evidence of pituitary stalk thickening or enhancement followed by cavernous sinus invasion (30.1%) or was dumbbell shaped (27.7%). Conclusion: Diagnosing metastatic pituitary tumors is important for the treating clinician in order to avoid unnecessary surgical excision in patients with limited life expectancy. Patients older than 60 years, or with a history of cancer, presenting with CDI or ophthalmoplegia are red flag clinical features. For these patients we recommend investigations for occult primary malignancy when early posterior pituitary involvement orcavernous sinus invasion is demonstrated on MRI.
Highlights
Symptomatic metastases to the pituitary gland are rare and diagnosed in less than 1% of pituitary tumor surgical resections [1]
Diagnosing metastatic pituitary tumors is important for the treating clinician in order to avoid unnecessary surgical excision in patients with limited life expectancy
Patients older than 60 years, or with a history of cancer, presenting with Cranial diabetes insipidus (CDI) or ophthalmoplegia are red flag clinical features. For these patients we recommend investigations for occult primary malignancy when early posterior pituitary involvement orcavernous sinus invasion is demonstrated on Magnetic Resonance Imaging (MRI)
Summary
The pituitary gland is a rare site for metastasis, but clinicians should be cognizant of this important diagnosis. Discussions on a comprehensive diagnostic strategy established by reviewing the existing literature are limited. Current understanding of pituitary metastasis is largely restricted to case reports and are indispensible given their rarity. The heterogeneity of reported clinicoradiological information poses challenges for in-depth analysis. Only 57% of documented patients with symptomatic pituitary metastasis have their MRI described. In spite of this limitation we offer an updated literature review of available data and propose several red flags that should alert the clinician. When the MRI reveals predominantly posterior pituitary abnormal signal changes further investigations for an occult primary malignancy is recommended
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