Case Of Pituitary Adenoma Research Articles

Comparison of Cerebrospinal Fluid Leakage in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenoma with and without Sellar Floor Reconstruction

Objectives: This study aimed to compare CSF leak in endoscopic endonasal TSS of pituitary adenoma with and without reconstruction of the sellar floor with no intraoperative CSF leakage. Materials and Methods: It was a randomized controlled trial of 116 patients of both genders diagnosed case of pituitary adenoma who underwent endoscopic endonasal TSS over 1 year. The cases were randomized into 2 groups. In Group A endoscopic endonasal TSS and the sellar floor, reconstruction was done while in Group B only endoscopic endonasal transsphenoidal surgery was done without reconstruction. Results: The patient’s mean age in group A was 40.7 ± 9.56 years, and in group, B was 41.9 ± 10.5 years. The gender distribution, for group A, males and females were 29 each (50%) and in group B, the males were 36 (62%) and females were 22 (38%). There were 52 (89.7%) cases of macroadenoma and 6 (10.3%) cases of microadenoma in each group. On the 1st postoperative day, CSF leakage was noted in 2 (3.4%) patients of group A, and CSF leakage was observed in 2 (3.4%) patients of group B. Results revealed no difference in CSF leakage between both groups. There were minor nasal complications in both groups. Conclusion: There is an equal chance of success with endoscopic endonasal transsphenoidal surgery (TSS) of pituitary adenoma with and without reconstruction of the sellar floor, concerning post-operative CSF leak, in patients who have no intraoperative CSF leak which enlarges the pool of options for treatment.

Cavernous segment internal carotid artery stenosis specific to meningiomas compared to pituitary adenomas.

Pituitary macroadenomas and meningiomas are common neoplasms arising within the cavernous sinus. Imaging characteristics on MRI can often distinguish these tumors from one another; however, some cases may be more difficult to differentiate. This study compares patterns of cavernous segment internal carotid artery (CS-ICA) stenosis between the two tumor types to establish a novel radiographic method of differentiation. A retrospective analysis of patients with pathology-confirmed meningioma and pituitary adenomas at Tufts Medical Center was performed. The diameter of the CS-ICA at the narrowest point within the cavernous sinus was measured and compared to the ipsilateral petrous segment ICA and contralateral CS-ICA. The mean and range of percent stenosis and frequency of cases of CS-ICA stenosis >15% were determined. Statistical analysis to compare the groups was conducted using the Chi-squared test, Fisher's exact test, and t-test. There were a total of 78 out of 231 patients who were included in the study. The mean % ICA stenosis for all meningiomas was 9.3%, with increasing stenosis with increasing World Health Organization grade. Of all meningioma cases, 13 (33%) had greater than 15% ICA stenosis. Mean ICA stenosis for pituitary adenomas was -1.48%. There were no cases of pituitary adenomas causing ICA stenosis >15%. Differentiating pituitary adenomas and intracavernous meningioma tumors can have important implications on surgical approach and outcome. Our study found that stenosis of the CS-ICA greater than 15% is highly specific to meningiomas and can serve as a radiologic sign to distinguish between these two tumors.

Concurrent mutations of germline GPR101 and somatic USP8 in a pediatric giant pituitary ACTH adenoma: a case report

BackgroundCushing’s disease (CD) is rare in pediatric patients. It is characterized by elevated plasma adrenocorticotropic hormone (ACTH) from pituitary adenomas, with damage to multiple systems and development. In recent years, genetic studies have shed light on the etiology and several mutations have been identified in patients with CD.Case presentationA girl presented at the age of 10 years and 9 months with facial plethora, hirsutism and acne. Her vision and eye movements were impaired. A quick weight gain and slow growth were also observed. Physical examination revealed central obesity, moon face, buffalo hump, supra-clavicular fat pads and bruising. Her plasma ACTH level ranged between 118 and 151 pg/ml, and sella enhanced MRI showed a giant pituitary tumor of 51.8 × 29.3 × 14.0 mm. Transsphenoidal pituitary debulk adenomectomy was performed and immunohistochemical staining confirmed an ACTH-secreting adenoma. Genetic analysis identified a novel germline GPR101 (p.G169R) and a somatic USP8 (p. S719del) mutation. They were hypothesized to impact tumor growth and function, respectively.ConclusionsWe reported a rare case of pediatric giant pituitary ACTH adenoma and pointed out that unusual concurrent mutations might contribute to its early onset and large volume.

Case Report A Rare Case of Plurihormonal Pituitary Adenoma Associating Cushing's Disease and Silent Prolactinoma

Plurihormonal pituitary adenomas are rare conditions that secrete two or more pituitary hormones. The association of prolactin with other hormones is described but associated with ACTH is uncommon. We report a rare case of mixed adenoma associating Cushing’s disease and silent prolactin adenoma in 21 years old male patient. This case highlights an unusual plurihormonal pituitary adenoma case with a rare association between ACTH and prolactin. It pathogeny is less clearly define.

A Cross Sectional Study of Clinical and Histopathological Spectrum of Pediatric Brain Tumours

Introduction: Brain tumors are the most common tumor of the childhood and the second most common malignancies after haematological malignancies. Childhood central nervous system (CNS) tumors differ significantly from adult brain tumors in reference to their sites of origin, clinical presentation, tendency to disseminate early, histological features and their biological behaviour. Aims and Objective: Analyse the Clinical and histopathological spectrum of brain tumors, in pediatric patients ≤18 year of age. Materials and Method: This was a cross sectional study conducted at the department of pathology, SMS medical college, Jaipur from January 2020 to October 2021. This is a laboratory based descriptive type of observational study and data of brain tumors in children equal or less than 18 year of age procured and their clinico-histopathological spectrum were analyszed. Result: In our study, Out of 116 patients 51.8 % were male and 48.2 % were female. Mean age for the male cases were 10.11 and for female cases were 9.78. we observed intracranial pediatric tumors 67 cases (57.7%) were located in infratentorial region and 49 cases (43.3%) were located in supratentorial region and incidence for intracranial tumor was 39(33.62%) cases of astrocytomas followed by 25 (21.55%)cases of medulloblastoma, 20 (17.24%)cases of ependymoma, 13 (11.20%) cases of craniopharyngioma, 5 (4.31%) cases of pituitary adenoma, 4 (3.44%) cases of meningioma, 3 (2.58%) cases of embryonal and choroid plexus tumor, 2 (1.72%) cases of ganglioglioma and 1 (0.86%) case of Schwannoma and PNET. In this article, Based on tumor location, the symptoms of CNS tumors on the supratentorial region were headache (22 cases, 44.8%), impaired vision (10 cases, 20.4%), seizures (6 cases, 12.2%), vomiting (4 cases, 8.1%). Symptoms of CNS tumors on the infratentorial region were headache (48 cases, 71.6%), vomiting (5 cases, 7.4%), impaired vision (4 cases, 5.9%), seizures (3 cases, 4.4%). Conclusion: Infratentorial cases, maximum number of cases were medulloblastomas and supratentorial cases, maximum number of cases were astrocytic tumours. Overall astrocytic tumours in all senses constituted the most common group of CNS tumours. Within astrocytoma, low grade astrocytoma (grade I & II) was most common CNS paediatric tumour.

Alcohol intake and risk of pituitary adenoma.

The association between alcohol intake and incidence of pituitary adenoma has not been reported previously. We examined this association in three large, prospective cohort studies. Using data from the Nurses' Health Study, Nurses' Health Study II, and Health Professionals Follow-Up Study, we computed multivariable-adjusted hazard ratios (MVHR) and 95% confidence intervals (CI) for pituitary adenoma by levels of alcohol intake using Cox proportional hazards regression. We identified 292 incident cases of pituitary adenoma (225 among women, 67 among men) among 235,973 participants with 6,548,732 person-years of follow-up. Compared with intake of ≤ 0.5g/day, cumulative average alcohol intake in all categories was associated with reduced risk of pituitary adenoma (MVHR = 0.60, 95% CI 0.43-0.83 for 0.5-≤ 2g/day, MVHR = 0.57, 95% CI 0.41-0.79 for > 2.0-≤ 8.0, MVHR = 0.70, 95% CI 0.47-1.04 for > 8.0-≤ 15.0, and MVHR = 0.51, 95% CI 0.32-0.83 for > 15.0g/day). Significant inverse findings were present in women and were similar but non-significant in men. For specific alcoholic beverages, inverse associations were statistically significant for total wine (MVHR = 0.58, 95% CI 0.43-0.79 comparing 0.5-≤ 2 to ≤ 0.5g/day), red wine (MVHR = 0.65, 95% CI 0.46-0.92 comparing 0.5-≤ 2 to ≤ 0.5g/day), and white wine (MVHR = 0.72, 95% CI 0.53-0.97 comparing 0.5-≤ 2 to ≤ 0.5g/day). Results were consistent using baseline intake, recent intake, and with an 8-year lag. In three prospective cohorts, compared to almost no consumption, alcohol consumption was associated with reduced risk of pituitary adenoma. Sensitivity analyses suggest that these results are unlikely to be the result of reverse causation or diagnostic bias.

Frequency of Pituitary Adenoma among the Patients with Chronic Headache

Background: Antero-superior, Pituitary Gland lies in vicinity of optic chiasm and antero-inferiorly, it is related with posterior wall of sphenoid bone. Pituitary Gland is consisting of three lobes: Anterior, intermediate and posterior and their secretion are regulated by hypothalamus.
 Aims and Objectives: To identify pituitary adenoma in the patients coming with complain of chronic headache.
 Materials and Methods: Seven hundred sixty-four patients were included in our study. All the patients with chronic headache with/without decreased vision and visual field defects were included our study. Those patients already diagnosed with any other cause of headache such as uncontrolled blood pressure, tumor or diagnosed case of pituitary adenoma and patient with glaucoma were excluded. Detailed history was taken and ocular examination was done. MRI orbit and brain with contrast was done in all patients.
 Results: Out of 764 patients, 32 patients were diagnosed as having pituitary adenoma. Macro-adenoma was present in 30 patients and micro-adenoma in 2 patients. On MRI majority of patients had optic chiasm compression with bi-temporal hemianopia.
 Conclusion: All the patients with chronic headache with/without visual disturbances and visual field defect must be properly examined and investigated as that will help other researchers to diagnose the Pituitary Adenomas.

Risk factors impacting intra- and postoperative cerebrospinal fluid rhinorrhea on the endoscopic treatment of pituitary adenomas: A retrospective study of 250 patients.

We aimed to identify the risk factors associated with intra- and postoperative cerebrospinal fluid (CSF) leakage in pituitary adenomas treated with endoscopic transsphenoidal surgery.This study is a retrospective analysis of 250 pituitary adenoma cases from January 2017 to December 2019 at our hospital. All patients underwent endoscopic endonasal transsphenoidal surgeries. Univariate and multivariate analyses were performed to investigate the risk factors associated with intra- and postoperative CSF rhinorrhea.Eighty (32.0%) and nine (3.6%) patients had intra- and postoperative CSF leakage, respectively. Tumor size was an independent risk factor for intraoperative CSF leakage (odds ratio [OR], 1.229; 95% confidence interval [CI], 1.133–1.334; P < .001); intraoperative CSF leakage was an independent risk factor for postoperative CSF leakage (OR, 7.707; 95% CI, 1.336–44.455; P = .022). Chronic respiratory disease (OR, 57.500; 95% CI, 8.031–411.682; P < .001) was also an independent risk factor for postoperative CSF leakage. Vascularized septal mucosal flap was a protective factor (OR, 0.107; 95% CI, 0.013–0.894; P = .039).Intraoperative CSF leakage is more likely to occur in large pituitary adenomas. In the presence of intraoperative CSF leakage, postoperative CSF rhinorrhea is very likely to occur. Patients with chronic respiratory disease are also more likely to develop postoperative CSF leakage. The sellar base reconstructed using vascularized nasal septal flaps can significantly decrease the risk. The Knosp grade, degree of tumor resection, and postoperative use of a lumbar subarachnoid drain did not have any effects on postoperative CSF rhinorrhea.

Visual disturbances in patients with pituitary tumors and early improvement of visual acuity and visual field defects after resection of pituitary tumors.

Objective: The aim behind this study was to determine the frequency of visual field and visual acuity disturbances before resection and improvement after resection of pituitary tumors in patients. Study Design: Observational study. Setting: Neurosurgery Department of Jinnah Post Graduate Medical Center, Karachi. Period: August 2015 to August 2016. Material &amp; Methods: A total of 30 patients presented with headache and visual deterioration and diagnosed as pituitary adenoma at neurosurgery OPD, ward and ER were included through a consecutive purposive sampling technique. The detailed visual and ocular analysis (visual acuity, visual field, and extra ocular movements) carried out at time of admission and postoperatively. Tumor was removed by consultant neurosurgeon through trans-sphenoidal approach. SPSS version 17.0 was used to analyze the collected data. Results: A total of 30 cases of pituitary adenoma were included. The average age of the patients was 34.5 ± 10.8 years and among them 17 (56.7%) were males and 13 (43.3%) were females. Pre-operative assessment of the mean deviation of visual function was -8.21 ± 6.10 dB which is significantly improved to -4.6 ± 3.9 dB post-operatively (P &lt; 0.0001). While pre-operative Visual Acuity (logMAR) was 0.3 ± 0.26 and post-operative 0.21 ± 0.2 (P &lt;0.0001). Conclusion: Scientific observation from our study has shown that more than 90% of the patients suffering from pituitary adenomas experience visual impairment which can be improved to significant extent if treated with trans-sphenoidal surgical resection of the tumor.

Segmented retinal analysis in pituitary adenoma with chiasmal compression: A prospective comparative study.

Purpose:The aim of this study was to determine the alteration in ganglion cell complex and its relationship with retinal nerve fiber layer (RNFL) thickness as measured by spectral-domain optical coherence tomography (OCT) in pituitary adenoma cases and also its correlation with visual field (VF).Methods:This is a prospective comparative study wherein detailed neuro-ophthalmic examination including perimetry, RNFL and ganglion cell layer inner plexiform layer (GCL-IPL) thickness were measured preoperatively in the cases of pituitary adenoma with chiasmal compression with visual symptoms and field changes who were planned for neuro-surgical intervention. These parameters were repeated 1 year after the surgery. GCL-IPL, RNFL parameters were compared with controls and were correlated with VF mean deviation (MD). The diagnostic power of GCL-IPL was tested using the receiver operating characteristic (ROC) curve. Healthy age and sex-matched controls without any ocular and systemic abnormality were taken for comparison.Results:Twenty-four patients qualified the inclusion criteria. A significant thinning of GCL-IPL (P = 0.002) and RNFL (P = 0.039) was noticed in the pituitary adenoma group. GCL-IPL (r = 0.780 P < 0.001) and RNFL (r = 0.669, P < 0.001) were significantly correlated with the MD. The ROC curve values of GCL-IPL were 0.859 (95% confidence interval 0.744% to 0.973) and of RNFL were 0.731 (95% confidence interval 0.585–0.877). The diagnostic ability of GCL-IPL was more as compared to the RNFL analysis, although it was statistically insignificant (P = 0.122).Conclusion:GCL-IPL measurements on the OCT are a sensitive tool to detect early anterior visual pathway changes in chiasmal compression for pituitary adenoma patients.

Recent Updates on Experience, Treatment and Prevalence of Adult Brain Tumor : Single Center Study

Introduction : Brain tumor is a disease with high morbidity and mortality rates. Treating brain tumors requiring medical providers to have basic understanding of brain tumor diagnosis and management. The most common brain tumors are meningiomas, gliomas, pituitary adenomas and brain metastasis. The treatment of each type of brain tumor is different and multidisciplinary involving other scientific fields besides neurosurgery.&#x0D; Case Series : We reported 131 cases of brain tumors at the Haji Adam Malik Hospital in the period January 2018-December 2019, consisting of 52 cases (40%) of meningioma, 34 cases (26%) of Glioma , 12 cases (9%) of pituitary adenomas and 33 cases (25%) of brain metastasis. Meningiomas were mostly treated with surgery alone in 38% of cases, gliomas with surgery followed by chemo-radiation in 41% of cases, all of pituitary adenomas were treated with endonasal transfenoid surgery, while brain metastasis in 70% of cases required whole brain radiation with controlled primary tumors.&#x0D; Discussion : The modalities for treating brain tumor patients has been increasing recently. Meningiomas are mostly benign and managed by surgical resection only, chemo-radiation reserved for high risk or refractory case of meningiomas. Glioblastoma is the most common glioma and aggressive malignant primary brain tumor, limited response to gross surgical tumor and chemo-radiation. Pituitary adenomas mostly treated with endonasal transfenoid surgery, radiotherapy use in recurrent case. Brain metastasis may require complex multidisciplinary care with neurosurgery, radiation oncology, and medical oncology.&#x0D; Conclusion: The treatment of brain tumors is influenced by various considerations such as age, patient condition,neurological deficits, location of the tumor, comorbidities, experience of the neurosurgeon and available modalities. Treatment methods for brain tumors continue to evolve.

The surgical management of pituitary apoplexy with occluded internal carotid artery and hidden intracranial aneurysm: illustrative case.

BACKGROUNDApproximately 0.6% to 12% of cases of pituitary adenoma are complicated by apoplexy, and nearly 6% of pituitary adenomas are comorbid aneurysms. Occlusion of the internal carotid artery (ICA) with hidden intracranial aneurysm due to compression by an apoplectic pituitary adenoma is extremely rare; thus, the surgical strategy is also unknown.OBSERVATIONSThe authors reported the case of a 48-year-old man with a large pituitary adenoma with coexisting ICA occlusion. After endoscopic transnasal surgery, repeated computed tomography angiography (CTA) demonstrated reperfusion of the left ICA but with a new-found aneurysm in the left posterior communicating artery; thus, interventional aneurysm embolization was performed. With stable recovery and improved neurological condition, the patient was discharged for rehabilitation training.LESSONSFor patients with pituitary apoplexy accompanied by a rapid decrease of neurological conditions, emergency decompression through endoscopic endonasal transsphenoidal resection can achieve satisfactory results. However, with occlusion of the ICA by enlarged pituitary adenoma or pituitary apoplexy, a hidden but rare intracranial aneurysm may be considered when patients are at high risk of such vascular disease as aneurysm, and gentle intraoperative manipulations are required. Performing CTA or digital subtraction angiography before and after surgery can effectively reduce the missed diagnosis of comorbidity and thus avoid life-threatening bleeding events from the accidental rupture of an aneurysm.

Plurihormonal pituitary macroadenoma:\xa0 a case report

BackgroundPlurihormonal pituitary adenomas are a unique type of pituitary adenomas that secrete two or more pituitary hormones normally associated with separate cell types that have different immunocytochemical and ultrastructural features. Although they represent 10–15% of all pituitary tumors, only a small fraction of plurihormonal pituitary adenomas clinically secrete multiple hormones. The most common hormone combinations secreted by plurihormonal pituitary adenomas are growth hormone, prolactin, and one or more glycoprotein hormones. The most common hormonal symptom is acromegaly (50%). The aim of this case report is to bring awareness about this rare type of pituitary adenomas and to describe the unique presentation of our patient, even though plurihormonal pituitary adenomas are known mostly as a clinically silent tumors.Case presentationHerein, we describe an unusual case of plurihormonal pituitary adenoma with triple-positive staining for adrenocorticotropic hormone, growth hormone, and prolactin. The patient is a 65-year-old Egyptian woman who presented with mass effect symptoms of the pituitary tumor, which primarily manifested as severe headache and visual field defects. She also presented with some cushingoid features, and further analysis confirmed Cushing’s disease; slightly high prolactin and normal growth hormone levels were observed. She underwent transsphenoidal surgery and has been in remission thus far. Only a few cases have been reported in the literature, but none has exhibited silent acromegaly or mass effect symptoms as the initial presentation.ConclusionThis case highlights an unusual plurihormonal pituitary adenoma case with a rare combination of secreted hormones; mass effect symptoms were dominant, as were uncommon visual field defects. Our case further proves that immunohistochemical analyses of all pituitary hormones are needed to ensure correct diagnosis and to alert clinicians to the need for more rigorous follow-up due to the higher morbidity of these patients. Our case report approval number Federal Wide Assurance NIH, USA is FWA00018774 IRB registration number with OHRP/NIH is IRB00010471.

Radiosurgical treatment of residual and recurrent pituitary adenomas

Objective ‒ the treatment result estimation of subtotally removed and recurrent pituitary adenomas using different algorithms of radiotherapy and radiosurgery.Materials and methods. The retrospective analysis of 21 cases of pituitary adenomas was performed. There were 11 women and 10 men included. The average age was 45 (from 18 to 72) years. All patients had relapse or residual tumor after incomplete surgical removal. The method of irradiation was chosen by a radiologist. Tumor size control was assessed by an independent radiologist in 3 months and 1 year after treatment. Endocrine function was estimated by an independent endocrinologist in 3 months and 1 year after treatment.Results. Following transsphenoidal removal ‒ 13 patients (4 were operated twice), 5 after cranial surgery and 3 were operated sequentially transnasally and transcranially. Irradiation of 14 cases of residual tumor was performed no later than 6 months after surgery. The mean term of treatment start of recurrent adenomas was 12 months (8‒17) after surgery. VARIAN Novalis was applied in 16 cases, VARIAN Clinac iX in 4 cases and VARIAN TrueBeam STx was used once. Single and total radiation doses were determined individually. None of patients had visual impairment after treatment. The hypopituitarism deterioration was not noted as well.Conclusions. Hypofractionated stereotactic radiosurgery allows to bring a high dose of radiation to the pituitary adenomas, minimizing damage to the visual pathways, the pituitary gland and infundibulum. As the sequence, it reduces the toxicity of the technique. The application of modern radiation technologies minimize the irradiation of healthy surrounding tissues and reduce the negative effects of treatment.

RARE-12. PITUITARY ADENOMA SURGERIES IN COVID-19 ERA: EARLY LOCAL EXPERIENCE FROM EGYPT

BackgroundThe pandemic of COVID-19 has a great impact on all health-care services worldwide. Neurosurgical recommendations are to postpone the endoscopic endonasal pituitary surgeries during the pandemic. We would like to express our experience with urgent pituitary adenomas during the current COVID-19 pandemic. MethodsIn our country, COVID-19 has started to become a paramount problem by March 2020. Nine cases of pituitary adenomas have presented with urgent manifestations. The endoscopic endonasal approach was performed in eight patients, while a craniotomy was selected for a recurrent pituitary adenoma. Pre- and postoperative thorough clinical evaluations with chest CT scans were performed. Other strict infection control measures have been applied. ResultsIn 8 weeks duration starting from the past days of February 2020, we have operated on four females and five males of pituitary adenomas. Visual deterioration was the main presenting symptom. The driving factor for surgery was saving vision in eight patients. Fortunately, the postoperative course was uneventful for all patients. No suspected COVID-19 infection has been reported in any patient or health-care team except one patient. In our city, PCR test was routinely not available. ConclusionIn the era of COVID-19, strict infection control precautions should be employed to limit the possibility of transmission of any possible infection to patient or any of the surgical team. We believe that the risk of getting such infection is not increased by the endonasal approach. Long-term follow-up and large numbers of prospective studies are recommended to delineate the impact of COVID-19 infection on pituitary surgeries.

Two thyrotropin secreting pituitary adenoma cases diagnosed after response to the somatostatin analogue

Two thyrotropin secreting pituitary adenoma cases diagnosed after response to the somatostatin analogue

Two thyrotropin secreting pituitary adenoma cases diagnosed after response to the somatostatin analogue

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Two thyrotropin secreting pituitary adenoma cases diagnosed after response to the somatostatin analogue

Two thyrotropin secreting pituitary adenoma cases diagnosed after response to the somatostatin analogue

A Rare Case of Metastatic Transformation to Pituitary Carcinoma

Background: Pituitary carcinomas are rare and comprise less than 0.5% of pituitary tumors and frequently arise from previously resected and/or radiated infiltrating adenomas.1 Radiation therapy is used to prevent regrowth but does not have significant data supporting improved prognosis.2 True pituitary carcinomas requires the presence of craniospinal and/or systemic metastases. Here, we present a case of benign pituitary adenoma that had progressed to a metastatic tumor and responded to radiation therapy. Clinical Case: Our patient was first diagnosed in 1982 with a pituitary mass after undergoing an MRI due to right eye blindness. He ultimately had a transcranial resection of the tumor and post-operative external radiation to residual tumor. Final pathology was consistent with a nonsecretory tumor. Additionally, he was diagnosed with panhypopituitarism and he was treated accordingly. Due to barriers of patient adherence, only one post-operative MRI was obtained, and he was lost to endocrine follow up. In 2007, he was again referred to endocrinology for new vision loss in the left eye. An MRI revealed a 3.0 x 3.8 x 4.4 cm tumor that compressed the optic chiasm. Additionally, multiple lesions were seen within the dural and leptomeningeal extra-axial areas including the largest left frontal lesion of 2.4 cm and a 1.7 cm lesion posterior to the cord within the foramen magnum. The patient underwent endonasal transsphenoidal resection of the sellar mass and biopsy of the frontal lesion in October 2007. Pathology showed pituitary adenocarcinoma in both the sellar and frontal lesions and immunoperoxidase staining was negative for all hormones. He completed salvage radiation to the sellar and craniospinal lesions in December 2007. MRI scans completed 7 months later showed stable residual pituitary and metastatic lesions. The patient received 6-month MRI screening exams for the first 2 years and then annually thereafter, as well as PET scanning, without significant progression or new metastatic lesions. Conclusion: We present a case of benign pituitary adenoma which transformed following resection to a malignant tumor with metastatic lesions in the brain and spinal cord that was treated with radiation with relative success. Despite the often-aggressive nature of these metastatic tumors, the patient has experienced a successful treatment course with minimal side effects and without progression 13 years after initial treatment of the metastatic pituitary carcinoma.

An Atypical Case of TSH-Secreting Pituitary Adenoma in a Patient Presenting With Low Libido and Insomnia

Background: TSH-secreting pituitary adenoma is an incredibly rare cause of hyperthyroidism. Most patients with TSHomas present with clinical hyperthyroidism, but some patients may have atypical signs. Here we present the case of a patient who had been suffering from low libido and insomnia who was found to have secondary hyperthyroidism from a TSH-secreting pituitary adenoma. Clinical Case: A 47-year-old man presented with complaints of progressive headache, fatigue, depression, insomnia, low libido and erectile dysfunction. After questioning, he noted the presence of intentional tremor for more than 5 years. He denied anxiety, palpitations, heat intolerance, hyper defecation, proximal muscle weakness, local compressive symptoms of the neck and ocular symptoms. Physical exam was notable for fine tremor and mild thyromegaly, but otherwise patient had no evidence of anxiety, exophthalmos, hyperreflexia or diaphoresis. The patient was found to have a normal free testosterone (46 pg/mL, n 30-140 pg/mL) but had an elevated TSH (6.302 IU/mL, n 0.4-5 IU/mL), elevated Free T4 (3.6 ng/dL, n 0.6-1.2 ng/dL) and an elevated T3 (422 ng/dL, n 73-178 ng/dL). Further lab work revealed elevated alpha-subunit (4.4 ng/mL, n <0.5 ng/mL) suggestive of TSH-secreting pituitary adenoma. Prolactin and IGF-1 levels were normal. Patient had an MRI pituitary which showed a 2.3 cm sellar mass abutting the optic chiasm without involvement of the cavernous sinus. Patient proceeded to trans-sphenoidal resection. Post-operatively, TSH had dropped from 6.534 to 0.002 IU/mL (n 0.4-5 IU/mL) and Free T4 had dropped from 3.1 to 0.5 ng/dL (n 0.6-1.2 ng/dL). Interestingly, immunohistochemical staining was negative for TSH but the specimen did show histologic features characteristic of TSH-producing adenoma including extensive stromal fibrosis and nuclear pleomorphism. Patient was seen in clinic post-operatively where he noted a dramatic improvement in his headache and insomnia. He did show signs of hypothyroidism including constipation and weight gain. Patient was started on levothyroxine 75 mcg PO daily. Conclusion: This demonstrates the case of a patient with a TSH-secreting pituitary adenoma who presented with minimal thyrotoxic symptoms despite elevated thyroid hormones. Patients with this condition may present with atypical symptoms, thus requiring clinicians to have a high index of suspicion for this rare tumor.