Transsphenoidal Resection Research Articles

Primary sellar melanocytoma.

We present an up-to-date review of all published cases of sellar melanocytoma, a benign melanocytic neoplasm arising from melanocytes present in the leptomeninges surrounding the pituitary. Both the Medline and Embase databases were searched for case reports or case series of patients with a sellar mass consisting of melanocytes. All 14 identified patients developed symptoms due to compression of the surrounding structures. Symptoms included pituitary dysfunction and visual impairment. All patients received a transsphenoidal resection as first-line treatment. The diagnosis is made on pathological examination but deciding whether a sellar melanocytic tumor is best classified as a melanocytoma or a melanoma is not straightforward. Genetic analyses can help differentiate between central nervous system origin and metastasis of a cutaneous melanoma with the presence of a GNAQ and GNA11 mutations or a BRAF mutation, respectively. First choice treatment is complete resection, and in case of incomplete resection or recurrence additional radiotherapy is advised.

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 & 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 < 0.0001). While pre-operative Visual Acuity (logMAR) was 0.3 ± 0.26 and post-operative 0.21 ± 0.2 (P <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.

Anatomical Variations of Sphenoid Sinus in South Indian Population: All That You Need for Trans-Sphenoidal Pituitary Surgery.

Pituitary adenomas are one among the most common neurosurgical tumors with an incidence of 10-25% among intracranial neoplasms (Ezzat et al., Cancer 101:613-619, 2004). Surgical management for the same has been practiced since long, and has evolved from trans cranial approach to endoscopic trans sphenoidal method (Hammer and Radberg, Acta Radiol 56:401-422, 1961). Preoperative radiological analysis with CT &MRI is inevitable in planning endonasal trans-sphenoid surgery to avoid complications because of the high variability concerned with sphenoid anatomy. The present study intends to analyze the incidence of various anatomical variations of sphenoid sinus in a cohort of south Indian population as detected by CT& MRI and assess its impact on surgical approach. Retrospective analysis of CT&MRI images of patients who underwent Endonasal Trans-sphenoidal resection of pituitary tumors at JSS Hospital Mysuru from a period of 2009 to 2020 is done. Anatomical variations of sphenoid sinus esp. degree of pneumatization, sellar configuration, septation pattern, inter carotid distance were evaluated. Results were significant and in concordance with other similar studies. Most frequently encountered pnuematization was sellar type and least was conchal type Sphenoid sinus pneumatization is directly linked to safe access to sella. Presence of septae within sinus need to be identified preoperatively to avoid damage and confusion intraoperatively. A meticulous preoperative analysis of sphenoid sinus anatomy will help surgeon in smooth conduct of a complication free surgery.

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.

Impact of modified Frailty Index-11 (mFI-11) on postoperative complications in patients undergoing transsphenoidal resection of pituitary tumors: Analysis of 2006–2014 ACS-NSQIP database

IntroductionFrailty is a measure of physiologic reserve that is frequently cited as a predictor of postoperative complications. However, the effect of frailty on patients undergoing a relatively common procedure such as transsphenoidal resection of pituitary tumors (TSRPT) is unknown. Therefore, we sought to explore this relationship using a large, national database. MethodsThe 2006–2014 American College of Surgeons National Surgical Quality Improvement Program database was retrospectively reviewed to identify all patients who underwent TSRPT. Frailty scores were assigned using the established 11-factor modified Frailty Index (mFI-11). Patients were divided into low-frailty and high-frailty groups, based on mFI comorbidities of ≤ 1 and ≥ 2, respectively. Univariable and multivariable analyses were performed to evaluate the impact of frailty on postoperative outcomes and mortality. ResultsA total of 993 patients were included in the analysis. The low-frailty group consisted of 825 patients; the high-frailty group comprised 168 patients. In univariable analysis, there were no significant differences in medical (low-frailty 4.8%, high-frailty 8.3%; p = 0.069) and surgical (low-frailty 1.1%, high-frailty 1.2%; p = 1.000) complications; however, the high-frailty group had a higher rate of mortality (3%) when compared with the low-frailty group (0.6%; p = 0.016, OR 4.07, p = 0.044) and longer hospitalization (4.5 ± 7.4 vs. 5.8 ± 6.8 days; p = 0.023). In multivariable analysis, frailty was a predictor of mortality but not complications or reoperation. ConclusionsOur study shows that frailty, as measured by the mFI-11, does not predict postoperative complications in patients who undergo TSRPT, but greater frailty is correlated with higher mortality and increased hospital length of stay.

Isolated Third Cranial Nerve Palsy in Pituitary Apoplexy: Case Report and Systematic Review

ObjectivesTo report a case of isolated third nerve palsy from pituitary apoplexy and perform a systematic literature review. Materials and methodsMEDLINE/EMBASE databases were searched up to September 2020. Inclusion criteria: Age≥18, isolated third nerve palsy from pituitary apoplexy. Exclusion criteria: Age<18, presence of other neurological findings, no hemorrhage or infarction of pituitary. ResultsCase report: A 76-year-old woman presented with headache and right-sided ptosis. Right-eye exam revealed complete ptosis, absent pupillary constriction and accommodation, depressed and abducted eye on primary gaze, and -1 impaired depression, adduction, elevation, without other neurological findings. Brain MRI was suggestive of pituitary apoplexy. Pathology after transsphenoidal resection revealed an infarcted pituitary adenoma. Third nerve palsy resolved completely in 21 days. Systematic review: Twenty-three studies reporting 35 patients were selected from 182 abstracts. Twenty-nine (83%) had complete isolated third nerve palsy. Headache was reported in 31 (97%). Thirty-one had hemorrhage and 1 had infarction of pituitary. Cavernous sinus invasion occurred in 14 (50%). Twenty-eight were managed surgically (80%) and 7 medically (20%). Nerve palsy resolved completely in 27 (82%) and partially in 4 (11%). ConclusionsPituitary apoplexy is an important differential diagnosis in patients with isolated third nerve palsy. Isolated third nerve palsy in apoplexy appears to have favorable prognosis.

Pituitary society expert Delphi consensus: operative workflow in endoscopic transsphenoidal pituitary adenoma resection

PurposeSurgical workflow analysis seeks to systematically break down operations into hierarchal components. It facilitates education, training, and understanding of surgical variations. There are known educational demands and variations in surgical practice in endoscopic transsphenoidal approaches to pituitary adenomas. Through an iterative consensus process, we generated a surgical workflow reflective of contemporary surgical practice.MethodsA mixed-methods consensus process composed of a literature review and iterative Delphi surveys was carried out within the Pituitary Society. Each round of the survey was repeated until data saturation and > 90% consensus was reached.ResultsThere was a 100% response rate and no attrition across both Delphi rounds. Eighteen international expert panel members participated. An extensive workflow of 4 phases (nasal, sphenoid, sellar and closure) and 40 steps, with associated technical errors and adverse events, were agreed upon by 100% of panel members across rounds. Both core and case-specific or surgeon-specific variations in operative steps were captured.ConclusionsThrough an international expert panel consensus, a workflow for the performance of endoscopic transsphenoidal pituitary adenoma resection has been generated. This workflow captures a wide range of contemporary operative practice. The agreed “core” steps will serve as a foundation for education, training, assessment and technological development (e.g. models and simulators). The “optional” steps highlight areas of heterogeneity of practice that will benefit from further research (e.g. methods of skull base repair). Further adjustments could be made to increase applicability around the world.

Somatotroph Adenoma with Dual Transcription Factor Expression

A 20-year-old male presented with evidence of gigantism/acromegaly. Endocrinological investigations identified elevated growth hormone levels and a failed glucose tolerance test. Imaging revealed a macroadenoma expanding the sella with encroachment on the optic chiasm and cavernous sinuses. Trans-sphenoidal resection was undertaken and a gross total removal was achieved. Histopathological features were typical of a densely granulated somatotroph adenoma with abundant growth hormone expression, scattered prolactin expression and sparse examples of fibrous bodies. Unexpectedly, the adenoma not only expressed PIT-1 but also SF-1 transcription factors. This finding suggests that the adenoma may have been pluripotent. The prognostic significance of this finding is uncertain although the patient is stable from an endocrinological and imaging perspective approximately one-year post-op. A pituitary adenoma of this nature has not been previously reported. The recent literature on atypical transcription factor expression patterns and revisions to the classification of pituitary adenomas will be reviewed.Learning ObjectivesAppreciate the rarity of dual transcription factor expression in pituitary adenomasRationalize the use of transcription factor characterization in the revised WHO classification of pituitary adenomas

Overview of omics biomarkers in pituitary neuroendocrine tumors to design future diagnosis and treatment strategies.

Pituitary neuroendocrine tumors (PitNETs) are the second most common type of intracranial neoplasia. Since their manifestation usually causes hormone hypersecretion, effective management of PitNETs is indisputably necessary. Most of the non-functioning PitNETs pose a real challenge in diagnosis as they grow without giving any signs. Despite the good response of prolactinomas to dopamine agonist therapy, some of these tumors persist or recur; also, about 20% are resistant and 10% behave aggressively. The silent corticotropinomas may not cause symptoms until the tumor mass causes a complication. In somatotropinomas, the possibility of recurrence after transsphenoidal resection is more common in pediatric patients than in adult patients. Therefore, detection of tumors at early stages or identification of recurrence and remission after transsphenoidal surgery would allow wiser management of the disease. Extensive studies have been performed to uncover potential signatures that can be used for preventive diagnosis and/or prognosis of PitNETs as well as for targeted therapy. These molecular signatures at multiple biological levels hold promise for the convergence of preventive approaches and patient-centered disease management and offer potential therapeutic strategies. In this review, we provide an overview of the omics-based biomarker research and highlight the multi-omics signatures that have been proposed as pitNET biomarkers. In addition, understanding the multi-omics data integration of current biomarker discovery strategies was discussed in terms of preventive, predictive, and personalized medicine. The topics discussed in this review will help to develop broader visions for pitNET research, diagnosis, and therapy, particularly in the context of personalized medicine.

Frailty does not preclude surgical success after endoscopic transsphenoidal surgery for pituitary adenomas.

Frailty is a state of physiological vulnerability that negatively influences surgical outcomes. The effect of frailty on pituitary adenoma surgery, however, is not clear, and patients may be wrongly denied surgery because they are "too frail". We examined the effects of frailty on surgical outcome and quality-of-life (QoL) in patients undergoing endoscopic transsphenoidal resection of pituitary adenomas. A prospective, consecutive cohort of surgically managed pituitary adenoma was analysed. Frailty was defined by the 5-factor modified Frailty Index (mFI-5) and the Charlson Comorbidity Index (CCI). QoL was measured by the anterior skull base questionnaire (ASBQ) and sinonasal outcomes test (SNOT). Of 304 patients with pituitary adenomas, 42 (13.8%) were frail (mFI5 of > 1). Frail patients tended to have smaller adenomas (p < 0.0001) with less suprasellar extension (p < 0.0001). Both overall (ASBQ) and sinonasal-specific (SNOT) QoL were not affected by frailty on multivariate analysis. Endocrine and visual outcomes were similarly not worsened by frailty. Overall, medical complications were uncommon, and perioperative morbidity or mortality was not significantly greater in the frail group. Frail patients experience the same QoL benefits from surgery as their non-frail counterparts, and have equivalently successful visual and endocrine outcomes. Frailty should not be seen as a barrier to successful surgical management of pituitary adenomas.

Unusual clinical presentation of a crooke cell adenoma – a rare and aggressive pituitary adenoma variant

Pituitary adenomas are common intracranial neoplasms, making up approximately 15% of all intracranial tumours.1 The clinically non-functioning pituitary adenomas that show hormonal or transcription factor production on immunohistochemistry are termed ‘silent’. Crooke cell adenoma (CCA) is one of the recently defined high-risk pituitary adenoma subtypes and comprises 4% of corticotroph adenomas.2 Most patients with CCAs present with Cushing's disease, however, there are rare cases of silent CCAs reported in the literature. We present a case of silent CCA in a 65-year-old female who presented with headache and vertigo. Histopathology of the resected macroadenoma showed characteristic immunohistochemical and ultrastructural findings. Pathologists should be aware of the diagnostic criteria for CCA regardless of the tumour’s functional status due to the high recurrence rates of CCA after transsphenoidal resection.3 1.Drummond J, Roncaroli F, Grossman AB, et al. Clinical and pathological aspects of silent pituitary adenomas. J Clin Endocrinol Metab 2019; 104: 2473–89.2.Lloyd RV, Osamura RY, Klöppel G, et al., editors. WHO Classification of Tumours of Endocrine Organs. 4th ed. Lyon: IARC, 2017.3.George D, Scheithauer B, Kovacs K, et al. Crooke’s cell adenoma of the pituitary: an aggressive variant of corticotroph adenoma. Am J Surg Pathol 2003; 27: 1330–6.

A somatotroph pituitary adenoma, with signet-ring like cells. A case report and review of the literature

Background: Pituitary adenomas are neoplasms affecting the adenohypophysis and are derived from either early progenitor or fully differentiated hormone secreting cells. Histologically signet-ring like cells in pituitary adenomas are considered a normal morphological variant. This is an extremely rare entity, with four cases reported in the literature to date. Aims: We report a case of a 36-year-old man with symptoms of acromegaly and MRI findings of a 6 mm pituitary adenoma. Methods: A transphenoidal resection of the pituitary tumour was undertaken and submitted for light microscopic, immunohistochemical and electron microscopic assessment Results and conclusions: On histology the adenoma consisted of a monotonous population of neuroendocrine cells diffusely positive for synaptophysin, cytokeratin AE1-3 and Pit-1, with patchy positive growth hormone staining. There were admixed signet-ring like cells in which the cytoplasmic vacuoles were positive for synaptophysin and PAS-diastase and negative for the CD68 macrophages stain. This case describes the rare morphological signet-ring like cell variant in pituitary adenomas as well as highlighting differences between this benign neoplasm and metastatic signet ring cell carcinoma. Reference Trabzonlu L, Trabzonlu TA, Girbuz Y, et al. ACTH-cell pituitary adenoma with signet ring cells: a rare case report and review of the literature. Appl Immunohistochem Mol Morphol 2018; 28: e13–16.

Necrotizing infundibulo-hypophysitis: case-report and literature review

Purpose We describe a rare case of histopathologic-proven necrotizing infundibulo-hypophysitis (NIH). Clinical history A 40-year-old female presented with coexistence of central diabetes insipidus and hypopituitarism. Imaging disclosed a thickened infundibulum and a diffusely enlarged pituitary mass with gadolinium rim enhancement pattern. Microsurgical endonasal transsphenoidal resection was performed. The presence of extensive liquefactive necrosis, surrounded by lymphoplasmocytic inflammatory infiltrate, allowed for the diagnosis of NIH. Follow-up cranial imaging 10 months after surgery showed no evidence of reappearance of the lesion. There was no progression to panhypopituitarism. Conclusion Surgery and histopathological confirmation are the key diagnostic feature in NIH. The current case is the fifth report of NIH and the first one with an indolent course and without progression to panhypopituitarism so far.

Use of a Surgical Stepdown Protocol for Cost Reduction After Transsphenoidal Pituitary Adenoma Resection: A Case Series

No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost. In 2018-2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated. Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P= 0.1). Overall costs were 12.5% less for stepdown patients (P= 0.01), a difference mainly driven by reduced facility utilization costs of -8.9% (P= 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to2016. These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients.

Abstract #1001394: A Rare Endocrine Complication of the COVID-19 Vaccine

Pituitary adenomas are a common, asymptomatic finding in the general population. They are usually diagnosed incidentally on imaging studies. Rarely, pituitary adenomas can progress to pituitary apoplexy, defined as hemorrhage and/or infarction and are often associated with a triggering event. A 44 year old man with a history of hypogonadism presented to the hospital for fevers, chills and blurry vision that started after he received his second COVID-19 vaccine three days prior. The day following his vaccine, he initially developed subjective fevers, chills and myalgia which he self-treated with over the counter analgesics at home. Three days after the vaccine, he developed blurry vision along with change in mental status which brought him to the hospital. When he initially presented to an outside hospital, vital signs showed hypotension with MAP of 57 and fever of 103 degrees fahrenheit. MRI of the head showed a 4.7cm sellar and suprasellar mass with optic chiasm compression and left sphenoidal extension. Labs at the time showed FSH 10.5 IU/L, LH 3.3 IU/L, Prolactin 1.2 ng/mL, Cortisol 9.3 ug/dL at 5am, ACTH 7 pg/mL, TSH 2.90 uIU/mL, free T4 1.33 ng/dL and free T3 3.88 ng/dL. Due to the patient's hypotension and findings on imaging studies, there was concern for adrenal insufficiency and the patient was started on stress dose steroids. He was transferred to a tertiary care center and vitals at the time were significant for a temperature 105.9 degrees fahrenheit but otherwise hemodynamically stable. He underwent an endoscopic transsphenoidal resection of the pituitary tumor given compression of the optic chiasm. Pathology report was consistent with pituitary adenoma with focal hemorrhage and necrosis of pituitary adenoma cells. Patient currently remains on maintenance dose steroids and levothyroxine. Pituitary apoplexy can occur either spontaneously or due to a stressful trigger. There have been no case reports showing the novel COVID-19 vaccine leading to pituitary infarction or hemorrhage. Although the pathophysiology is not entirely clear, our patient may have developed a robust immune response that could have potentially been a trigger leading to a pituitary apoplexy.

Abstract #996232: A Rare Case Of Actinomyces Infected Prolactinoma

BACKGROUND: Pituitary abscesses are rare and can be dire. During MRI (the preferred imaging modality for prolactinomas) they present as a solid tumor displaying an intrasellar or suprasellar mass with attenuation similar to the brain, demonstrating moderate contrast enhancement. Here we present a patientwho had transsphenoidal resection of a prolactinoma and pathology revealed a gram positive filamentous bacteria.

Transcavernous Approach to the Anteromedial Triangle for Residual Functional Pituitary Adenoma.

Surgical treatment of functional pituitary adenomas is as rule performed by transsphenoidal approach. However, when then lesion invades the parasellar structures and the cavernous sinus, the transsphenoidal removal of these adenomas is usually incomplete. In this video, we present the technical nuances of a transcavernous approach to the anterio-medial triangle for the resection of a residual functional pituitary adenoma. The patient is a 40-year-old male who was diagnosed with growth hormone secreting pituitary macroadenoma. He underwent two transsphenoidal resections in 2013 and 2016 with a small residue in the left cavernous sinus. Subsequently, due to a failure of biochemical remission despite medical management, a transcranial transcavernous surgery was performed. Brain magnetic resonance imaging showed a mass in the roof of the left cavernous sinus, located at the level of the anteromedial triangle, adherent to the clinoidal segment of the internal carotid artery (ICA). The computed tomographic scan showed an osteolysis of the inferior surface of the anterior clinoidal process. After performing an extended pterional craniotomy and an extradural clinoidectomy, the cleavage plane is extended between the temporal dura and the inner layer of the lateral wall of the cavernous sinus. Intraoperative Doppler and stimulation are used to localize the clinoidal segment of the ICA and the third cranial nerve, delimiting the anteromedial triangle. The lesion is progressively dissected and removed. An optic neuropexy with the previously harvested fat is performed in case of a complementary radio surgical treatment. The patient had an uneventful postoperative course and showed a biochemical remission at the 3-month follow-up. The link to the video can be found at: https://youtu.be/oHfugVtU-Nc .

134 Quantitative Assessment of Visual Function for Pituitary Macroadenomas: A Practical Scoring Algorithm

Abstract Introduction There is a myriad of existing terms by which visual capacity is recorded. The lack of a standardised categorisation of observations commonly results in ambiguities. We report the utility of a visual function score (VFS) in patients managed by transsphenoidal surgery. Method A VFS (expressed as a percentage) with a maximum score of 20 was calculated for each eye using the Snellen VA (40% weighting: score 0-8) and Humphrey Allergan 30-2 automated visual field (60% weighting: score 0-12). Results 280 patients (560 eyes) underwent transsphenoidal pituitary adenoma resections with complete pre- and post-operative visual function assessment. Mean age 56 years; 56.4% male. 26.1% were treated by endoscopic technique and 73.9% were treated by microscopic technique. Pre-operative vision was normal in 38.0% eyes. All these had full post-operative vision. In patients with pre-operative visual loss (347 eyes), the mean pre-operative VFS rose from 70.8% to 87.5% post-operatively. 43.8% eyes attained full post-operative vision, 28% improved, and 25.6% remained unchanged. 9 patients (2.6%) had worse immediate post-operative vision. Conclusions The VFS is a convenient single measure of visual function that may facilitate local and national audit of transsphenoidal surgery. Studies are planned to correlate this with patient reported visual quality of life measures.

Occult Carcinoid Causes Cushing’s Syndrome

Introduction: Lung neuroendocrine tumors (NETs) are a common cause of ectopic ACTH-secretion. Only 3% of NETs cause Cushing’s syndrome1; the majority are small and may be radiographically occult. Additionally, the responses to dexamethasone, metyrapone, and oCRF can be indistinguishable from that observed in pituitary Cushing’s disease2. These challenges lead to misdiagnosis and unnecessary procedures. Case Description: 45-year-old male presented for resection of right-sided pulmonary carcinoid tumor. He was diagnosed with Cushing’s syndrome in 2011 when he experienced uncontrolled hypertension and excessive weight gain with elevations in cortisol and ACTH levels. He underwent transsphenoidal pituitary resection in May 2011 for a possible pituitary microadenoma. Post-operative worsening hypertension, weight gain, and striae led to bilateral adrenalectomy in November 2011, complicated by retroperitoneal hemorrhage and resuscitation-induced pulmonary edema. On chest CT in early 2012, an 8 mm incidental right pulmonary nodule was documented. 8 years later, chest imaging for mild COVID-19 infection again revealed a right-sided pulmonary nodule. He underwent CT-guided biopsy of the nodule in July 2020 with pathology demonstrating carcinoid histology. Right lower lobectomy was performed. Pre-operative ACTH was 1673 pg/mL (normal: 10-60 pg/mL) and post-operative ACTH was 16 pg/mL. The resected tumor stained positive for ACTH, confirming that carcinoid tumor was the source of Cushing’s for the past decade. Conclusion: The diagnosis of ectopic Cushing’s syndrome can be elusive, leading to surgeries with significant morbidity, as seen in our patient. In one retrospective review, 14% of patients with Cushing’s had transsphenoidal resection before they were diagnosed with an ectopic source3. Ectopic Cushing’s syndrome can be a challenging diagnosis to make and a multidisciplinary approach with close collaboration between endocrinologist, radiologist, surgeon and pathologist may increase the diagnosis accuracy. Citations: 1Kamp, K, Alwani, R A, Korpershoek, E, Franssen, G., de Herder, W W, & Feelders, R A. (2016). Prevalence and clinical features of the ectopic ACTH syndrome in patients with gastroenteropancreatic and thoracic neuroendocrine tumors, European Journal of Endocrinology, 174(3), 271-280. Retrieved Jan 15, 2021, from https://eje.bioscientifica.com/view/journals/eje/174/3/271.xml 2Malchoff CD, Orth DN, Abboud C, Carney JA, Pairolero PC, Carey RM. Ectopic ACTH syndrome caused by a bronchial carcinoid tumor responsive to dexamethasone, metyrapone, and corticotropin-releasing factor. The American Journal of Medicine. 1988;84(4):760-764. doi:10.1016/0002-9343(88)90116-7 3Ioannis Ilias, David J. Torpy, Karel Pacak, Nancy Mullen, Robert A. Wesley, Lynnette K. Nieman,Cushing’s Syndrome Due to Ectopic Corticotropin Secretion: Twenty Years’ Experience at theNational Institutes of Health, The Journal of Clinical Endocrinology & Metabolism, Volume 90, Issue8, 1 August 2005, Pages 4955–4962, https://doi.org/10.1210/jc.2004-2527

Reduced Visual Field Activity Due to Covid-19 in a Patient With a Pituitary Macroadenoma

Background: Vision changes can be the presenting symptom of pituitary macroadenomas. The first-line therapy is transsphenoidal resection except for macroprolactinomas where medical therapy with dopamine agonist (DA) is the initial treatment of choice. Surgical resection is reserved if treatment with DA did not result in decreased serum prolactin (PRL), size of adenoma and/or alleviation of symptoms. With the Covid-19 pandemic, there have been a variety of symptoms reported including ophthalmic manifestations (1). We will present how an acute decrease in vision from Covid-19 nearly led to surgical intervention of macroprolactinoma. Clinical Case: A 61-year-old woman presented to the emergency room (ER) with complaints of headache in 6/2020. MRI Brain showed a 4.0 x 4.0 x 4.5 cm pituitary macroadenoma with suprasellar extension and invasion of the cavernous sinuses. The mass engulfed the adjacent circle of Willis, the MCAs bilaterally, the PCAs and the superior aspect of the vertebrobasilar system. Initial PRL was 7441 ng/mL (5.2-26.25 ng/mL). She was discharged on Cabergoline 0.25 mg twice weekly. Visual field exam showed mild nonspecific field defects in the right eye and larger diffuse field defects in the left eye slightly more temporal. One month later, Cabergoline dose was increased to 0.5 mg twice weekly with PRL drop to 1161.7 ng/mL. In 8/2020, she started to complain of worsening vision. Ophthalmological exam showed worsening visual fields in both eyes and the optic discs showed temporal pallor. She was referred to ER where she tested positive for Covid-19 and was admitted. CT Head showed stable partially calcified enhancing sellar and suprasellar mass. Repeat PRL was 635.6 ng/mL. Despite reduction in PRL, transsphenoidal resection was considered but was deferred to 9/2020 due to Covid-19. Follow up appointment with Neuro-ophthalmology in 9/2020 prior to scheduled surgery, showed visual field improvement with just mild nonspecific defects and surgery was canceled. PRL in 10/2020 decreased to 239.1 ng/mL. Patient’s visual fields continued to improve after recovery from Covid-19 and with reduction in PRL. It was determined that the patient’s reduction in visual fields was due to Covid-19 and not her macroadenoma. Conclusion: There have not been many reported cases of decreased visual fields due to Covid-19 (1). Proposed mechanisms include expression of ACE-2 receptors in the aqueous humor, which is the main receptor for Covid-19, and thromboembolic disease (1). More studies and data are needed to conclude the mechanism of decreased visual fields. This will avoid unnecessary surgical interventions for patients with macroprolactinomas.