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Table of Contents
CASE REPORT
Year : 2013  |  Volume : 17  |  Issue : 1  |  Page : 167-169

Hypopituitarism as the presenting feature of bronchogenic carcinoma with metastases to the pituitary gland


1 Department of Endocrinology and Diabetes, Altnagelvin Area Hospital, Londonderry Belfast, United Kingdom
2 Department of Geriatric Medicine, Altnagelvin Area Hospital, Londonderry Belfast, United Kingdom
3 Department of Respiratory Medicine, Altnagelvin Area Hospital, Londonderry Belfast, United Kingdom
4 Department of Palliative Care, Altnagelvin Area Hospital, Londonderry Belfast, United Kingdom

Date of Web Publication27-Feb-2013

Correspondence Address:
John R Lindsay
Department of Endocrinology and Diabetes, Altnagelvin Hospital, Glenshane Road, Londonderry BT47 6SB
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-8210.107876

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   Abstract 

Tumours metastasizing to the pituitary gland are uncommon. Symptomatic patients with pituitary metastases can present with diabetes insipidus, headache, visual field defects and/or anterior pituitary hormonal dysfunction. Treatment options for pituitary metastases include, surgical resection, cranial or parasellar irradiation and/or chemotherapy, and hormonal replacement if indicated. The overall prognosis of pituitary metastases is poor. We present a case of hypopituitarism as the presenting feature of bronchogenic carcinoma with metastases to the pituitary gland.

Keywords: Bronchogenic carcinoma, hypopituitarism, pituitary metastases


How to cite this article:
Johnston PC, Black NR, McIlroy J, Sharkey R, Garvey A, Lindsay JR. Hypopituitarism as the presenting feature of bronchogenic carcinoma with metastases to the pituitary gland. Indian J Endocr Metab 2013;17:167-9

How to cite this URL:
Johnston PC, Black NR, McIlroy J, Sharkey R, Garvey A, Lindsay JR. Hypopituitarism as the presenting feature of bronchogenic carcinoma with metastases to the pituitary gland. Indian J Endocr Metab [serial online] 2013 [cited 2019 Mar 24];17:167-9. Available from: http://www.ijem.in/text.asp?2013/17/1/167/107876


   Introduction Top


Tumours metastasizing to the pituitary gland are uncommon and are a rare cause of hypopituitarism. We present a case of an unusual extra-pulmonary manifestation of pituitary metastases from a bronchogenic carcinoma causing hypopituitarism.


   Case Report Top


A 78-year-old male presented with a four month history of general lethargy and one stone weight loss. He had a history of well controlled type 2 diabetes mellitus, hypertension and Barrett's oesophagus. He was an ex-smoker of 50 pack years. On clinical examination he had a blunted affect, grade 2 finger clubbing, a palpable liver edge and appeared unsteady on his feet; visual fields were normal and visual acuity was N5 bilaterally. Initial biochemical investigations, revealed normal renal function and central hypothyroidism fT4 8.3 pmol/L (NR: 9.4-18.6), TSH 0.21 mu/L (NR: 0.3- 4.4). Five months prior to admission, he was biochemically euthyroid fT4 14.0 pmol/L, TSH 1.16 mu/L, on routine testing at his general practitioner. On further questioning, he had no headache, visual disturbance, galactorrhoea or polyuria. The presence of a rapid progression of central hypothyroidism, as well as a sub-optimal short synacthen response [Table 1], prompted gadolinium-enhanced brain and pituitary magnetic resonance imaging (MRI). This revealed cerebral and cerebellar metastases and a sellar mass measuring 9.5 mm in AP dimension [Figure 1]a and b, with invasion into the floor of the sella consistent with a pituitary metastatic deposit. Hypopituitarism (secondary hypothyroidism, hypoadrenalism and hypogonadism was confirmed biochemically [Table 1]. The rise in prolactin was attributable to pituitary stalk compression.
Table 1: Anterior pituitary hormonal investigations at presentation


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Figure 1: (a) Gadolinium-enhanced brain magnetic resonance imaging (MRI) showing multiple enhancing lesions (white arrows). (b) Gadolinium-enhanced pituitary MRI revealing a mass lesion without evidence of haemorrhage or cystic change, occupying almost all of the pituitary gland (blue arrow), with invasion to the floor of the sella

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He was commenced on hydrocortisone 30 mg at 8 am and 10 mg at 5 pm initially, and subsequently levothyroxine 100 mcg was cautiously introduced. As there were no clinical symptoms of hypogonadism, testosterone replacement was not commenced in the initial treatment phase. A computed tomography (CT) scan of chest [Figure 2] revealed a 4.3 Χ 3.3 cm right hilar mass consistent with bronchogenic carcinoma. In addition, features of liver and bilateral adrenal metastases were also present. There was no evidence of diabetes insipidus present possibly attributed to by the low serum cortisol levels, which can mask this condition. His admission was complicated by a brief episode of psychosis attributed to high dose dexamethasone (8 mg bd) for treatment of brain metastases, which resolved upon dose reduction. After discussion with the multidisciplinary team and given the extent of his disseminated disease he was treated with palliative measures. He subsequently died shortly after his admission.
Figure 2: Computed tomography scan of thorax demonstrating a right hilar mass (red arrow)

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   Discussion Top


Tumours metastasizing to the pituitary gland are uncommon, accounting for 1-5% of all malignant tumours. [1],[2],[3] The majority of pituitary metastases are asymptomatic, as they mostly represent end stage disease and thus before the tumour effects are clinically or biochemically apparent, the patient succumbs to the original cancer. In an autopsy series by Teers et al., only 7% of pituitary metastases were reported to be symptomatic. [4] Most symptomatic patients with pituitary metastases present with diabetes insipidus, headache, visual field defects and/or anterior pituitary hormonal dysfunction. [5],[6],[7] Around 70% of pituitary gland metastases originate from breast and lung malignancy. [2] less common sites of origin, include gastrointestinal tract, prostate and kidney. [8],[9],[10] In a review by Komninos et al., of 380 patients with pituitary metastases on primary tumour origin, 90 (23.7%) originated from lung cancer, [11],[12] due to lymphatic or haematogenous spread. In another review of 201 cases of pituitary metastases, Chiang et al., showed that the posterior lobe either alone or combined with the anterior lobe accounted for 84.6% of cases, the anterior lobe alone was involved only in 15.4%. [2] The presence of biochemical anterior pituitary dysfunction as in this case, as a result of destruction of the anterior lobe due to pituitary metastases is relatively uncommon, [13] the presence of biochemical central hypothyroidism as the initial presenting feature of lung cancer from pituitary metastases, is even rarer. Treatment options for pituitary metastases include, surgical resection, cranial or parasellar irradiation and/or chemotherapy, the overall aim of treatment is to focus on the relief of symptoms, and offer hormonal replacement if indicated. [14] In the current case, surgical intervention was not undertaken, as there was no evidence of visual field defect or headache, a further reason for this, is that evidence suggests surgical intervention does not reverse established anterior pituitary dysfunction in pituitary metastases, [15] or improve survival time in comparison to non-surgically treated patients, however in some cases quality of life has been improved after surgery. [7] There is insufficient evidence to demonstrate whether localised sellar or whole cranial radiation confers any additional benefit. The choice to initiate chemotherapy depends on the pre-morbid status of the patient and the extent of the aggressive nature of the primary cancer, however, there is limited data on the use of chemotherapy on the effect of pituitary metastases. Due to the aggressive nature of the advanced cancer, the overall prognosis of pituitary metastases is poor with a mean survival time of 6-7 months. [16]

The rapid onset of central hypothyroidism, and subsequent hypopituitarism, the coexistence of extensive cerebral and cerebellar metastases, as well as radiological inferior extension to the floor of the sella, would indicate in this case, that the sellar mass was attributed to pituitary metastases and not from a pituitary adenoma. In this case, the extra-pulmonary manifestation of central hypothyroidism from pituitary metastases was the initial clue as to the underlying diagnosis of lung cancer in the absence of respiratory symptoms. While pituitary metastases are a rare cause of hypopituitarism the differential diagnosis should be always considered, particularly in patients within the setting of rapid onset of pituitary dysfunction, which should prompt evaluation for pituitary metastases and thus any underlying malignancy.

 
   References Top

1.Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer 1950;3:74-85.  Back to cited text no. 1
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2.Chiang MF, Brock M, Patt S. Pituitary metastases. Neurochirurgia (Stuttg) 1990;33:127-31.  Back to cited text no. 2
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3.Sioutos P, Yen V, Arbit E. Pituitary gland metastases. Ann Surg Oncol 1996;3:94-9.  Back to cited text no. 3
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4.Teears RJ, Silverman EM. Clinicopathologic review of 88 cases of carcinoma metastatic to the putuitary gland. Cancer 1975;36:216-20.  Back to cited text no. 4
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5.Branch CL Jr, Laws ER Jr. Metastatic tumors of the sella turcica masquerading as primary pituitary tumors. J Clin Endocrinol Metab 1987;65:469-74.  Back to cited text no. 5
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6.Max MB, Deck MD, Rottenberg DA. Pituitary metastasis: Incidence in cancer patients and clinical differentiation from pituitary adenoma. Neurology 1981;31:998-1002.  Back to cited text no. 6
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7.Morita A, Meyer FB, Laws ER Jr. Symptomatic pituitary metastases. J Neurosurg 1998;89:69-73.  Back to cited text no. 7
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8.Kattah JC, Silgals RM, Manz H, Toro JG, Dritschilo A, Smith FP. Presentation and management of parasellar and suprasellar metastatic mass lesions. J Neurol Neurosurg Psychiatry 1985;48:44-9.  Back to cited text no. 8
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9.Losa M, Grasso M, Giugni E, Mortini P, Acerno S, Giovanelli M. Metastatic prostatic adenocarcinoma presenting as a pituitary mass: Shrinkage of the lesion and clinical improvement with medical treatment. Prostate 1997;32:241-5.  Back to cited text no. 9
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10.Koshiyama H, Ohgaki K, Hida S, Takasu K, Yumitori K, Shimatsu A, et al. Metastatic renal cell carcinoma to the pituitary gland presenting with hypopituitarism. J Endocrinol Invest 1992;15:677-81.  Back to cited text no. 10
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11.Komninos J, Vlassopoulou V, Protopapa D, Korfias S, Kontogeorgos G, Sakas DE, et al. Tumors metastatic to the pituitary gland: Case report and literature review. J Clin Endocrinol Metab 2004;89:574-80.  Back to cited text no. 11
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12.Weilbaecher C, Patwardhan RV, Fowler M, Willis BK, Nanda A. Metastatic lesions involving the sella: Report of three cases and review of the literature. Neurol India 2004;52:365-8.  Back to cited text no. 12
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13.Delattre JY, Castelain C, Davila L, Schadeck B, Poisson M. [Metastasis to the pituitary stalk in a case of breast cancer]. Rev Neurol (Paris) 1990;146:455-6.  Back to cited text no. 13
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14.Gsponer J, De Tribolet N, Déruaz JP, Janzer R, Uské A, Mirimanoff RO, et al. Diagnosis, treatment, and outcome of pituitary tumors and other abnormal intrasellar masses. Retrospective analysis of 353 patients. Medicine (Baltimore) 1999;78:236-69.  Back to cited text no. 14
    
15.Pinet C, Raholimina V, Ferri RM, Kleisbauer JP. [Panhypopituitarism secondary to pituitary metastases]. Presse Med 2000;29:17-8.  Back to cited text no. 15
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16.Houck WA, Olson KB, Horton J. Clinical features of tumor metastasis to the pituitary. Cancer 1970;26:656-9.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Twelve cases of pituitary metastasis: a case series and review of the literature
Mendel Castle-Kirszbaum,Tony Goldschlager,Benjamin Ho,Yi Yuen Wang,James King
Pituitary. 2018;
[Pubmed] | [DOI]



 

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