Shrinkage of a pituitary metastasis of melanoma induced by pembrolizumab: a case report

Background Pituitary metastases are rare, often deriving from lung or breast cancer owing to the upper vena cava proximity. Pituitary metastases can manifest with signs and symptoms of pituitary tumors, consequent to mass effect (headache, visual impairment) and/or hormonal alterations (hyperprolactinemia, hypopituitarism, and diabetes insipidus). Immune checkpoint inhibitors burst immunity against tumors, significantly increasing patients’ survival, but their autoimmune side effects frequently involve the skin, the gastrointestinal tract, and the endocrine glands (pituitary, thyroid, pancreas). Case presentation A 77-year-old Caucasian man had undergone trans-nasal sphenoidal surgery for a nonsecreting pituitary macroadenoma in 2001, without remnant or endocrine deficits. In 2016, he was operated for a shoulder melanoma. In February 2018, imaging evaluation demonstrated metastases in lung, liver, and femur. Therefore, treatment with pembrolizumab (anti-programmed death 1) was scheduled in May 2018, but, before starting this therapy, a brain computed tomography performed for a sudden loss of consciousness detected a sellar mass of 17 × 12 mm, which extended to the pituitary stalk and compressed the optic chiasma. Focused magnetic resonance imaging confirmed the size and characteristics of the lesion, while emergency evaluation of the hormonal profile demonstrated an impairment of adrenal and thyroid function. The pituitary lesion demonstrated a remarkable shrinkage (8 × 6 mm), which was confirmed by subsequent imaging evaluations. Conclusions This is the first case reporting on effectiveness of immune checkpoint inhibitors in a patient with pituitary metastasis from a melanoma.

Metastases to the Pituitary Gland: Histological Patterns of Spread and Review of the Literature

Few studies have focused on histological patterns of metastatic spread to the pituitary gland. We review our experience and that in the literature, 1970–present. Departmental cases, 1998–2021, were assessed for anterior versus posterior gland and/or capsular involvement and cohesive tumor obliterating underlying pituitary architecture versus metastatic cells filling pituitary acini with relative acinar preservation. Eleven autopsy/15 surgical cases, including 2 metastases to pituitary adenomas, were identified. Cohesive/obliterative patterns predominated histologically in both surgical and autopsy cases, but acinar filling by metastatic cells was extensive in 3/26 cases, focal in 5/26, and had resulted in initial erroneous impressions of atypical pituitary adenoma/pituitary carcinoma in 1 case and pituitary adenoma with apoplexy in another, likely due to focusing on necrotic areas in the specimen where the acinar pattern had been broken down and not appreciating nearby areas with acinar filling by metastatic cells. Although most pituitary metastases produce readily identifiable cohesive/obliterative patterns, diagnostic challenges remain with the less frequently seen “acinar filling” pattern. A dichotomy exists between patients with symptomatic pituitary metastases occurring early in the disease course and requiring surgical excision versus patients in whom asymptomatic small pituitary metastases are found incidentally at autopsy, the latter almost invariably in late disease stages, with widely disseminated metastatic disease.

A tale of many tumors and one endocrine site: A case series of pituitary metastases

Background: Metastases to the pituitary gland are extremely rare with an incidence rate reported from an autopsy series of 1.8%–12%, and only 20% was diagnosed clinically. Tumors that commonly metastasize are breast and lung tumors. Case series: We present a series of five cases, including four female patients and one male patient with metastatic cancer. Two women had metastatic small lung cancer and presented with diabetes insipidus (DI). Two women had metastatic breast cancer, of which one presented with DI and the other with panhypopituitarism. The male patient had bronchogenic adenocarcinoma and presented with DI. Conclusion: Our case series confirmed earlier reports that DI is the most common presentation of metastases to the pituitary gland.

Pituitary metastases from neuroendocrine neoplasms: case report and narrative review

Purpose Pituitary metastases (PM) are uncommon findings and are mainly derived from breast and lung cancers. No extensive review of PM from neuroendocrine neoplasms (NENs) is on record. Here we describe a clinical case of PM from pancreatic NEN and review the clinical features of PM from NENs reported in the literature. Methods A case of PM from a pancreatic NEN followed at our institution is described. We also reviewed the 43 cases of PM from NENs reported in the literature. Results A 59-year old female patient, previously submitted to duodeno-cephalo-pancreasectomy for a well-differentiated pancreatic NEN, with known hepatic metastases, underwent a 68 Ga-DOTATOC PET/CT that revealed an uptake in the pituitary gland. A subsequent MRI displayed a pituitary lesion, with suprasellar extension. After a hormonal and genetic diagnostic workup that excluded the diagnosis of MEN 1, the worsening of headache and visual impairment and the growth of the lesion lead to its surgical removal. A pituitary localization of the pancreatic NEN was identified. Regarding the published cases of PM from NENs, the most common tumour type was small cell lung cancer (SCLC), accounting for nearly half of the cases, followed by bronchial and pancreatic well differentiated NENs. The most frequent symptom was a variable degree of visual impairment, while headache was reported in half of the cases. Partial or total anterior hypopituitarism was present in approximately three quarters of the cases, while diabetes insipidus was less common. The most frequent treatment for PM was surgical resection, followed by radiotherapy and chemotherapy. The clinical outcome was in line with previous reports of PM from solid tumours, with a median survival of 14 months. Surgery of PM was associated with prolonged survival. Conclusions PM from NENs have clinical features similar to metastases derived from other solid tumours, albeit the involvement of the anterior pituitary seems more frequent; a thorough pituitary hormonal evaluation is mandatory, after focused radiological studies, particularly if a surgical approach is considered. The optimal management of PM remains disputed and seems mainly driven by the aggressiveness of the primary tumour and the presence of symptoms. In well-differentiated NENs, particularly in the case of symptomatic PM, surgical removal may be a reasonable approach.

A very rare case of pituitary metastasis infiltrating a non-secretory gonadotroph adenoma

Pituitary adenomas are the commonest sellar tumours. Pituitary metastases are very rare, with the most common primaries being breast and lung cancers. We report the case of an 83-year-old man with a history of breast carcinoma who presented with recent-onset headaches and progressive deterioration of visual acuity. MRI brain showed a large sellar and suprasellar mass compressing the optic chiasm and involving the pituitary stalk. Transsphenoidal debulking resulted in symptomatic relief and visual recovery. Specimen examination revealed a combination of a gonadotroph pituitary adenoma that was infiltrated by metastatic breast carcinoma. He had no symptoms of diabetes insipidus. He was subsequently treated with pituitary radiotherapy. This is a very rare presentation of a pituitary mass with mixed pathology. To our knowledge, this is the third description of a breast carcinoma metastasis into a gonadotroph cell pituitary adenoma. Highlight points: Infiltrating metastases into pituitary adenomas are very rare but do occur. To our knowledge this is the third case of breast adenocarcinoma metastasising to a gonadotroph pituitary adenoma. Pituitary metastases should always be considered in rapidly evolving pituitary symptoms in a cancer patient. Not all complex pituitary lesions are associated with panhypopituitarism. Early invasive local management (TSS and post TSS radiotherapy) can provide rapid satisfactory outcomes.

Rare case of hepatocellular carcinoma metastasising to the pituitary and cavernous sinus causing panhypopituitarism and bilateral ophthalmoplegia

Pituitary metastases, especially from a primary hepatocellular carcinoma (HCC), are rare. Review of the literature revealed only few cases reporting pituitary metastases complicated by panhypopituitarism from HCC. Calvarial metastases from HCC are even more rare. Here, we present a unique case of primary HCC with metastases to both the calvarium and the pituitary causing panhypopituitarism and bilateral ophthalmoplegia, respectively. To our knowledge, this is the first reported case of two unique and rare complications from metastatic HCC.

Endometrial adenocarcinoma metastatic to the pituitary gland: a case report and literature review

Pituitary metastases are rare, and metastatic pituitary lesions originating from endometrial adenocarcinoma are extremely rare. These lesions can be mistaken for pituitary adenomas and their diagnosis can be very difficult. Pituitary metastases mostly affect the posterior lobe and patients may develop diabetes insipidus. Patients with endometrial cancer complicated with diabetes, including poor glycemic control, may also suffer from thirst, making it more difficult to diagnose diabetes insipidus. A 68-year-old woman who was being followed-up for primary endometrial adenocarcinoma was admitted for gradually worsened polyuria and polydipsia. Her laboratory findings were compatible with diabetes insipidus. Magnetic resonance imaging revealed thickening of the pituitary stalk, involvement of the superior pituitary gland, and disappearance of hyperintensity in the posterior lobe, indicating pituitary metastasis. Increased urine output and oral fluid intake in a patient with a diagnosis of carcinoma may indicate possible pituitary metastasis, and the hormonal insufficiency should be corrected to improve the patient’s quality of life.