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INTrODUcTION: Malignant prolactinoma is an exceedingly rare endocrine tumor and cannot be diagnosed on histological grounds alone. similarly to other neuroendocrine tumors such as pheochromocytoma, the mitoses index, Ki-67, p53, and others are utilized in helping understand whether a tumor is benign or malignant or to better predict tumor behavior. We here present the unusual case of an unfortunate young man with an aggressive prolactinoma, the complications of which led to his premature death. cAsE rEPOrT: A 25-year-old white man developed severe headaches, low energy, and decreased libido. A brain magnetic resonance imaging (MrI) showed a 4 x 3 x 2 cm pituitary tumor invading the left cavernous sinus. Laboratory findings revealed elevated prolactin (470 ng/mL) and adrenocorticotropic hormone (AcTH, 82 pg/ml) and decreased total testosterone (176 ng/dl). Visual fields showed superior quadrantanopia in the left eye. Transsphenoidal pituitary resection was undertaken. Pathology revealed a prolactinoma with atypical cells, diffuse p53 nuclear labeling, and a Ki-67 index of 23% (high). Postoperatively, prolactin remained elevated (725-891 ng/ml) and cabergoline was increased to 1 mg three times weekly, with serum prolactin further increasing to 3507 ng/ml five months postoperatively. repeat MrI revealed extension of the tumor with optic chiasm compression and left orbit invasion. Because of acute left vision loss with ophthalmoplegia, an urgent left frontotemporal craniotomy and tumor resection were conducted. The Ki-67 index of the tumor was 24.8%, the mitotic figure immunostain phosphohistone-H3 positive. sixty percent (60%) of tumor cells were positive for p53. cabergoline was increased to 1 mg daily but prolactin remained elevated (770 ng/ml). The patient then underwent proton beam radiation to the area of concern involving the sella. Prolactin thereafter improved to 44 ng/ml. He then developed acute vision loss of the right eye with an MrI showing tumor in the right cavernous Case report HORMONES 2012, 11(4):477-482

Background Pituitary apoplexy (PA) is a rare but life-threatening condition characterized by pituitary infarction and hemorrhage, most often in the setting of a preexisting adenoma. The risk factors and mechanisms associated with PA are poorly understood. Although neurovascular manifestations of coronavirus disease-19 (COVID-19) infection have been documented, its association with PA is to be determined. Methods From a prospectively collected database of patients treated at a tertiary care center for pituitary adenoma, we conducted retrospective chart review of PA cases during the COVID-19 pandemic from March 2020 to December 2020. We also conducted a literature review to identify other reported cases. Results We identified three consecutive cases of PA and concomitant COVID-19 infection. The most common symptoms at presentation were headache and vision changes. Included patients were successfully treated with surgical decompression and medical management of associated endocrinopathy, ultimately experiencing improvement of their visual symptoms by most recent follow up. COVID-19 infection in the perioperative period was corroborated by polymerase chain reaction testing in all patients. Conclusions With the addition of our series to the literature, there are now 10 cases of confirmed PA in the setting of COVID-19 infection. This series is limited in its ability to draw conclusions about the relationship between these two entities, but COVID-19 infection may represent a risk factor for developing PA. Further studies are required.

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Onyx embolization under balloon catheter flow arrest allows for greater nidal penetration of embolic material and improved reflux control. The technique is limited by the current deliverability of balloon catheters and the potential risk for earlier embolization of dangerous anastomosis.