Introduction: Pituitary Metastases (MTS) are infrequently seen in clinical practice. The incidence ranges from 0.14 to 28%. Breast and lung cancer are the primary sites that most frequently metastasize to sellar region, between the sixth and seventh decades of life. Most cases are diagnosed in patients with advanced malignant disease, however, in 20-30%, symptoms of pituitary involvement can precede the diagnosis of the primary tumor. Objectives: To evaluate symptoms at presentation, hormonal, radiological and histological findings, management and outcome of a series of patients with pituitary MTS. Patients and methods: medical records of 16 patients from eight Endocrine Centers were reviewed. Ten patients had histological confirmation of the pituitary MTS, 6 were not operated, being the diagnostic criteria the presence of sellar mass associated with diabetes insipidus (DI) and / or sudden-onset of neuro-ophthalmological symptoms in patients with confirmed primary neoplasia. Results: The median age was 54 years (range 35-70), 9 women (56.2%). The sites of the primary tumor were: 7 lung (44%), 5 breast (32%), 1 follicular thyroid carcinoma (6%), 1 Hodgkin lymphoma (6%), 1 poorly differentiated carcinoma (6%), and 1 clear cell renal carcinoma (6%). The median time between the diagnosis of the primary neoplasm and the occurrence of the pituitary MTS was 12 months (range: 3-120). In 9 patients (56.2%), the diagnosis of the primary neoplasm was made after the finding of the symptomatic sellar mass. DI was found in 14 patients (87.5%), adenohypophyseal deficit in 12 (75%), visual disorders in 10 (62.5 %), headache in 6 (37.5%) and cranial nerve deficits in 6 (37.5%). In 68.7% (11 patients), other MTS were detected. Fifteen patients were evaluated by MRI and one by CT: 13 (81.3%) harbored supra / parasellar masses, and the remaining 3 had lesions limited to the pituitary gland, with stalk thickening and lack of spontaneous neurohypophysis hyperintensity in 2 of them. In all cases diffuse gadolinium uptake was present. Fourteen patients died (87.5%), with a median survival time of 6,5 months (range: 1-36); the remaining 2 are still alive with a follow-up period of 4 and 12 months respectively. Conclusions: In this series of 16 patients with pituitary MTS, the most frequent primary neoplasms were lung and breast. Median age was lower than in published series. DI was the most common condition at presentation, followed by hypopituitarism and visual disorders. The short survival was related to the extent of the disease at the time of diagnosis. In more than half of the cases the diagnosis of primary neoplasia was made through the symptomatic pituitary mass. In the presence of a pituitary lesion with diffuse gadolinium uptake, associated with DI and / or acute visual deficit, pituitary MTS should be suspected even in patients without a history of oncological disease.
Introduction Acromegaly is associated with higher morbidity and mortality due to malignant neoplasms. However, data on the incidence and evolution of thyroid cancer in acromegaly is controversial. Objectives: To describe the clinical and biochemical characteristics of a group of acromegalic patients with differentiated thyroid carcinoma (DTC). Identify any predicting factor for DTC evolution. Analyze risk of recurrence (RR), initial response to treatment and response at the end of follow-up (RFU), comparing the outcomes with non-acromegalic patients with DTC. Patients and methodsRetrospective, multicenter study of 16 acromegalic patients with DTC. Acromegaly control or remission was defined with an IGF-1 ≤1 ULN with or without medical treatment (MT) respectively. AJCC Staging System 8th Edition was used for TNM staging, and the initial RR, initial response and RFU were defined according to ATA Guidelines 2015. As a control group, 56 patients with DTC without acromegaly were selected. Statistical analyses were done using SPSS Statistics 2.0. Results Median age of patients at the diagnosis of acromegaly was 44 years (range 12-69). Delay in diagnosis of acromegaly was a median of 2.5 years (range 0.5-10). Basal mean IGF-1 level was 3.2 ± 1.2 xULN. Surgery was performed in 85.7%. Post surgically, the best mean IGF-1 was 1.24 ± 0.34 xULN. Control with MT was achieved in 80%, with a median time to control since diagnosis of 21 months (6-132). Mean age at CDT diagnosis was 46.5 years (18-69). No patient had personal history of cervical irradiation. Most patients (86.7%) had normal thyroid function tests At the moment of diagnosis of DTC 62.5% of the patients had active acromegaly, IGF-1 of 2.5 ± 1.4 xULN. Median time from CDT diagnosis to acromegaly control was 1 year (0.5-7). Mean DTC tumor diameter of the bigger lesion was 13.7 ± 7.4 mm, being multifocal in 40% of the cases. All were papillary carcinoma, one case an aggressive variety. In 6/15 lymph node dissection was done, 50% with metastasis. One patient had distant metastasis. Radioiodine ablation was given to 87.5%, mean dose 115 ± 64.5 mCi. Twelve of the patients were stage I, 3 stage II and 1 IVb. Initial RR was low in 14/16, intermediate in 1 and high in 1 patient. RFU was: 13/15 with no evidence of disease, 1 patient with biochemical incomplete response and 1 with structural incomplete response, on average at 47.7 ± 33.3 months of FU. No statistically significant correlations were found between characteristics of the acromegalics and DTC outcomes. When comparing response on FU between acromegalics and controls no statistically significant differences were found. Conclusions The acromegalics with DTC had a low initial RR, that could be related to an early diagnosis of DTC (anticipated bias). We did not find any predisposing factor for unfavorable evolution. When comparing with the control group, we can conclude that DTC in acromegaly does not have a worse evolution.
Prolactinomas represent approximately 40-60% of all pituitary tumors. Dopamine agonists (DA) are the first-line treatment, with a 70-90% response. However, up to 10% are resistant (R) to DA. Our objectives were to describe the clinical, biochemical and imaging characteristics of a group of patients with prolactinomas R to DA; and to determine the presence of prognostic factors by performing a comparative analysis with the population of non-R prolactinomas. We analized retrospectively the medical records of patients diagnosed with prolactinoma, with follow-up (f-up) at the same hospital from 1998 to 2017. They were classified as R when prolactin (PRL) was not normalized and/or a reduction ≤ than 50% of the tumor (Tx) volumen, with a cabergoline (CBG) dose ≥2mg/week (mg/w), with, at least 6 months of treatment. Macroadenomas (MA) were defined as Tx ≥10mm and as invasive with a classification of Knosp 3 or 4 by MRI. Of 95 prolactinomas, 14 patients with R to DA were described. The mean age was 32.7 ± 15.6 years (y). We found no statistically significant differences (SSD) in terms of gender, with a higher distribution (53%) and a tendency to age (37.9 vs 26.9, p = 0.09) in the male gender (M). The mean time of f-up was 34.7 ± 28.7 months (m). Majority were MA (87%) and invasive Tx (64%). The initial manifestations were: headache (85.7%), visual field alteration (50%), menstrual cycle alterations (86%), galactorrhea (20%). The mean PRL value was 7419.4 ± 1149.7 ng/ml, being higher in the M group (11652.6 vs 1653.3, p <0.001). 93% of the patients received CBG as the main treatment. The mean dose was 6.8 ± 4.3 mg/w, with a mean time of 34.3 ± 23.1 m. 57% of the patients achieved a reduction ≥ 50% of PRL, 2 normalized it. 4 patients presented ≥ 50% reduction in Tx size. All were MA, invasive, none normalized PRL, in 3/4 surgical resolution was indicated. When comparing with the population of non-R prolactinomas (n = 81), we found a higher proportion of M with a statistical tendency in the R group (p=0.053) and a greater proportion of MA (p=0.04) and invasive (p = 0.03). Higher values of PRL were evident at diagnosis in this group (508.9 vs 7482.5, p <0.0001), higher dose of CBG (1.8 vs 6.6, p <0.001), but without SSD in the time of use of DA, the age at diagnosis or the time of f-up. A value of PRL at diagnosis above 1065 ng/mL has a specificity of 85% for R. Patients in the non-R group had a biochemical response ≥ 50% with the treatment (p<0.001), but not in terms of the structural response (p=0.13) nor in the biochemical response time (p=0.12). Similar to that reported in the literature, we evidenced a frequency of 15% of R in our population. In contrast to classic prolactinomas, a greater proportion of R Tx was found in the M gender, in MA and with invasive characteristics. We can conclude that larger Tx with a higher PRL value at the time of diagnosis and, probably, the M gender are more likely to present R to DA
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