A rare ophthalmic presentation of pituitary metastases

Abstract

BACKGROUNDPituitary metastases are very rare and the most common clinical presentation with a pituitary metastasis is diabetes insipidus, which may be the fi rst manifestation of the underlying tumour. We present a case who presented with an ophthalmoplegia, headache and reduced vision and later on diagnosed with pituitary metastases. CASE PRESENTATIONAn 83-year-old woman presented to the eye casualty department with a history of progressive horizontal diplopia, fronto-occipital headache and reduced vision in her right eye over a period of 1 month. On examination, she had complete right ptosis with partial oculomotor nerve paralysis with pupil involved. Best corrected visual acuity was 6/18 right and 6/6 left eye, respectively. Confrontational visual fi eld analysis showed no absolute scotoma and the optic discs and retinae were normal. Systemic examination was unremarkable and there was no lymphadenopathy. She reported being a smoker of 10 cigarettes per day over last several decades. Her bloods tests showed an elevated erythrocyte sedimentation rate (ESR) of 82 mm/h with C reactive protein (CRP) of 115 mg/l. There were no associated symptoms of jaw claudication or weight loss. Her white cell count was 18.41×109/l. The initial working diagnosis was that of giant cell arteritis and a temporal artery biopsy was organised but in view of the ophthalmoplegia we arranged an urgent MRI scan of head. The patient was started on 40 mg/day of oral prednisolone at this point and she also had an urgent chest x-ray. INVESTIGATIONSThe temporal artery biopsy was negative. Chest x-ray showed mild heart enlargement with a perihilar shadowing on right side. Head MRI scan showed a large pituitary tumour with suprasellar extension involving the right cavernous sinus and superiorly the optic chiasm on the right was compressed ( fi gure 1 ). There was homogenous enhancement with intravenous gadolinium indicating a likely pituitary macroadenoma ( fi gure 2 ).Due to the consolidation in the right lung we arranged urgent CT scan of the thorax. This showed a 2.5 cm soft tissue mass in the right perihilar region with deeper infi ltration causing a partial collapse of the middle lobe. It was thought that this was consistent with central bronchial tumour ( fi gure 3 ). Bronchoscopy was unfortunately not diagnostic. Further haematological and radiological investigations did not show any secondaries. OUTCOME AND FOLLOW-UPSubsequent transphenoidal debulking of the pituitary yielded histology showing a metastatic adenocarcinoma of primary lung origin. DISCUSSIONMetastasis to the pituitary gland is very uncommon and a fi rst presentation of any systemic tumour through pituitary metastasis is rare. There have been few reports of pituitary metastases in the literature. James et al found no cases of pituitary gland or sellar metastasis in their cross sectional, retrospective analysis of neuro-imaging (CT and MRI) of 155 patients diagnosed with intracranial metastatic disease. 1 In 1857, L Benjamin fi rst described a case of metastasis to the pituit...

Pituitary metastasis: a rare condition

“…The frequencies of primary sites are summarized in Fig. 1 (10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 10...…”

“…In the City of Hope series contained herein, breast cancer and lymphoma were equally the most common primary metastasis source. It is hypothesized that elevated hormone levels in the pituitary gland, especially prolactin, may attract metastatic cells (85). Recent studies have found that anti-HER-2 treatment can facilitate Pit Met (145, 146, 147).…”

Hypophyseal metastases: A report of three cases and literature review

“…At least in part the reason is that these two types of malignancies are most commonly encountered in clinical practice. Less often described are metastasis of renal cell carcinoma, gastrointestinal tumours, lymphomas, leukemias, thyroid carcinomas, myeloma, hepatocellular carcinoma and rhabdomyosarcoma (Table 1) [1,2,[7][8][9][10][11][12][13][14][15][16][17][18][19]. When confirming the metastasis in the pituitary, there are frequently metastases present at several other locations, most often in bones.…”