Extensive Pituitary Apoplexy after Chemotherapy in a Patient with Metastatic Breast Cancer

Abstract

Surgery, anticoagulation therapy, pregnancy, and hormone treatments, such as bromocriptine, are well-characterized precipitating factors for pituitary apoplexy. However, whether cytotoxic chemotherapy for systemic cancer could cause pituitary apoplexy has not been investigated. Here, we present a case of a 41-year-old woman who developed a severe headache with decreased visual acuity after intravenous cytotoxic chemotherapy to treat metastatic breast cancer. Preoperative neuroimaging revealed pituitary adenoma with necrosis. Operative findings and pathologic examination concluded extensive necrosis with a small intratumoral hemorrhage in a pre-existing pituitary adenoma. We reviewed two additional previously published cases of pituitary apoplexy after systemic chemotherapy and suggest that cytotoxic chemotherapy may induce pituitary apoplexy.

Pituitary Apoplexy Precipitated by Systemic Chemotherapy

“…Given the complex array of side effects that often accompany chemotherapy treatment and the potential for PA to present insidiously rather than acutely [ 17 - 18 ], the incidence of PA in patients in this setting is likely underappreciated. In the absence of formal guidelines, because the risk of chemotherapy-related PA is theoretically increased with macro- versus microadenomas, we agree with previous authors that prophylactic surgical removal may be considered for patients with known or incidentally identified larger pituitary tumors requiring cytotoxic chemotherapies to reduce PA risk [ 5 ]. This decision must nonetheless balance the oncologic risk of delaying chemotherapy.…”

Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET)

“…( Table 1 ) Headache was severe, often described as the most painful headache episode an individual has ever experienced, and graded, for example, as high as 9 on a scale from 0 to 10, with 10 being the most severe in one study [ 31 ]. For practical purposes we point out that headache was absent in some cases; thus, an index of suspicion should be provided by other endocrine and non-endocrine clinical elements [ 43 , 86 , 196 , 197 , 198 , 199 , 200 , 201 , 202 , 203 , 204 , 205 , 206 , 207 , 208 , 209 , 210 , 211 , 212 , 213 , 214 , 215 , 216 ]. For instance, Enatsu et al reported a 65-year-old woman admitted for a nonfunctioning pituitary adenoma-associated PA who presented third cranial nerve palsy and sudden decrease in visual acuity unaccompanied by headache [ 196 ].…”

“…Visual field defects varied from (mostly common) hemianopia [ 33 , 39 , 55 , 80 , 126 , 135 , 179 , 187 , 197 ] to cranial nerve palsies manifesting as diplopia in the majority of these cases [ 32 , 34 , 35 , 49 , 50 , 58 , 63 , 66 , 68 , 75 , 84 , 85 , 91 , 92 , 114 , 115 , 117 , 127 , 130 , 142 , 147 , 150 , 157 , 163 , 164 , 186 , 191 , 194 , 195 , 207 , 214 ] followed by ptosis [ 34 , 35 , 50 , 59 , 75 , 77 , 79 , 92 , 107 , ...…”

“…Optic chiasm compression was specified in 18 articles [ 32 , 33 , 46 , 55 , 62 , 63 , 65 , 69 , 80 , 123 , 125 , 169 , 177 , 185 , 186 , 191 , 192 , 218 ] or, rarely, an invasion of the cavernous sinus [ 44 , 63 , 65 , 196 ]. Interestingly, two patients, a 45-year-old male [ 34 ] and a 71-year-old female [ 207 ] were admitted for PA-associated proptosis.…”

“…Other vascular and clotting triggers include Takotsubo cardiomyopathy [ 213 ], heparin-induced thrombocytopenia [ 35 ], thrombocytopenia of other causes [ 97 , 208 ], and polycythemia [ 108 ]. Medical treatments in point are further on (at the statistical level of rare case reports): androgen deprivation therapy for prostate cancer [ 52 , 88 , 99 , 157 , 168 ], systemic chemotherapy like bleomycin, etoposide, cisplatin [ 184 ], doxorubicin, cyclophosphamide [ 207 ], and thyroxine therapy [ 61 ].…”