Long-Term Follow-Up of Growth Hormone-Producing Pituitary Carcinoma With Multiple Spinal Metastases Following Multiple Surgeries: Case Report

Abstract

This report describes a rare case of a patient with growth hormone (GH)-secreting pituitary adenoma with malignant transformation resulting in multiple metastases to the dura mater of the cerebral convexity and high cervical spine. The patient was a 60-year-old man with a previous history of pituitary adenoma with suprasellar extension who had undergone transsphenoidal surgery, craniotomy for a convexity tumor, and suboccipital craniotomy for a cerebellar tumor. Thirteen years after the initial surgery, suboccipital craniotomy for a cervicomedullary junction tumor and cervicospinal surgery for a metastatic tumor was performed. Histologic findings of resected specimens demonstrated that the primary pituitary tumor was typical adenoma (similar to specimens from the initial surgery) but that the cerebellar and the dural tumor from the high cervical spine had a high incidence of mitotic figures, and cellular anaplasia with nuclear polymorphism and necrosis. In addition, the serum levels of GH were noted to have decreased with recurrence of the tumor. It was concluded that patients with pituitary adenoma, even when benign, must be carefully followed for signs of malignant transformation, and spinal or distant metastases.

Growth Disturbances in Childhood Cancer Survivors

“…GH-secreting adenomas may be more aggressive and invasive than in adults [88, 94-97], have cosecretion of prolactin, and be associated with other pituitary hormone deficiencies in up to 25% of cases [91, 98-100], and they can be sporadic or associated with certain conditions including Carney complex, McCune Albright syndrome, MEN-1 syndrome, MEN-4 syndrome, and 3P association [101-104]. …”

Aggressive and malignant pituitary tumours: state-of-the-art

“…Radiation has been reported to be implicated in the development of fibrosarcoma, but may also induce malignant changes in PAs (Casson et al 1986, Tanaka et al 2013. Tanaka et al presented a case report showing cerebro-spinal metastases after radiation and gamma-knife treatment, suspecting that repeated radiation therapy for the pituitary and intracranial tumours may induce malignant transformation and the multiple spinal metastases (Tanaka et al 2013). However, this concept is very difficult to prove, as aggressive tumours are more likely to be irradiated and such a correlation does not prove cause and effect.…”

“…While this patient received CyberKnife therapy for a residual mass following the initial surgery, there is no evidence to support radiation-induced PAs specifically (Minniti et al 2005), and it remains possible that there was iatrogenic seeding along the surgical tract (Taylor et al 1994). Tanaka et al described a case of a patient who developed multiple supra-tentorial, cerebellar and cervical spine dural metastases 13 years after initial surgical operation for a pituitary adenoma (Tanaka et al 2013). Thus, even apparently benign adenomas require long-term follow-up (Krueger & Seibly 2017).…”

“…However, while the majority of aggressive pituitary tumours require multiple operations as well as radiation therapy, it seems (albeit on evidence which is incomplete at present) that therapeutic modalities of surgery and radiation are unlikely to be major mediators of malignant transformation (Tanaka et al 2013).…”

Giant GH-secreting pituitary adenomas: management of rare and aggressive pituitary tumors

“…These large tumors tend to prevail in young adults, usually 20-30 years old. Albeit aggressive, these tumors are mostly benign, rarely developing into malignant pituitary carcinomas (6). Giant tumors are usually unsuitable for complete removal, thus surgery alone is not expected to achieve disease control or hormonal remission in almost all cases (2).…”