Category: Pituitary Disorders/Neuroendocrinology
We present a patient with small cell lung carcinoma (SCLC) with suspected metastasis to the pituitary gland.
Case presentation and literature review.
Results : 61-year-old male presented with weakness, fatigue, weight loss and dyspnea. He had 45-pack-year history of smoking. Initial chest imaging revealed a large left-sided pulmonary mass. PET-CT showed hypermetabolic activity within the left lung and bilateral adrenal glands. The patient came to the hospital for endobronchial biopsy, but he was found to be in new onset atrial fibrillation and had hyponatremia. He was admitted to the hospital. Further history revealed that he was also complaining of diplopia and blurry vision that started in the week prior to admission. On physical exam, he had evidence of left 3rd and 4th cranial nerve palsy with anisocoria, left dilated pupil, left ptosis, and restriction on left upper gaze. Magnetic resonance imaging of the brain showed an irregularly enhancing 22 x 13 x 21 mm pituitary mass with superior and posterior suprasellar extension, extending to the roof of the sphenoid sinus and invading left cavernous sinus. Hormone tests showed secondary hypothyroidism, secondary hypogonadism and hyperprolactinemia (prolactin: 22.1 ng/ml, normal: 2.6-13.1). There was no evidence of adrenal insufficiency and growth hormone deficiency on basal tests, although appropriate stimulation tests were not performed. Cosyntropin stimulation test was normal. He underwent bronchoscopy with biopsy of adjacent lymph nodes, which were positive for SCLC. The patient was started on chemotherapy, but he worsened clinically with pancytopenia, pneumonia, sacral ulcers and poor performance status, although PET-CT showed improvement in hypermetabolic activity of the lung mass. Chemotherapy was held and the patient expired before we were able to obtain follow-up imaging of the pituitary.
Metastasis to the pituitary is observed in 5% of patients with cancer and 2/3 of them are latent. Given his extensive stage SCLC, short history of left oculomotor and trochlear nerve involvement, MRI appearance of irregular enhancement with involvement of left cavernous sinus and suprasellar extension, we feel that it is unlikely that his pituitary mass was of pituitary origin, but metastasis from SCLC. Hormonal evaluation did not show hypersecretion of pituitary hormones. There is possibility of non-secreting pituitary adenoma. Ultimately tissue diagnosis of the pituitary mass was not obtained, because it would be contraindicated in SCLC metastasis.
We suspect that at the patient's pituitary mass was most likely metastatic spread of SCLC without brain metastasis representing an unreported occurrence.
Christopher Barnes– Fellow, Division of Endocrinology and Metabolism, Arnot-Ogden Medical Center, Lake Erie College of Osteopathic Medicine, Horseheads, New York
Ahmet Can– Program Director and Faculty, Arnot-Ogden Medical Center, Lake Erie School of Osteopathic Medicine, Horseheads, New York
Christopher Barnes– Program Director and Faculty, Arnot-Ogden Medical Center, Lake Erie School of Osteopathic Medicine, Horseheads, New York
Division of Endocrinology and Metabolism, Arnot-Ogden Medical Center, Lake Erie College of Osteopathic Medicine
Horseheads, New York
Dr. Barnes graduated from Lake Erie College of Osteopathic Medicine in 2014. He completed residency in Internal Medicine at the Arnot Ogden Medical Center and remains there for fellowship in Endocrinology.
Program Director and Faculty
Arnot-Ogden Medical Center, Lake Erie School of Osteopathic Medicine
Horseheads, New York
Ahmet Selcuk Can, MD went to medical school in Istanbul Faculty of Medicine and graduated in 1989. He did his internship and residency in internal medicine in Cabrini Medical Center affiliated with New York Medical College, in New York City between 1994 and 1996. He completed his Endocrinology Fellowship in Weill Cornell Medicine and Memorial Sloan-Kettering Cancer Center combined program. During his fellowship, he worked in inborn errors of steroid metabolism and published a paper about molecular genetics of 5 alpha reductase deficiency. After fellowship, he worked in various Hospitals and Universities in Turkey. He published about prevalence of the metabolic syndrome and on the sensitivity and specificity of the thyroid fine needle aspiration biopsies. Before joining to Arnot-Ogden Medical Center in Elmira, New York, he worked in a private practice and had affiliations in the Community Medical Center, in Toms River and Ocean Medical Center in Brick, New Jersey and after that worked as a Professor of Medicine in Termal Vocational School in Yalova, Turkey. He has 20 publications in peer-reviewed journals. He serves as the Program Director for Endocrinology, Diabetes and Metabolism Fellowship at Arnot-Ogden Medical Center in Elmira, NY, affiliated with Lake Erie School of Osteopathic Medicine.