Category: Pituitary Disorders/Neuroendocrinology

Monitor: 19

19 - CASE OF RECURRENT NONFUNCTIONING PITUITARY MACROADENOMA: MANAGEMENT ISSUES IN AN ENDOCRINOLOGY CLINIC

Friday, Apr 26
11:30 AM – 12:00 PM

Objective :

Nonfunctioning pituitary macroadenomas (NFMA) are one of the most common types of pituitary tumors. Recurrence of pituitary tumors is estimated to be up to 65% in ten years. Treatment and follow up remains a difficult challenge for clinicians, more specifically deciding whether radiotherapy should be given after tumor resection.


Methods : n/a


Results : n/a


Discussion :

This is a case of a 54 year-old male who consulted his doctor in 2004 due to visual field deficits and behavioral changes initially noticed 4 years prior. A brain magnetic resonance imaging (MRI) was done which showed a pituitary macroadenoma causing compression of optic nerve. The diagnosis was a nonfunctioning pituitary macroadenoma. He underwent transsphenoidal resection in 2004. His vision improved after surgery, presumably due to decompression of optic pathways. In 2005, he underwent follow up brain MRI which showed recurrent tumor growth, reason for which he underwent repeat transsphenoidal resection. He remained clinically stable until 2011 where recurrence of tumor was again demonstrated. He underwent transsphenoidal subtotal resection and remained in good condition until 2017 when surveillance MRI showed progression of the residual tumor and underwent a transsphenoidal subtotal resection. Pathology showed atypical adenoma due to elevated mitotic index and MIB-1. Due to recurrent growth of the adenoma and subtotal resection he underwent a total of 25 sessions of stereotactic radiation. Most recent MRI done in 2018 showed stable sized pituitary adenoma.


Conclusion :

This is a rare case of recurrent NFMA. Surgery is the treatment choice in patients with NFMA and visual field defects. Post-operative remnants are strongly associated with relapse. Complete resection of NFMA is often impossible, even for experienced surgeons. There is some controversy about whether radiotherapy should be given immediately after surgery and if so to which patients.  Post-operative radiotherapy decreases the recurrence rate of pituitary tumors. Some studies have shown that the progression-free survival was 94% at 10 years in patients who received radiotherapy compared to 59% at 10 years in non-radiotherapy patients. One must also recognize that radiotherapy carries a risk of complications, including hypopituitarism, cerebrovascular disease, neurocognitive dysfunction and secondary intracranial tumors. Long term follow-up of patients who do receive radiotherapy is, therefore, important to detect recurrence which can occur as late as 14 years after initial surgery.

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Gabriela Mroueh

Endocrinology Fellow - PGY4
Texas Tech University
Odessa, Texas

EDUCATION/TRAINING:
Saint Joseph’s College, Rensselaer, IN BS 2011-2015 Biology, Minor in Chemistry
San Juan Bautista School of Medicine, Caguas, PR MD 2011-2015
VA Caribbean Healthcare System, San Juan, PR 2015-2018 Internal Medicine
Internal Medicine Board Certified 2018
Currently: Endocrinology Fellow in Texas Tech University

SELECTED PUBLICATIONS/PRESENTATIONS:
Autoimmune Diabetes in Adults: A Frequently Missed Diagnosis
December 9, 2016
Puerto Rico’s College of Physicians Annual Convention
San Juan, PR

A Case of Asymptomatic Streptococcus Endocarditis Masking as Lumbar Discitis
November 12, 2016
American College of Physicians Annual Convention
San Juan, PR

Acute Lymphocytic Leukemia masking as viral syndrome
VA Caribbean Healthcare System Internal Medicine Dept. San Juan, PR
October 21, 2015

Ramachandra Chemitiganti

Endocrinology Faculty
Texas Tech University health Sciences Center, Permian Basin, Odessa Texas, Texas

IM/Endocrinology associate Professor

SYED AZHAR. HASSAN

Endocrinology fellow
TTUHSC

Endocrinology Fellow-5