PMC9344046_01
Timeline of disease progression and treatment. The scheme represents the course of the disease along time, including the diagnosis, hormone levels, and treatments. TSS, Transsphenoidal surgery; T4, thyroxine.
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TSS,  Figure 1  and  Figures 2A, B ). The postoperative medical controls showed visual acuity and visual field recovery. TSS,  Figure 1 ). This time, the tumor had turned fibrotic and compromised critical structures ( Figure 2C ) that made it too complex for resection.  Figure 2D  shows the partially resected tumor. Cushing s disease but it did not reduce tumor growth (tumor size: 29x31x23 mm in control MRI  Table 1 ). Consequently, a new surgery was performed in 2015 (3rd TSS,  Figure 1  and  Figures 2E, F ) with partial resection of the tumor mass. The tumor proliferation index was 4% ( Figure 3B ), and positive cells for p53 were found ( Figure 3C  and  Table 1 ).
MRI images. (A) 2008-Preoperative pituitary MRI with gadolinium (sagittal view), evidencing a large pituitary mass with suprasellar extension and compression of the optic chiasm. (B) Postoperative MRI with gadolinium (sagittal view) showing complete tumor resection and decompression of the optic chiasm. (C) 2014-pituitary MRI (sagittal view) evidencing a tumor mass with extensive sphenoid and nasal invasion. (D) Postoperative MRI with gadolinium (sagittal image) showing partial resection with a remnant tumor in the nasal, sphenoid, and sellar region. (E) Control MRI in 2015 shows tumor regrowth in the sagittal image. (F) Postoperative MRI (sagittal view) showing less remnant tumor mass than in 2015. Tumor remains stable after radiotherapy and both cabergoline and ketoconazole treatment until 2021.
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TSS,  Figure 1  and  Figures 2A, B ). The postoperative medical controls showed visual acuity and visual field recovery. TSS,  Figure 1 ). This time, the tumor had turned fibrotic and compromised critical structures ( Figure 2C ) that made it too complex for resection.  Figure 2D  shows the partially resected tumor. Cushing s disease but it did not reduce tumor growth (tumor size: 29x31x23 mm in control MRI  Table 1 ). Consequently, a new surgery was performed in 2015 (3rd TSS,  Figure 1  and  Figures 2E, F ) with partial resection of the tumor mass.
Pathology of the different tumor samples. The excised tumor tissue from the 2015 surgery showed high ACTH IR cells (A), increased Ki-67 proliferation index (B) and p53 immunoexpression (C) as we determined by IHC (20X, 40X, and 40X magnification, respectively). (D) Representative images of immunohistochemistry (IHC) for alpha-SMA of each tumor specimen obtained in 2008, 2014, and 2015 surgeries, respectively (10X magnification, scale: 50 microm). The vascular area (blood vessels area/total area), blood vessel size (microm2), and microvascular density (number of blood vessels/microm2) determined by alpha-SMA stained vessels are summarized in the table (E). Values correspond to the mean and standard error of two different experiments of immunohistochemistry. (F) Representative images of beta-CATENIN immunoexpression in tumor samples of 2008, 2014, and 2015 surgeries, respectively (40X, scale: 30microm). (G) beta-CATENIN positive cells at membrane, cytoplasm, and nucleus of tumor samples from 2014 and 2015 were counted and expressed as percentages of total nuclei (mean and SE).
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The pathology report confirmed in the tumor sample numerous ACTH IR cells when evaluated both by immunohistochemistry ( Figure 3A ), while the tumor was negative for any other pituitary hormone. The tumor proliferation index was 4% ( Figure 3B ), and positive cells for p53 were found ( Figure 3C  and  Table 1 ). Instead, tumor samples from 2014 and 2015 in which the Ki-67 proliferation index was higher than in 2008, showed a reduction in their vascularization coincident with the aggressive transformation ( Figures 3D, E ). IHC the expression of beta-CATENIN, the main protein of the canonical Wnt cell signaling. Interestingly, we found positive immunostaining for beta-CATENIN along pituitary tumor transformation pointing out a possible role of this protein in aggressive corticotroph tumor development and evolution ( Figure 3F ). This protein is localized in the membrane, cytoplasm, and nucleus of tumor cells ( Figure 3F ), and beta-CATENIN quantification was possible in samples from 2014 and 2015 surgeries. We determined a reduction in the percentage of membrane beta-CATENIN positive cells in a tumor sample from 2014 to 2015, while cytoplasmic beta-CATENIN positive cells showed a marked increase ( Figure 3G ).