PMC9321396_01
(A) Preoperative pituitary enhanced MRI (April 2016) showed: mass-shaped obvious enhanced signal could be seen in intrasellar and suprasellar area; the lesion extended upward to the suprasellar cistern, and the pituitary stalk was compressed, with the optic chiasm compressed and raised. (B) Postoperative pituitary enhanced MRI (October 2016) indicated: postoperative changes showed in the sellar region; abnormal enhancement of the upper left posterior pituitary appeared, with left cavernous sinus closely related.
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Subsequently, the patient underwent pituitary enhanced magnetic resonance imaging (MRI), and the results suggested: a tumor in the SR compressed the pituitary stalk, with the optic chiasm compressed and raised, and PA was considered ( Figure 1A ). The GH level increased significantly (>50.00 ng/mL), and the pituitary enhanced MRI indicated: postoperative changes showed in the SR; abnormal enhancement of the upper left posterior pituitary appeared, with left cavernous sinus closely related, which was considered as postoperative residual of SA ( Figure 1B ).
(A) Pituitary enhanced MRI in October 2020 indicated: multiple enhanced nodules appeared in bilateral auditory nerve area, pons, medulla oblongata and near cerebral falx; (B) 68Ga DOTA-TATE PET-CT in March 2021 showed: no abnormal increase in 68Ga DOTA-TATE uptake was seen in the low-density shadow in the sella turcica; 68Ga DOTA-TATE uptakes in multiple soft tissue nodules in the brain (obvious in the bilateral jugular foramen area, corpus callosum knee, left ventricular triangle, etc.) increased; (C) Before the patient underwent whole-brain radiotherapy, a spinal cord enhanced MRI was completed, which revealed abnormal enhanced nodules in the sixth cervical vertebrae and fourth thoracic vertebral plane of the spinal cord.
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However, follow-up in October 2020 showed that GH was 14.29 ng/mL and pituitary enhanced MRI demonstrated multiple enhanced nodules (new lesions) in the bilateral auditory nerve area, pons, medulla oblongata and near cerebral falx ( Figure 2A ). The patient underwent 68Ga DOTA-TATE PET-CT on March 25, 2021 ( Figure 2B ), and the results suggested: 68Ga DOTA-TATE uptakes in multiple soft tissue nodules in the brain increased, and neoplastic lesions were considered. Before the patient underwent whole-brain radiotherapy, a spinal cord enhanced MRI was completed, and abnormal enhanced nodules were found in the sixth cervical vertebrae and fourth thoracic vertebral plane of the spinal cord, which were considered as metastases ( Figure 2C ).
The IHC is positive for PiT-1, whereas keratin (CAM 5.2) reveals the presence of fibrous bodies in the cytoplasm. Therefore, the diagnosis of a somatotroph carcinoma of sparsely granulated type was established. HE staining (x400): small round nucleus tumor cells in a lamellar nest-like arrangement with rich cytoplasm and nucleus eccentricity, nucleus atypia with visible mitosis; IHC staining (x400): PIT-1 (+), GH (+), Syn (+), SSTR2a (+), Ki-67 (8%), and CAM5.2 (+).
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Also, taking into consideration the immunopositivity for PiT-1, the diagnosis of a carcinoma of sparsely granulated somatotroph type was established ( Figure 3 ).
(A) Brain enhanced MRI in May 2021 (before treatment); (B) Brain enhanced MRI in November 2021 (after treatment) showed: multiple lesions all reduced in size compared with A; (C) Spinal cord enhanced MRI in June 2021 (before treatment); (D) Spinal cord enhanced MRI in November 2021 (after treatment) showed: enhanced nodules in the sixth cervical vertebrae and fourth thoracic vertebral plane of the spinal cord both mildly decreased compared with C; (E) Serum GH levels variation curve of the patient.
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Follow-up MRI in November 2021 showed: metastases in both the intracranial and spinal cord appeared to shrink ( Figures 4A-D ), with reference to the RANO-BM criteria, the intracranial and spinal cord lesions were rated as partial response. In addition, the GH level decreased to 5.68 ng/mL ( Figure 4E ), and the IGF-1 level decreased to 378.0 mug/L.