PMC5997786_01
Sagittal (A) and coronal (B) plane of the first pituitary magnetic resonance imaging (MRI) with an invasive macroadenoma with gadolinium enhancement. The pituitary tumor measured 32 mm x 30 mm x 25.5 mm in anteroposterior, craniocaudal, and transverse dimensions, respectively. The lesion had invasion of the right cavernous sinus, superior deviation of the left internal carotid artery, sphenoid sinus invasion, and compression and stretching of the optical chiasm. The tumor was isossignal area in T1 and T2 with small cysts and had marked contrast enhancement. The possible nasal metastasis was localized near the sphenoid rostrum in the left nasal fossa (arrows). The postoperative MRI (C,D) revealed a persistent expansive pituitary lesion with right cavernous sinus invasion. The last pituitary MRI (E,F) performed in October 2017 showed a pituitary tumor with markedly reduced dimensions.
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F1
She underwent a pituitary magnetic resonance imaging (MRI) that revealed a pituitary macroadenoma with right cavernous sinus invasion, sphenoid sinus invasion, and suprasellar growth (Figures 1A,B). After reassessing the MRI images performed 5 months before the surgery, a millimetric area of difficult visualization was identified in the left nasal fossa that could correspond to the excised nasal metastasis (Figures 1A,B). The postoperative pituitary MRI revealed a persistent expansive lesion with cystic transformation and necrotic areas (Figures 1C,D). Concerning the prolactin-secreting pituitary carcinoma, she has normal serum prolactin levels under bromocriptine 20 mg/day and a pituitary lesion with markedly reduced dimensions on MRI compared to pre-radiotherapy period (Figures 1E,F).
Histology of a prolactin-producing pituitary tumor. Tumor with diffuse growth pattern of cells with elongated nuclei and inconspicuous nucleoli and moderate amount of slightly acidophilic cytoplasm [(A):HE 400x]. Prolactin expression in neoplastic cells [(B):400x].
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F2
Histology of the surgical specimen (Figure 2) revealed an adenoma with prolactin expression, diffuse growth pattern, and Ki-67 LI of 4%.
Thyroid ultrasonography (A) showed a normal size gland, with heterogeneous texture and pseudonodular areas, without nodular lesions, suggesting thyroiditis. The color flow Doppler signal showed significantly increased vascularity with diffuse homogeneous distribution (thyroid inferno). There was a markedly hyperfunctioning thyroid in scintigraphy (B), with homogeneous activity distribution and no focal areas suggestive of hyper- or hypoactive nodular formations. The radioactive iodine uptake was 70.2% at the end of 24 h, markedly elevated compared to normal range (10-30%). Panel (C) shows the evolution of thyroid function. After pituitary surgery in 2009 the patient developed secondary hypothyroidism and initiated LT4. She was admitted with primary hyperthyroidism in April 2015 and initiated MMI. During antithyroid drug withdrawal before scintigraphy, FT4 and FT3 re-increased above the reference range. MMI was progressively reduced after 6 months of treatment, but after withdrawal in October 2015, central hypothyroidism recurred and she resumed LT4 since March 2016. Abbreviations: LT4, levothyroxine; MMI, methimazole; FT4, free thyroxine; FT3, free triiodothyronine.
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F3
To confirm the etiology of thyrotoxicosis, the patient underwent a thyroid ultrasound and scintigraphy (Figure 3). Ultrasonography (Figure 3A) suggested thyroiditis and revealed increased vascularity with diffuse homogeneous distribution. Scintigraphy (Figure 3B) revealed a markedly hyperfunctioning thyroid with a radioactive iodine uptake (RAIU) markedly elevated. FT4 0.52 ng/dL) and had to resume the treatment with exogenous thyroid hormone. Figure 3C shows the thyroid function evolution since the diagnosis of central hypothyroidism after pituitary surgery.
Evolution of serum prolactin levels over time and its relation with medical, surgical, and radiation therapy. *Samples not diluted.
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F4
The evolution of serum prolactin levels since the diagnosis is showed in Figure 4.