Poster Presentation ESA-SRB-APEG-NZSE 2022

A Rare Cause of Hypopituitarism (#362)

Sin Dee Yap 1 , Diana Mackay 1 2 , Anna Wood 1 2
  1. Department of Medicine, Royal Darwin Hospital, Tiwi, NT, Australia
  2. Menzies School of Health Research , Tiwi, NT, Australia

JD is a 68-year-old man, who presented with 1-week history of abdominal pain associated with nausea and diarrhoea, secondary to aperient use in the setting of opioid-induced constipation. He was diagnosed with a BRAF-mutated non-small cell lung cancer with liver and bony metastases in June 2021 and completed radiotherapy to his cervico-thoracic spine. He received oral cobimetinib/vemurafenib for 5 months, ceased due to immune-related cardiomyopathy.

In hospital, he developed symptomatic hypotension with a BP of 80/50mmHg. He received hydrocortisone 100 mg intravenously prior to diagnosis of adrenal insufficiency. Results of his endocrine testing are shown in Table 1.

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Given the features consistent with a pituitary metastasis (figures 1-2), a pituitary biopsy was not required. Due to multiple intracranial metastases (figures 1-3), surgical resection was inappropriate.

Intravenous hydrocortisone was changed to oral hydrocortisone 20 mg mane and 10 mg at 4pm. Thyroxine 100 mcg daily was also started. He was readmitted a week later with progressive lethargy and exertional dyspnoea. Computed tomography pulmonary angiogram did not show evidence of pulmonary embolism. Repeat echocardiogram showed improvement in his ejection fraction. Testosterone replacement was considered, but not started. JD was planned for radiation therapy, however he deteriorated rapidly and passed away in hospital.

Discussion

Breast cancer in women and lung cancer in men are the most common primary cancers associated with pituitary metastases. Adrenal insufficiency was the commonest hormonal dysfunction, followed by central hypothyroidism, hyperprolactinaemia and diabetes insipidus1.

JD’s MRI brain showed features consistent with a pituitary metastasis1,2. A biopsy is recommended to confirm the diagnosis. However, a pituitary biopsy was not indicated in his case and it would not have changed the management.

Treatment includes management of the primary tumour and relieve of symptoms associated with mass effect1. As surgical resection was inappropriate, radiotherapy to the pituitary stalk metastasis was considered.

 

  1. Schill, F, Nilsson, M, Olsson, D, Ragnarsson, O, Berinder,K, Engstrom, B et al, ‘Pituitary metastases: A Nationwide Study on Current Characteristics with Special Reference to Breast Cancer’ 2019, Journal of Clinical Endocrinology and Metabolism, vol. 104, no. 8, pp. 3379-3388.
  2. Gaillard, F, Rasuli, B, ‘Pituitary metastasis’, Radiopaedia.org. Obtained from http://doi.org/10.53347/rID-17912, accessed on 24 July 2022.
  3. Spinelli, G, Russo, G, Miele, E, Prinzi, N, Tomao, F, Antonelli, M et al, ‘Breast Cancer Metastatic to Pituitary Gland: A Case Report’ 2012, World Journal of Surgical Oncology, vol. 10, no. 137.
  4. Javanbakht, A, D’Apuzzo, M, Badie, Salehian, B, ‘ Pituitary Metastasis: A Rare Condition’, 2018, Endocrine Connections, vol. 7, no. 10, pp. 1049-1057.
  5. He, W, Chen, F, Dalm, B, Kirby, P, Greenlee, J, ‘ Metastatic involvement of the pituitary gland: a systematic review with pooled individual patient data analysis’, 2015, Pituitary, vol 18, no. 1, pp. 159-168
  6. Ho, K, Fleseriu, M, Kaiser, U, Salvatori, R, Brue, T, Lopes, M et al, ‘Pituitary Neoplasm Nomenclature Workshop: Does Adenoma Stand The Test of Time?’, 2021, Journal of the Endocrine Society, vol. 5, no. 3, pp. 1-9.