Endocrine Abstracts

Pituitary macroadenomas often extend to the suprasellar region, however rarely they can extend inferiorly and include erosion into the sphenoid bone, presenting unique challenges. We present a 74-year-old female who received pituitary radiotherapy in 1995 for a pituitary macroadenoma with sphenoid extension. She initially presented in 1994 with secondary amenorrhoea and hyperprolactinaemia (30,000 mu/l). She could not tolerate MRI and subsequent CT showed a pituitary macroadenoma with destruction of the sellar floor to the sphenoid sinus. She was managed for a macroprolactinoma with bromocriptine. One year later prolactin was reduced (670 mu/l) however CT showed no change in size to the lesion eroding into the sphenoid sinus. There was no visual compromise and surgery was felt not to be indicated but she received external beam radiation in 1995 to reduce further growth. Thereafter, she remained well with modest prolactin levels and normal vision. A more recent CT in 2017 showed no residual pituitary mass but ongoing destruction of the sellar floor extending into the sphenoid sinus. In 2018, she presented with severe epistaxis with haemorrhage requiring operative management. Intra-operatively, bleeding from the right sphenoid sinus ostium was documented. Subsequent CT angiography described the bony defect in the right sphenoid sinus with exposure of the right internal carotid artery with features of recent haemorrhage, the likely site of epistaxis. We postulate that this is a long-term complication from bony erosion from the initial pituitary disease exacerbated by subsequent pituitary radiotherapy causing osteonecrosis and artery exposure. Internal carotid artery haemorrhage has previously been described in the context of osteoradionecrosis of the skull base secondary to radiotherapy for nasopharyngeal cancers, although has not been previously described with pituitary radiotherapy. Given the significant comorbidity this patient has been treated conservatively and counselled on the risk of possible life threatening haemorrhage.