Endocrine Abstracts

Section 1: Case history: A 52 years old gentleman initially presented with visual field defect and headache due to a large multi-lobulated pituitary adenoma and underwent an endoscopic transsphenoidal sub-total resection in March 2018. Histology revealed a non-functioning adenoma with mitotic index Ki-67 of 3%–5%. His visual field defects resolved post-operatively and he was monitored with serial imaging. A year later he suffered a collapse at his GP surgery and was found to have a new visual field defect. Repeat MRI scan demonstrated an increase in the size of the adenoma with a haemorrhage. At the time of his elective re-do surgery, he happened to mention to have been experiencing some leg pain and on examination a mild quadriceps weakness was noted which prompted an MRI lumbar spine.

Section 2: Investigations: The initial CT and MRI scans of the pituitary demonstrated an increase in tumour size, suggestive of apoplexy event in the residual pituitary adenoma. Visual fields testing revealed a new onset of incomplete bitemporal hemianopia. MR lumbar spine showed a bulky left renal mass and subsequent scans showed multiple metastases. Histology from his pituitary tissue from the repeat surgery demonstrated morphological and immunological features in keeping with a metastatic carcinoma.

Section 3: Results and treatment: He developed hypopituitarism following apoplexy and was commenced on hormone replacement therapy. He underwent a second endoscopic resection of the haemorrhagic suprasellar mass and the visual field defect resolved post-operatively. Due to patient’s complex burden of disease, multi-specialties input had been gathered and he is currently being treated with palliative immunotherapy.

Section 4: Conclusions and points for discussion: This gentleman who was fit and healthy with no significant past medical history, presented with a convincing history suggestive of pituitary apoplexy with a background history of pituitary adenoma. He would not have undergone surgery if he did not have a new visual field defect and the diagnosis of renal cell carcinoma would have been delayed. We present this case to highlight the importance of lateral thinking to consider malignancy and metastasis, especially with early recurrence and rapid increase in the size of adenoma.