2009 Southern Regional Meeting Abstracts

Case Report: 69-year-old Caucasian male with 50 pack year smoking history presented initially with two month history of hemoptysis and twenty pound weight loss. CT of thorax revealed 2.6 x 2.5 cm right hilar mass with right hilar lymphadenopathy suspicious for malignancy. Patient was scheduled for PET scan and transbronchial biopsy, however, prior to biopsy, the patient presented to the ER with right temporal headache. Physical exam findings upon admission included blurry vision and decreased pin-prick sensation in right trigeminal nerve.
Head CT and subsequent MRI showed 1.1 x 1.3 cm high density suprasellar mass extending inferiorly into the sphenoid sinus and superiorly into the suprasellar region, compressing the left undersurface of the optic chiasm. There were no definite metastatic lesions identified on MRI. Of interest, patient had a Brain MRI six months prior for sinus problems that was within normal limits. Whole body PET scan corresponded with prior CT of thorax showing hypermetabolic right hilar mass without other areas of hypermetabolic activity. Transbronchial biopsy was expedited, revealing small cell lung cancer. On formal visual fields testing, bitemporal hemianopsia consistent with chiasmal compression was found. Due to intense headache and optic nerve compression, Neurosurgery performed a trans-sphenoidal biopsy with partial debulking of the pituitary mass with differential diagnosis of metastasis from lung versus separate primary tumor. Histology revealed small cell cancer of the pituitary. The patient was referred to Oncology with a diagnosis of extensive stage small cell lung cancer, and at time of this report, was scheduled to undergo cranial irradiation dose of 30 Gray in 10 fractions and subsequent systemic chemotherapy with carboplatin and etoposide.
That only 1 to 2 % of pituitary tumors are due to metastases lends significance to this case. When metastases do occur, they most commonly arise from the two most common malignant cancers: lung and breast cancer. Unlike this patient, the majority of pituitary metastases are asymptomatic. Only 7% show symptoms that can include diabetes insipidus, headache, and visual field deficits. Although surgical treatment of pituitary mass can improve a patient’s quality of life, there is no recorded overall improvement in survival, with mean survival rates 6 to 22 months after diagnosis.