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J Neurol Surg A Cent Eur Neurosurg 2018; 79(01): 090-095
DOI: 10.1055/s-0037-1600515
Case Report
Georg Thieme Verlag KG Stuttgart · New York

A Case of Pituitary Carcinoma Initially Diagnosed as an Ectopic Growth Hormone Producing Pituitary Adenoma with a High Ki-67 Labeling Index

Toshiki Endo
1   Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
,
Yoshikazu Ogawa
2   Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
,
Mika Watanabe
3   Department of Pathology, Tohoku University Hospital, Sendai, Japan
,
Teiji Tominaga
1   Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
› Author Affiliations
Further Information

Publication History

27 August 2016

20 December 2016

Publication Date:
06 June 2017 (online)

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Abstract

We report a case of a 66-year-old woman with a malignant transformation of a growth hormone (GH)-producing pituitary adenoma that was mainly located in the clivus. The patient originally presented with left oculomotor and abducens nerve palsies. Magnetic resonance imaging revealed a clival tumor separated from the normal pituitary gland, and the patient subsequently underwent transsphenoidal surgery. Analysis of the resected clival tissue revealed proliferation of tumor cells with slightly irregular nuclei but no mitosis. Although the Ki-67 labeling index was as high as 8.7%, p53 was negative. Histologic analysis confirmed the diagnosis of a GH-producing pituitary adenoma. Two months after the first operation, the tumor acutely enlarged and caused a subarachnoid hemorrhage. Pathologic findings of the second surgical specimen showed significant nuclear atypia. The Ki-67 labeling index increased to 27.7% and the p53 was positive; there was no GH immunoreactivity. Following the second surgical intervention, the patient was diagnosed with an atypical pituitary adenoma and underwent postoperative local radiotherapy (50 Gy in 25 fractions). Twenty months after the first surgery, multiple bone metastases were detected that led to the diagnosis of pituitary carcinoma. This is the first report of a clival pituitary adenoma undergoing malignant transformation. Because neuroimaging may underestimate local invasiveness in ectopic pituitary tumors, it is essential to conduct a histologic examination to evaluate it. Further analysis of similar cases is necessary to improve clinical management for this confused diagnostic criterion.

Keywords

ectopic pituitary adenoma - clivus - malignant transformation - pituitary carcinoma
 

  • References

  • 1 Guerrero CA, Krayenbühl N, Husain M, Krisht AF. Ectopic suprasellar growth hormone-secreting pituitary adenoma: case report. Neurosurgery 2007; 61 (04) E879 ; discussion E879
    CrossrefPubMedGoogle Scholar
  • 2 Kurowska M, Tarach JS, Zgliczyński W, Malicka J, Zieliński G, Janczarek M. Acromegaly in a patient with normal pituitary gland and somatotropic adenoma located in the sphenoid sinus. Endokrynol Pol 2008; 59 (04) 348-351
    PubMedGoogle Scholar
  • 3 Mitsuya K, Nakasu Y, Nioka H, Nakasu S. Ectopic growth hormone-releasing adenoma in the cavernous sinus—case report. Neurol Med Chir (Tokyo) 2004; 44 (07) 380-385
    CrossrefPubMedGoogle Scholar
  • 4 Appel JG, Bergsneider M, Vinters H, Salamon N, Wang MB, Heaney AP. Acromegaly due to an ectopic pituitary adenoma in the clivus: case report and review of literature. Pituitary 2012; 15 (Suppl. 01) S53-S56
    CrossrefPubMedGoogle Scholar
  • 5 Yang BT, Chong VF, Wang ZC, Xian JF, Chen QH. Sphenoid sinus ectopic pituitary adenomas: CT and MRI findings. Br J Radiol 2010; 83 (987) 218-224
    CrossrefPubMedGoogle Scholar
  • 6 Kaltsas GA, Nomikos P, Kontogeorgos G, Buchfelder M, Grossman AB. Clinical review: Diagnosis and management of pituitary carcinomas. J Clin Endocrinol Metab 2005; 90 (05) 3089-3099
    CrossrefPubMedGoogle Scholar
  • 7 Thapar K, Scheithauer BW, Kovacs K, Pernicone PJ, Laws Jr ER. p53 expression in pituitary adenomas and carcinomas: correlation with invasiveness and tumor growth fractions. Neurosurgery 1996; 38 (04) 765-770 ; discussion 770–771
    CrossrefPubMedGoogle Scholar
  • 8 Di Ieva A, Rotondo F, Syro LV, Cusimano MD, Kovacs K. Aggressive pituitary adenomas—diagnosis and emerging treatments. Nat Rev Endocrinol 2014; 10 (07) 423-435
    CrossrefPubMedGoogle Scholar
  • 9 Hardy J. Transsphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg 1969; 16: 185-217
    CrossrefPubMedGoogle Scholar
  • 10 Knosp E, Steiner E, Kitz K, Matula C. Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 1993; 33 (04) 610-617 ; discussion 617–618
    CrossrefPubMedGoogle Scholar
  • 11 Ogawa Y, Watanabe M, Tominaga T. Somatostatin-producing atypical null cell adenoma manifesting as severe hypopituitarism and rapid deterioration—case report. Endocr Pathol 2010; 21 (02) 130-134
    CrossrefPubMedGoogle Scholar
  • 12 Miermeister CP, Petersenn S, Buchfelder M. , et al. Histological criteria for atypical pituitary adenomas—data from the German pituitary adenoma registry suggests modifications. Acta Neuropathol Commun 2015; 3: 50
    CrossrefPubMedGoogle Scholar
  • 13 Pernicone PJ, Scheithauer BW, Sebo TJ. , et al. Pituitary carcinoma: a clinicopathologic study of 15 cases. Cancer 1997; 79 (04) 804-812
    CrossrefPubMedGoogle Scholar
  • 14 Bhatoe HS, Kotwal N, Badwal S. Clival pituitary adenoma with acromegaly: case report and review of literature. Skull Base 2007; 17 (04) 265-268
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Ferraz-Filho JR, Torres US, Teixeira AC, Castro ML, Dias MA. Ectopic growth hormone-secreting pituitary adenoma involving the clivus treated with octreotide: role of magnetic resonance imaging in the diagnosis and clinical follow-up. Arq Neuropsiquiatr 2012; 70 (09) 744-745
    CrossrefPubMedGoogle Scholar
  • 16 Liu B, Zhuang Z, Luo J, Wang Y. A case report of an ectopic clival growth hormone adenoma associated with an empty sella and a review of the literature. Clin Neurol Neurosurg 2013; 115 (12) 2533-2536
    CrossrefPubMedGoogle Scholar
  • 17 Rocque BG, Herold KA, Salamat MS, Shenker Y, Kuo JS. Symptomatic hyperprolactinemia from an ectopic pituitary adenoma located in the clivus. Endocr Pract 2009; 15 (02) 143-148
    CrossrefPubMedGoogle Scholar
  • 18 Lloyd RV, Kovacs K, Young Jr WF. , et al. Pituitary tumours: introduction. In: DeLellis RA, Lloyd RV, Heitz PU, Eng C. , eds. WHO Classification of Tumours. Pathology and Genetics of Tumours of Endocrine Organs. Lyon, France: IARC Press; 2004: 10-13
    Google Scholar
  • 19 Saeger W, Lüdecke DK, Buchfelder M, Fahlbusch R, Quabbe HJ, Petersenn S. Pathohistological classification of pituitary tumors: 10 years of experience with the German Pituitary Tumor Registry. Eur J Endocrinol 2007; 156 (02) 203-216
    CrossrefPubMedGoogle Scholar
  • 20 Zada G, Lin N, Laws Jr ER. Patterns of extrasellar extension in growth hormone-secreting and nonfunctional pituitary macroadenomas. Neurosurg Focus 2010; 29 (04) E4
    PubMedGoogle Scholar
  • 21 Salehi F, Agur A, Scheithauer BW, Kovacs K, Lloyd RV, Cusimano M. Ki-67 in pituitary neoplasms: a review—part I. Neurosurgery 2009; 65 (03) 429-437 ; discussion 437
    CrossrefPubMedGoogle Scholar
  • 22 Ogawa Y, Ikeda H, Tominaga T. Clinicopathological study of prognostic factors in patients with pituitary adenomas and Ki-67 labeling index of more than 3%. J Endocrinol Invest 2009; 32 (07) 581-584
    CrossrefPubMedGoogle Scholar
  • 23 Kontogeorgos G. Predictive markers of pituitary adenoma behavior. Neuroendocrinology 2006; 83 (3-4): 179-188
    CrossrefPubMedGoogle Scholar
  • 24 Salehi F, Agur A, Scheithauer BW, Kovacs K, Lloyd RV, Cusimano M. Biomarkers of pituitary neoplasms: a review (Part II). Neurosurgery 2010; 67 (06) 1790-1798 ; discussion 1798
    CrossrefPubMedGoogle Scholar