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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 21  |  Issue : 1  |  Page : 87-90

Breast carcinoma with pituitary metastasis


Department of Medicine and Medical Oncology, INHS Asvini, Mumbai, Maharashtra, India

Date of Submission16-Jun-2018
Date of Acceptance31-Oct-2018
Date of Web Publication19-Jun-2019

Correspondence Address:
Surg Lt Purvesh Agrawal
Department of Medicine, INHS Asvini, Colaba, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_38_18

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  Abstract 


Background: Metastatic tumors are among the most common lesions in the brain. The pituitary gland is an uncommon site of metastasis for malignancies. Breast cancer is the most common primary neoplasm metastasizing to pituitary in women. It may cause hormonal problems in different patterns due to mass effect and invasion to the pituitary gland. Case Report: We report here a 47-year-old woman with estrogen receptor-positive, progesterone receptor-negative, of human epidermal growth factor-2-positive metastatic breast cancer being treated with palliative radiotherapy, immunotherapy, and antihormonal therapy. Conclusion: Pituitary metastasis is a rare event in cancer progression. Diabetes insipidus is the most important criterion for differentiation of pituitary metastasis from adenomas. Metastases to the pituitary gland from breast and lung primaries may indicate more advanced disease; however, despite this, localized radiotherapy nearly always needs to be considered to provide improvement in symptoms.

Keywords: Diabetes insipidus, metastatic breast carcinoma, pituitary metastasis, radiotherapy


How to cite this article:
Chowdhary GS, Agrawal P. Breast carcinoma with pituitary metastasis. J Mar Med Soc 2019;21:87-90

How to cite this URL:
Chowdhary GS, Agrawal P. Breast carcinoma with pituitary metastasis. J Mar Med Soc [serial online] 2019 [cited 2019 Jul 23];21:87-90. Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/1/87/260662




  Introduction Top


Metastatic tumors are among the most common lesions in the brain. The most common origins of brain metastasis are systemic cancer of the lung, breast, skin, or gastrointestinal tract. Breast cancer is the main source of metastatic disease in women.[1],[2] The interval between the diagnosis of primary breast cancer and brain metastasis can be up to 3 years. The first site of distant failure is the brain alone or as a component of metastatic disease.

The pituitary gland and infundibulum can be involved in a variety of medical conditions, including infiltrative diseases, fungal infections, tuberculosis, and primary and metastatic tumors. Metastases to the pituitary gland are absolutely rare, and they are often related to primary breast or lung cancers.[2] Pituitary metastases more commonly affect the posterior lobe and the infundibulum rather than the anterior lobe.[3] The most common sign of this metastatic involvement is diabetes insipidus.[2]


  Case Report Top


A 47-year-old premenopausal woman presented with right breast lump involving whole of the breast. She was a known case of primary hypertension with no other comorbidities. She had no family history of malignancy. She had infiltrative ductal carcinoma on histopathology. Immunohistochemical staining for estrogen receptors was positive whereas for progesterone receptors was negative. However, overexpression of human epidermal growth factor-2 (HER2) was detected. A whole-body positron emission tomography–computed tomography (CT) scanning was suggestive of Fluorodeoxyglucose (FDG)-avid soft tissue lesion noted in the right breast with specks of calcification noted within [Figure 1] and multiple FDG-avid hepatic lesions with multiple skeletal metastases. Focal FDG-avidity noted in the pituitary fossa [Figure 2] with no overt morphological abnormality noted in the CT images. She was staged T4N1M1 and started on tamoxifen + GnRH analog and bisphosphonates with palliative radiotherapy to dorsal spine in view of fracture DV8 and DV12. She was also started on immunotherapy with trastuzumab in view of HER2-positive status.
Figure 1: Fluorodeoxyglucose-avid soft tissue lesion noted in the right breast with specks of calcification noted within. There is fat stranding noted in the region around the lesion

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Figure 2: Focal fluorodeoxyglucose-avidity noted in the pituitary fossa

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During follow-up, after fifth cycle of maintenance trastuzumab, the patient reported with 2-week history of polydipsia, polyuria, and loss of body weight. She did not have headache or visual complaints. Physical examination revealed no neurological or visual field deficits. The results of laboratory tests revealed a very low urine osmolality (104 mOsm/kg) compared to that of the plasma (352 mOsm/kg) and a plasma sodium of 158 mEq/L, a glucose of 110 mg/dl, and a calcium of 8.1 mg/dl. An endocrinological evaluation showed normal cortisol hormone, plasma growth hormone, follicle-stimulating hormone, luteinizing hormone, thyroid-stimulating hormone, and adrenocorticotropic hormone, except mild hyperprolactinemia.

Magnetic resonance imaging (MRI) of the brain revealed contrast-enhanced lesion in sella with thickening of infundibulum [Figure 3], [Figure 4], [Figure 5]. Based on the clinical symptoms, laboratory results, and radiological findings, the diagnosis of diabetes insipidus without compromising anterior pituitary function was caused by a metastasis in the dorsal part of the pituitary gland. She was then treated with nasal spray l-desamino-8-D-arginine vasopressin 20 mcg twice daily. She was referred for radiotherapy to the pituitary fossa. She was treated with radiotherapy to the pituitary fossa and received a total of 30 Gy in 10 fractions to the pituitary fossa. This resulted in a very significant improvement in her symptoms. The symptoms of polyuria and polydipsia resolved completely under treatment and local radiotherapy.
Figure 3: T1-weighted axial section magnetic resonance imaging brain with a well-defined heterogeneously enhancing nodular soft tissue lesion noted in sella inseparable from the pituitary gland

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Figure 4: T2-weighted coronal section magnetic resonance imaging brain showing heterogeneous enhancement in sella

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Figure 5: T2-weighted sagittal section magnetic resonance imaging brain – the infundibulum appears to be thickened and shows enhancement. Another well-defined ring-enhancing lesion noted in the left frontal region in the parasagittal location

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  Discussion Top


Pituitary metastasis of cancers is an uncommon occasion. Furthermore, less than 1% of pituitary masses surgically resected are diagnosed as metastatic tumors.[3] The metastasis to the pituitary more commonly involves posterior lobe alone or in combination with anterior pituitary in 85% of cases, while anterior pituitary alone is involved only in 15%.[4] The hematogenous spread (from portal vessels to the pituitary parenchyma or diaphragma sellae) is the most important mechanism for the development of these metastases. Alternative hypotheses for the spread are extension from juxtasellar and skull base metastasis or a meningeal spread through the suprasellar cistern.[5] At diagnosis, most patients are elderly in the sixth or seventh decade of life and have widespread diseases with multiple sites of metastases.[5]

The most common symptom of pituitary metastasis seems to be diabetes insipidus. Diagnosis of pituitary metastasis might be missed in the absence of overt clinical symptoms of hormonal insufficiency and vision problems caused by a large metastatic hypophyseal mass compressing chiasma opticum. Patients may have signs and symptoms of nausea, vomiting, fatigue, and weight loss could be seen in panhypopituitarism and also be easily attributed to the side effects of chemotherapy received or the primary malignancy. Diabetes insipidus is the most important criterion for differentiation of pituitary metastasis from adenomas. The general clinical manifestations of metastases in the hypothalamo–pituitary region differ from pituitary adenoma. Metastases present with diabetes insipidus or, less commonly, with extraocular nerve palsies.[5],[6],[7] These symptoms occur in less than 2% of patients with pituitary adenoma.[8] Thus, diabetes insipidus is the most important criterion for the differentiation of pituitary metastasis from adenomas. Other clinical characteristics that raise the suspicion for a pituitary lesion to represent a metastatic lesion rather than a benign adenoma include headaches, visual field deficits due to cranial nerve palsies (especially abducens nerve palsy), presence of skull bone destruction, demonstration of rapid growth on serial scans, and presence of coexisting focal lesions.[9] In general, a significantly elevated prolactin level is seen with adenomas; however, any hypothalamic–pituitary mass lesion compressing the pituitary stalk can cause elevation of the prolactin level.[10] The MRI findings are useful in trying to differentiate the cause of the pituitary mass lesion. Pituitary metastases are usually isointense on T1-weighted images with usually high intensity on T2-weighted images. This is in contrast to adenomas which tend to be isointense on T1 and T2 although these findings may not be highly specific. There is also homogeneous enhancement with gadolinium.[1]

The treatment modalities for pituitary metastases include surgical resection, three-dimensional conformal radiotherapy, and stereotactic radiotherapy. Systemic treatment with endocrine therapy or chemotherapy can also be used. The role of surgery in the setting of metastatic disease seems to be mainly in establishing the diagnosis. Surgery seems to be recommended when a symptomatic mass is present and the diagnosis is uncertain and when obtaining tissue would be useful in establishing the diagnosis in patients with limited metastatic disease.[1],[11],[12] When metastases are likely, radiotherapy or gamma knife radiosurgery are good options for relief of symptoms. Prognosis of pituitary metastasis is poor. Median survival is 6–7 months.[11] However, the prognosis and survival primarily depend on the characteristics of the tumor.


  Conclusion Top


Pituitary metastasis is a rare event in cancer progression. Diabetes insipidus is the most important criterion for differentiation of pituitary metastasis from adenomas. Metastases to the pituitary gland from breast and lung primaries may indicate more advanced disease; however, despite this, localized radiotherapy nearly always needs to be considered to provide improvement in symptoms. In this case, despite the progression of disease to the pituitary gland, treatment with localized radiotherapy proved very beneficial with resolution of her symptoms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Komninos J, Vlassopoulou V, Protopapa D, Korfias S, Kontogeorgos G, Sakas DE, et al. Tumors metastatic to the pituitary gland: Case report and literature review. J Clin Endocrinol Metab 2004;89:574-80.  Back to cited text no. 1
    
2.
He W, Chen F, Dalm B, Kirby PA, Greenlee JD. Metastatic involvement of the pituitary gland: A systematic review with pooled individual patient data analysis. Pituitary 2015;18:159-68.  Back to cited text no. 2
    
3.
Kovacs K. Metastatic cancer of the pituitary gland. Oncology 1973;27:533-42.  Back to cited text no. 3
    
4.
McCormick PC, Post KD, Kandji AD, Hays AP. Metastatic carcinoma to the pituitary gland. Br J Neurosurg 1989;3:71-9.  Back to cited text no. 4
    
5.
Max MB, Deck MD, Rottenberg DA. Pituitary metastasis: Incidence in cancer patients and clinical differentiation from pituitary adenoma. Neurology 1981;31:998-1002.  Back to cited text no. 5
    
6.
Branch CL Jr., Laws ER Jr. Metastatic tumors of the sella turcica masquerading as primary pituitary tumors. J Clin Endocrinol Metab 1987;65:469-74.  Back to cited text no. 6
    
7.
Roessmann V, Kaufman B, Friede RL. Metastatic lesions in the sella tunica and pituitary gland. Cancer 1970; 25: 478-80.  Back to cited text no. 7
    
8.
Hollenhorst RW, Younge BR. Ocular manifestations produced by adenomas of the pituitary gland: Analysis of 1000 cases. In: Kohler PO, Ross GT, editors. Diagnosis and Treatment of Pituitary Tumors. Amsterdam: Excerpta Medica; 1973. p. 53-64.  Back to cited text no. 8
    
9.
Al-Aridi R, El Sibai K, Fu P, Khan M, Selman WR, Arafah BM, et al. Clinical and biochemical characteristic features of metastatic cancer to the sella turcica: An analytical review. Pituitary 2014;17:575-87.  Back to cited text no. 9
    
10.
Levy A. Pituitary disease: Presentation, diagnosis, and management. J Neurol Neurosurg Psychiatry 2004;75 Suppl 3:iii47-52.  Back to cited text no. 10
    
11.
Morita A, Meyer FB, Laws ER Jr. Symptomatic pituitary metastases. J Neurosurg 1998;89:69-73.  Back to cited text no. 11
    
12.
Iwai Y, Yamanaka K, Honda Y, Matsusaka Y. Radiosurgery for pituitary metastases. Neurol Med Chir (Tokyo) 2004;44:112-6.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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