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  • Malignant Transformation of an Aggressive Pituitary Prolactinoma After Radiotherapy and During Dopaminergic Agonist Treatment: Case Report

    Final Number:

    Juliana Perez Pinzon; Deyanira Gonzalez Devia MD Internal medicine endocrinologist; Enrique Jimenez Hakim MD; ROCIO LOPEZ PANQUEVA MD; WILLIAM KATTAH CALDERON MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting - Late Breaking Science

    Introduction: Pituitary carcinomas are rare tumors with heterogeneous behaviors. Their carcinogenesis is unknown. The treatment is multimodal, non-standardized and radiotherapy can be used for local control of invasive adenomas.

    Methods: .

    Results: A 47-year-old man consulted for headaches, decreased libido, impaired vision and gynecomastia. A CT scan revealed a pituitary macroadenoma with suprasellar extension and invasion of the left sinus cavernosus and sphenoidal sinus. Prolactin levels were of 2750 ng/mL (reference value:<25 ng/mL). The patient began treatment with bromocriptine 2.5 mg/day, and underwent a transsphenoidal adenomectomy (TSA). Post-operatively the patient began prednisone, testosterone and levothyroxine therapy. Due to tumoral persistence with invasion to adjacent structures a transfrontal craniotomy was realized in the following year with sellar radiotherapy of 50 Gy. Subsequently, the patient presented a normal campimetry, prolactin levels of 88 ng/mL and symptomatic improvement. The patient remained asymptomatic for 5-years with concurrent bromocriptine treatment. Due to bromocriptine intolerance, he began cabergoline 1 mg/week. Posteriorly, prolactin rose gradually reaching levels of 1800 ng/mL, so he started therapy again with bromocriptine until reaching 40 mg/day. However, 6-years later he reported lumbar pain and a MRI scan showed a hypointense lesion in L1; confirming with biopsy a prolactinoma metastasis. Spine radiotherapy was administered with symptomatic improvement. Three TSA were later needed due to recurrence of the sellar lesion, with prolactin averaging levels of 1000 ng/mL. The patient, then with oligo-metastatic disease, declined any further treatment. He had a death associated with extensive cranial involvement, and survival of 6-years after initial metastatic diagnosis.

    Conclusions: The clinical course in this patient was unusual. He presented a 14-year overall survival without any systemic antitumor therapy. While radiotherapy is used in recurrent and aggressive pituitary tumors in which surgery fails, we hypothesize that it contributed to the tumoral malignant transformation and the late resistance to dopaminergic analogues in our patient.

    Patient Care: Our case report will show researchers and the medical community how important it is to investigate in therapeutic strategies for pituitary carcinomas. Due to the fact that we don’t know how tumors will behave in each patient, treatment is non-standardized and depends mainly on the judgement of the treating doctor and specific case. There is no possibility of evidence based medicine strategies in these types of patients. Likewise, new strategies through new and better research will permit us to better control these tumors and further prolong the survival of our patients. It will further remain a challenge to treat pituitary tumors, specially in patients whose tumoral aggressiveness affects much more patient’s survival than in our case.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1. Know that pituitary carcinomas present heterogeneous behaviors with patient’s overall survival being 14 years even after initial tumoral aggressiveness and metastatic diagnosis. 2. Understand that previous radiotherapy treatments may play an influential role in malignant tumor transformation and dopaminergic analogue resistance. 3. Understand why new randomized trials regarding survival and therapeutic strategies of pituitary carcinomas to further understand their pathophysiology are needed.

    References: A macroprolactinoma becoming resistant to cabergoline and developing atypical pathology. Sbardella E, Farah G, Fathelrahman A, Cudlip S, Ansorge O, Karavitaki N, Grossman AB. Endocrinol Diabetes Metab Case Rep. 2016;2016. pii: 16-0038. Epub 2016 Oct 18.PMID:27855233 Current approach to treatments for prolactinomas. Tirosh A, Shimon I. Minerva Endocrinol. 2016 Sep;41(3):316-23. Epub 2015 Sep 24. Review.PMID: 26399371 Temozolomide Therapy for Aggressive Pituitary Tumors: Results in a Small Series of Patients from Argentina. Bruno OD, Juárez-Allen L, Christiansen SB, Manavela M, Danilowicz K, Vigovich C, Gómez RM. Int J Endocrinol. 2015;2015:587893. doi: 10.1155/2015/587893. Epub 2015 May 27. PMID:26106414 Case report of sarcoma of the sella caused by postoperative radiotherapy for a prolactin-producing pituitary adenoma. Kurosaki M, Kambe A, Ishibashi M, Watanabe T, Horie Y.Brain Tumor Pathol. 2014 Jul;31(3):187-91. doi: 10.1007/s10014-014-0175-3. Epub 2014 Jan 21. PMID: 24446079 What causes a prolactinoma to be aggressive or to become a pituitary carcinoma? Phillips J, East HE, French SE, Melcescu E, Hamilton RD, Nicholas WC, Fratkin JF, Parent AD, Luzardo G, Koch CA.Hormones (Athens). 2012 Oct-Dec;11(4):477-82.PMID: 23422771

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