Malignant prolactinoma: case report and review of the literature

in European Journal of Endocrinology
(Correspondence should be addressed to M Kars; Email: m.kars@lumc.nl)

Pituitary carcinomas are extremely rare. In general, the initial clinical, biochemical, and histological characteristics are of minimal utility in distinguishing benign adenomas from pituitary carcinomas. We describe a 63-year-old woman with a macroprolactinoma, who presented with diplopia and blurred vision. This unusual initial presentation and the subsequent aggressive clinical course, with diffuse local and distant intramedulary metastases, prompted us in retrospect to make a detailed analysis of the therapeutic interventions and histology. In addition, we reviewed all available literature on published cases of malignant prolactinoma and detailed their epidemiological, clinical, and histopathological characteristics. In brief, it is postulated that pituitary carcinomas arise from the transformation of initially large, but benign, adenomas. Unusual and/or atypical clinical manifestations appear to occur more frequently. In vivo, the development of dopamine agonist resistance in invasive macroprolactinoma is indicative of malignancy and should prompt the clinician to perform a biopsy of the tumor. For pituitary tumors that exhibit high mitotic activity, increased Ki-67 and/or p53 immunoreactivity, it may be useful to denote these tumors as ‘atypical’ prolactinomas to raise the possibility of future malignant development.

Abstract

Pituitary carcinomas are extremely rare. In general, the initial clinical, biochemical, and histological characteristics are of minimal utility in distinguishing benign adenomas from pituitary carcinomas. We describe a 63-year-old woman with a macroprolactinoma, who presented with diplopia and blurred vision. This unusual initial presentation and the subsequent aggressive clinical course, with diffuse local and distant intramedulary metastases, prompted us in retrospect to make a detailed analysis of the therapeutic interventions and histology. In addition, we reviewed all available literature on published cases of malignant prolactinoma and detailed their epidemiological, clinical, and histopathological characteristics. In brief, it is postulated that pituitary carcinomas arise from the transformation of initially large, but benign, adenomas. Unusual and/or atypical clinical manifestations appear to occur more frequently. In vivo, the development of dopamine agonist resistance in invasive macroprolactinoma is indicative of malignancy and should prompt the clinician to perform a biopsy of the tumor. For pituitary tumors that exhibit high mitotic activity, increased Ki-67 and/or p53 immunoreactivity, it may be useful to denote these tumors as ‘atypical’ prolactinomas to raise the possibility of future malignant development.

Introduction

Although pituitary tumors are relatively common, occurring in approximately 10–20% of normal subjects on autopsy or magnetic resonance imaging (MRI), the incidence of pituitary carcinoma is extremely low (1). To date, a total of approximately 140 cases have been reported, one third of them being malignant prolactinomas (2). The histological, clinical, and biochemical characteristics are reported to be of minimal utility in distinguishing benign from malignant tumors, unless (distant) metastases have developed. Presently, it is postulated that pituitary carcinomas arise from the transformation of initially large but benign adenomas (1). The arguments are based on observations that the initial presentation is not different from other macroadenomas, the long-duration needed for the transformation into carcinoma, and the increasing accumulation of genetic aberrations (3). We describe a patient with a malignant prolactinoma, whose unusual initial presentation and clinical course prompted us, in retrospect, to make a detailed analysis of the case with respect to the therapeutic interventions and histology. For comparison, we reviewed all published cases of malignant prolactinoma and detailed their epidemiological, clinical, biochemical, and histological characteristics.

Case report

A 63-year-old woman, who presented with diplopia and blurred vision, was diagnosed with a macroprolactinoma in 1998. On neurological examination, ptosis of the right eye was present, together with abducens palsy and impaired convergence. Furthermore, bitemporal hemianopsia was present (Fig. 1). Prolactin concentration was increased 20-fold: 490 μg/l (normal value < 22 μg/l). MRI showed a pituitary mass with a diameter of 2.5 cm, extending into the right sphenoidal sinus as well as the cavernous sinus and compressing the temporal lobe (Fig. 2). Therapy was initiated with bromocriptine (1.25 mg t.i.d) resulting in normalization of the visual fields and decrease in prolactin levels to 56 μg/l within a few months.

The visual field defects recurred and prolactin levels increased to 206 μg/l (Fig. 3), 6 months later. Therefore, bromocriptine treatment was switched to quinagolide (up to 300 μg/day). Nonetheless, in January 2000, MRI showed progression of the pituitary tumor with encasement of the internal carotid artery and compression of the optic chiasm. The macroprolactinoma did not react satisfactory to medical treatment, even with cabergoline, which was stopped, since prolactin levels progressively increased in the presence of further progression of tumor growth. Furthermore, she developed progressive anterior pituitary insufficiency (de novo adrenocorticotropic hormone and thyroid-stimulating hormone deficiency) and the visual field defects increased. Therefore, she was operated in April 2000. Decompression of the optic chiasm was performed via transcranial route. Histological investigation of the tumor revealed positive immunostaining for prolactin without mitotic activity, but high Ki-67 (MIB-1) labeling index (10–15%). Fractionated conventional radiotherapy was administered by a linear accelerator (6 MeV) in a total dose of 54 Gray (Gy) in June 2000. Thereafter, prolactin concentrations decreased gradually without dopaminergic therapy from 445 μg/l in June 2000 to a nadir of 33 μg/l in February 2001 (Fig. 3). The effect on tumor volume in response of radiotherapy was evaluated 8 months after radiotherapy with MRI. A slight reduction in tumor volume was noted. Encasement of the internal carotid artery persisted.

Serum prolactin levels started to rise again in August 2001. MRI of the brain did not reveal progression of the tumor, but the rise in prolactin concentration proved to be due to metastases in the spinal cord (Fig. 4), which was confirmed with epidepride (dopamine D2 receptor) scintigraphy (Fig. 5). Laminectomy was performed in December 2001 because of compression of the myelum in the sacral region, followed by fractionated radiotherapy (6 × 4 Gy) from L5 to S5 in February 2002. Histological examination confirmed a prolactin-producing metastasis.

Subsequently, the patient developed extensive metastases throughout the spinal cord. Therefore, the spinal cord was irradiated with fractionated radiotherapy aimed at C2 to L4 with a total dose of 40 Gy in June 2002 to relieve pain and prevent paralysis from compression of the myelum.

In August 2002, she developed progressive ptosis of the right eye and facial paralysis due to infiltration of the tumor into the orbital cavity. Repeat radiotherapy to the skull (total dose of 25 Gy) was given in September 2002, resulting only in partial improvement of visual disturbances. However, prolactin concentrations continued to increase (Fig. 3) to a final concentration of 6000 μg/l in May 2003, 1 month before she died at home. Autopsy was not performed.

Discussion

Pituitary carcinomas are considered to arise from the transformation of initially large, but benign, adenomas (1). This notion is based on observations that demonstrate that the initial presentation of pituitary carcinomas does not differ from other (invasive) macroadenomas, the long-duration needed for transformation into a carcinoma, and the progressive accumulation of genetic aberrations (3). The present case of malignant prolactinoma is consistent with many, but not all, of these observations. This gave us an opportunity to compare carefully the data of our patient and review the intriguing features associated with malignant transformation of pituitary prolactinomas.

To date, only 47 cases of malignant prolactinoma have been reported, summarized in Table 1 (441). The first report of a patient with malignant prolactinoma was in 1981 by Martin et al. (4). Of the reported cases, 65% were male and the mean age at presentation was 44 years with a range of 14–70 years (Table 2). The presenting symptoms were related to hyperprolactinemia in 35% of the reported cases, including amenorrhea, galactorrhea, impotency, and decreased libido. At presentation, 71% of the patients had symptoms of local compression, such as headache and bitemporal hemianopsia. Only five other patients presented with ptosis (27, 40), diplopia (34), oculomotor paresis (17), or lateral rectus paresis (13). Diabetes insipidus was a feature in only one patient (12). The treatment modalities after diagnosis were transsphenoidal or transcranial surgery (96%), radiotherapy (79%), chemotherapy (2%), and dopamine agonists (DA) in 65% of the cases (Table 3). A study by Isobe et al. shows that, in particular, large prolactinomas are very difficult to control with radiation doses between 50 and 60 Gy (42). Therefore, even benign prolactinomas do not respond very well to radiotherapy. The effect of radiotherapy on malignant prolactinoma has not been systematically documented. Therefore, a small response to radiotherapy, as in our case, cannot be interpreted as an indication of the malignant nature of the tumor. The presentation of our patient with diplopia and blurred vision is a very unusual manifestation of pituitary macroadenoma. Such a presentation is most frequently associated with pituitary apoplexia. In the absence of apoplexia, nerve paralysis is strongly suggestive of compression or infiltration of the nerve, secondary to the high proliferative activity of the tumor. The presentation with diplopia as a result of oculomotor nerve paralysis has been reported previously in only one other case(17). In the present case, oculomotor nerve paralysis was due to tumoral orbital invasion (Fig. 2). Orbital invasion of a pituitary adenoma is very uncommon, being reported in only 16 patients, only 2 of whom manifested diplopia (43). Thus, in retrospect, the initial clinical and radiological presentation was highly indicative for an adenoma with high infiltrative potency.

Kaltsas et al. described histological and immunohistochemical parameters that predict the biological behavior of pituitary tumors (1, 3). Histological parameters associated with an atypical or aggressive behavior of the adenoma are cellular atypia, nuclear pleomorphism, more than two mitotic figures per ten high-powered fields, a proliferative index of Ki-67 more than 3%, positive p53 immunoreactivity, and invasion. They are also called atypical parameters. Histological investigation of the tissue initially obtained by surgery, biopsy, or autopsy of the prolactinoma revealed a benign classification in 37% and an atypical classification in 40% (Table 3). In the remaining 23% of cases, no documentation of the histological findings was given. The histological investigation in our case demonstrated a prolactinoma with a high proliferative index, such as nuclear pleomorphism and high Ki-67 labeling index. Estimation of the cell cycle-specific antigen Ki-67, using the MIB-1 antibody, has been demonstrated to correlate best with invasiveness and probably prognosis (1). Malignant and invasive tumors exhibit much higher Ki-67 labeling indices than benign adenomas (11.9 vs 4.66 vs 1.37% respectively) (44), although there is considerable case-to-case variability (1). Others even suggested that an increased Ki-67 labeling index is associated with secondary resistance or escape to DA treatment (45).

The time interval between the onset of symptoms at presentation and subsequent metastases in the published cases was highly variable, with a median duration of 7 years, but ranging from 1 month to 20 years. Local recurrence after adenomectomy followed by repeated surgical interventions for local regrowth and extension of the pituitary tumor is frequently observed in malignant prolactinoma. Symptoms of prolactin hypersecretion rarely dominated the clinical picture of metastatic disease. However, symptoms of local compression at the metastatic sites were present in 73% of the cases. In some cases, metastases only manifested during autopsy (14, 18, 20, 21).

Intracranial metastases were reported in the frontal lobe (7, 9, 12, 18, 19, 22, 23, 27, 33, 34), parietal–occipital lobe (6, 22, 29), temporal lobe (10, 18, 24, 28, 33), cerebellum (4, 8, 12, 14, 29, 38), cerebello–pontine angle (5, 18, 31), brainstem (17, 20, 28, 38), and subarachnoid space (9, 14, 20). Less commonly involved areas were the cranial nerves (20, 27) and the orbital space (15, 18, 28, 35). Extracranial metastases within the central nervous system involved the spinal cord (8, 11, 13, 14, 17, 26, 27, 29, 3033, 35, 38, 39). Approximately 40% of the malignant prolactinomas were associated with systemic metastases in bone (10, 16, 21, 29, 32, 35, 37), lymph nodes (18, 21, 28, 29, 31, 37), lung (13, 16, 21, 31, 37), liver (21, 25, 31, 36), and, rarely, ovaries (24, 29).

Treatment of metastatic disease consisted of surgery in 69%, radiotherapy in 54%, and chemotherapy in 21% of cases. There is a case-to-case variability of the effect of chemotherapy on prognosis. At publication, three out of ten patients were still alive. Survival time of the remaining seven patients after being diagnosed with metastases was 2.1 years compared with 1.9 years for the whole cohort of patients. The mean time interval of diagnosis until death was 7.8 years compared with 8 years in all reported cases. Although, these data involve only a limited number of cases, we conclude that chemotherapy does not improve prognosis of malignant prolactinoma. In addition, 60% of the patients were treated with dopamine agonists. Only a minority of the patients was treated with octreotide (8, 21, 28, 36) or gamma-knife radiosurgery (26, 32, 35, 38). Survival in these patients was not different from the other patients.

Histological investigation of the metastatic lesions showed more often tissue with atypical parameters, compared with the results obtained from the primary tumor. Atypical features were present in 62% in the metastatic lesions versus 40% in the primary tumor.

The prognosis of malignant prolactinoma is poor. Survival after the onset of initial symptoms of prolactinoma is approximately 8 years, although there are patients who have survived for as long as 25 years. Only 60% of reported cases with a prolactin-secreting pituitary carcinoma survive more than 1 year after the development of metastases. It is presently difficult to estimate long-term survival in all patients since long-term follow-up has not been reported in most of these patients.

Another feature indicative of a non-benign clinical course is the disappearance of prolactin-suppressive effects of treatment with DA. DA resistance, or an escape to the prolactin-suppressive effects, during treatment of prolactinoma is rare, but has been reported in the majority of patients with malignant prolactinomas (Table 3). Only six patients, however, including our case, were treated with cabergoline. When non-compliance is ruled out, this phenomenon is associated with dedifferentiation of the tumor and thus of malignant transformation. In our case, it is certainly remarkable because we found positive visualization of the pituitary tumor and the metastases by the epidepride scan (Fig. 5). Apparently, the tumor still expressed the D2 receptors because [123I] epidepride binds with high affinity to dopamine D2 receptors (46). Epidepride scintigraphy was only performed in our case and one previously reported case by Petrossians, et al. (32). Scintigraphy in the latter detected metastases in the spine, rib, mediastinum, and right femur. The metastases were treated with radiotherapy. In general, it is currently unclear how to translate these results in only two patients to the diagnostic value of this procedure in benign and malignant prolactinomas. The development of pituitary insufficiency within a time frame of several weeks is also consistent with tumor dedifferentiation and growth. The occurrence of pituitary insufficiency within such a short time interval is exceptional in pituitary adenoma.

In conclusion, malignant prolactinoma can present with unusual and atypical clinical manifestations. In the case of an invasive macroprolactinoma, these features, together with the development of resistance to dopamine agonists, should prompt the clinician to obtain histological information. In the presence of atypical indices, such as nuclear pleomorphism, numerous mitosis, and increased Ki-67 labeling index, the prolactinoma could be termed atypical to denote the potential of malignant transformation.

Table 1

List of previously published cases of malignant prolactinoma.

Author, year of publicationAge/sexPrimary treatmentaPA primary tumorTime interval diagnosis – metastases (years)Metastatic sitesTreatment of metastasesaPA metastasesCause of deathTime interval diagnosis – death (years)
M, male; F, female; Chemo, chemotherapy; CT, craniotomy; DA, dopamine agonist; F, female; HPF, high powered field; LT, laminectomy; M, male; PA, pathological anatomic investigation; Octreo, octreotide; Rt, radiotherapy; TSS, transsphenoidal surgery.
aNumbers in parentheses indicate number of treatments.
bPathological anatomic findings on autopsy.
cPathological anatomic findings on biopsy.
Martin, 198131/FTSS, Rt, CT, DA, RtPleomorphism, rare mitotic figures5.5CerebellumCTNumerous mitotic figuresDeath due to disease progression8.5
Cohen, 198370/MNo mitotic figuresb3.5Cerebellopontine angleNo mitotic figuresbPulmonary edema, circulatory shock3.58
U, 198463/MCT, RtMitosis 3/20 HPF6CerebrumCT, Rt, DAMitosis 11/20 HPF, pleomorphicPulmonary embolus6.25
Gasser, 198528/MCT, Rt, DAMitosis, pleomorphism9CerebrumCT, DA, Rt, CTMitosis, pleomorphism; tumor cells in subarachnoidal space and in venous blood channelsDeath due to disease progression12
Landgraf, 198544/FCT, Rt, DABenign4Cerebellum, spinal cordLT, Rt, DA, chemo, octapeptidesomato-statin, chemoBenignDeath due to disease progression5.5
Plangger, 198528/MCT, RtBenign9Cerebrum, subarachnoid nodulesCT, Rt, DA, CTMitotic figure rareStill alive at publication
Scheithauer, 198552/FRt, CT, TSS(2x), DAMitotic figures rare11Cerebrum, vertebrae, occipital bone, ribsDA, Rt(2x)Mitotic figure rarecDeath due to disease progression13.5
Von Werder, 198543/FCT, Rt, DANot documented4Spinal cordDA, LT, Rt, DANot documentedUnknown
Muhr, 198814/MCT, RtBenign12Cerebellum, frontal lobeSurgery, DAMitosisStill alive at publication
Atienza, 199134/MDA, CT(2x), Rt, DANo mitotic figures4Spinal cord, pulmonary nodulesDA, Rt, TSSMitosis 2/10 HPF, vascular invasionDeath due to disease progression5.5
Popovic, 199147/MDA, CT(2x), RtMitosis 6/HPF2Dura, cerebrum, cerebellumCTMitosis 6/HPFGastrointestinal bleeding2.02
56/FTSS, RtMitosis 5/10 HPF12Roof fourth ventricle, cerebrum, spinal cordCTMitosis 5/10 HPFAcute pulmonary edema, Staphylococcus aureus septicemia12.33
Berezin, 199232/FCT, RtBenign20IntraorbitalCT, enucleation left eye and retroorbital mass, RtMitosis 3–4/10 HPF, pleomorphismAnorexia, pneumonia, comatose, death due to disease progression25
Figarella, 199245/MTSS, DA, CT(2x)Mitosis 1/2 HPF8Vertebrae, lungNot documentedUnknown
Kamphorst, 199245/MCT, Rt, chemo, RtMitotic figures rare13Pons, medulla oblongata, spinal cordMitotic figures rarebDeath due to disease progression13.02
Petterson, 199240/MCT, Rt, DAMitotic figures5Encasement carotid bifurcation, retro-orbital space, cerebrum, cerebello- pontine angle, nodule vertebral arteryCT, DA, CT, chemo, CT, chemoPleomorphic, invading over-lying cerebral tissueDeath due to disease progression8
Assies, 199363/MCT, Rt, DANot documented7CerebrumSurgery, DA, RtNot documentedDeath due to disease progression8
Kasantikul, 199330/FDANo mitotic figuresbPons, subarachnoid spaceNo mitotic figuresbPneumonia, duodenal ulcer, deep vein thrombosis left leg0.17
22/MCT, RtBenign3Optic nervesCTMitotic figures in large numbersStill alive at publication
Walker, 199332/MTSS, Rt, DA, TSS(4x), CTNo mitotic figures5Sphenoidal and ethmoidal sinuses, orbit, liver, lungs, hilar nodsChemo, TSS, 125 I implantation, TSS, DA, Octreotide, TSS, Rt, ChempNo mitotic figuresPneumonia9.5
48/FRt, DA, TSSNo mitotic figures15Vertebrae, sacroiliac joints, femurDA, Rt, chemoNo mitotic figurescRenal failure15.5
49/MCT, RtBenign2Mediastinal lymph node, lungDA, CT, Rt, OctreotideNo mitotic figuresPulmonary embolus post-operatively after hip replacement3.5
Long, 199470/MTSSNo mitotic figures6CerebrumCT, Rt, CT, Rt, DANo mitotic figuresbStill alive at publication
O’Brien, 199548/MCT, Rt, DABenign5CerebrumCTMitoses frequentStill alive at publication
Gollard, 199533/FTSS, DA, TSS biopsy, RtNo mitotic figures12Cheek pouch, cerebrum, pelvis, ovariesDA, surgery, Rt, hysterectomy, salpingo oophorectomy, chemoMitosis 1–3/HPFStill alive at publication
Saeger, 199559/MDA, TSS(2x), RtMitotic figures5LiverChemo, DAPleomorphiccPulmonary embolus6
Rockwell, 199650/MTSS, CT, Rt, DABenign16Spinal intraduralGamma-knife radiosurgery, LT, Rt, DAMitotic figuresStill alive at publication
Bayindir, 199732/FDA, TSSMitoses and necroses, pleomorphic0.08Oculomotor nerve, the optic foramen, encasement carotid artery, cerebrum, spinal cordCT, LT, CTMitoses and necrosesDeath due to disease progression0.25
Hurel, 199749/FTSS, Rt, DABenign, p53 positive5Ethmoidal sinuses, orbita, temporal fossa, pons, maxillary antrum, sub- mandibular nodeCT, Rt, DA, Octreotide, chemoPleomorphic, p53 positive, Ki-67 positiveTumor infarction or hemorrhage, coma7
Pernicone, 199744/FTSS, RtNot documented3Oral submucosa, ovaries, myometrium, pelvic nodesSurgery, Rt, chemo, DANot documentedStill alive at publication
34/MDA, Rt, TSSNot documented3Vertebrae, femurRtNot documentedDeath due to disease progression4
62/MCT, RtNot documented3CerebellumRt, DA, SurgeryNot documentedDeath due to disease progression11
54/FTSSNot documented1Spinal subarachnoidRt, DA, chemoNot documentedDeath due to disease progression3
37/MTSS(2x)Not documented6Lymph nodesRtNot documentedDeath due to disease progression7
64/MTSSNot documented6Occipital lobe, tentoriumUnknownNot documentedStill alive at publication
Popadic, 199951/MCT, DA, RtInvasive prolactinoma, pleomorphism, no mitotic figures4Spinal cordTSS, LT, Rt, DAPleomorphism with rare mitotic figures, tumor cells in nervous and fibrous tissueStill alive at publication
Arias, 200032/MDA, CT, RtMitosis1Medulocerebral angle, vertebrae, spinal epidural spaceCT, RtMitosis; tumor cells in subarachnoid space and in venous blood channelsPneumonia3
Petrossians, 200043/MCT, TSS(2x), DANot documented7Spinal cord, rib, mediastinum, femurCT, Rt, DA, gamma-knife radiosurgery(4x), CT(2x), RtNot documentedDeath due to disease progression15
Sironi, 200245/MTSS, CT, TSS, Rt, SandostatinMitosis 1/20 HPF9Cerebrum, spinal cordCT(2x), RtMitosis 5–25/10 HPF, Ki-67 positive, pleomorphicPulmonary embolism10.42
Vaquero, 200340/MCT, RtNot documented14CerebrumSurgeryKi-67 < 2%Still alive at publication
Winkelmann, 200253/MDA, TSS, CT, RtPleomorphism, Ki-67 positive6Orbita, foramen magnum, medulla oblongata, spinal cord, vertebraeDA, gamma- knife radiosurgery(2x)Pleomorphic, Ki- 67 positivebRenal failure, lung edema, death due to disease progression7
Harinarayan, 200426/MCT, DABenign7Liver, gastricDA, OctreoBenigncUnknown
Lamas, 200414/MTSS, DA, Rt, CTPleomorphism, numerous mitotic figures6Cerebrum, skull, pulmonary hilum, nodules lungs, ribs, pelvis, spineChemo, DAMitotic figurescStill alive at publication
Noda, 200452/FTSS, CT, Rt, DABenign7Cerebellum, medulla oblongata, spinal cordGamma-knife radiosurgery, Rt, DAPleomorphism, Ki- 67 positivecRespiratory arrest9
Uum Van, 200420/FCT(2x), DANot documented13LeptomeningealLT, DALow mitotic indexStill alive at publication
Vaishya, 200455/FCT, Rt, DABenign10Encasement internal carotis artery, sphenoid sinusTSS, DAMitosis 2/10 HPF, vascular invasion, Ki-67 positiveDeath due to disease progression11
Crusius, 200547/MTSS, CT, Rt, DAKi-67 2.80% and 4.40%6CerebrumKi-67 4.45%cCardiac arrest6.02
Kars, 200662/FDA, CT, RtNo mitotic figures, Ki-67 10–15%3.5Sinus sphenoidales, encasement internal carotis artery, spinal cord, vertebraeLT, Rt(3x)Mitosis 6/HPF, Ki- 67 positiveDeath due to disease progression5
Table 2

Summary of clinical features of malignant prolactinoma presented between 1981 and 2005.

n= 48
Gender, male (%)65
Age, years43.6 (range 14–70 years)
Most prevailing symptomatology, number (%)Primary tumorMetastases
    Hyperprolactinemia17 (35)1 (2)
    Local compression34 (71)35 (73)
Metastatic sites (%)
    Intracranial75
    Extracranial33
    Extramedullary40
Mean time interval diagnosis – metastases (years)6.9 (range 1 month–20 years)
Mean time interval metastases – death (years)1.9 (range I week–8 years)
Mean time interval diagnosis – death (years)8.0 (range 2 months–25 years)
Alive at publication (%)29
Table 3

Histological, biochemical and therapeutic characteristics of the primary pituitary tumor and metastases.

n= 48, number (%)Primary tumorMetastasesOverall
DA, dopamine agonists.
Histological classification
    Typical18 (37)8 (17)
    Atypical19 (40)30 (62)
    Not documented11 (23)10 (21)
Response to DA
    DA resistance15 (31)
        Cabergoline2 (13)
        Others13 (87)
    DA escape25 (52)
    Cabergoline4 (16)
    Others21 (84)
Therapy
    Surgery46 (96)33 (69)
    Radiotherapy38 (79)26 (54)
    Surgery and radiotherapy38 (79)20 (42)
    Chemotherapy1 (2)10 (21)
    Dopamine agonist31 (65)29 (60)
Figure 1
Figure 1

Visual field investigation in October 1999, revealing bitemporal hemianopsia.

Citation: European Journal of Endocrinology eur j endocrinol 155, 4; 10.1530/eje.1.02268

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Figure 2
Figure 2

Magnetic resonance image (axial T1-weighted image) obtained in April 1999, demonstrating a pituitary mass of 2.5 cm, invading the right sphenoidal and cavernous sinus (Hardy classification IV-E (47)), and encasement of internal carotid artery.

Citation: European Journal of Endocrinology eur j endocrinol 155, 4; 10.1530/eje.1.02268

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Figure 3
Figure 3

Serum prolactin concentrations from October 1998 to April 2003 (normal value < 22 μg/l).

Citation: European Journal of Endocrinology eur j endocrinol 155, 4; 10.1530/eje.1.02268

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Figure 4
Figure 4

MRI (sagittal T1-weighted image) obtained in November 2001, demonstrating spinal lesions (arrows) in the lumbar and sacral region.

Citation: European Journal of Endocrinology eur j endocrinol 155, 4; 10.1530/eje.1.02268

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Figure 5
Figure 5

Total-body scintigraphy after [123I] epidepride injection in December 2001. Physiological accumulation of activity in basal ganglia, liver, kidneys, bowel, and urinary bladder. Anterior view (left image): intracranial accumulation of the isotope reflecting the macroprolactinoma (arrow). Posterior view (right image): multiple accumulations of the isotope reflecting multiple metastases in the spine (arrows).

Citation: European Journal of Endocrinology eur j endocrinol 155, 4; 10.1530/eje.1.02268

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    KasantikulV, Boonjunwerwat D & Suwangool P. Prolactin cell carcinoma of the pituitary. Journal of the Medical Association of Thailand199376230–237.

  • 21

    WalkerJD, Grossman A, Anderson JV, Ur E, Trainer PJ, Benn J, Lowy C, Sonksen PH, Plowman PN, Lowe DG, Doniach I, Wass JAH & Besser IM. Malignant prolactinoma with extracranial metastases: a report of three cases. Clinical Endocrinology199338411–419.

  • 22

    LongMA & Colquhoun IR. Case report: multiple intra-cranial metastases from a prolactin-secreting pituitary tumour. Clinical Radiology199449356–358.

  • 23

    O’BrienDP, Phillips JP, Rawluk DR & Farrell MA. Intracranial metastases from pituitary adenoma. British Journal of Neurosurgery19959211–218.

  • 24

    GollardR, Kosty M, Cheney C, Copeland B & Bordin G. Prolactin-secreting pituitary carcinoma with implants in the cheek pouch and metastases to the ovaries. Cancer1995761814–1820.

  • 25

    SaegerW, Bosse U, Pfingst E, Schierke G, Kulinna H, Atkins D & Gullotta F. Prolaktinbildendes hypophysenkarzinom. Kasuistik eines ausserst seltenen metastasierenden tumors. Der Pathologe199516354–358.

  • 26

    RockwellBH, Pica R, Raji MR, Dastur KJ, Altschuler EM & Johnston JM. Intrathecal metastatic pituitary prolactinoma. American Journal of Roentgenology19961671295–1296.

  • 27

    BayindirC, Balak N & Gazioglu N. Prolactin-secreting carcinoma of the pituitary: clinicopathological and immunohistochemical study of a case with intracranial and intraspinal dissemination. British Journal of Neurosurgery199711350–355.

  • 28

    HurelSJ, Harris PE, McNicol AM, Foster S, Kelly WF & Baylis PH. Metastatic prolactinoma: effect of octreotide, cabergoline, carboplatin and etoposide; immunocytochemical analysis of proto-oncogene expression. Journal of Clinical Endocrinology and Metabolism1997822962–2965.

  • 29

    PerniconePJ, Scheithauer BW, Sebo TJ, Kovacs KT, Horvath E, Young WF, Lloyd RV, Davis DH, Guthrie BL & Schoene WC. Pituitary carcinoma. A clinicopathologic study of 15 cases. Cancer199779804–812.

  • 30

    PopadicA, Witzmann A, Buchfelder M, Eiter H & Komminoth P. Malignant prolactinoma. Case report and review of the literature. Surgical Neurology19995147–55.

  • 31

    AriasM, Pereiro I, Requena I, Ventura M, Iglesias C & Lema C. Malignant prolactinoma with intra- and extracranial metastasis: clinicoradiologic study. Anales de Medicina Interna200017192–194.

  • 32

    PetrossiansP, De Herder W, Kwekkeboom D, Lamberigts G, Stevenaert A & Beckers A. Malignant prolactinoma discovered by D2 receptor imaging. Journal of Clinical Endocrinology and Metabolism200085398–401.

  • 33

    SironiM, Cenacchi G, Cozzi L, Tonnarelli G, Lacobellis M, Trere D & Assi A. Progression on metastatic neuroendocrine carcinoma from a recurrent prolactinoma. Journal of Clinical Pathology200255148–151.

  • 34

    VaqueroJ, Herrero J & Cincu R. Late development of frontal prolactinoma after resection of pituitary tumor. Journal of Neuro-Oncology200364255–258.

  • 35

    WinkelmannJ, Pagotto U, Theodoropoulou M, Tatsch K, Saeger W, Muller A, Arzberger T, Schaaf L, Schumann EM, Trenkwalder C & Stalla GK. Retention of dopamine 2 receptor mRNA and absence of the protein in craniospinal and extracranial metastasis of a malignant prolactinoma: a case report. European Journal of Endocrinology200214681–88.

  • 36

    HarinarayanCV & Reddy K. Metastasising pituitary neuroendocrinal tumour with peptide secretion. Journal of the Association of Physicians of India20045274–75.

  • 37

    LamasC, Nunez R, Garcia-Uria J, Salas C, Saucedo G, Estrada J, Parajon A & Lucas T. Malignant prolactinoma with multiple bone and pulmonary metastases. Journal of Neurosurgery (Pediatrics)2004; 101: (Suppl 1) 116–121.

  • 38

    NodaM, Suzuki R, Moriya M, Itokawa H, Asai J, Nagashima G & Fujimoto T. A case of prolactin-secreting pituitary carcinoma and its histological findings. Brain Tumor Pathology200421149–154.

  • 39

    Van UumSHM, Van Alfen N, Wesseling P, Lindert E, Pieters GFFM, Nooijen P & Hermus ARMM. Massive reduction of tumour load and normalisation of hyperprolactinaemia after high dose cabergoline in metastasised prolactinoma causing thoracic syringomyelia. Journal of Neurology, Neurosurgery and Psychiatry2004751489–1491.

  • 40

    VaishyaA & Tondon A. Malignant prolactinoma: is metastasis a must? Clinico-pathologic and immunohistochemical study of a case. Journal of Neurosurgical Sciences20044837–41.

  • 41

    CrusiusPS, Forcelini CM, Mallmann AB, Silveira DA, Lersch E, Seibert CA, Crusius MU, Carazzo CA, Crusius CU & Goellner E. Metastatic prolactinoma: case report with immunohistochemical assessment for p53 and Ki-67 antigens. Arquivos de Neuropsiquiatria200563864–869.

  • 42

    IsobeK, Ohta M, Yasuda S, Uno T, Hara R, Machida N, Saeki N, Yamaura A, Shigematsu N & Ito H. Postoperative radiation therapy for pituitary adenoma. Journal of Neuro-oncology200048135–140.

  • 43

    VaudauxJ, Portmann L, Maeder P & Borruat FX. Orbital invasion by a pituitary macroadenoma without visual loss: case report and review of the literature. Eye2003171032–1034.

  • 44

    ThaparK, Kovacs K, Scheithauer BW, Stefaneanu L, Horvath E, Pernicone PJ, Murray D & Laws ER. Proliferative activity and invasiveness among pituitary adonomas and carcinomas: an analysis using the MIB-1 antibody. Neurosurgery19963899–106.

  • 45

    ZornitzkiT, Knobler H, Nass D, Hadani M & Shimon I. Increased MIB-1/Ki-67 labeling index as a predictor of an aggressive course in a case of prolactinoma. Hormone Research200461111–116.

  • 46

    De HerderWW, Reijs AEM, Swart J, Kaandorp Y, Lamberts SWJ, Krenning EP & Kwekkeboom DJ. Comparison of iodine-123 epidepride and iodine-123 IBZM for dopamine D2 receptor imaging in clinically non-functioning pituitary macroadenomas and macroprolactinomas. European Journal of Nuclear Medicine and Molecular Imaging19992645–50.

  • 47

    HardyJ & Somma M. Acromegaly. Surgical treatment by transsphenoidal microsurgical removal of the pituitary adenoma. In Clinical Management of Pituitary Disorders, p 209. Eds WF Collins & GT Tindall, New York: Raven Press, 1979.

 

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European Society of Endocrinology

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Figures

  • Visual field investigation in October 1999, revealing bitemporal hemianopsia.

    View in gallery
  • Magnetic resonance image (axial T1-weighted image) obtained in April 1999, demonstrating a pituitary mass of 2.5 cm, invading the right sphenoidal and cavernous sinus (Hardy classification IV-E (47)), and encasement of internal carotid artery.

    View in gallery
  • Serum prolactin concentrations from October 1998 to April 2003 (normal value < 22 μg/l).

    View in gallery
  • MRI (sagittal T1-weighted image) obtained in November 2001, demonstrating spinal lesions (arrows) in the lumbar and sacral region.

    View in gallery
  • Total-body scintigraphy after [123I] epidepride injection in December 2001. Physiological accumulation of activity in basal ganglia, liver, kidneys, bowel, and urinary bladder. Anterior view (left image): intracranial accumulation of the isotope reflecting the macroprolactinoma (arrow). Posterior view (right image): multiple accumulations of the isotope reflecting multiple metastases in the spine (arrows).

    View in gallery

References

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Von WerderK, Landgraf R, Oeckler R & Rjosk HK. Treatment of prolactinoma. In Proceedings of the First Symposium of the European Neuroendocrine Association (ENEA), Dopamine and Neuroendocrine Active Substances, pp 73–82. Eds E Del Pozo & E Fluckiger Basle: Academic Press, 1985.

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MuhrC, Bergstrom M, Lundberg PO, Hartman M, Bergstrom K, Pellettieri L & Langstrom B. Malignant prolactinoma with multiple intracranial metastases studied with positron emission tomography. Neurosurgery198822374–379.

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AtienzaDM, Vigersky RJ, Lack EE, Carriaga M, Rusnock EJ, Tsou E, Cerrone F, Kattah JG & Sausville EA. Prolactin-producing pituitary carcinoma with pulmonary metastases. Cancer1991681605–1610.

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PopovicEA, Vattuone JR, Siu KH, Busmanis I, Pullar MJ & Dowling J. Malignant prolactinomas. Neurosurgery199129127–130.

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BerezinM, Gutman I, Tadmor R, Horowitz A & Findler G. Malignant prolactinoma. Acta Endocrinologica1992127476–480.

16

Figarella-BrangerD, Trouillas J, Morange I, Gambarelli D, Harle JR, Hassoun J, Grisoli F & Pellissier JF. Prolactin pituitary carcinoma with multiple systemic metastases. Endocrine Pathology19923S11–S12.

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KamphorstW, Wolbers JG, Ponssen H & Karim ABMF. Ectopic parasellar pituitary adenoma with subarachnoid seeding. Journal of Neurology, Neurosurgery and Psychiatry19925573–74.

18

PettersonT, MacFarlane IA, MacKenzie JM & Shaw MDM. Prolactin secreting pituitary carcinoma. Journal of Neurology, Neurosurgery and Psychiatry1992551205–1206.

19

AssiesJ, Verhoeff NPLG, Bosch DA & Hofland LJ. Intracranial dissemination of a macroprolactinoma. Clinical Endocrinology199338539–546.

20

KasantikulV, Boonjunwerwat D & Suwangool P. Prolactin cell carcinoma of the pituitary. Journal of the Medical Association of Thailand199376230–237.

21

WalkerJD, Grossman A, Anderson JV, Ur E, Trainer PJ, Benn J, Lowy C, Sonksen PH, Plowman PN, Lowe DG, Doniach I, Wass JAH & Besser IM. Malignant prolactinoma with extracranial metastases: a report of three cases. Clinical Endocrinology199338411–419.

22

LongMA & Colquhoun IR. Case report: multiple intra-cranial metastases from a prolactin-secreting pituitary tumour. Clinical Radiology199449356–358.

23

O’BrienDP, Phillips JP, Rawluk DR & Farrell MA. Intracranial metastases from pituitary adenoma. British Journal of Neurosurgery19959211–218.

24

GollardR, Kosty M, Cheney C, Copeland B & Bordin G. Prolactin-secreting pituitary carcinoma with implants in the cheek pouch and metastases to the ovaries. Cancer1995761814–1820.

25

SaegerW, Bosse U, Pfingst E, Schierke G, Kulinna H, Atkins D & Gullotta F. Prolaktinbildendes hypophysenkarzinom. Kasuistik eines ausserst seltenen metastasierenden tumors. Der Pathologe199516354–358.

26

RockwellBH, Pica R, Raji MR, Dastur KJ, Altschuler EM & Johnston JM. Intrathecal metastatic pituitary prolactinoma. American Journal of Roentgenology19961671295–1296.

27

BayindirC, Balak N & Gazioglu N. Prolactin-secreting carcinoma of the pituitary: clinicopathological and immunohistochemical study of a case with intracranial and intraspinal dissemination. British Journal of Neurosurgery199711350–355.

28

HurelSJ, Harris PE, McNicol AM, Foster S, Kelly WF & Baylis PH. Metastatic prolactinoma: effect of octreotide, cabergoline, carboplatin and etoposide; immunocytochemical analysis of proto-oncogene expression. Journal of Clinical Endocrinology and Metabolism1997822962–2965.

29

PerniconePJ, Scheithauer BW, Sebo TJ, Kovacs KT, Horvath E, Young WF, Lloyd RV, Davis DH, Guthrie BL & Schoene WC. Pituitary carcinoma. A clinicopathologic study of 15 cases. Cancer199779804–812.

30

PopadicA, Witzmann A, Buchfelder M, Eiter H & Komminoth P. Malignant prolactinoma. Case report and review of the literature. Surgical Neurology19995147–55.

31

AriasM, Pereiro I, Requena I, Ventura M, Iglesias C & Lema C. Malignant prolactinoma with intra- and extracranial metastasis: clinicoradiologic study. Anales de Medicina Interna200017192–194.

32

PetrossiansP, De Herder W, Kwekkeboom D, Lamberigts G, Stevenaert A & Beckers A. Malignant prolactinoma discovered by D2 receptor imaging. Journal of Clinical Endocrinology and Metabolism200085398–401.

33

SironiM, Cenacchi G, Cozzi L, Tonnarelli G, Lacobellis M, Trere D & Assi A. Progression on metastatic neuroendocrine carcinoma from a recurrent prolactinoma. Journal of Clinical Pathology200255148–151.

34

VaqueroJ, Herrero J & Cincu R. Late development of frontal prolactinoma after resection of pituitary tumor. Journal of Neuro-Oncology200364255–258.

35

WinkelmannJ, Pagotto U, Theodoropoulou M, Tatsch K, Saeger W, Muller A, Arzberger T, Schaaf L, Schumann EM, Trenkwalder C & Stalla GK. Retention of dopamine 2 receptor mRNA and absence of the protein in craniospinal and extracranial metastasis of a malignant prolactinoma: a case report. European Journal of Endocrinology200214681–88.

36

HarinarayanCV & Reddy K. Metastasising pituitary neuroendocrinal tumour with peptide secretion. Journal of the Association of Physicians of India20045274–75.

37

LamasC, Nunez R, Garcia-Uria J, Salas C, Saucedo G, Estrada J, Parajon A & Lucas T. Malignant prolactinoma with multiple bone and pulmonary metastases. Journal of Neurosurgery (Pediatrics)2004; 101: (Suppl 1) 116–121.

38

NodaM, Suzuki R, Moriya M, Itokawa H, Asai J, Nagashima G & Fujimoto T. A case of prolactin-secreting pituitary carcinoma and its histological findings. Brain Tumor Pathology200421149–154.

39

Van UumSHM, Van Alfen N, Wesseling P, Lindert E, Pieters GFFM, Nooijen P & Hermus ARMM. Massive reduction of tumour load and normalisation of hyperprolactinaemia after high dose cabergoline in metastasised prolactinoma causing thoracic syringomyelia. Journal of Neurology, Neurosurgery and Psychiatry2004751489–1491.

40

VaishyaA & Tondon A. Malignant prolactinoma: is metastasis a must? Clinico-pathologic and immunohistochemical study of a case. Journal of Neurosurgical Sciences20044837–41.

41

CrusiusPS, Forcelini CM, Mallmann AB, Silveira DA, Lersch E, Seibert CA, Crusius MU, Carazzo CA, Crusius CU & Goellner E. Metastatic prolactinoma: case report with immunohistochemical assessment for p53 and Ki-67 antigens. Arquivos de Neuropsiquiatria200563864–869.

42

IsobeK, Ohta M, Yasuda S, Uno T, Hara R, Machida N, Saeki N, Yamaura A, Shigematsu N & Ito H. Postoperative radiation therapy for pituitary adenoma. Journal of Neuro-oncology200048135–140.

43

VaudauxJ, Portmann L, Maeder P & Borruat FX. Orbital invasion by a pituitary macroadenoma without visual loss: case report and review of the literature. Eye2003171032–1034.

44

ThaparK, Kovacs K, Scheithauer BW, Stefaneanu L, Horvath E, Pernicone PJ, Murray D & Laws ER. Proliferative activity and invasiveness among pituitary adonomas and carcinomas: an analysis using the MIB-1 antibody. Neurosurgery19963899–106.

45

ZornitzkiT, Knobler H, Nass D, Hadani M & Shimon I. Increased MIB-1/Ki-67 labeling index as a predictor of an aggressive course in a case of prolactinoma. Hormone Research200461111–116.

46

De HerderWW, Reijs AEM, Swart J, Kaandorp Y, Lamberts SWJ, Krenning EP & Kwekkeboom DJ. Comparison of iodine-123 epidepride and iodine-123 IBZM for dopamine D2 receptor imaging in clinically non-functioning pituitary macroadenomas and macroprolactinomas. European Journal of Nuclear Medicine and Molecular Imaging19992645–50.

47

HardyJ & Somma M. Acromegaly. Surgical treatment by transsphenoidal microsurgical removal of the pituitary adenoma. In Clinical Management of Pituitary Disorders, p 209. Eds WF Collins & GT Tindall, New York: Raven Press, 1979.

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