Session: SAT 164-196-Pituitary
Poster Board SAT-170
Clinical Case: The patient is a 73 yo woman who presented with cold agglutinins hemolytic anemia in 2002. Her IgM was elevated, and bone marrow biopsy in 2004 demonstrated evolving lymphoplasmacytic lymphoma. Rituximab therapy was administered from 2004 to 2006 resulting in remission. In 2009, intracranial extra-axial masses were identified in the occipital and parietal regions. Needle biopsy of one of the masses demonstrated grade 1 Follicular NHL, and Rituximab was restarted. The patient also received radiation therapy (36 Gy) to the scalp and dura. Progressive disease in lymph nodes and the lungs was treated with 8 cycles of Bendamustine/Rituximab. These therapies resulted in complete clinical response.
In 2011, the patient reported left-sided retro-orbital pain and diplopia, and was found to have a partial left 3rd nerve palsy. Brain MRI demonstrated soft tissue density in the sella and left cavernous sinus with deviation of the pituitary stalk to the right. Transsphenoidal biopsy of the sellar mass was consistent with CD10+ large B cell lymphoma of follicular center origin. Ki 67 index was 80-90% suggesting aggressive clinical behavior. The patient received two cycles of R-CHOP, but treatment was discontinued due to toxicities. She was then treated with five fractions of stereotactic image-guided radiosurgery (CyberKnife). The pain and diplopia resolved. Pituitary hormone evaluation six months after CyberKnife was normal. MRI ten months after CyberKnife demonstrated resolution of the sellar mass.
Conclusion: Transformation of follicular lymphoma to diffuse large B cell lymphoma is associated with poor prognosis and resistance to chemotherapeutic agents, especially when involving the CNS. Isolated pituitary involvement is rare in transformed B cell NHL. Pituitary biopsy should be considered to plan further treatment. In this case, radiosurgery in the form of CyberKnife was an effective therapeutic option with resolution of the sellar mass and preservation of pituitary function. Although focused radiation is not typically considered to be sufficient for control of high-grade lymphomas, this case demonstrates that CyberKnife can be considered for palliation and control of isolated lymphomatous CNS lesions.
Nothing to Disclose: MIK, ART, NL, TAL, HWG, MJL
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