Session: SAT 164-196-Pituitary
Poster Board SAT-172
A 45 year old man with no significant history was referred to the emergency room by his primary care physician for Guaiac positive stools, anemia, and weight loss of 40 lb in 5 months. Exam revealed T 101.1, HR 80, BP 113/65, weight 108kg, and was otherwise normal. Initial labs showed low serum sodium, mild pancytopenia, and a low TSH. A CT scan of the abdomen revealed generalized lymphadenopathy and an enlarged, nodular, irregular prostate with indistinct borders invading the posterior bladder wall with mass-like enlargement of the seminal vesicles. Further tests revealed pan-hypopituitarism. Pituitary MRI showed an enlarged gland with several hypointensities compatible with multiple microadenomas. He was started on steroids followed by thyroid hormone supplementation. Lymph node biopsy revealed a diffuse large B-cell lymphoma. He was then started on chemotherapy with R-CHOP. To date, he has had 4 cycles of R-CHOP, continued on steroid and thyroid hormone supplementation. In the interim, he appeared to have recovered partial pituitary function as evident by a subnormal increase in testosterone levels, normal LH, FSH and prolactin levels. Testosterone supplementation resulted in a dramatic response to a low dose patch. A follow-up pituitary imaging is planned.
We suspect this patient to have secondary pituitary lymphoma in view of the MRI findings and peripheral tissue diagnosis. Further evidence is that after lymphoma treatment some anterior pituitary function has recovered, based on the increase in the levels of testosterone, FSH, LH and prolactin without any gonadal hormone supplementation. Differential diagnosis includes hypophysitis that may have responded to high dose steroids, however, the MRI description did not fit that of hypophysitis, which is described as loss of the hyperintense “bright spot” signal of the posterior pituitary, thickening of the pituitary stalk, or enlargement of the posterior gland. Furthermore, the role of steroids in primary hypophysitis is unclear2.
Very few cases of secondary pituitary lymphoma have been described in the literature, incidence being regarding 0.5% as noted in a review. Prognosis has been good in the few cases that have been described in the literature3,4.
Nothing to Disclose: AK, ES
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