Endocrine Abstracts

We report an 84-year-old lady with stage A chronic lymphatic leukaemia which has been stable since 2002. She presented to our A&E in January 2013 with 3 days history of worsening frontal headache. She did not report visual disturbance or weakness. Examination revealed right sided homonymous hemianopia with no other neurological deficit.

White cell count and lymphocytes were 53.9×10⁹/l and 42.0×10⁹/l respectively. CT head showed an enlarged pituitary gland measuring 1.7 cm with features suggesting recent hemorrhage. MRI confirmed above findings and revealed optic chiasmal compression. CSF analysis showed elevated protein, normal glucose and no organisms were seen. CSF cytology was not performed. Blood tests were consistent with hypogonadotrophic hypogonadism. Cortisol was 6429 nmol/l, reduced to 1724 nmol/l after 2 days. Prolactin was undetectable. TFT and IGF1 were normal.

She underwent transsphenoidal hypophysectomy. The pituitary gland and hematoma were evacuated successfully with no immediate complications. Histology showed necrotic and haemorrhagic adenoma. Pathological features were consistent with apoplexy. It was thought that the pituitary vessels were clogged by CLL cells which led to apoplexy. Immunocytochemistry showed features diagnostic of leukemic infiltrate and consistent with chronic lymphocytic leukaemia. She developed hormone deficiency and Diabetes insipidus post surgery and is currently on hydrocortisone, thyroxine and desmopressin. She has residual right sided homonymous hemianopia. Haematologists are continuing to monitor her as usual.

Tumour metastasis to the pituitary gland is unusual and pituitary metastasis from CLL is extremely rare. Only 1% of the pituitary surgeries are performed for pituitary metastasis. The prognosis depends on the course of the primary neoplasm. Only 7% of pituitary metastasis are reported to be symptomatic with Diabetes insipidus being the most frequent presenting symptom in 50% of cases. Their rarity as well as the lack of specific clinical and radiological features impede their differentiation from other more common sellar lesions.