Pituitary adenomas are the most common lesions of sellar cavity. The usual symptoms are associated with endocrine dysfunctions and mass effects. In this case, a 39 year old female presented with headache for one year and progressive blurred vision, nausea, vomiting for two days. Brain magnetic resonance imaging showed a 16×9 mm hemorrhagic macroadenoma in sellar cavity concordant with apoplexia and anterior pituitary hormone deficiency. The patient underwent transshphenoidal surgery and necrotic, heterogeneous hemorrhagic adenoma was excised. Pathology showed extensive coagulation necrosis and hemosiderin pigments therefore immunohistochemical staining could not be performed. After her admission to our clinic there were no typical features suggesting acromegaly or Cushings disease and postoperative anterior pituitary hormone deficiency has not been recovered as well as insulin like growth factor 1 (IGF1) levels. Hence, she was put on hormone replacement therapy for desmopressin, levothyroxine, hydrocortisone, estrogen and progesterone. After 5-years of follow up period, some clinical features such as; enlargement of hands and feet, macroglossia and maloclusion in teeth were noticed. Subsequent investigations showed moderately elevated serum growth hormone (GH) (7.39 ng/ml) and IGF1 levels (553.4 ng/ml). An oral glucose tolerance test was perfomed and nadir GH level was 2 ng/ml. Pituitary MRI revealed a recurrent pituitary adenoma 25×16×19 mm in size without invasion to adjacent structures. The patient was diagnosed as recurrent GH secreting pituitary adenoma which had been cured by apoplexia before. Transshphenoidal surgery was performed for adenomectomy and the pathology confirmed the diagnosis. Ki-67 proliferation index was very high as 20% and p53 was immunoreactive, which predicted an agressive tumor. As GH and IGF1 levels were still elevated at the third month of surgery she was put on lanreotide LAR 90 mg/28 day. The dose was titrated to 120 mg/28 day as we could not achieve controlled disease. Although there were no visible residual tumor on postoperative MRI, the disease was uncontrolled even though cabergoline addition. Disease control was achieved on the 6. months of gamma-knife therapy. The clinical signs of hormonal hypersecretion might regress in case of apoplexia, therefore the clinicians should always be alert for reappearance of the disease on follow-up. This case also underscores the higher Ki-67 index and extensive p53 immunoreactivity which might be seen in recurrent cases after apoplexia.
19 May 2018 - 22 May 2018