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Stephanie Teasdale Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia

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Fahid Hashem Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia

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Sarah Olson Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia

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Benjamin Ong Department of Radiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia

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Warrick J Inder Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
School of Medicine, The University of Queensland, Brisbane, Queensland, Australia

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Summary

A case of recurrent pituitary apoplexy is described in a 72-year-old man who initially presented with haemorrhage in a non-functioning pituitary adenoma. Five years later, he re-presented with a severe pituitary haemorrhage in an enlarging sellar mass invading both cavernous sinuses causing epistaxis and bilateral ocular paresis. Subsequent histology was consistent with a sellar malignant spindle and round cell neoplasm. Multiple pituitary tumours have previously been reported to coexist in the same individual, but to our knowledge this is the only case where two pathologically distinct pituitary neoplasms have sequentially arisen in a single patient. This case is also notable with respect to the progressive ocular paresis, including bilateral abducens nerve palsies, and the presentation with epistaxis.

Learning points

  • Ocular paresis in pituitary apoplexy can result from tumour infiltration of nerves, or by indirect compression via increased intrasellar pressure.

  • Epistaxis is a very rare presentation of a pituitary lesion.

  • Epistaxis more commonly occurs following trans-sphenoidal surgery, and can be delayed.

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Roberto Salvatori Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

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Adrian F Daly Department of Endocrinology, Centre Hospitalier Universitaire de Liège, University of Liège, Liège, Belgium

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Alfredo Quinones-Hinojosa Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

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Albert Thiry Department of Pathology, Centre Hospitalier Universitaire de Liège, University of Liège, Liège, Belgium

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Albert Beckers Department of Endocrinology, Centre Hospitalier Universitaire de Liège, University of Liège, Liège, Belgium

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Summary

Heterozygous germline inactivating mutations in the aryl hydrocarbon receptor-interacting protein (AIP) gene lead to pituitary adenomas that most frequently present in the setting of familial isolated pituitary adenoma syndrome, usually as somatotropinomas and prolactinomas. More recently, they have been found in a significant percentage of young patients presenting with pituitary macroadenoma without any apparent family history. We describe the case of a 19-year-old man who presented with a gigantic somatotropinoma. His family history was negative. His peripheral DNA showed a heterozygous AIP mutation (p.I13N), while tumor tissue only had the mutated allele, showing loss of heterozygosity (LOH) and suggesting that the mutation caused the disease.

Learning points

  • AIP mutations may be observed in sporadic somatotrope adenomas occurring in young patients.

  • LOH is a strong indicator that an AIP variant is disease causing.

  • Somatotrope adenomas in carriers of AIP mutations are generally larger and more difficult to cure.

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Ramez Ibrahim Royal Hallamshire Hospital, Sheffield, UK

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Atul Kalhan University Hospital of Wales, Cardiff, UK

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Alistair Lammie Cardiff University, Cardiff, UK

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Christine Kotonya Bronglais Hospital, Aberystwyth, UK

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Ravindra Nannapanenni University Hospital of Wales, Cardiff, UK

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Aled Rees Institute of Molecular and Experimental Medicine, Cardiff University, Cardiff, UK

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Summary

A 30-year-old female presented with a history of secondary amenorrhoea, acromegalic features and progressive visual deterioration. She had elevated serum IGF1 levels and unsuppressed GH levels after an oral glucose tolerance test. Magnetic resonance imaging revealed a heterogeneously enhancing space-occupying lesion with atypical extensive calcification within the sellar and suprasellar areas. Owing to the extent of calcification, the tumour was a surgical challenge. Postoperatively, there was clinical, radiological and biochemical evidence of residual disease, which required treatment with a somatostatin analogue and radiotherapy. Mutational analysis of the aryl hydrocarbon receptor-interacting protein (AIP) gene was negative. This case confirms the relatively rare occurrence of calcification within a pituitary macroadenoma and its associated management problems. The presentation, biochemical, radiological and pathological findings are discussed in the context of the relevant literature.

Learning points

  • Calcification of pituitary tumours is relatively rare.

  • Recognising calcification in pituitary adenomas on preoperative imaging is important in surgical decision-making.

  • Gross total resection can be difficult to achieve in the presence of extensive calcification and dictates further management and follow-up to achieve disease control.

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