Pituitary prolactinoma

Case contributed by Ryan Thibodeau
Diagnosis certain

Presentation

Decrease visual acuity in both eyes, right greater than left. Right optic nerve atrophy noted on fundoscopic exam.

Patient Data

Age: 55 years
Gender: Male

brain with pituitary protocol

mri

There is a large avidly enhancing multilobulated mass arising from the sella turcica with suprasellar extension. There is a focus of intrinsic T1 hyperintensity along the superior lateral
aspect of the lesion on the right side likely representing superimposed hemorrhage or blood products. The suprasellar extension of the mass results in superolateral displacement of the prechiasmatic optic nerves and the superior displacement of the optic chiasm.

Inferiorly, there appears to be invasion into the clivus as well as erosive changes of the floor the sella turcica protruding significantly into the sphenoid sinus. The anterior aspects of the sphenoid sinuses that the lesion does not extend into do appear well aerated. There appears to be thinning of the dorsal cortex of the clivus, without a significant degree of extension of the mass into the prepontine cistern or interpeduncular cistern.

There is a protrusion of the mass into the left cavernous sinus inferiorly. There is likely at least partial encasement of the left carotid artery vascular flow void which is not narrowed. The mass abuts the right cavernous sinus, without definite invasion. However, the suprasellar component of the mass on the right lateral protrusion demonstrates broad contact with the carotid supraclinoid internal carotid artery in addition to superior displacement of the right A1 segment of the anterior cerebral artery. The left A1 segment of the anterior cerebral artery also has a broad contact with a lobulated component of the mass and the proximal left A2 segment of the anterior cerebral artery courses along the margin of the lobulated portion of the mass.

Case Discussion

This case is highly suggestive of a prolactinoma (prolactin secreting pituitary macroadenoma) given the radiographic appearance (snowman sign) and elevated prolactin laboratory values.

The patient had pituitary labs drawn which showed low testosterone <10 ng/dL and elevated prolactin 4990.0 ng/mL). Findings were highly suggestive of a macroprolactinoma. After consultation with neurosurgery, the patient opted for medical treatment in favor of surgical resection. The patient was treated with cabergoline twice weekly per endocrinology. The mass responded very well to the dopamine agonist with interval shrinkage of the pituitary mass. Eventually, the mass no longer exhibited mass effect onto the adjacent structures. Clinically, the patient was stable with improvement in his bilateral visual fields.

Co-author:
Jun Yang

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