Efficacy of Trans-septal Trans-sphenoidal Surgery in Correcting Visual Symptoms Caused by Hematogenous Metastases to the Sella and Pituitary Gland

ABSTRACT

The rate of symptomatic improvement of visual symptoms associated with hematogenous metastases to the sella and pituitary was evaluated retrospectively in seven patients (five men, two women; mean age, 52.3 years) with primarily visual symptoms (diplopia alone in three, diplopia with blurred vision in one, blurred vision alone in one, loss of peripheral vision in one, and unilateral complete blindness in one). Symptom duration ranged from 0.5 to 2 months. The primary diseases were non-small cell lung cancer in two patients, renal cell carcinoma in two patients, prostate cancer in two patients, and medullary thyroid carcinoma in one patient. All patients had widespread metastatic disease. Three patients had a suprasellar tumoral component. One patient had a clival extension, and one patient had extension into the cavernous sinus. All underwent trans-sphenoidal surgery to correct visual symptoms. Gross total resection was achieved in three patients. Subtotal resections and a partial resection were performed in three patients and one patient, respectively. Surgical blood loss averaged 282 mL. One patient died from sepsis. Five patients developed complications (cerebrospinal fluid leakage in three, diabetes insipidus in two, anterior pituitary dysfunction in two, and colitis in one). At a mean follow-up of 15 months, three patients were alive. Visual symptoms improved in five patients and were unchanged in two. Trans-sphenoidal surgery helped improve visual symptoms in most patients. The morbidity rate was high and likely related to the locally destructive and extensive nature of the lesions in overall morbid patients with widespread metastatic disease. Unless nonoperative measures can provide equal results, however, this approach provides reasonable palliation.

KEYWORDS

Metastatic disease - pituitary gland - transnasal - sublabial - vision - sellar mass

REFERENCES

• 1 Kovacs K. Metastatic cancer of the pituitary gland.  Oncology. 1973;  27 533-542
• 2 Abrams H L, Spiro R, Goldstein N. Metastases in carcinoma: analysis of 1000 autopsied cases.  Cancer. 1950;  3 74-85
• 3 Heshmati H M, Scheithauer B W, Young Jr W F. Metastases to the pituitary gland.  Endocrinologist. 2002;  12 45-49
• 4 Teears R J, Silverman E M. Clinicopathologic review of 88 cases of carcinoma metastatic to the pituitary gland.  Cancer. 1975;  36 216-220
• 5 Komninos J, Vlassopoulou V, Protopapa D et al.. Tumors metastatic to the pituitary gland: case report and literature review.  J Clin Endocrinol Metab. 2004;  89 574-580
• 6 Juneau P, Schoene W C, Black P. Malignant tumors in the pituitary gland.  Arch Neurol. 1992;  49 555-558
• 7 Landolt A M. Comments on: Nelson PB, Robinson AG, Martinez AJ. Metastatic tumor of the pituitary gland.  Neurosurgery. 1987;  21 941-944
• 8 McCormick P C, Post K D, Kandji A D, Hays A P. Metastatic carcinoma to the pituitary gland.  Br J Neurosurg. 1989;  3 71-79
• 9 Gsponer J, De Tribolet N, Deruaz J P et al.. Diagnosis, treatment, and outcome of pituitary tumors and other abnormal intrasellar masses: retrospective analysis of 353 patients.  Medicine (Baltimore). 1999;  78 236-269
• 10 Branch Jr C L, Laws Jr E R. Metastatic tumors of the sella turcica masquerading as primary pituitary tumors.  J Clin Endocrinol Metab. 1987;  65 469-474
• 11 Max M B, Deck M D, Rottenberg D A. Pituitary metastasis: incidence in cancer patients and clinical differentiation from pituitary adenoma.  Neurology. 1981;  31 998-1002
• 12 Houck W A, Olson K B, Horton J. Clinical features of tumor metastasis to the pituitary.  Cancer. 1970;  26 656-659
• 13 Sioutos P, Yen V, Arbit E. Pituitary gland metastases.  Ann Surg Oncol. 1996;  3 94-99
• 14 Morita A, Meyer F B, Laws Jr E R. Symptomatic pituitary metastases.  J Neurosurg. 1998;  89 69-73
• 15 Fassett D R, Couldwell W T. Metastases to the pituitary gland.  Neurosurg Focus. 2004;  16 E8
• 16 McCutcheon I E, Waguespack S G, Fuller G N, Couldwell W T. Metastatic melanoma to the pituitary gland.  Can J Neurol Sci. 2007;  34 322-327
• 17 McCutcheon I E, Kitagawa R H, Sherman S I, Bruner J M. Adenocarcinoma of the salivary gland metastatic to the pituitary gland: case report.  Neurosurgery. 2001;  48 1161-1165
• 18 Marin F, Kovacs K T, Scheithauer B W, Young Jr W F. The pituitary gland in patients with breast carcinoma: a histologic and immunocytochemical study of 125 cases.  Mayo Clin Proc. 1992;  67 949-956
• 19 Post K D, McCormick P C, Hays A P, Kandji A G. Metastatic carcinoma to pituitary adenoma: report of two cases.  Surg Neurol. 1988;  30 286-292
• 20 Weber J, Gassel A M, Hoch A, Spring A. Concomitant renal cell carcinoma with pituitary adenoma.  Acta Neurochir (Wien). 2003;  145 227-231
• 21 Molinatti P A, Scheithauer B W, Randall R V, Laws Jr E R. Metastasis to pituitary adenoma.  Arch Pathol Lab Med. 1985;  109 287-289
• 22 McDermott R S, Anderson P R, Greenberg R E, Milestone B N, Hudes G R. Cranial nerve deficits in patients with metastatic prostate carcinoma: clinical features and treatment outcomes.  Cancer. 2004;  101 1639-1643
• 23 Murata Y, Ogawa Y, Yokoe I et al.. Pituitary stalk metastasis from breast cancer treated with systemic chemotherapy.  Oncol Rep. 2003;  10 1973-1975
• 24 Patel N, Teh B S, Powell S, Lu H H, Amato R, Butler E B. Rare case of metastatic prostate adenocarcinoma to the pituitary.  Urology. 2003;  62 352
• 25 Iwai Y, Yamanaka K, Honda Y, Matsusaka Y. Radiosurgery for pituitary metastases.  Neurol Med Chir (Tokyo). 2004;  44 112-116
• 26 Piedra M P, Brown P D, Carpenter P C, Link M J. Resolution of diabetes insipidus following gamma knife surgery for a solitary metastasis to the pituitary stalk: case report.  J Neurosurg. 2004;  101 1053-1056
• 27 Losa M, Grasso M, Giugni E, Mortini P, Acerno S, Giovanelli M. Metastatic prostatic adenocarcinoma presenting as a pituitary mass: shrinkage of the lesion and clinical improvement with medical treatment.  Prostate. 1997;  32 241-245
• 28 Kattah J C, Silgals R M, Manz H, Toro J G, Dritschilo A, Smith F P. Presentation and management of parasellar and suprasellar metastatic mass lesions.  J Neurol Neurosurg Psychiatry. 1985;  48 44-49