Pituitary apoplexy following metastasis of bronchogenic adenocarcinoma to a prolactinoma

A 42-year-old house wife presented with worsening headaches over 6 months i n the absence of visual symptoms or symptoms suggestive of focal neurology. She was a life-long smoker. Systems review was unremarkable apart from sec ondary amenorrhoea and galactorrhoea of 6 months duration. Her serum prolac tin was found to be 620 mU/I (60-400), FT4 12.6 nmol/l (9.8-23.1), TSH 1.38 mU/l (0.35-5.5), oestradiol < 73 pmol/l, LH and FSH of 4.4 and 12.6 mlU/l, respectively. She was on bromocriptine. A presumptive diagnosis of pneumon ia, based on pyrexia and CXR findings, was made and she was started on IV a ntibiotics. Two days later she developed meningism and deterioration of con scious level. (Lumbar puncture results: no organisms, 312 neutrophils and 1 64 lymphocytes). CT scan revealed a 2.5-cm pituitary adenoma, with suprasel lar extension. A repeat hormonal profile revealed FSH 1.4, LH < 0.3 mU/l, o estradiol <73 pmol/l, prolactin 488 mU/I (60-400), and low random cortisol at 29 nmol/l. T1-weighted MR1 revealed a large pituitary mass with evidence of haemorrhag e. The patient subsequently underwent a transsphenoidal exploration with resec tion of the pituitary lesion. Whilst awaiting the histopathology results, C T of chest revealed a 1.5-cm diameter rounded well defined density in the r ight lower lobe associated with hilar, pre-and right para-tracheal lymphade nopathy. The histopathology of the pituitary lesion, obtained piecemeal, revealed fr agments of fibrous tissue infiltrated by sheets of acidophilic prolactin-po sitive cells, in keeping with a prolactinoma. In addition, other fragments with blood clot included highly atypical epithelial cells with mitotic figu res. These were negative for prolactin but showed HMFG-and CEA-positivity, excluding them from a pituitary lineage. Transbronchial biopsy revealed mod erately differentiated adenocarcinoma, with evidence of lymphatic spread. T he overall conclusion was of bronchogenic adenocarcinoma, metastasizing to a prolactinoma and complicated by apoplexy.