Silent mixed corticotroph and somatotroph macroadenomas presenting with pituitary apoplexy

We discuss three unique cases of pituitary macroadenoma presenting with pit uitary hemorrhage but without typical endocrine symptomatology. Immunohisto chemical analysis indicated positive reactivity for adrenocorticotropic hor mone (ACTH) and growth hormone (GH), and in situ hybridization indicated th e expression of proopiomelanocortin (POMC) and GH mRNA. We designated these cases silent mixed corticotroph and somatotroph adenoma. Patient 1 was a 3 0-year-old man, patient 2 was a 29-year-old woman, and patient 3 was a 59-y ear-old woman. All patients presented with a headache of sudden onset and v isual disturbance. The patients did not exhibit typical Cushing's or acrome galic features. Serum ACTH level was remarkably elevated in patient 1, and slightly elevated in patients 2 and 3. In all patients, serum GH levels wer e within normal range and magnetic resonance imaging revealed an intra- and suprasellar mass with pituitary hemorrhage. Transnasal pituitary surgery i n the three patients disclosed a pituitary adenoma producing ACTH and GH. I n patient 2, the residual adenoma reappeared along with an intratumoral. he morrhage, and was resected by secondary transnasal surgery. Silent mixed co rticotroph and somatotroph adenomas are characterized by the following: no endocrine symptoms; presentation dominated by mass effect symptoms; macroad enoma presenting with acute pituitary hemorrhage; and production of both AC TH and GH.