Chronic necrotising aspergillosis mimicking ACTH-secreting tumour in a case of Cushing's disease.

An 18-year-old man presenting with speech and behaviour disorders was found to suffer from Cushing's syndrome. Ectopic ACTH secretion was initially suspected on the basis of very high cortisoluria and ACTH concentrations, severe hypokalemia, a lung hypermetabolic lesion and a normal pituitary on conventional magnetic resonance imaging (MRI). After lung surgery, this lesion proved to be chronic necrotising aspergillosis (CNA). Diagnostic reevaluation by bilateral inferior petrosal sinus sampling disclosed a right-sided petrosal sinus gradient consistent with Cushing's disease (CD). A new high resolution thin-section MRI demonstrated a 5 mm pituitary adenoma, which could be removed successfully. Thus, a lung mass associated with several clues in favour of ectopic ACTH secretion may hide a diagnosis of CD. Such a mass can be CNA, an opportunistic infection favoured by immunosuppression, which to our knowledge, is the first case reported in CD.

Pituitary incidentaloma: to operate or not to operate?

The wide use of sophisticated imaging techniques has led to the discovery of asymptomatic pituitary lesions, which are called 'incidentalomas'. Their global prevalence averages 10% whereas that of macroadenomas (> 10 mm) is less than 1%. The most frequently encountered lesions are non-functioning adenomas followed by Rathke's cleft cysts. Physiological pituitary hypertrophy is also frequent in young women. Silent functioning adenomas especially prolactinomas can be found among incidentalomas. Hypopituitarism appears to be more frequent in larger lesions but can occur in microadenomas (< 10 mm). The incidence of tumour growth is higher in macroadenomas and solid lesions in comparison with microadenomas and cystic lesions. The baseline evaluation should include in all patients a complete history and physical examination, a screening for hormone hypersecretion and hypopituitarism and a visual field examination if the lesion abuts the optic nerves or chiasm. If there is hormone hypersecretion, an appropriate treatment is indicated (dopamine agonists for prolactinomas and surgery for tumours producing GH, ACTH or TSH). If there is hypopituitarism, adequate hormone replacement therapy is required. According to recent guidelines, the indications for surgery of non-functioning incidentalomas include a visual field deficit, other visual abnormalities such as ophtalmoplegia or a lesion abutting the optic nerves or chiasm on magnetic resonance imaging (MRI). Regarding the follow-up of incidentalomas not meeting the criteria for surgery, the following tests should be performed: MRI at 1 year for micro-incidentalomas, at 6 months for macro-incidentalomas and then less frequently if unchanged in size, visual field examination for lesions enlarging to abut or compress the optic nerves or chiasm (6 months and yearly) and endocrine testing for macro-incidentalomas (6 months and yearly). Nowadays, data are insufficient to suggest the routine use of medical therapy in non-functioning tumours. Pituitary radiotherapy may be useful as an adjunctive treatment for tumour remnants growing progressively.

Metastasis of a small cell carcinoma from undetected origin to the pituitary gland--the otolaryngologist's view.

Tumour metastasis to the anterior pituitary-hypothalamic area is rare. We present a patient who had severe headache, bitemporal quadrant hemianopsia and an expanding mass in the sella turcica as revealed by MRI. Partial resection via a transsphenoidal approach was performed and postoperative radiation therapy was initiated. Immunohistochemical investigation identified the tumour as a metastatic small cell carcinoma whose primary site remained undetected for more than 12 months despite repeated oncological evaluations. We reviewed the literature on metastatic disease of the pituitary gland.