Progression of an Invasive ACTH Pituitary Macroadenoma with Cushing's Disease to Pituitary Carcinoma.

Pituitary carcinomas are very rare tumors that in most cases produce prolactin and adrenocorticotropic hormone (ACTH). It is a challenge to diagnosis of a pituitary carcinoma before disclosed symptomatic metastasis. We report the case of a female patient with Cushing's disease who underwent three transsphenoidal surgeries, with pathological findings of common ACTH pituitary adenoma including Ki-67 expression <3%. She achieved hypocortisolism after the 3rd surgery although ACTH levels remained slightly elevated. The patient returned some time later with fast worsening of hypercortisolism. Magnetic resonance imaging showed clivus invasion, which led to a fourth surgery and radiation. This time, immunohistochemistry revealed strong Ki-67 (10% to 15%) and p53 expression. Liver and lumbar spine metastases were found on workup. The patient died after few months due to lung infection. Pituitary carcinomas are rare, and the transformation of an ACTH-secreting pituitary adenoma into a carcinoma is exceptional. The difficulty of defining markers for the diagnosis of carcinoma, before metastasis diagnosis, in order to change the management of the disease, is a challenge.

Chronic spinal and oral morphine-induced neuroendocrine and metabolic changes in noncancer pain patients.

OBJECTIVE: Interactions between opioid use and hormonal function are documented in the literature. However, it is unclear if therapeutic intrathecal opioid therapy can induce hormonal changes, compared to oral opioid therapy. METHODS: The authors studied hormone and metabolic changes in 22 women (18-60 years) and 38 men (18-45 years) who were referred to a pain center. The patients were allocated to different treatment groups (based on assistant physicians' decision), as follows: 20 patients received oral morphine (60-120 mg/day); 20 patients, spinal morphine (0.2-10 mg/day); and 20 patients, nonopioid analgesic treatment. RESULTS: All three groups experienced substantial improvement in pain scores during the whole follow-up period. Significantly impaired libido, reduced potency, hot flashes, and menstrual cycle dysfunction occurred more often in both morphine groups than in the nonopioid group. Significantly low serum total testosterone levels were more prevalent in the spinal morphine group and the oral morphine group (58.3% and 70.0%, respectively) than in the control group (16.7%). Total cholesterol values above 200 mg/dL and higher ultrasensitive C-reactive protein levels were significantly more frequent in the morphine groups than in the controls. Total body bone mineral density was below normal in men receiving spinal morphine (P = 0.014). CONCLUSIONS: Hypogonadotrophic hypogonadism was more prevalent in the morphine groups and was correlated with clinical findings. Significant bone mass loss occurred in morphine users, even without hormone dysfunction when compared to nonopioid treatment. Growth hormone, thyroid stimulating hormone, adrenocorticotrophic hormones, and cardiovascular risk parameters were less compromised in morphine users.

Hypopituitarism due to hydrocephalus: case report and review of the literature.

INTRODUCTION: Although rare, chronic hydrocephalus may cause amenorrhea and delayed puberty associated with obesity as the main endocrine manifestations. Since the first operation carried out in 1950 on a patient with amenorrhea and hydrocephalus, fewer than 30 patients with these features have been reported. CASE REPORT: Our patient represents a teenage case of primary amenorrhea, partial adrenal insufficiency and adult growth hormone deficiency caused by hydrocephalus due to aqueductal stenosis. Our English-language literature search for similar well-documented cases yielded less than 30 cases. Our management consisted of endoscopic third ventriculostomy, which resulted in regular menstrual cycles and normalization of somato- and adrenocorticotropic axes. DISCUSSION: This is a rare case of a 20-year-old woman with primary amenorrhea caused by hydrocephalus due to aqueductal stenosis. Neurosurgical treatment produced relief in hypothalamic hydrodynamics tension, allowing recovery of hormonal function and restoring normal menstrual cycles.