Imaging diagnosis
Case 118
【Progress】He experienced consistent headache but no visual damages. Then, our neurosurgeon introduced him to other hospital where he was able to get multi-disciplinary treatment of chemotherapy, neuro-surgical resection, and platelets transfusion. Treatment for leukemia might be surpassed rather than that for pituitary adenoma.
【Discussion】
Leukemia with the decrease of platelet count causes bleeding complication such as subcutaneous minute bleeding (bruising, petechiae), gum bleeding and nasal bleeding. In our case, laboratory test revealed majority of white cells were occupied by blast cells, compatible with diagnosis of leukemia and the count of platelets was less than 15000/mm3, implying bleeding tendency. Although our patients had no findings of subcutaneous petechiae, gum and nasal bleedings, he experienced pituitary bleeding. In the literature, the incidence with pituitary apoplexy with leukemia is rare, only one report in 2000 (1), to best of our knowledge.
Pituitary apoplexy has been classically used for acute bleeding or infarction which typically causes loss of vision of the outer side of the visual field on both sides. It usually indicates acute hemorrhage in the pituitary adenoma (2-4). Pituitary bleeding is reported to be often accompanied with pituitary adenoma that is observed in 14 – 36 % of surgically resected adenomas (5). Non-functioning adenoma is more susceptible to cause bleeding rather than functioning adenoma. Of the bleeding pituitary adenomas, non-functioning adenomas are observed in 70 – 84 % (5). This is simply because non-functioning adenoma is delayed to being recognized, resulting in that the size of non-functioning adenoma is larger than that of hormone-producing adenoma when it is diagnosed.
Pituitary gland is divided into anterior lobe and posterior lobe. Anterior lobe is blood-supplied from a pair of superior hypophyseal artery and posterior lobe is blood-supplied from a pair of inferior hypophyseal artery. Both pairs of superior and inferior hypophyseal arteries are directly branched from C3 and C4, respectively of right and left internal carotid arteries. Superior hypophyseal artery forms the first network around the hypothalamus and the second network surrounding the anterior pituitary lobe. Both networks communicate, which is called hypothalamo-hypophyseal portal system and allows neuro-transmitters from hypothalamus to pituitary gland. Meanwhile, inferior hypophyseal artery supply infundibulum and posterior lobe forming posterior pituitary portal system. Both hypothalamo-hypophyseal portal system and posterior pituitary portal system drain into cavernous sinus.
The mechanism of pituitary bleeding is not clarified but considered due to the growing of immature tumor vessels with a tendency to hemorrhage or kinking or erosion of hypophyseal artery by tumor growth to against the diaphragm sellae (2-5). In our case, we do not have proof whether our patient had pituitary adenoma. However, possible hemorrhage is inferred to come from the combination of immature tumor vessels of latent pituitary adenoma combined with coagulopathy by leukemia.
Urgent surgery is required for persistent headache plus neuro-ophthalmic disorder. Elective surgery can be applied for persistent headache by hematoma compressing the surrounding without neuro-ophthalmic disorder if clinical treatment is not effective (2-5). In our case, CT showed high density area in the pituitary gland which was not so large to compress the surrounding. Further, he probably had leukemia. Then, urgent resection was not necessary and treatment for leukemia including platelets transfusion was preceded.
【Summary】
We present a forty six-year-old male suffering from leukemia and pituitary gland bleeding. Because he had no neuro-ophthalmic disorder, he was not scheduled to urgent surgery, but was transported to the hospital in order to get multidisciplinary treatment for leukemia and pituitary gland bleeding. The combination of leukemia with pituitary gland bleeding was rare, only one case in the literature. Although histologic specimen was not obtained, our patient has a possibility of having latent pituitary adenoma since pituitary bleeding was usually found based on the background of adenoma. It should be borne in mind that pituitary hemorrhage is often found in the surgically resected pituitary adenoma and pituitary gland bleeding occurs more in non-functioning adenoma rather than hormone-producing adenoma. Further, pituitary gland is blood-supplied from a pair of superior hypophyseal artery and inferior hypophyseal artery branched from C3 and C4 of both internal carotid arteries, respectively. Both of hypothalamo-hypophyseal portal system and posterior pituitary portal system, drain into cavernous sinus.
【References】
1.Wongpraparut N, et al. Pituitary apoplexy in a patient with acute myeloid leukemia and thrombocytopenia. Pituitary. 2000 Oct;3(2):113-116
2.Rajasekaran S, et al. (Jan 2011). UK guidelines for the management of pituitary apoplexy. Clin Endocrinol. 2011; 74 : 9–20.
3.Murad-Kejbou S, et al. "Pituitary apoplexy: evaluation, management, and prognosis". Current Opinion in Ophthalmology. 2009; 20 (6): 456–61.
4.Nawar RN, et al. "Pituitary tumor apoplexy: a review". J. Intens. Care Med. 2008; 23 : 75–90.
5.Kim DJ, et al. Pituitary Hemorrhage : Classification and Related Factors. J Korean Neurosurg Soc. 2009 ; 46: 23–30.
2018.8.29