Endo Toshiki, Ogawa Yoshikazu, Watanabe Mika, Tominaga Teiji
Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan.
Department of Neurosurgery, Kohnan Hospital, Sendai, Japan.
J Neurol Surg A Cent Eur Neurosurg. 2018 Jan;79(1):90-95. doi: 10.1055/s-0037-1600515. Epub 2017 Jun 6.
We report a case of a 66-year-old woman with a malignant transformation of a growth hormone (GH)-producing pituitary adenoma that was mainly located in the clivus. The patient originally presented with left oculomotor and abducens nerve palsies. Magnetic resonance imaging revealed a clival tumor separated from the normal pituitary gland, and the patient subsequently underwent transsphenoidal surgery. Analysis of the resected clival tissue revealed proliferation of tumor cells with slightly irregular nuclei but no mitosis. Although the Ki-67 labeling index was as high as 8.7%, p53 was negative. Histologic analysis confirmed the diagnosis of a GH-producing pituitary adenoma. Two months after the first operation, the tumor acutely enlarged and caused a subarachnoid hemorrhage. Pathologic findings of the second surgical specimen showed significant nuclear atypia. The Ki-67 labeling index increased to 27.7% and the p53 was positive; there was no GH immunoreactivity. Following the second surgical intervention, the patient was diagnosed with an atypical pituitary adenoma and underwent postoperative local radiotherapy (50 Gy in 25 fractions). Twenty months after the first surgery, multiple bone metastases were detected that led to the diagnosis of pituitary carcinoma. This is the first report of a clival pituitary adenoma undergoing malignant transformation. Because neuroimaging may underestimate local invasiveness in ectopic pituitary tumors, it is essential to conduct a histologic examination to evaluate it. Further analysis of similar cases is necessary to improve clinical management for this confused diagnostic criterion.
我们报告一例66岁女性，其生长激素（GH）分泌型垂体腺瘤发生恶变，肿瘤主要位于斜坡。患者最初表现为左侧动眼神经和展神经麻痹。磁共振成像显示斜坡肿瘤与正常垂体分离，患者随后接受了经蝶窦手术。对切除的斜坡组织进行分析，发现肿瘤细胞增殖，细胞核略不规则，但无有丝分裂。尽管Ki-67标记指数高达8.7%，但p53为阴性。组织学分析证实诊断为GH分泌型垂体腺瘤。首次手术后两个月，肿瘤急剧增大并导致蛛网膜下腔出血。第二次手术标本的病理结果显示明显的核异型性。Ki-67标记指数增至27.7%，p53呈阳性；无GH免疫反应性。第二次手术干预后，患者被诊断为非典型垂体腺瘤，并接受了术后局部放疗（25次分割，共50 Gy）。首次手术后20个月，检测到多处骨转移，从而诊断为垂体癌。这是斜坡垂体腺瘤发生恶变的首例报告。由于神经影像学可能低估异位垂体肿瘤的局部侵袭性，因此进行组织学检查以评估其情况至关重要。有必要对类似病例进行进一步分析，以改善这种诊断标准混乱的临床管理。
