The pituitary gland is an uncommon site of metastatic involvement, with a reported overall incidence ranging from less than 1% to 5% in autopsy series. The most common primary sources of metastatic lesions are breast, lung, colon, and prostate. Solitary renal cell carcinoma (RCCA) metastasis to the pituitary is an unusual pathological finding. Of the 8 such cases that have been reported so far, there have been only 2 cases with impotence being the presenting symptom. A 68-year-old man was diagnosed with RCCA in 2001. After right radical nephrectomy he was clinically stable till 2005 when he developed diplopia, headaches, fatigue, and impotence over a period of 6 months. Magnetic resonance imaging (MRI) of the brain done upon initial presentation to the local physician was reported as negative and the patient was empirically started on steroids for presumed temporal arteritis. His headaches improved partially. Temporal artery biopsy was negative but because of symptomatic relief he was continued on 15 mg of prednisone per day. Four months later he developed left sixth nerve palsy and repeat MRI revealed a 3.6 cm hypodense enhancing intrasellar mass involving all of the left cavernous sinus and much of the sella turcica with high signal densities within the lesion consistant with hemorrhages. Hormonal tests showed primary hypogonadism (FSH 2.5, LH 1.1, testosterone 63) and central hypothyroidism (free T4 0.31 TSH 0.25). Prolactin, cortisol, and IGF-1 were within normal limits. The patient had no polyuria or polydipsia and the serum sodium was normal. CT chest and PET scan were performed and showed no evidence of metastais. He underwent transnasal transsphenoidal resection of the lesion. Final pathology was consistent with metastatic RCCA. Metastasis to the pituitary is most frequently found in the posterior lobe and symptoms that arise are due to diabetes insipidus. Review of the reported cases of metastatic RCCA shows that such cases have a predilection for the anterior pituitary, often presenting as visual disturbances. The aggressive nature of the RCCA metastatic lesions, its slow growth, and its highly vascular nature may explain the earlier involvement of the anterior pituitary gland. Our case is unusual because of impotence being one of the initial presenting symptoms, which is very rare and often easily ignored. This underscores the fact that onset of impotence in an otherwise healthy individual should be regarded as an important symptom that merits further investigation.
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