Abstract: MON 464
Diabetes Insipidus in a Patient with Leukemia and Lung Cancer
Presenter: Susana Mallea Gil
Background: Metastatic tumors to the pituitary gland are rare. The most frequent are metastases from breast and lung cancer. Sellar metastasis should be suspected in patients with diabetes insipidus, elderly patients, rapid progression of relevant symptoms and lesions in the pituitary gland, visible on MRI, and even in those patients without known malignancy.view more
Background: Metastatic tumors to the pituitary gland are rare. The most frequent are metastases from breast and lung cancer. Sellar metastasis should be suspected in patients with diabetes insipidus, elderly patients, rapid progression of relevant symptoms and lesions in the pituitary gland, visible on MRI, and even in those patients without known malignancy.
Clinical case: A 55-year woman was hospitalized because she presented with fever, edema and pain in the left arm for 1 week, venous thrombosis of left axillary, humeral and jugular veins was diagnosed and treated with acenocoumarol and enoxaparine. The patient had a 90 pack-year smoking history. Seventeen years before she had had thallium intoxication with nephritis and amaurosis of the right eye. Two months before hospitalization, a pericardial effusion was diagnosed and the patient began treatment with furosemide, carvedilol and losartan. Three weeks before her admission to the hospital, she stopped smoking and began with polyuria and polydipsia, a restriction test was performed and diabetes insipidus was confirmed and treated with desmopressin; pituitary MRI showed pituitary stalk thickening (5 mm) and neurohypophysis was not visualized. Hormonal test showed decreased LH (1.2 mUI/ml, n: 8-58), and FSH (9 mUI/ml, n: 25.8-134.8) and slight hyperprolactinemia (45 ng/ml, n: 4.6-21.4), the remaining hormones were normal. Thoracic CT-scan and neck ultrasonography showed multiple lymphadenopathies in the neck, axillary regions and mediastinum, severe pericardial effusion (23 mm), slight left basal and posterior pleural effusion with lung atelectasis, emphysema mainly in both lung apexes. The patient developed pulmonary embolism of the right inferior lobe. Bone scintigraphy showed pathologic images in 2 ribs (left and right). Neck lymphadenopathy biopsy showed replacement of the normal tissue by atypical lymphocytes and metastasis of a carcinoma. Immunohistochemistry study was positive for CD20, CD23, CD5, CD43, which confirmed chronic lymphocytic leukemia (CLL); and parakeratin, TTF-1 and Napsin A, confirmed lung adenocarcinoma. Chemotherapy and radiotheraphy were scheduled but she never received these treatments because the patient began with dyspnea and dysphagia, thoracic and left arm pain worsened and the pleural effusion progressed. MRI showed brain metastases. The patient died 2 months after diagnosis.
Conclusion: Our patient presented with 2 newly diagnosed cancers, CLL and lung adenocarcinoma; a pituitary lesion with diabetes insipidus and hypogonadism. We assumed that the pituitary metastasis was due to lung cancer because central nervous system involvement by CLL has extremely low frequency. The surgical resection could lead to the improvement of symptoms, but we could not operate this patient. The prognosis of the disease is usually poor, as it was the case in our patient.