A Case of Giant Pituitary Adenoma Associated with a Postoperative Mental Disorder That Ultimately Resulted in Bilateral Blindness

Abstract

Purpose: To report the case of a patient with adrenocorticotropic hormone (ACTH)-producing pituitary adenoma who developed a mental disorder after initial surgery that kept him from undergoing scheduled follow-up visits and who ultimately had a giant recurrent tumor that resulted in blindness.

Case report: A 37-year-old male presented with the primary complaint of decreased visual acuity (VA) in both eyes and visual field defects. Visual field examination revealed bitemporal hemianopia. Magnetic resonance imaging (MRI) showed a pituitary tumor of approximately 4 cm in diameter extending from the intrasellar region to the sphenoid sinus and the suprasellar region. Transnasal transsphenoidal surgery was performed. Immunostaining of tumor tissue collected intraoperatively showed ACTH-positive cells, thus leading to the diagnosis of ACTH-producing pituitary adenoma. Postoperatively, the patient reportedly developed mental disorder that possibly interfered with scheduled appointments or continuous follow-up visits for many years, so we had no postoperative data about the vision/visual filed. Seven years later, he presented with markedly decreased VA (i.e., no light perception) in both eyes. Fundus examination showed bilateral marked optic disc atrophy. MRI showed a larger than 8-cm diameter giant recurrent pituitary adenoma in the suprasellar region, for which craniotomy was performed for partial tumor resection. Preoperatively, his blood cortisol level was low, and the lesion was deemed a nonfunctioning pituitary adenoma. Postoperatively, no significant complications occurred, yet his VA was no light perception OD and light perception OS.

Conclusions: Clinicians should be aware that patients with ACTH-producing pituitary adenomas may develop a mental disorder following surgery and possibly be unable to undergo scheduled follow-up, thus illustrating the importance of establishing an adequate patient follow-up system.

Keywords: Adrenocorticotropic hormone; Blindness; Depression; Giant recurrent tumor; Pituitary adenoma.

Fig. 1

Fundus photographs (a: right eye, b: left eye) and Goldmann visual field perimetry findings (c: left eye, d: right eye) obtained before the first operation in 2010. Fundus examination showed predominant optic disc atrophy in the right eye. Goldmann perimetry findings showed bitemporal hemianopia, and in detail, complete temporal loss and inferonasal defect in the right eye and defects in the temporal half of the left eye.

Fig. 2

MRI images of the patient's head obtained before the first operation in 2010 and before the second operation in 2017. Before the first operation in 2010, the MRI sagittal (a) and coronal section (b) showed a giant cystic mass approximately 4 cm in diameter extending from the intrasellar region to the sphenoid sinus and the suprasellar region. Before the second operation in 2017, the MRI sagittal (c) and coronal section (d) showed a giant cystic mass larger than 8 cm in diameter in the suprasellar region (T1-weighted image).

Fig. 3

Histopathological finding of the tumor tissue collected at the first operation (a: hematoxylin and eosin stain, b: immunostaining for ACTH). Immunostaining of the tumor tissue, which was collected intraoperatively, showed adrenocorticotropic hormone (ACTH)-positive cells.