Early and isolated breast cancer metastasis to the pituitary: A case report and systematic review

Abstract

Background: Pituitary metastases (PMs) arising from breast cancer tend to occur many years following initial diagnosis, and after other systemic metastasis have been identified. Survival is generally considered to be poor. However, there are cases where patients present with an isolated metastatic lesion in the pituitary. Survival in this subset of patients has not been evaluated. We present a case of isolated PM that presented two years after initial diagnosis of breast cancer. We performed a systematic review of 38 breast cancer patients with PM. We report presentation, treatment strategy, and outcomes of breast cancer metastasis to the pituitary and highlight cases of isolated PM.

Case description: A 39 year old female presented with complaints of headache and polydipsia two years after diagnosis with breast cancer. Systemic workup was unremarkable, but brain imaging identified an isolated PM. Transsphenoidal debulking was performed with adjuvant radiation therapy (RT) targeted to the sellar region. Unfortunately, she passed away 9 months later from systemic progression.

Conclusion: A total of 38 patients were included systematic review. Of these, 13 had isolated PM. Prevalent signs/ symptoms included visual disturbance, diabetes insipidus (DI), and hypothalamic dysfunction. Patients treated with surgical resection and adjuvant chemotherapy (ChT), or RT had better survival than those treated with resection alone. Patients that receive treatment for isolated PM may survive for many years without progression or recurrence.

Keywords: Breast cancer; Breast neoplasms; Pituitary gland; Pituitary metastasis; Pituitary neoplasms; Skull base.

Figure 1:

MRI showing PM and. (a-d) Preoperative coronal and sagittal T1 MRI with and without contrast showing a lesion in the pituitary stalk and gland. There is mild splaying of the optic chiasm with lateral displacement of the left optic nerve. (e and f) A residual tumor involving the stalk and hypothalamus was identified on postoperative coronal and sagittal T1 MRI with contrast. (g and h) A follow-up MRI of the brain and cervical spine with contrast showed a leptomeningeal metastatic disease. (i) A follow-up MRI of the brain with contrast showing hydrocephalus due to leptomeningeal disease. A palliative ventriculoperitoneal shunt was placed.

Figure 2:

Histological appraisal of PM. (a) Hematoxylin and eosin stained section demonstrating neoplastic cells with anaplastic nuclei, prominent nucleoli, and mitotic activity. (b) Cytokeratin 7 immunohistochemically stained section showing strong, diffuse cytoplasmic immunopositivity. (c) Cytokeratin 20 immunohistochemically stained section showing immunonegativity. (d) Gata3 labeled section showing strong nuclear positivity.

Figure 3:

PRISMA flowchart for literature review.

Figure 4:

Kaplan–Meier representation of survival. (a) Comparing overall survival with and without adjuvant RT. (b) Comparing overall survival between isolated PM and patients with peripheral metastasis. PM: Pituitary metastases, RT: Radiation therapy, ChT: Chemotherapy.