Long-term response of pituitary carcinoma to temozolomide

Report of two cases

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✓Pituitary carcinoma is a rare tumor characterized by poor responsiveness to therapy, leading to early death. Reported responses to standard chemotherapy have only been anecdotal, with no single agent or combination demonstrating consistent efficacy in the treatment of patients with this disease. The authors report rare examples of a persistent response to cytotoxic chemotherapy in two patients with pituitary carcinoma.

One patient was a 38-year-old man with visual field loss caused by a luteinizing hormone–secreting pituitary carcinoma that had recurred despite multiple surgeries and radiation therapy. Intradural metastases to the spine that had failed to respond to radiation therapy were pathologically confirmed. The second patient was a 26-year-old man with hyperprolactinemia from a prolactin-secreting pituitary tumor. Spine magnetic resonance images obtained to search for causes of neck pain showed a vertebral tumor, which was later confirmed through pathological analysis to be a metastatic pituitary carcinoma. His disease progressed despite radiation therapy, high-dose bromocriptine, and chemotherapy.

Both patients were treated monthly with temozolomide, which was administered orally on the first 5 days of a 28-day cycle. The patient in the first case underwent all 12 treatment cycles without serious side effects, and his visual field deficits improved. The patient in the second case had undergone only 10 cycles when the drug was stopped because of his severe fatigue. Nonetheless, his pain disappeared and his serum prolactin concentration decreased. Both patients continue to have partial responses and have been employed full-time for more than 1 year after discontinuing temozolomide therapy. These two examples demonstrate that temozolomide may be effective in treating pituitary carcinomas and thus should be considered in the treatment algorithm for these difficult cases.

Abbreviations used in this paper:MIBG = metaiodobenzylguanidine; MR = magnetic resonance; PET = positron emission tomography.

Article Information

Address reprint requests to: Camilo E. Fadul, M.D., Section of Hematology/Oncology, Dartmouth–Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire 03756-0001. email: camilo.e.fadul@hitchcock.org.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. a: Visual field testing printout revealing severe bitemporal hemianopia before chemotherapy. b: Visual field testing printout obtained after 12 cycles of chemotherapy, demonstrating marked improvement in the visual fields. There was clinical improvement in the visual fields after the first three cycles of therapy, according to confrontation techniques.

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    Case 1. A: Coronal contrast-enhanced T1-weighted MR image of the brain obtained before treatment, revealing an invasive pituitary mass with suprasellar extension. B: Sagittal contrast-enhanced T1-weighted MR image of the spine obtained before treatment, demonstrating three extramedullary masses, the largest at C2–4. C and D: Coronal (C) and sagittal (D) contrast-enhanced T1-weighted MR images showing decreases in the pituitary mass and spinal metastases, respectively, after 12 cycles of chemotherapy. Response was stable more than 1 year after stopping treatment.

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    Case 2. Graph showing the serum prolactin concentration at approximately 6-month time intervals. The prolactin level was 694 ng/ml before starting temozolomide (TMZ) and decreased to 52 ng/ml after 10 treatment cycles. Prolactin levels remained below 50 ng/ml for more than 1 year after discontinuing chemotherapy. This patient continues to take high-dose bromocriptine.

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    Case 2. A: Coronal contrast-enhanced T1-weighted MR image of the brain revealing an enhancing pituitary mass infiltrating the cavernous sinus. B: Sagittal contrast-enhanced T1-weighted MR image of the spine obtained at baseline, demonstrating areas of marrow replacement within the T-1 and T-2 (arrows) vertebral bodies. C and D: Coronal (C) and sagittal (D) contrast-enhanced T1-weighted MR images obtained after 10 cycles of chemotherapy, exhibiting a pituitary mass stable in size and less apparent spine lesions (arrows) with a return of fat within the vertebral bodies, respectively.

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