Combined chronic lymphocytic leukemia and prolactinoma: a rare occurrence in a patient presenting with pituitary apoplexy

Case report

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The authors describe a rare case of combined pituitary chronic lymphocytic leukemia (CLL) and prolactinoma in a 77-year-old man presenting with apoplexy. This case highlights the importance of evaluating the pituitary gland in patients with CLL who present with clinical manifestations of apoplexy as well as the need to carefully evaluate pathological specimens from the gland for the presence of lymphocytic cells in those patients. This is the first reported case of a combined CLL–prolactinoma pituitary lesion presenting with apoplexy.

Abbreviation used in this paper:CLL = chronic lymphocytic leukemia.

Article Information

Address correspondence to: William T. Couldwell, M.D., Ph.D., Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, Utah 84132. email: neuropub@hsc.utah.edu.

Please include this information when citing this paper: published online May 17, 2013; DOI: 10.3171/2013.4.JNS122041.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial CT scans of the patient's head. A: Images without contrast enhancement demonstrating a large isodense expansile sellar lesion with patchy areas of hyperdensity within the sellar portion of the lesion, suggestive of acute hemorrhage. B: Images showing suprasellar extension and left cavernous sinus invasion, as well as erosion of the sellar floor and left sphenoid wing, including the foramen rotundum and vidian canal.

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    Magnetic resonance imaging obtained in the patient. Coronal and axial T1-weighted MR images with Gd enhancement (A) demonstrate a large, minimally enhancing tumor measuring 4.0 ×3.7 ×3.7 cm located within an expanded sella and extending into the adjacent suprasellar compartment, compressing both the pituitary stalk and optic chiasm, and into the left cavernous sinus space, encasing the left internal carotid artery. Axial and sagittal T1-weighted (B) and axial T2-weighted MR images without contrast enhancement (C) reveal acute and chronic hemorrhage of mixed ages.

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    Photomicrographs demonstrating fragments of pituitary adenoma surrounded by acute hemorrhage (A) as well as intermingled, small, monotonous lymphocytic cells (B); H & E. Immunohistochemical analysis revealed all of the lymphocytes to be positive for CD5 (C), and the majority were CD20 positive. The pituitary adenoma cells were prolactin positive (D) but negative for adrenocorticotropic hormone and growth hormone. Original magnification ×400 (A–D).

References

  • 1

    Altay TKrisht KMCouldwell WT: Sellar and parasellar metastatic tumors. Int J Surg Oncol 2012:6472562012

  • 2

    Barcos MLane WGomez GAHan TFreeman APreisler H: An autopsy study of 1206 acute and chronic leukemias (1958 to 1982). Cancer 60:8278371987

  • 3

    Bills DCMeyer FBLaws ER JrDavis DHEbersold MJScheithauer BW: A retrospective analysis of pituitary apoplexy. Neurosurgery 33:6026091993

  • 4

    Bjerre PLindholm J: Pituitary apoplexy with sterile meningitis. Acta Neurol Scand 74:3043071986

  • 5

    Bleibtreu L: Ein Fall von Akromegalie (Zerstörung der Hypophyse durch Blutung). Münch Med Wochenschr 52:207920801905

  • 6

    Bonicki WKasperlik-Załuska AKoszewski WZgliczyński WWisławski J: Pituitary apoplexy: endocrine, surgical and oncological emergency. Incidence, clinical course and treatment with reference to 799 cases of pituitary adenomas. Acta Neurochir (Wien) 120:1181221993

  • 7

    Bower JHHammack JEMcDonnell SKTefferi A: The neurologic complications of B-cell chronic lymphocytic leukemia. Neurology 48:4074121997

  • 8

    Brougham MHeusner APAdams RD: Acute degenerative changes in adenomas of the pituitary body—with special reference to pituitary apoplexy. J Neurosurg 7:4214391950

  • 9

    Cardoso ERPeterson EW: Pituitary apoplexy: a review. Neurosurgery 14:3633731984

  • 10

    Cramer SCGlaspy JAEfird JTLouis DN: Chronic lymphocytic leukemia and the central nervous system: a clinical and pathological study. Neurology 46:19251996

  • 11

    Fain JSNaeim FBecker DPVan Herle AYan-Go FPetrus L: Chronic lymphocytic leukemia presenting as a pituitary mass lesion. Can J Neurol Sci 19:2392421992

  • 12

    Gétaz EPMiller GJ: Spinal cord involvement in chronic lymphocytic leukemia. Cancer 43:185818611979

  • 13

    Hernández JALand KJMcKenna RW: Leukemias, myeloma, and other lymphoreticular neoplasms. Cancer 75:1 Suppl3813941995

  • 14

    Hoeller SZhou YKanagal-Shamanna RXu-Monette ZYHoehn DBihl M: Composite mantle cell lymphoma and chronic lymphocytic leukemia/small lymphocytic lymphoma: a clinicopathologic and molecular study. Hum Pathol 44:1101212013

  • 15

    Kingdon CCSidhu PSCohen J: Pituitary apoplexy secondary to an underlying abscess. J Infect 33:53551996

  • 16

    Lane PKTownsend RMBeckstead JHCorash L: Central nervous system involvement in a patient with chronic lymphocytic leukemia and non-Hodgkin's lymphoma (Richter's syndrome), with concordant cell surface immunoglobulin isotypic and immunophenotypic markers. Am J Clin Pathol 89:2542591988

  • 17

    Liepman MKVotaw ML: Meningeal leukemia complicating chronic lymphocytic leukemia. Cancer 47:248224841981

  • 18

    Linet MSDevesa SSMorgan GJThe leukemias. Schottenfeld DFraumeni JF Jr: Cancer Epidemiology and Prevention ed 3New YorkOxford University Press2006. 841871

  • 19

    López Guillermo ACervantes FBladé JMatutes EUrbano AMontserrat E: Central nervous system involvement demonstrated by immunological study in prolymphocytic variant of chronic lymphocytic leukemia. Acta Haematol 81:1091111989

  • 20

    Mitterlechner TFiegl MMühlböck HOberaigner WDirnhofer STzankov A: Epidemiology of non-Hodgkin lymphomas in Tyrol/Austria from 1991 to 2000. J Clin Pathol 59:48552006

  • 21

    Nimubona SBernard MMorice PBrassier GCaulet-Maugendre SCarsin B: Complications of malignancy: case 3. Chronic lymphocytic leukemia presenting with panhypopituitarism. J Clin Oncol 22:3743762004

  • 22

    Oshimi KAkahoshi MHagiwara NTanaka MMizoguchi H: A case of T-cell chronic lymphocytic leukemia with an unusual phenotype and central nervous system involvement. Cancer 55:193719421985

  • 23

    Rawstron ACBennett FLO'Connor SJKwok MFenton JAPlummer M: Monoclonal B-cell lymphocytosis and chronic lymphocytic leukemia. N Engl J Med 359:5755832008

  • 24

    Reid RLQuigley MEYen SS: Pituitary apoplexy. A review. Arch Neurol 42:7127191985

  • 25

    Rye ADStitson RNDyer MJ: Pituitary infiltration in B-cell chronic lymphocytic leukaemia. Br J Haematol 115:7182001

  • 26

    Semple PLWebb MKde Villiers JCLaws ER Jr: Pituitary apoplexy. Neurosurgery 56:65732005

  • 27

    Stagg MPGumbart CH: Chronic lymphocytic leukemic meningitis as a cause of the syndrome of inappropriate secretion of antidiuretic hormone. Cancer 60:1911921987

  • 28

    Steinberg JPPecora MLokey JL: Leukemic meningitis in B-cell chronic lymphocytic leukemia. Cancer Treat Rep 69:6876881985

  • 29

    Verrees MArafah BMSelman WR: Pituitary tumor apoplexy: characteristics, treatment, and outcomes. Neurosurg Focus 16:4E62004

  • 30

    Wakai SFukushima TTeramoto ASano K: Pituitary apoplexy: its incidence and clinical significance. J Neurosurg 55:1871931981

  • 31

    Winer JBPlant G: Stuttering pituitary apoplexy resembling meningitis. J Neurol Neurosurg Psychiatry 53:4401990. (Letter)

  • 32

    Yamamoto JFGoodman MT: Patterns of leukemia incidence in the United States by subtype and demographic characteristics, 1997–2002. Cancer Causes Control 19:3793902008

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