A 65‐year‐old man with a 50‐pack‐year smoking history but no known chronic medical problems presented to the emergency department with eight days of left retro‐orbital pain and frontal headache and five days of diplopia and left ptosis. Within the past few days, a neurologist had started topiramate, without effect on his symptoms. Exam revealed evidence of dysfunction of the left third, fifth, and sixth cranial nerves. Computed tomographic (CT) scan of the head and subsequent magnetic resonance imaging scan of the sella turcica revealed a sellar mass, extending into the suprasellar cistern and left cavernous sinus. There was no clinical or laboratory evidence of pituitary dysfunction. Neurosurgery felt that the imaging findings were consistent with meningioma and planned surgical resection. Hospital Medicine was consulted for pre‐operative risk assessment. On further questioning, the patient reported two months of mild, stable dyspnea on exertion following treatment of a pulmonary infection with a five‐day course of an unknown antibiotic. A chest radiograph revealed an ill‐defined left upper lung opacity. CT scan of the chest revealed a spiculated left hilar mass, a smaller right upper lung nodule, extensive intrathoracic lymphadenopathy, and left pleural effusion. Transbronchial lung biopsy and thoracentesis revealed poorly‐differentiated adenocarcinoma. The sellar mass noted on imaging was felt to represent metastatic lung adenocarcinoma, not meningioma. Surgery was cancelled. The patient sought outpatient evaluations by radiation oncology and medical oncology and was lost to follow up.
Non‐small cell lung cancer (NSCLC) most frequently metastasizes to the liver, adrenal glands, bones, and brain. Although NSCLC can spread to any part of the body, involvement of the pituitary gland is rare. Pituitary adenoma is the most common cause of sellar mass in adults. Metastases to the hypothalamus and pituitary gland account for only 1‐2% of sellar masses. They can be associated with many cancers, but most commonly with breast cancer in women and lung cancer in men. Only 7% of pituitary metastases are symptomatic. Diabetes insipidus, anterior pituitary dysfunction, visual field defects, retro‐orbital pain, and ophthalmoplegia are the most commonly reported symptoms. Survival among patients with pituitary metastases is poor, with mean survival rates ranging 6‐22 months.
The purpose of reporting this case is to highlight an unusual clinical presentation and site of metastasis of a malignancy which is frequently encountered in the practice of hospital medicine. Hospitalists are frequently called upon to provide “routine” pre‐operative risk assessment. This case highlights the importance of a detailed history, physical exam, and chart review with every new patient encounter, even in seemingly mundane circumstances.
To cite this abstract:Wixted D. The Eyes Have It: Rare Presentation of a Common Malignancy. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 679. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/the-eyes-have-it-rare-presentation-of-a-common-malignancy/. Accessed April 3, 2020.