Simultaneous Convexity Meningioma and Prolactinoma

Sir,

The coexistence of simultaneous pituitary adenoma and intracranial tumor is frequent and is widely identified in patients who have had radiotherapy as treatment for adenoma, as well as patients with neurocutaneous syndromes, such as Neurofibromatosis, and patients with breast cancer and meningioma apparently due to hormonal influence.[123] However, the presence of pituitary adenoma simultaneous with intracranial tumor is very rare, especially as an adjacent lesion.[12345]

A 57-year-old right-handed dominant man, with Type 2 diabetes, presented to the emergency unit after experiencing a generalized tonic–clonic seizure; he mentioned that he has had 3 previous episodes of seizures in past month, all of them involving disconnection with the environment, perioral cyanosis, urinary incontinence, and decreasing visual acuity. On neurological examination, the patient has motor aphasia and right hemiparesis. Magnetic resonance image of the brain reported a lesion in the sellar region and a tumor mass suggestive of a convexity left frontal meningioma [Figure 1a-d].

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Figure 1(a-d)

Magnetic resonance imaging of brain showing two tumor lesions, the first compatible with convexity meningioma and the second with hypophyseal adenoma with supra sellar expansion of 2 cm × 1.7 cm

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It was decided for surgical treatment, with resection of the left frontal convexity meningioma (Simpson I). An extra-axial dura mater adherent, regularly vascularized, solid neoplasm with local bone involvement, exerting significant mass effect over cerebral parenchyma was found. The lesion was completely removed, along with the involved dura mater portion, a 1 cm dural margin and the affected bone portion. A duroplasty with pericranium was then performed, and medical treatment with cabergoline was started by the endocrinology team for a prolactin-producing pituitary macroadenoma.

Postsurgery follow-ups with total seizure control and partial improvement of motor and language impairment were pathology results: mixed and metaplastic meningioma. The patient was discharged home 7 days after the procedure for outpatient follow-up.

There were few case reports of pituitary adenomas coincident with tumors of glial origin, such as medulloblastomas, schwannomas, meningiomas, and some of them even with contiguous lesions.[14] Pituitary adenomas represent 10% of all intracranial neoplasms, and meningiomas 15%, nevertheless, it is very uncommon to find a synchronic growth of these two lesions.[5] The most common concurrence of simultaneous tumors is of glioma with meningioma, followed by pituitary adenoma with meningioma, and neurinoma with meningioma.[4] The synchronic appearance of pituitary adenoma and meningioma has several theories; Furtado et al. suggest an undetermined genetic association among simultaneous intracranial tumors, and describe certain abnormalities in chromosomes 14 and 22, which are shared between pituitary adenomas and meningiomas.[34] High levels of prolactin receptors or insulin-like growth factors 1 that stimulate mesodermic and ectodermic cell growth, that leads to tumor growth, may be present in functional adenomas.[4] Ubea et al. have described that pituitary adenomas express fibroblast growth factor 1 and 2, along with multiple endocrine neoplasm, meningiomas and high circulating levels. Cannavò et al.[1] found no relation between simultaneous growth hormone-secreting adenoma with meningioma, and receptors for growth hormone and growth factors in meningiomas; forth is reason, the authors believe these are independent events. High-resolution imaging techniques can influence the fortuitous detection of coexistent intracranial tumors.[6] The relationship between pituitary adenomas treated with radiation and asynchronous growth of a meningioma is deeply studied and well recognized, given that it is more frequent in these situations growth of sarcoma and glioma neoplasms.[2356] Functioning and nonfunctioning pituitary adenomas associated to meningiomas have approximately the same prevalence, from which growth hormone-secreting and prolactinoma are more frequent. The predominant histological types of meningioma are meningoendothelial and transitional.[13]

Finally, surgical resection is indicated for the meningioma, and the management of the pituitary adenoma is depended on tumor size and hormonal type. The multidisciplinary management by neurosurgery and endocrinology team will be fundamental for the successful resolution of these pathologies.