title: Double pituitary lesions in three patients with Cushing's disease.
abstract: Double pituitary adenomas are rare in surgical specimens and the most common clinical feature in reported patients has been acromegaly. We report 3 cases of double pituitary lesions in patients who presented with Cushing's disease. In a 22-year-old man (case 1) with delayed puberty and low testosterone levels, mild hyperprolactinemia was diagnosed and treated with dopamine agonist therapy that reduced the prolactin (PRL) levels to normal. Over a 1-year period Cushing's disease developed gradually and was confirmed with classical endocrine testing. In a 27-year-old woman (case 2) who initially presented with severe depression and morbid obesity there was a gradual onset of Cushing's disease; initially she had minimally elevated serum PRL. In a 33-year-old woman (case 3) there was a 2-year history of Cushing's disease characterized by hirsutism, hypertension and weight gain; serum PRL was normal. Magnetic resonance imaging in all 3 patients revealed a microadenoma that was successfully removed by transsphenoidal pituitary surgery. Histology and immunocytochemistry in case 1 and case 3 revealed a corticotroph cell adenoma and a PRL cell adenoma in separate areas of the pituitary. In case 3 the PRL cell adenoma was "silent" but in case 1 the PRL cell adenoma may have been the cause of the mild hyperprolactinemia. In case 2 nodular corticotroph hyperplasia was the cause of Cushing's disease and a "silent" PRL cell adenoma was also identified. We conclude from these cases and a literature review that double pituitary lesions may occur in patients with Cushing's disease. The corticotroph part of the double lesion may consist of a corticotroph cell adenoma or, as reported in this study, of corticotroph nodular hyperplasia. The counterpart of the double lesion may consist either of a "silent" PRL cell adenoma or a functional PRL cell adenoma causing hyperprolactinemia.
authors.affiliation: Department of Neurosurgery, Health Sciences Center, University of Virginia, Charlottesville, Virginia 22908-0214, USA.
authors.forename: B P
authors.initials: BP
authors.lastname: Meij
authors.forename: M B
authors.initials: MB
authors.lastname: Lopes
authors.forename: M L
authors.initials: ML
authors.lastname: Vance
authors.forename: M O
authors.initials: MO
authors.lastname: Thorner
authors.forename: E R
authors.initials: ER
authors.lastname: Laws
mesh_terms: D000236:Adenoma / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery; D000328:Adult; D003480:Cushing Syndrome / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D008279:Magnetic Resonance Imaging; D008297:Male; D008854:Microscopy, Electron; D010911:Pituitary Neoplasms / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery