title: Different imaging characteristics of concurrent pituitary adenomas in a patient with Cushing's disease.
abstract: We report a patient with Cushing's disease (CD) and two pituitary adenomas that demonstrated different imaging characteristics and therefore suggest an alternative imaging strategy for these patients. A 42-year-old woman presented with signs and symptoms of CD. Biochemical evaluation confirmed hypercortisolemia and suggested CD. On pituitary MRI with spoiled gradient recalled acquisition in the steady-state and T1-weighted spin echo protocols, a 5mm hypoenhancing region typical for a pituitary adenoma was identified on the left. However, after surgical resection the patient remained hypercortisolemic and pathology revealed a non-functional adenoma. At early repeat surgical exploration a 10mm adenoma was found in the right side of the gland. Postoperatively the patient became hypocortisolemic and pathology demonstrated an adrenocorticotropic hormone (ACTH)-staining adenoma. On review of the initial MRI this tumor corresponded to a region of contrast retention best visualized on delayed fluid attenuated inversion recovery (FLAIR) imaging. While the incidentaloma in this case demonstrated classical imaging characteristics of a pituitary adenoma the larger ACTH-secreting tumor was best appreciated by contrast retention. This suggests a role for delayed postcontrast FLAIR imaging in the preoperative evaluation of CD. ACTH-secreting tumors causing CD cause significant morbidity. Due to their small size, a pituitary adenoma is frequently not identified on imaging despite endocrinologic testing suggesting CD. Regardless of improvements in MRI, many tumors are only identified at surgical exploration.
authors.affiliation: Surgical Neurology Branch, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Room 3D20, 10 Center Drive, Bethesda, MD 20814, USA.
authors.forename: Gautam U
authors.initials: GU
authors.lastname: Mehta
authors.affiliation: Surgical Neurology Branch, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Room 3D20, 10 Center Drive, Bethesda, MD 20814, USA.
authors.forename: Blake K
authors.initials: BK
authors.lastname: Montgomery
authors.affiliation: Section on Reproductive Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
authors.forename: Pooja
authors.initials: P
authors.lastname: Raghavan
authors.affiliation: Section on Reproductive Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
authors.forename: Susmeeta
authors.initials: S
authors.lastname: Sharma
authors.affiliation: Section on Reproductive Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
authors.forename: Lynnette K
authors.initials: LK
authors.lastname: Nieman
authors.affiliation: Diagnostic Radiology, Walter Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Patronas
authors.affiliation: Surgical Neurology Branch, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Room 3D20, 10 Center Drive, Bethesda, MD 20814, USA; Department of Neurosurgery, University of Virginia Health Sciences Center, University of Virginia, Charlottesville, VA, USA.
authors.forename: Edward H
authors.initials: EH
authors.lastname: Oldfield
authors.affiliation: Surgical Neurology Branch, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Room 3D20, 10 Center Drive, Bethesda, MD 20814, USA. Electronic address: prashant.chittiboina@nih.gov.
authors.forename: Prashant
authors.initials: P
authors.lastname: Chittiboina
mesh_terms: D000236:Adenoma / Q000150:complications* / Q000175:diagnosis* / Q000601:surgery; D000328:Adult; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D011939:Mental Recall; D047748:Pituitary ACTH Hypersecretion / Q000150:complications* / Q000175:diagnosis* / Q000601:surgery; D010902:Pituitary Gland / Q000473:pathology / Q000601:surgery; D010911:Pituitary Neoplasms / Q000150:complications* / Q000175:diagnosis* / Q000601:surgery
keywords: Cushing’s disease; Delayed MRI; Fluid attenuated inversion recovery imaging; Pituitary adenoma; Transsphenoidal surgery
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