Case Report
Pituitary apoplexy following gonadotropin-releasing hormone agonist administration with gonadotropin-secreting pituitary adenoma

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Abstract

Gonadotropin-releasing hormone (GnRH) agonists are widely used in hormone therapy for prostate cancer. We report a patient with pituitary apoplexy following this therapy as a rare complication and review the related literature. A 62-year-old man presented with elevated prostate specific antigen. Transrectal ultrasound guided biopsy of the prostate gland revealed adenocarcinoma. Whole-body 18F-fluorodeoxyglucose (FDG) positron emission tomography/CT scan showed FDG-uptake in the pituitary region. MRI also demonstrated a pituitary tumor, diagnosed as an incidental non-functioning adenoma. The patient received his first dose of GnRH agonist (leuprolide 11.25 mg) against prostate cancer. He complained of a severe headache 10 minutes after leuprolide administration and suffered from right third nerve palsy in the next 48 hours. MRI demonstrated a high intensity area on T1-weighted images, diagnosed as pituitary apoplexy. The patient underwent transsphenoidal surgery. Pathology revealed predominantly necrotic tissue and a gonadotropin secreting pituitary adenoma. Overall, 15 patients, including ours, have been reported with pituitary apoplexy after GnRH agonists with pathologic gonadotropin secreting adenoma. Fourteen of 15 patients were male. Pituitary apoplexy developed within 4 hours after administration of the agents in 8/15 patients. The combined data suggest that GnRH agonists have the potential to precipitate pituitary apoplexy in men with gonadotropin secreting adenoma. Therefore, prior to GnRH agonist therapy for prostate cancer, a known pituitary adenoma should be treated. Otherwise, the patients should be cautiously observed for any symptomatic change following drug administration.

Introduction

Gonadotropin-releasing hormone (GnRH) agonists have become the a common treatment for prostate cancer, premenopausal breast cancer, and myoma of the uterus [1]. We encountered a patient with a pituitary macroadenoma who developed pituitary apoplexy following administration of a GnRH agonist for the treatment of prostate cancer.

Section snippets

Case report

A 62-year-old man was initially evaluated for an elevated prostate specific antigen level of 7.5 ng/mL (normal range 0–4 ng/mL). A transrectal ultrasound guided biopsy of the prostate gland revealed adenocarcinoma. Whole-body 18F-fluorodeoxyglucose positron emission tomography/CT scan for the detection of metastatic lesions showed uptake in the pituitary region. MRI demonstrated a 22 mm pituitary tumor extending into the sphenoid sinus without compressing the optic chiasm (Fig. 1A). His basal

Discussion

Fifteen patients, including the current one, have been reported to have suffered pituitary apoplexy after GnRH agonist administration (Table 1) [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. All reported patients had a gonadotropin secreting macroadenoma. Pituitary apoplexy developed within 4 hours after the administration of the agents in 8/15 patients. All patients experienced severe headache as the first clinical sign and progressive symptoms (visual disturbance,

Conclusion

The combined data suggest that GnRH agonists have the potential to precipitate pituitary apoplexy in men with gonadotropin-secreting adenoma. When GnRH agonist therapy is planned for a patient with a known pituitary adenoma, the pituitary adenoma should be treated prior to GnRH agonist administration. Otherwise, the patient should be observed cautiously for any symptomatic change following drug administration.

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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