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CASE REPORT
Year : 2009  |  Volume : 5  |  Issue : 4  |  Page : 309-311

Chordoma with increased prolactin levels (pseudoprolactinoma) mimicking pituitary adenoma: A case report with review of the literature


1 Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
2 Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
3 Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Date of Web Publication11-Feb-2010

Correspondence Address:
Pavan Kumar
Department of Radiotherapy, Regional Cancer Centre, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.59912

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 > Abstract 

The article deals with a rare case of chordoma with increased prolactin levels. It could often result in a diagnostic dilemma and problems in differentiating it from a pituitary adenoma.

Keywords: Chordoma, pituitary adenoma, pseudoprolactinoma


How to cite this article:
Kumar P, Kumar P, Singh S, Kumari N, Datta N R. Chordoma with increased prolactin levels (pseudoprolactinoma) mimicking pituitary adenoma: A case report with review of the literature. J Can Res Ther 2009;5:309-11

How to cite this URL:
Kumar P, Kumar P, Singh S, Kumari N, Datta N R. Chordoma with increased prolactin levels (pseudoprolactinoma) mimicking pituitary adenoma: A case report with review of the literature. J Can Res Ther [serial online] 2009 [cited 2020 Oct 26];5:309-11. Available from: https://www.cancerjournal.net/text.asp?2009/5/4/309/59912


 > Introduction Top


Chordomas are rare neoplasms of the axial skeleton arising from remnants of primitive notochord. The tumor typically originates either in sacrum or clivus and usually presents with headache, visual disturbances, nasal stuffiness, or cranial nerve defects. Increased serum prolactin levels are diagnostic of prolactin secreting pituitary adenoma and are rarely seen with chordomas. Hyperprolactinemia in these cases could result in a diagnostic dilemma. To the best of our knowledge, only two such cases of chordoma mimicking a pituitary tumor have been reported in the literature so far. [1],[2]


 > Case Report Top


A 60-year-old, postmenopausal lady presented to the department of neurosurgery with the complaints of headache, grand mal-seizures, diplopia, and progressive vision loss in both eyes for 2 months. Ophthalmic examination revealed visual acuity of 6/60 and 6/36 in the right and left eye respectively with bitemporal field defects along with bilateral primary optic atrophy. There were no other neurological deficits.

Computed tomography (CT) showed a contrast-enhancing sellar and suprasellar mass with right parasellar extension and few specks of calcification. The sella was enlarged and showed destruction of the floor. On magnetic resonance imaging (MRI), T1- and T2-weighted images revealed a similar lesion with mass effect on optic chiasm [Figure 1]a, b, and c. Pituitary gland was not seen separately. The prepontine cistern and clivus fat signals were maintained [Figure 1]c.

On endocrinal work-up, serum TSH and free thyroxin levels were 3.82 mIU/ml (normal 0.270-4.20 mIU/ml) and 9.55 pmol/l (normal 12.00-22.00 pmol/l) respectively. Serum prolactin levels were markedly elevated to 1982.0 mIU/ml (normal for females: 72-511 mIU/ml). The patient was started on intravenous dexamethasone (4 mg every 6 h), phenytoin (100 mg every 8 h), and thyroxine (0.1 mg once daily) prior to surgery.

She underwent right pterional craniotomy and decompression of the lesion. Peroperatively, the tumor was grey coloured, firm, and relatively avascular with variable consistency.

Histopathology [Figure 2]a of the resected specimen showed tumor disposed in cords and groups embedded in an extensive myxoid background. On immunohistochemistry, tumor cells were positive for cytokeratin, epithelial membrane antigen, and S 100 [Figure 2]b. Based on these findings, the diagnosis of a sellar suprasellar chordoma with an increased prolactin level ("pseudoprolactinoma") was established.

Postoperatively, the patient showed gradual improvement in all the symptoms and was referred for adjuvant radiotherapy (RT). She was planned for RT to the local site by two parallel opposing lateral fields and a dose of 54 Gy in 30 fractions over a period of 6 weeks. At the follow-up of 12 months, her prolactin level was normalized to 379 mIU/ml. She was maintained on Tab. phenytoin, Tab. prednisolone (7.5 mg daily), and Tab. thyroxine (100 µg daily) and was on regular follow-up.

After 2 years post-RT, she presented with complains of recurrent vomiting, headache, and deterioration of vision for last 15 days. A MRI scan showed recurrence of tumor with right parasellar extension, compressing the optic chiasm and invading cavernous sinus. She had a right MPVP shunt placement as she had features of raised intracranial tension and was planned for surgical decompression; however, her general condition deteriorated and she succumbed to the disease 3 years after the initial diagnosis.


 > Discussion Top


Chordomas are tumors of axial skeleton arising from primitive notochord remnants and constitute approximately 2-4% of all primary bone tumors. [3] About 50% arise in the sacrococcygeal area and 35% arise intracranially (where they typically involve the clivus). The remaining 15% occur in the midline along the path of the notochord, primarily involving cervical vertebrae. [4] A male predominance is reported with a sex ratio of 2:1 to 3:1. [5]

Chordomas are slow-growing, locally invasive tumors which invade adjacent bone and soft tissues. The lethality of these tumors rests on their critical location, aggressive local behavior, and extremely high local recurrence rate. [6]

On CT and MRI, the chordomas of the skull base are usually found to have a lobulated, "honeycomb" appearance, that may extend posteriorly to prepontine cistern, Circle of Willis, cavernous sinuses, brain stem, and cause bone erosion. [7]

Sellar and suprasellar chordomas may mimic pituitary adenoma, but are usually differentiated by the presence of calcification and/or bony destruction in the former condition and hormonal hypersecretion in the latter condition. However, a chordoma presenting with increased prolactin levels ("pseudoprolactinoma"), as in this case, is very rare.
"Pseudoprolactinoma" obstructs the flow of dopamine to the pituitary gland through the hypothalamic pituitary axis, and this loss of dopaminergic inhibition on the pituitary lactotrophs, the "stalk section effect," causes a rise in serum prolactin levels. However, prolactin levels are usually less than 2 U/l (100 µg/l). Treatment with dopamine agonist reduces prolactin levels but does not result in tumor shrinkage. Therefore, surgical decompression is usually the treatment modality of choice. [2],[8]

On the other hand, true prolactinomas are usually characterized by prolactin levels of more than 2 U/l (100 µg/l) and usually respond to the treatment by dopamine agonists like bromocriptine, with tumor shrinkage occurring in about two-thirds of the patients. [2],[8] Moreover, there may be clinical manifestations of amenorrhea - galactorrhea syndrome, which is rare in pseudoprolactinomas.

A preoperative differentiation between prolactinomas and pseudoprolactinomas is useful to decide between surgical and medical treatment. However, this is often not possible. The retrospective study of 44 cases by Smith et al. showed that there was no significant correlation of prolactin level and the degree of pituitary stalk compression, stalk deviation, or tumor size as seen on MRI. The differentiation between prolactinomas and pseudoprolactinomas could therefore be difficult on MRI. [2]

In the present case, significant calcification and bony destruction were not evident on preoperative imaging studies. Moreover, due to extensive disease, normal pituitary gland could not be distinguished from the rest of the lesion. Further, she was postmenopausal and had amenorrhea; therefore, clinically, the differentiation between the prolactinoma and pseudoprolactinomas was not possible. Pituitary adenomas may rarely present with posterior extension or destructive invasion of the clivus leading to difficulties in differentiating from chordoma. [9] Thus, in the presence of significant hyperprolactinemia (that was much higher than may be seen in the "stalk section effect"), differentiation between a prolactinoma and pseudoprolactinoma was just not possible preoperatively in our case.

Total removal of chordoma is a theoretical goal, which is seldom achieved since these lesions have a distinct tendency to invade the surrounding bone. Adjuvant therapy in the form of postoperative RT has therefore been mostly advocated. This could be delivered through stereotactic radiosurgery/radiotherapy in centers where such facilities are available. [10]


 > Conclusion Top


A rare case of chordoma with increased prolactin levels (pseudoprolactinoma) is reported. The entity presents a preoperative diagnostic dilemma until a surgical intervention is carried out.

 
 > References Top

1.Haridas A, Ansari S, Afshar F. Chordoma presenting as pseudoprolactinoma. Br J Neurosurg 2003;17:250-62.  Back to cited text no. 1
    
2.Smith MV, Laws ER Jr. Magnetic resonance imaging measurements of pituitary stalk compression and deviation in patients with nonprolactin secreting intrasellar and parsellar tumors: Lack of correlation with serum prolactin levels. Neurosurgery 1994;34:834-9.  Back to cited text no. 2
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3.Nguyen TT, McComb JG. Tumors of the skull. In: Berger MS, Prado MS. Textbook of neuro-oncology. Pennsylvania; Elsevier Saunders: 2005. p. 771.  Back to cited text no. 3
    
4.Sze G, Uichanco LS 3rd, Brant-Zawadzki MN, Davis RL, Gutin PH, Wilson CB, et al. Chordomas: MR imaging. Radiology 1988;166:187-91.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Higinbotham NL, Phillips RF, Farr HW, Hustu HO. Chordomas Thirty-five year study at Memorial Hospital. Cancer 1967;20:1841-50.  Back to cited text no. 5
[PUBMED]    
6.Perez CA, Chao KSC: Unusual Non-epithelial tumors of the Head and Neck. In Perez CA, Brady LW, Halperin EC, Schmidt-Ullrich RK (4th ed): Principles and practice of Radiation Oncology. Philadelphia: Lippincott Williams and Wilkins; p. 1125.  Back to cited text no. 6
    
7.Doucet V, Peretti-Viton P, Figarella-Branger D, Manera L, Salamon G. MRI of intracranial chordomas. Extent of tumour and contrast enhancement: criteria for differential diagnosis. Neuroradiology 1997;39:571-76.  Back to cited text no. 7
    
8.Besser M. Criteria for medical as opposed to surgical treatment of prolactinomas. Acta Endocrinol (Copenh) 1993;129:27-30.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Wong K, Raisanen J, Taylor SL, McDermott MW, Wilson CB, Gutin PH. Pituitary adenoma as an unsuspected clival tumor. Am J Surg Pathol 1995;19:900-3.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Thodou E, Kontogeorgos G, Scheithauer BW, Lekka I, Tzanis S, Mariatos P, et al. Intrasellar chordomas mimicking pituitary adenoma. J Neurosurg 2000;92:976-82.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2]


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2 Sellar chordoma presenting as pseudo-macroprolactinoma with unilateral third cranial nerve palsy
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