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case_images: Brain MRI showing tumor progression. (A coronal; B sagittal) showing initial tumor presentation. (C coronal; D sagittal) showing tumor prior to first operation. (E coronal; F sagittal) showing tumor after first operation. (G coronal; H sagittal) showing continued tumor progression postoperatively and prior to temozolomide therapy.
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case_images: A brain MRI was ordered and revealed a 2 x 2 cm pituitary mass ( Figures 2A, B ). A brain MRI showed progression of the mass with suprasellar extension, left cavernous sinus invasion, and evidence of apoplexy ( Figures 2C, D ). Surgical resection was recommended, and the tumor was debulked through a transsphenoidal approach ( Figures 2E, F ). In November 2021, the patient reported significant decrease in vision of the left eye; follow-up MRI revealed progression of the residual tumor with bilateral invasion of the cavernous sinuses and compression of the left optic nerve ( Figures 2G, H ).
case_images: Timeline showing the course of the disease and management. DA, dopamine agonist; CN, cranial nerve; TS, Trans-Sphenoidal; FU, follow-up; TMZ, temozolomide.
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case_images: The tumor size stabilized, and serum prolactin levels decreased ( Figure 3 ).
case_images: Brain MRI showing tumor progression. (A coronal; B sagittal) showing continued tumor progression after temozolomide therapy and prior to second operation. (C coronal; D sagittal) showing tumor prior to pazopanib therapy. (E coronal; F sagittal) showing tumor response to pazopanib therapy, tumor size slightly decreased and stabilized for 6 months. (G coronal; H sagittal) showing continued tumor progression despite ongoing therapy.
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case_images: He was prescribed two courses of TMZ; however, his vision deteriorated and the tumor continued to grow ( Figures 4A, B ). In January 2022, he underwent a second operation through a transcranial approach and subtotal resection was achieved, decompressing the optic nerves ( Figures 4C, D ). Additionally, serum prolactin decreased to 122 ng/mL, and MRI showed a reduction in tumor size along with a decrease in the cystic and necrotic components of the tumor ( Figures 4E, F ). However, after 7 months of starting pazopanib treatment, MRI revealed tumor progression ( Figures 4G, H ).
case_images: Histological section of resected tumor tissue showing positive PD-L1staining (marked in green).
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case_images: Based on PD-L1 positive staining of the tumor tissue ( Figure 5 ), the PD-L1 inhibitor pembrolizumab was added to the patient's treatment regimen, however, the tumor continued to progress.
case_images: Circos Plot of the genome sequencing by microarray analysis of the patient's tumor. Green: Chromosomal gain(s), Yellow: Focal chromosome amplification(s), Red: Chromosomal loss(es), Purple: Copy neutral loss(es) of heterozygosity, and Orange: Chromosomal chromothripsis. Created using Circa software by https://omgenomics.com/.
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case_images: Other abnormalities detected via microarray analysis included regional chromosomal gain(s) in chromosomes 1, 3, 5, 7, 8, 9, 12, 14q, 16, 17p, 18p, and 19; regional chromosomal loss(es) in chromosomes 1p, 4, 9p, 12p, 17p, 18q, and Yq; and copy neutral loss of heterozygosity in chromosomes 8p, 9p, 13q, 15q, 19p, 20, and 21q ( Figure 6 ).