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 5 mm 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 10 mm 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.
Keywords
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Article info
Publication history
Published online: January 17, 2015
Accepted:
January 10,
2015
Received:
January 6,
2015
Identification
Copyright
Published by Elsevier Inc.
