{'fraction_non_alphanumeric': 0.029211295034079845, 'fraction_numerical': 0.012333657903278157, 'mean_word_length': 5.627956989247312, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Neuro-Ophthalmic Manifestations of Pituitary Carcinoma.

P ituitary carcinomas are rare, representing 0.1%–0.2% of pituitary neoplasms (1). The only true diagnostic criterion for carcinoma is metastatic spread, making it difficult to differentiate pituitary adenoma from carcinoma. However, certain features may suggest this as a more aggressive pituitary lesion. These include histologic features of “atypical” cells within a pituitary adenoma, rapid recurrence or progression of disease, and the development of metastatic lesions in a patient with a presumed benign pituitary tumor. We describe 2 patients who demonstrate the prolonged latency period between the diagnosis of pituitary adenoma and pituitary carcinoma. A 54-year-old woman presented with bitemporal hemianopia and headache. Neuroimaging demonstrated a suprasellar mass, and transsphenoidal resection revealed a typical pituitary adenoma. Five years later, MRI showed residual tumor growth, and she underwent stereotactic radiosurgery. Serial neuroimaging studies remained stable. The patient was asymptomatic for 13 years when repeat MRI showed tumor recurrence with extension to the paranasal sinuses. She underwent repeat surgical resection, but histopathology now showed features of “atypical pituitary adenoma,” including larger than usual cells with prominent nucleoli, scattered mitotic figures, rare positive nuclei for p53, and an MIB-1 antibody labeling index of 9.1%. The patient received a postoperative radiotherapy. Two years later, MRI revealed extension of the tumor into the right orbit. Positron emission tomography (PET) demonstrated metastatic lesions in the neck, chest, lung, and several lymph nodes. On neuro-ophthalmic examination, visual acuity was 20/20 in both eyes, but there was a right relative afferent pupillary defect and mild diffuse depression of the right visual field. There was a slight limitation to elevation of the right eye, and the remainder of the examination was unremarkable. Right frontotemporal craniotomy coupled with multiple lymph node biopsies showed synaptophysin-positive pituitary cells negative for all hormone markers, including prolactin, adrenocorticotropic hormone (ACTH), growth hormone, thyroid-stimulating hormone, follicle-stimulating hormone, and luteinizing hormone. Scattered nuclei were p53 positive, the MIB-1 labeling index was 24.2%, and lymph node dissection revealed 4 mitoses per 10 highpower fields (Fig. 1). Together, the morphologic features, immunophenotype, and nodal metastases supported the diagnosis of pituitary carcinoma. After surgery, visual acuity was 20/25 in the right eye and 20/20 in the left eye. There was a right relative afferent pupillary defect. Extraocular motility revealed a moderate limitation of elevation and abduction of the right eye. The patient received additional boost radiotherapy to the tumor bed and right neck nodal metastatic lesions and was administered systemic chemotherapy with temozolomide and capecitabine. She has remained stable clinically and radiographically for 3 years after the diagnosis