Persistent Central Hypercortisolemia following Pituitary Stalk Tumor Resection: Case Lesson
Bibliographic record
Abstract
Background: Pituitary stalk lesions are rare entities with variable clinical manifestations. Their detection during workup for endocrinologic abnormalities represents a decision-making challenge. We present the case of a 57-year-old female with central ACTH-dependent hypercortisolemia who was discovered to have a pituitary stalk lesion, which we decided to treat surgically. Case Description: A 57-year-old female was referred to endocrinology for management of her diabetes. She had a Cushingoid appearance and underwent subsequent workup which demonstrated evidence of ACTH-dependent central Cushing's Syndrome (Morning cortisol > 500 nmol/L; Cortisol post-low dose suppression 792 nmol/L; cortisol post-high dose suppression test 324 nmol/L). Imaging demonstrated a 4.7mm nodule originating from the pituitary infundibulum. Management: Inferior petrosal sinus sampling and PET-CT was considered, however, given the cortisol suppression seen on HDDST, presence of stalk lesion, and absence of any gland lesion on imaging, glandular pituitary and extracranial ectopic sources were thought to be unlikely. We elected to proceed with endoscopic endonasal approach with extended transtubercular exposure for resection of the infundibular lesion with goal of biochemical cure. Outcome: A satisfactory technical and radiographic resection of the infundibular lesion was achieved. However, the patient’s hypercortisolemia failed to resolve. Histopathologic analysis identified the lesion as a granulocytoma. Subsequent inferior petrosal sinus sampling further demonstrated evidence of ACTH-dependent central Cushing's syndrome. The patient has since been referred for consideration of bilateral adrenalectomy for management of her persistent hypercortisolemia with no clear neurosurgical target. Conclusion: Our case demonstrates a complex clinical picture in which our patient presented with biochemical results suggestive of central ACTH-dependent hypercortisolemia; however, no glandular lesion identified on imaging. The presence of an infundibular lesion led to subsequent surgical intervention which unfortunately did not result in biochemical cure despite adequate technical results. The authors believe this case illustrates a challenging clinical conundrum which emphasizes the uncertainty that should be associated with management of pituitary stalk lesions. Publication History Article published online: 07 February 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.005 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.002 | 0.002 |
| Scholarly communication | 0.001 | 0.004 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.008 | 0.007 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".