A 53-YEAR-OLD MAN had a 1-month history of headaches, lethargy, decreased libido, and increased thirst. Subsequently, he developed diplopia, bitemporal hemianopsia, and a right third nerve palsy. He recently had 1 bout of hematuria following exercise. His physical examination was otherwise unrevealing. His medical, surgical, and family history were unremarkable. Endocrine testing revealed panhypopituitarism and diabetes insipidus (DI); urinalysis showed microscopic hematuria. Magnetic resonance imaging demonstrated an enhancing, invasive sellar and parasellar mass (Figure 1, A-C). Transsphenoidal decompression and subtotal resection were performed, with resolution of his headache and improvement in his visual field deficits and diplopia. Diabetes insipidus and hypopituitarism persisted. A clear cell carcinoma was identified histologically (Figure 1, D-E). Results of a workup revealed a 6-cm solid mass in the right kidney, which was resected. The patient received fractionated radiotherapy to the parasellar region, with stabilization of his residual metastatic pituitary disease. He died of disseminated systemic disease at 12 months.
Magnetic resonance imaging (MRI) and microscopic views of the tumor. A, Coronal, nonenhanced, T1-weighted image. B and C, Coronal (B) and axial (C), T1-weighted, gadolinium-enhanced MRIs of the tumor. There is homogeneous enhancement of the tumor, which fills the sella and suprasellar spaces, compresses the optic apparatus, and invades the cavernous sinuses, especially on the right. D and E, Low-power (D) and high-power (E) views of a clear cell carcinoma, consistent with renal cell metastasis. Microscopically, this tumor consists of large cells with a clear cytoplasm surrounded by a sharply demarcated cell membrane. Nuclei are located centrally, with mild atypia. There are solid nests of tumor cells surrounded by a scant, sinusoidal stroma (arrows, D) and narrow endothelial channels containing erythrocytes (arrow, E).
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