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Brain magnetic resonance imaging with
gadolinium enhancement showed a tumor, 0.7 by
0.9 cm in size, in the pituitary gland. Cushing\'s disease
secondary to ACTH-secreting pituitary tumor was
diagnosed. Ketoconazole therapy was given without
clinical improvement. Transsphenoidal exploration
was done 1 year later. Histologic sections showed
atrophic and degenerative change of the pituitary
tumor without definite living tumor tissue on histological
study. Although the ACTH and cortisol level
returned to normal range several months later, the
patient’s clinical condition showed little improvement.
Six months after the operation, ACTH and cortisol
level elevated gradually. At the same time, she began
to suffer from right hip pain.
Three months later, after a minor sprain of the
right hip, she was unable to walk. Pelvic radiograph
taken 1 month after the sprain showed avascular
necrosis of the right femoral head and a markedly
displaced pathologic fracture of the femoral neck (Fig.
1). Because of the underlying endocrine condition,
only conservative treatment was suggested for the hip
problems. Repeated magnetic resonance imaging
study of the brain showed a residual tumor in the
pituitary gland. Transsphenoidal surgery was performed
again in December 1992. A fragile pituitary
tumor, 0.7 0.3 0.4 cm in size, was removed. Histological
examination showed pituitary adenoma
composed of monotonous basophilic tumor cells
arranged in sheets with a delicate vascular stroma.
Immunochemistry showed diffuse positive staining
for ACTH. Adjuvant radiotherapy to the pituitary area
of 16 Gy (daily fraction, 2 Gy) was also performed.
Postoperatively, the general condition of the patient
improved gradually.