Fig. 1

MRI of the pituitary throughout the patient’s clinical course. Coronal T1-weighted post-gadolinium images are shown. After partial resection at another facility, she presented to us for more definitive endoscopic endonasal resection of the residual sellar tumor (a), which was successful (b). She then underwent radiation therapy 3 months after this repeat surgery, at which point her cavernous sinus residual disease had already subtly progressed (c). Radiation therapy was initially successful for local control of disease 3 months after completion of fractionated IMRT (d). Two months following this MRI, her ACTH levels increased dramatically despite stability of her cavernous sinus residual disease (e), and metastasis to the liver was diagnosed (see Fig. 4). Six months after resection of the liver metastasis, her sellar and cavernous sinus disease remained stable (f), but then quickly progressed over the next 6 months (g). She was started on dual-agent oral chemotherapy, and 8 months later her local disease was stable (h), although she has suffered additional liver metastases