A 65 year old woman, first presenting in 1977 with a functioning Lactotroph adenoma, underwent surgical resection with an uncomplicated post-operative period and normal biochemistry.

24 years later she was diagnosed with Acromegaly and underwent another surgical resection and adjuvant radiotherapy of her pituitary adenoma; initially achieving gross total resection but then radiological and biochemical recurrence 4 years later.

Treatment with Octreotide and Cabergoline were unsuccessful in controlling tumour growth and she required further surgical resection and radiotherapy due to optic chiasm compression. Pasireotide monotherapy was also unsuccessful in controlling tumour growth and function, culminating in an admission with a T7 spinal cord compression confirmed to be metastatic pituitary carcinoma. This required radiotherapy to her affected vertebrae, adjuvant Temozolomide and ongoing Pasireotide.

She underwent molecular profiling to consider novel treatment options and was enrolled in a phase 1 trials of a CDK inhibitor, then a humanised anti-CD47 IgG4 monoclonal antibody and finally underwent treatment with Bevacizumab (Avastin).

Pituitary carcinomas are rare and there are multiple case reports of malignant transformation of pituitary adenomas of varying lineages. Monitoring and early diagnosis are important due to their high mortality rate of 66% at 1 year and almost 80% within 8 years of diagnosis. Treatment of pituitary carcinomas are still limited, with varying levels of success.

This case illustrates the difficulty in managing patients with treatment-resistant metastatic pituitary carcinoma and highlights the concept of molecular profiling and biomarkers for treatment; the future of personalised medicine.