Transsphenoidal hypophysectomy in the clinically normal dog

Pituitary function and short-term clinical effects after transsphenoidal hypophysectomy were investigated in clinically normal dogs. In study I, 8 dogs were given polyionic fluids IV during the first 12 hours after surgery. In study II, 4 dogs were given polyionic fluids IV and glucocorticoid supplementation for 7 days. Pituitary function was assessed by evaluating basal ACTH concentrations and results of a growth hormone stimulation test before and 1 and 12 weeks after hypophysectomy, an ACTH stimulation test, a thyrotropin-releasing hormone-stimulation test, and a modified water deprivation/vasopressin response test before and 1, 4, 8, and 12 weeks after hypophysectomy. Gross and histologic evaluations of the surgery site, thyroid and adrenal glands, and skin were done at 12 weeks after surgery. Four dogs from study I died within 27 hours after hypophysectomy. Postmortem examinations of these dogs revealed liver and lung congestion compatible with circulatory collapse. None of the dogs in study II died. For the surviving dogs in both studies, diabetes insipidus developed immediately after hypophysectomy and resolved within 2 weeks. Hypernatremia also developed immediately after hypophysectomy and resolved by 1 week. Production of ACTH was evident at 1 and 12 weeks after hypophysectomy in all dogs, and results of ACTH stimulation tests after surgery were not notably different from results obtained before surgery. Results of thyrotropin-releasing hormone stimulation and growth hormone-stimulation tests supported the diagnosis of hypothyroidism and hyposomatotropism attributable to hypophysectomy. Histologic examination revealed thyroid atrophy, epidermal and dermal atrophy, and normal adrenal glands in all dogs and remnants of the hypophysis in 2 dogs from study I.(ABSTRACT TRUNCATED AT 250 WORDS)

Transsphenoidal pituitary surgery for the treatment of Cushing's disease: results in 64 patients and long term follow-up studies

Transsphenoidal pituitary surgery was performed in 64 patients with Cushing's disease in search of a corticotroph adenoma. In 4 patients, profuse local bleeding prevented completion of the exploration. Of the 60 patients who had an adequate exploration, 4 could not be followed after surgery. Short term assessment of the surgical outcome (3-6 months postoperatively) was performed on 60 patients, including the 4 who had incomplete pituitary exploration. Forty-two patients (70%) were judged as immediate successes [urinary cortisol excretion, less than 90 micrograms (less than 248 nmol)/day]; the mean urinary cortisol excretion and plasma ACTH level fell from 463 +/- 70 (+/- SE) to 26.7 +/- 3.6 micrograms/day (1277 +/- 193 to 74 +/- 10 nmol/day; n = 33) and from 111 +/- 33 to 36 +/- 14 pg/mL (24 +/- 7 to 8 +/- 3 pmol/L; n = 23) in patients who had both measurements pre- and postoperatively. Eighteen patients (30%) were judged as immediate failures; neither urinary cortisol excretion nor plasma ACTH levels changed significantly in patients who had both measurements pre- and postoperatively. The preoperative epidemiological, clinical, hormonal, and radiological characteristics of the 2 groups were similar. Histological examination of pituitary fragments removed in 58 of the 60 patients evaluated postoperatively revealed the presence of tumoral tissue in a higher percentage of patients in the immediate success group (72%) than in the immediate failure group (24%; P less than 0.01). The 42 patients in the immediate success group were followed from 6 months to 7 yr (median, 2 yr); 6 patients had recurrences from 2-3 yr after operation. Actuarial analysis indicates that the probability of a patient remaining well 6 yr after surgery is 72 +/- 20% (95% confidence limit). Most of the patients in the immediate success group had transient ACTH deficiency preceding a progressive return to normal pituitary-adrenal function.

Transphenoidal meningohydroencephalocoele

A case of transsphenoidal meningohydroencephalocoele is presented. The clinical features and pathogenic factors are discussed briefly. An awareness of this condition should prevent attempted biopsy--which might otherwise prove disasterous. Air or contrast cisternography, with plain or computerised tomographic radiology, would seem to be the investigation of choice.

Treatment of chiasmatic/hypothalamic gliomas of childhood with chemotherapy: an update

Chiasmatic/hypothalamic gliomas (CHG) of childhood may cause progressive neurological and visual deterioration. Radiotherapy results in at least transient stabilization of tumor growth in most patients but may also have adverse long-term effects, especially in young children. Since 1977, children with progressive CHG under 5 years of age at diagnosis have been treated with combination chemotherapy (actinomycin D and vincristine) without radiotherapy. Twenty-four patients, a median of 1.6 years of age at diagnosis, have been treated and followed for a median of 4.3 years (range, 0.3-10 years). All patients are alive. Nine have developed radiographic or clinical progression, occurring a median of 3 years (range, 2-6.5 years) after initiation of treatment. Fifteen of 24 (62.5%) have remained free of progressive disease and have received no other therapy. Tumor shrinkage was documented in 9 of 24 patients but did not clearly relate to long-term outcome. Full-scale intelligence quotient (IQ) obtained a median of 3.5 years after diagnosis in patients who received only chemotherapy was a mean of 103 (range 84-133). We conclude that chemotherapy can significantly delay the need for radiotherapy in children with CHG and such a delay may be beneficial regarding long-term outcome.

Female patients with meningioma of the sphenoid ridge and additional primary neoplasms of the breast and genital tract

Of 283 meningioma patients seen at the University of Kansas from 1948 to 1984, eight women acquired two primary extraneural cancers in addition to their meningiomas. Of these eight patients, six (75%) had sphenoid ridge meningiomas compared with 15% of meningioma patients overall (P less than 0.001). Seven (87.5%) had at least one breast or genital cancer (P less than 0.001). Of the six with sphenoid ridge meningiomas, five (83.3%) had both of their additional tumors in these two organ systems, and the sixth had one such tumor. It is proposed that this grouping of sphenoid ridge meningioma, breast cancer, and genital cancer represents a unique constellation of neoplasms in women.

Invasive v non-invasive assessment of the carotid arteries prior to trans-sphenoidal surgery

Imaging studies in 47 patients who were to undergo trans-sphenoidal surgery were analysed with reference to the vascular structures in the parasellar region. The results of cavernous sinography, dynamic contrast enhanced Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) showed good correlation with each other and with the appearances found at operation. CT and MRI, both non-invasive investigations, are therefore reliable preliminary screening methods for identifying the small proportion of patients on whom other imaging techniques need to be performed.

Intradiploic epidermoid cyst of the sphenoid wing

Epidermoids are blastomatous malformations of abnormal epithelial proliferation. Intradiploic epidermoids are very rare lesions that may occur in all flat bones of the calvarium and in the paranasal sinuses, maxilla, temporal bone, and sphenoid bone. This article describes the unique case of an intradiploic epidermoid tumor located in the greater sphenoid wing. Theories of pathogenesis, clinical behavior, diagnosis, and treatment of diploic epidermoids are reviewed.

Demonstration of cytokeratins and an epithelial membrane antigen in chondroid chordoma

Chondroid chordomas are shown to possess cytokeratins and to stain with HMFG-2 as do ordinary chordomas. These findings support the concepts that these neoplasms are a variant of chordoma and that they are unrelated to myxoid chondrosarcoma.

A combined neurilemmoma and angioma of the parasellar region. Case report

A combined neurilemmoma and angioma of the parasellar region is presented that clinically simulated a pituitary tumor. The lesion produced increased intracranial pressure and subarachnoid hemorrhage (SAH). This neoplasm is believed to have originated from the leptomeninges or the perivascular neural elements, or both. The angiomatous network within the tumor could have been the source of the SAH.

[Radiotherapy of chordoma--a report of 10 patients]

A consecutive series of 10 patients with chordoma was treated in our hospital from 1956 to 1982. Six were male and four were female. The age ranged 19 approximately 52 years. Eight lesions occurred in the base of sphenoid and two in the sacrum. All were treated by postoperative radiotherapy with a medium dose of 4,500 approximately 6,000 rad. Recurrent patients were given a hyperfractionated radiotherapy (100 rad, 4/D, at intervals of 3 hours, total dose 2000 rad). The 5 and 10 year survival rates were 75% and 50%. No complications were found after radiation. In this paper, literature on chordoma and radiotherapy for chordoma are reviewed. An optimal schedule is proposed: operation be the choice of treatment, which be as thorough as possible; two months after the operation, radiotherapy be given at a suitable dose of 5000 approximately 6000 rad; the recurrent lesions be treated by hyperfractionated radiotherapy.

Atraumatic suture of the mucoperiosteal flap in the transsphenoidal approach. A new technique

Fifty-three patients were operated on with the transsphenoidal approach and a biologic tissue adhesive was used, in order to fix the mucoperiosteal flap. Results and advantages of the technique are discussed.

[Isolated sphenoidal tumor localization in a child, disclosing histiocytosis X]

A case of isolated sphenoidal tumor localization in a child without any endocrinological disorder and revealing an histiocytosis X is reported. This mode of presentation is extremely rare. The diagnosis of histiocytosis X must be evoked and proved in lesions of the sellar region in children.

Percutaneous thermocoagulation for sphenopalatine ganglion neuralgia

The authors describe percutaneous radiofrequency (rf) thermocoagulation of the sphenopalatine ganglion used to treat seven patients with sphenopalatine ganglion neuralgia. The procedure was effective in relieving pain, without significant side-effects. All the patients have actually been free of pain during a follow-up of 6-28 months. The surgical technique and the rationale for its use are pointed out.

[Focal metastatic symptom as the initial presentation of lung cancer--report of two autopsied cases]

From 1956 to 1985, autopsy was done on 17 lung cancer patients in our hospital. There were two patients with focal metastasis as the presenting symptom without any primary cancer manifestations. One patient was admitted for severe right epigastric pain followed by severe pain in the left epigastrium. The chest film revealed nothing except some indefinite inflammatory lesions in the left upper lung. The patient died of uremia in 6 months. A primary carcinoma of 2 cm in diameter in the left lower lung was found on autopsy, which widely spread to the right lung, ovaries, upper segment of the left ureter, peribronchial and periaortic lymph nodes. Histological diagnosis was poorly differentiated adenocarcinoma. The other patient had destruction of the sphenoid bone with cranial nerve paralysis and hypothalamic syndrome at first. The primary cancer, a poorly differentiated adenocarcinoma of 2 X 3 X 1.5 cm in size, was found in the right upper lung on autopsy. Focal metastatic symptom as the initial presentation of lung cancer is rare. These tumors, as small lesions, frequently occur in the peripheral part of the lung. However, the site in which the presenting symptom develops may not necessarily be the place prone to metastasis. The presenting symptom, in turn, would depend upon the tendency of causing symptoms in the involved site. The author suggests that careful searching and identifying of the pulmonary lesion be routinely done for patients with metastatic carcinomatous symptoms only.

Chondromyxoid fibroma of the petrous-sphenoid junction

A case of primary chondromyxoid fibroma of the petrous and sphenoid bones extending into the posterior clinoid process, sella, and cavernous sinus in a 26-year-old man is reported. The presence of this tumor was heralded solely by the progressive paresis of the abducens nerve. The occurrence of this tumor is exceedingly rare, and to our knowledge, this is the first report of a primary chondromyxoid fibroma in the parasellar region. The natural history of this tumor, its pathologic diagnosis, and its treatment will be discussed with reference to this unusual case.

Chondroid chordoma

We reject the notion that the concept of "chondroid chordoma" be abandoned in favor of an interpretation of the cartilaginous origin of these lesions. We have demonstrated by electron microscopic and immunohistochemical means that these neoplasms can exhibit distinctly epithelial characteristics in their chondroid as well as their epithelial areas. The presence of desmosomes, cytokeratin, carcinoembryonic, and epithelial membrane antigen in the cells of the chondroid as well as the epithelial areas; the presence of the microtubular inclusions, vimentin, and S-100 protein in the cells of the epithelial as well as chondroid areas; and the intermingling of the two and gradual transitions from one to the other all point to the conclusion that the chondroid and epithelial areas are only differing morphologic expressions of the same entity. The gradual evolution witnessed in the sequential biopsies of this case study, through which a predominantly chondromatous neoplasm became a chordoma of typical histologic appearance, provides further strong evidence to support the contention that chondroid chordoma is a variant of chordoma and not a primary chondrocytic neoplasm.

Clivus chordoma in a 9-year-old child: case report and review of the literature

Chordomas are bone tumors of the axial skeleton. They arise from notochordal remnants. In children these tumors are extremely rare and are predominantly located in the skull base. The authors report on a clivus chordoma in a 9 7/12-year-old girl. It presented as a nasopharyngeal mass with destruction of the clivus and paralyses of the ninth, tenth, and eleventh cranial nerves on the right side. After incomplete resection by a transoral transclival route, high-dose radiotherapy was added. This treatment was effective as demonstrated by follow-up CAT scans. A short review of the current literature is given. The local recurrence rate is extremely high, and distant metastases may occur. Complete resection is rarely possible, and combined management with postoperative radiotherapy is propagated. Permanent cure is rare, and at the present time, chemotherapy appears to be of no value in the primary treatment of chordomas.

An useful accessory device for nasal speculum utilized in the trans-sphenoidal approach to the sella turcica. Technical note

We present an accessory device for nasal speculum utilized in the transphenoidal approach to the sella turcica. It, stopping the bulging of the superior lip and the soft tissues viciniori between the two opening valves, permits perfect visibility of the operating field and a greater space for surgical manoeuvres.

Benign schwannoma of the pterygopalatine fossa with intracranial extension: a case report

The authors present a rare case of benign schwannoma arising in the pterygopalatine fossa. The patient, an 18-year-old female, initially noticed blurring of her left eye but later, sudden loss of her left vision occurred. Radiological and computed tomographic studies outlined a mass occupying the left pterygopalatine fossa, which extended into the middle cranial fossa, the maxillary, ethmoid and sphenoid sinuses and the orbit. The histology of a transantral biopsy was reported as a benign schwannoma. The tumor was successfully removed by a transmaxillary approach. The eye symptoms disappeared four weeks following surgery. The nerve of origin of the tumor was not identified. The authors posturate that erosion of the skull base with mild to moderate extension into the middle cranial fossa, does not appear to be a contraindication for excising a schwannoma by the transmaxillary approach in this area.

Resolution of optociliary shunt vessels

A 40-year-old woman developed profound bilateral loss of vision from chronic atrophic papilledema. There were striking optociliary shunt vessels on the right optic disc. Within 1 month after removal of a massive intracranial meningioma, the shunt vessels had regressed markedly. This regression was evident on fluorescein angiograms. We attribute their resolution to the normalization of intracranial pressure.