Differential diagnosis of sellar masses

Pituitary incidentalomas: application of an evidence-based approach at the individual patient and population levels

With the widespread use of imaging techniques, incidental discovery of clinically unsuspected pituitary adenomas is increasing in frequency and will increase further. The Endocrine Society Task Force on Pituitary Incidentalomas has developed practice guidelines which reflect the best available evidence combined with the opinions of experts in pituitary diseases. For incidental macroadenomas, evidence supporting comprehensive evaluation (for hyperfunction, hypopituitarism and anatomy) and management (whether surgical or careful follow-up) is strong. By contrast, evidence supporting approaches to microadenomas without clinical suggestion of hormonal hypersecretion are relatively weak and practice varies. Developing more evidence will require approaches other than randomized controlled trials, such as comparative effectiveness studies. Incidentalomas represent part of a larger societal issue, that being overdiagnosis and its consequences.

Pituitary gland metastasis from rectal cancer: report of a case and literature review

Pituitary metastases are unusual complications of malignancies. In about only 2% of patients they origin from colorectal cancer (CRC), with breast and lung as the most common primary tumors. Nevertheless, some authors reported a recent increase of the incidence of metastases in infrequent sites, such as brain or bone, arising from gastrointestinal cancers, probably due to the expanded treatment options and the resulting improved survival. Here, we report the case of a 54-year old woman diagnosed with lung metastases from rectal cancer, who, after several cycles of radio- and chemotherapy, presented symptoms and signs of pituitary disfunction (i.e. diabetes insipidus, hypothyroidism and diplopy). The diagnosis of pituitary metastasis from rectal cancer was histologically confirmed after surgery.

Magnetic resonance imaging validation of pituitary gland compression and distortion by typical sellar pathology

OBJECT

Identification of the normal pituitary gland is an important component of presurgical planning, defining many aspects of the surgical approach and facilitating normal gland preservation. Magnetic resonance imaging is a proven imaging modality for optimal soft-tissue contrast discrimination in the brain. This study is designed to validate the accuracy of localization of the normal pituitary gland with MRI in a cohort of surgical patients with pituitary mass lesions, and to evaluate for correlation between presurgical pituitary hormone values and pituitary gland characteristics on neuroimaging.

METHODS

Fifty-eight consecutive patients with pituitary mass lesions were included in the study. Anterior pituitary hormone levels were measured preoperatively in all patients. Video recordings from the endoscopic or microscopic surgical procedures were available for evaluation in 47 cases. Intraoperative identification of the normal gland was possible in 43 of 58 cases. Retrospective MR images were reviewed in a blinded fashion for the 43 cases, emphasizing the position of the normal gland and the extent of compression and displacement by the lesion.

RESULTS

There was excellent agreement between imaging and surgery in 84% of the cases for normal gland localization, and in 70% for compression or noncompression of the normal gland. There was no consistent correlation between preoperative pituitary dysfunction and pituitary gland localization on imaging, gland identification during surgery, or pituitary gland compression.

CONCLUSIONS

Magnetic resonance imaging proved to be accurate in identifying the normal gland in patients with pituitary mass lesions, and was useful for preoperative surgical planning.

Pathologic and clinical features of pituitary adenomas showing TSH immunoreactivity

Patients with thyrotropin-secreting pituitary adenomas may present with mass effect, hypopituitarism, and/or hyperthyroidism. The spectrum of pathologic and clinical features of patients whose tumors demonstrate β-thyrotropin immunoreactivity (β-TSH IR) has not been characterized. To characterize the phenotype of patients with pituitary adenomas with positive β-TSH IR, we conducted a retrospective analysis of patient records of all adult patients (n = 1,223) undergoing pituitary surgery in our institution over one decade (1999-2009). The search identified 166 adults with tumors which had β-TSH IR. These patients were individually matched to 166 patients whose tumors revealed no β-TSH IR. Clinical, pathological, imaging and biochemical data were extracted. 332 patients, aged 51.4 ± 15.1 years [150 women (45 %) and 182 men (55 %)], with pituitary adenomas (mean tumor diameter ± SD: 22.7 ± 9.0 mm) were studied. The degree of β-TSH IR was associated with the presence of central hyperthyroidism (p < 0.0001) or goiter (p = 0.0217). Patients whose tumors expressed more extensive β-TSH IR were less likely to develop pituitary apoplexy than those without β-TSH IR (p = 0.0428). In addition, the degree of β-TSH IR correlated with the presence of immunoreactivity for β-FSH (p < 0.0001), β-LH (p < 0.0001), alpha subunit (p < 0.0001), and GH (p = 0.0036).

CONCLUSIONS

Pituitary adenomas expressing β-TSH IR were more likely to demonstrate immunoreactivity for β-FSH, β-LH, GH or alpha subunit. Patients with such tumors were more likely to exhibit hyperthyroidism and goiter, but less likely to develop pituitary apoplexy than patients without β-TSH IR. These findings suggest that β-TSH IR is associated with specific phenotypic features in patients with pituitary adenomas.

Hypothalamo-pituitary sarcoidosis: a multicenter study of 24 patients

AIM

To assess clinical features, treatment and outcome of Hypothalamo-pituitary (HP) sarcoidosis and to determine whether HP is associated with a particular clinical phenotype of sarcoidosis.

DESIGN

Multicentric retrospective study.

METHODS

Retrospective chart review. Each patient was matched with two controls.

RESULTS

Twenty-four patients were identified (10 women, 14 men). Their median age at the sarcoidosis diagnosis was 31.5 years (range: 8-69 years). HP involvement occurred in the course of a previously known sarcoidosis in 11 cases (46%), whereas it preceded the diagnosis in 13 patients (54%). All but two patients had anterior pituitary dysfunction, 12 patients presented with diabetes insipidus. The most common hormonal features were gonadotropin deficiency (n=21), TSH deficiency (n=15) and hyperprolactinemia (n=12). Magnetic Resonance Imaging (MRI) revealed infundibulum involvement (n=8), pituitary stalk thickness (n=12) and involvement of the pituitary gland (n=14). All but two patients received prednisone. After a mean follow-up of 4 years, only two patients recovered from hormonal deficiencies. MRI abnormalities improved or disappeared in 12 cases under corticosteroid. There was no correlation between the hormonal dysfunctions and the radiologic outcomes. Patients with HP sarcoidosis had significantly more frequent sinonasal localizations and neurosarcoidosis and required a systemic treatment more frequently than controls.

CONCLUSION

Although HP sarcoidosis is unusual, physicians should be aware that such specific localization could be the first manifestation of sarcoidosis. HP involvement is associated with general severity of sarcoidosis. MRI abnormalities can improve or disappear under corticosteroid treatment, but most endocrine defects are irreversible.

Bronchial carcinoid tumors causing Cushing's syndrome: more aggressive behavior and the need for early diagnosis

BACKGROUND

The aim of this study was to revisit the characteristics and outcomes of adrenocorticotropin-secreting bronchial carcinoid tumor (BCT) responsible for Cushing's syndrome (CS).

METHODS

We conducted a single-institution retrospective review of 14 patients who underwent pulmonary resection for BCT that presented as CS from October 1993 to November 2011.

RESULTS

The group consisted of 8 male patients (57%) and 6 female patients. The mean age was 40 years (range, 16-63 years). Three patients (21%) underwent unnecessary adrenalectomy or hypophysectomy, or both, before diagnosis of the main cause. The mean interval between clinical presentation and the chest operation was 33 months (range, 3-136 months). Operations included 12 lobectomies (86%), 1 segmentectomy, and 1 wedge excision. All patients underwent radical lymph node dissection. Histologic examination showed 11 typical carcinoids (79%) and 3 atypical carcinoids. Twelve patients were classified pT1 (86%) and 2 patients were classified pT3 because of the presence of 2 tumors in the same lobe. Lymph node metastases were found in 7 patients (50%) (3 pN1 and 4 pN2). The mean follow-up was 59 months (range, 3-174 months). No recurrence was observed.

CONCLUSIONS

Early detection of adrenocorticotropin-secreting BCTs is challenging. However, it avoids adrenalectomy and unnecessary hypophysectomy, limits the deleterious effects of chronic hypercortisolism, and reduces the risk of metastasis. The high prevalence of lymph node involvement confirms the aggressiveness of these tumors and justifies anatomic resection and radical lymph node dissection. Under these circumstances, the prognosis remains favorable, even in cases of N2 disease.

Pituitary incidentalomas

The widespread use of sensitive neuroradiological imaging studies (i.e. computed tomography scan and magnetic resonance imaging) over the last years lead to the diagnosis of an increased number of asymptomatic pituitary lesions. The management of these so-called "pituitary incidentalomas" is still controversial, due to the limited data so far available on both the clinical relevance and the natural history of such incidentally discovered pituitary masses. Most pituitary incidentalomas are less than 1 cm in diameter (microincidentalomas) and are pituitary adenomas. Although these tumours are in general hormonally inactive, all the patients with incidentalomas should be screened for pituitary hypo- or hyper-function. Macroincidentalomas have greater growth potential and, when associated with hypopituitarism and/or visual disturbances, should be surgically removed. Conversely, incidentalomas not associated with hormonal alterations and dimensionally stable could be managed conservatively. This review will focus on the last data on the natural history and clinical management of pituitary incidentalomas.

Sellar plasmacytomas: a concise review

The diagnosis of a sellar plasmacytoma is often missed and is mistaken for a non functioning pituitary adenoma. We reviewed the literature on reported cases of sellar plasmacytoma in order to identify its clinical presentation, laboratory, radiological and pathological characteristics. We describe the management of these cases after the correct diagnosis was made and provide insight to preoperative diagnosis of this entity. Preoperative diagnosis may help avoid unnecessary surgical resection of an otherwise radiosensitive tumor. We also report and describe in detail a new case of sellar plasmacytoma that we have recently evaluated.

Xanthogranuloma of the intrasellar region presenting in pituitary dysfunction: a case report

Introduction

Differentiation of cystic mass lesions of the sellar and parasellar regions may pose a diagnostic dilemma for physicians, neurosurgeons, radiologists and pathologists involved in treating patients with these entities. A considerable number of tumors previously identified as craniopharyngiomas may, in fact, have been xanthogranulomas. We report a case of pituitary dysfunction caused by xanthogranuloma of the intrasellar region.

Case presentation

A 47-year-old man of Japanese descent presented to our institution with a tumor located exclusively in the intrasellar region which manifested as severe hypopituitarism. MRI revealed a clearly defined intrasellar mass that was heterogeneously hyperintense on T1-weighted images and markedly hypointense on T2-weighted images. We preoperatively diagnosed the patient with Rathke's cleft cyst or non-functioning pituitary adenoma. Although the tumor was completely removed using a transsphenoidal approach, the improvement of the patient's endocrine function was marginal, and continued endocrine replacement therapy was needed. Postoperatively, a histological examination revealed the tumor to be a xanthogranuloma of the intrasellar region. His visual field defects and headache improved.

Conclusion

Because diagnosis depends on surgical intervention and xanthogranulomas of the intrasellar region are very rare, the natural history of xanthogranuloma is still unknown. Therefore, this entity is difficult to diagnose preoperatively. We suggest that xanthogranuloma should be included in the differential diagnosis, even in the case of sellar lesions, to formulate appropriate postoperative management and improve endocrine outcomes.

A rare case of primary sellar lymphoma presenting a diagnostic challenge

Primary sellar lymphoma (PSL) is an exceptional diagnosis, among the most unusual causes of a sellar mass. Distinguishing PSL from other sellar lesions is often difficult as clinical and radiological features are typically non-specific. We present a case in which unusual presentation and previous medical history made diagnosis particularly challenging.

T-cell lymphoblastic lymphoma/leukemia presenting as a pituitary mass lesion: a case report and review of the literature

We present a rare case of primary T-cell lymphoblastic lymphoma of the pituitary gland. A 58-year-old woman presented with headaches, right-sided ptosis and cranial nerve III palsy. She subsequently developed polyuria, polydipsia, and hyperglycemia and was found to have hypopituitarism. MRI revealed a large, heterogeneously enhancing intrasellar/suprasellar lesion displacing the optic chiasm and extending into the right cavernous sinus. Radiologically, these findings were thought to represent an invasive pituitary adenoma. Pterional craniotomy was performed with subtotal tumor resection. Histopathological examination revealed a T-cell lymphoblastic lymphoma/leukemia (T-LBL) admixed with pituitary corticotrophic cell hyperplasia. CT scans of the chest, abdomen and pelvis showed no evidence of systemic disease. Analysis of peripheral blood and bone marrow, including flow cytometry, demonstrated no involvement by T-LBL. Follow-up MRI of the spine revealed abnormalities in the distal thoracic spinal cord and conus medullaris, raising suspicions of leptomeningeal dissemination. Only five case reports of T-cell primary pituitary lymphoma (PPL) have been previously described, four of which were associated with hypopituitarism and/or concurrent pituitary adenoma. We present the first report of a T-cell PPL associated with adenohypophyseal hyperplasia and the third documented occurrence of a primary pituitary T-LBL.

Primary pituitary lymphoma in immunocompetent patient: diagnostic problems and prolonged follow-up

Primary pituitary lymphoma in immunocompetent patients is a rare disease and has been described in less than 20 cases. Moreover, low-grade lymphomas constitute only 3% of all primary central nervous system lymphoma. The objective of this report is to report a low-grade primary pituitary lymphoma, diagnostic problems and to give more evidence about the evolution of this rare disease. A 49 y.o. woman was referred to our clinic with symptoms of hypopituitarism. A diagnostic work-up showed mild anemia, an erythrocyte sedimentation rate of 122 mm/h and a negative Elisa test for HIV. Panhypopituitarism was confirmed and the MRI showed a 20 mm sellar and suprasellar enhancing mass with a thickening of the pituitary stalk, chiasmal compression and bitemporal hemianopsia. She underwent transsphenoidal resection only 10 months later for non medical reasons. During this period she was clinically asymptomatic on hormonal replacement therapy. A new MRI showed regression of the suprasellar extension and invasion to the left cavernous sinus. A firm and infiltrative mass was found during transsphenoidal surgery, and only partial resection was performed. Biopsy showed a low-grade lymphoplasmacytic lymphoma. Staging was negative for other localizations. She was given chemotherapy and localized radiotherapy. Four years after surgery, the sellar MRI showed a 10 mm residual sellar mass with the persistence of a cavernous sinus invasion and she is considered to be in remission. The neurosurgeon and clinician should consider primary pituitary lymphoma as a potential cause of a sellar mass, especially in the presence of diabetes insipidus and an enhancing invasive mass. Neurosurgical biopsy is crucial for a correct diagnosis and prognosis could be better than classic CNS primary lymphomas.

Rare Tumors of the Sellar Region

Context

The sellar/ parasellar region is the location for a vast array of neoplastic and nonneoplastic intracranial space-occupying lesions. While several common lesions arising in this location have been well-described in the literature, there are rare and challenging tumors that may also arise in this region.

Objective

We focus this review on five rare tumors reported to arise in the sellar region, including spindle cell oncocytoma of the adenohypophysis, pituicytoma, intravascular papillary endothelial hyperplasia, epithelioid hemangioendothelioma and xanthogranuloma. We review their clinical presentation, histologic features, differential diagnosis and outcomes for these tumors.

Data sources

All medical literature pertaining to these entities that was searchable on PubMed was comprehensively reviewed.

Conclusions

Spindle cell oncocytoma and pituicytoma have recently been included in the 2007 edition of the World Health Organization classification of tumours of the CNS, while intravascular papillary endothelial hyperplasia, epithelioid hemangioendothelioma and xanthogranuloma have only rarely been described in this region. Knowledge of these may help prevent possible diagnostic pitfalls during postmortem evaluation.

Pituitary incidentaloma

Pituitary incidentalomas (PIs) are commonly encountered in clinical practice. While most are microincidentalomas (<1 cm) and not functional, in some cases their identification may lead to discovery of unrecognized abnormalities such as pituitary hormonal deficiencies, excess hormone secretion or visual field defects. Although the majority are pituitary adenomas, the potential list of differential diagnosis is extensive. A limited biochemical work up for asymptomatic patients with microincidentalomas, to include measurement of prolactin and IGF-1, is reasonable, with further studies to be tailored based on the clinical picture. All patients with macroincidentalomas (≥1 cm) should be evaluated for hypopituitarism and undergo visual field testing if the sellar mass abuts or compresses the optic chiasm. Most PIs can be followed, closely without surgery over time, but some may require surgical removal, especially if they are found to be macroincidentalomas at presentation, encroaching on or abutting the optic chiasm, or are found to be functional, excluding prolactinomas. Recovery of pituitary function may be seen in some patients with mass effect following resection of a sellar mass. The association of headache and pituitary incidentalomas remains a diagnostic challenge. There are no randomized controlled studies to guide the follow up approach when surgery is not indicated; most of the follow up algorithms in the literature are based on personal experience. Most retrospective series on natural history indicate that microincidentalomas tend not to grow; without a need for long-term follow up unless the patient becomes symptomatic. Macroincidentalomas, on the other hand, have a propensity to grow and need a more aggressive follow up approach to minimize morbidity.

Advances in pituitary imaging technology and future prospects

There have been substantial advances in pituitary imaging in the last half-century. In particular, magnetic resonance imaging is now established as the imaging modality of choice, providing high quality images of the hypothalamic-pituitary axis and adjacent structures. More recent technological advances, such as the emergence of 3 Tesla MRI, are already being widely incorporated into imaging practice. However, other advanced techniques, including a variety of potential imaging biomarkers, still require further research to evaluate their potential and define their precise role. The recent development of intraoperative MRI appears promising and may have the potential to improve the outcome of pituitary surgery. Modern high quality imaging inevitably leads to the discovery of incidental lesions, including those within the pituitary gland, although it also plays a central role in their subsequent evaluation and management.

Intrasellar plasmacytoma: an illustrative case and literature review

Intrasellar plasmacytoma is a rare pituitary pathology. Pre-operative diagnosis remains a challenge as a sellar plasmacytoma mimics a pituitary adenoma in clinical and radiological features. We report a 45-year-old woman, known to have multiple myeloma, presenting to our clinic with a pituitary mass eventually diagnosed as a plasmacytoma. We review 26 similar cases reported in the literature and divide them into three categories, based on their presentation and follow-up data. Pitfalls in diagnosis and reported treatment modalities are also discussed. We conclude that presentation with cranial nerve palsies and an aggressive sellar mass on imaging, and without gross anterior hypophyseal hormonal imbalance, are features of a pituitary plasmacytoma. The presentation and follow-up characteristics may help to determine the prognosis of such patients.

Management of giant pituitary tumors affecting vision in Nigeria

OBJECTIVE

The management of pituitary tumors has evolved considerably in the past few decades. One of the indices for effective surgical outcome is the size of the tumor on presentation. Reports from west and central Africa have largely indicated late presentation with very large tumors. In the present study we examined this trend and the impact of late presentation on visual outcomes.

METHODS

This is a retrospective analysis of the patterns of visual presentation of giant pituitary tumors and the factors that influenced treatment outcomes. We analyzed 44 patients who presented with pituitary tumors extending into the suprasellar region during a five-year period. All patients had computerized tomography or magnetic resonance imaging confirmation of their tumor.

RESULTS

About 43% of patients were referred from ophthalmologists. The main symptoms were impaired vision (100%) and visual field defect was present in 47.1%. Optic atrophy was found in 38 eyes (43.1%) and 30% of the patients were already blind on presentation. An additional 23% were functionally blind. Five patients had hydrocephalus from third ventricle obstruction. Of those who had surgery, five patients had additional radiotherapy. There were no perioperative deaths but there were two deaths during follow-up. Vision improved in 14 patients, was unchanged in nine and deteriorated in two.

CONCLUSIONS

Tumors of the pituitary present late in developing countries resulting in increased morbidity. Intervention even at this stage results in visual improvement and efforts must be made to cascade this information to frontier health workers.

The coexistence of an intrasellar adenoma, lymphocytic hypophysitis, and primary pituitary lymphoma in a patient with acromegaly

The concomitant presence of three histopathologically different entities in the pituitary gland is a rare occurrence. Most publications identify at least two distinct pathologies, mainly, a pituitary adenoma coexisting with a second intrasellar lesion. We present a case of a 71-year-old female referred for evaluation and treatment of acromegaly. Questioning revealed she was experiencing facial palsy, visual disturbances, and syncopal spells for several weeks. When laboratory evaluation showed elevated somatomedin (IGF-I) levels and an oral glucose tolerance test failed to demonstrate any suppression of her growth hormone (GH) values, an MRI of the pituitary revealed a sellar mass. A presumptive diagnosis of pituitary adenoma was established. The patient underwent transsphenoidal resection of the sellar mass, which proved to be a large B-cell lymphoma (Stage I-E) associated with areas of adenoma and lymphocytic hypophysitis.

Sellar and parasellar metastatic tumors

The sellar and parasellar (SPS) region is a complex area rich in vital neurovascular structures and as such may be the location of first manifestation of a systemic malignancy. Metastases to this region are rare; breast cancer is the most common source among those that metastasize to the SPS region. Ophthalmoplegia, headache, retroorbital or facial pain, diabetes insipidus, and visual field defects are the most commonly reported symptoms. Lack of specific clinical and radiological features renders SPS metastases difficult to differentiate from the other frequently encountered lesions in this area, especially when there is no known history of a primary disease. Currently accepted management is multimodality therapy that includes biopsy and/or palliative surgical resection, radiation, and chemotherapy. Although no significant survival benefits have been shown by the surgical series, surgical resection may improve quality of life. Here we review the relevant literature and present six illustrative cases from our own institution.

Diffuse large B-cell non Hodgkin's lymphoma in a 65-year-old woman presenting with hypopituitarism and recovering after chemotherapy: a case report

INTRODUCTION

Diffuse large B-cell non Hodgkin's lymphoma may involve the pituitary either as a primary central nervous system lymphoma or, more frequently, as metastasis from systemic lymphoma leading to hypopituitarism. A partial recovery of pituitary function after treatment with chemotherapy has previously been described but complete recovery with cessation of all hormone supplements is excessively rare. We report a patient presenting with anterior hypopituitarism with subsequent complete and sustained recovery of pituitary function after successful treatment of the lymphoma.

CASE PRESENTATION

A 65-year-old Caucasian woman with lethargy, loss of appetite and peripheral edema was found to have anterior hypopituitarism. Magnetic resonance imaging showed no mass lesions in the pituitary although a positron emission tomography scan showed abnormal pituitary activity. An abdominal computed tomography scan revealed multiple intra-abdominal lymph nodes, which on histology proved diagnostic of diffuse large B-cell non Hodgkin's lymphoma. She received six cycles of R-CHOP chemotherapy, after which she achieved a complete metabolic response at all known previous sites of the disease, confirmed by positron emission tomography scanning. Concomitant with the tumor response, there was full recovery of adrenal, thyroid and gonadal axes which has persisted at 10 months follow-up.

CONCLUSION

Although rare, it is important to recognize lymphomatous infiltration of the pituitary as a potentially reversible cause of hypopituitarism.

Primary pituitary lymphoma in an immunocompetent patient: a rare clinical entity

Primary pituitary lymphoma in immunocompetent patients is an exceedingly rare clinical entity. We report the case of a 41-year-old woman with initial polydipsia and polyuria. When laboratory evaluation revealed panhypopituitarism, a pituitary enhanced MRI was performed and was suggestive of a pituitary adenoma. Obstructive hydrocephalus provoked by enlarged sellar mass was also demonstrated during observation, and a shunt procedure following lesion resection was carried out. Histopathological examination and immunophenotyping verified diffuse large B-cell non-Hodgkin's lymphoma. No systemic disease was found on staging of the patient. We will also review the clinical, radiological features and outcomes of 28 cases that have been reported since 1993.

Pituitary incidentaloma: an endocrine society clinical practice guideline

OBJECTIVE

The aim was to formulate practice guidelines for endocrine evaluation and treatment of pituitary incidentalomas.

CONSENSUS PROCESS

Consensus was guided by systematic reviews of evidence and discussions through a series of conference calls and e-mails and one in-person meeting.

CONCLUSIONS

We recommend that patients with a pituitary incidentaloma undergo a complete history and physical examination, laboratory evaluations screening for hormone hypersecretion and for hypopituitarism, and a visual field examination if the lesion abuts the optic nerves or chiasm. We recommend that patients with incidentalomas not meeting criteria for surgical removal be followed with clinical assessments, neuroimaging (magnetic resonance imaging at 6 months for macroincidentalomas, 1 yr for a microincidentaloma, and thereafter progressively less frequently if unchanged in size), visual field examinations for incidentalomas that abut or compress the optic nerve and chiasm (6 months and yearly), and endocrine testing for macroincidentalomas (6 months and yearly) after the initial evaluations. We recommend that patients with a pituitary incidentaloma be referred for surgery if they have a visual field deficit; signs of compression by the tumor leading to other visual abnormalities, such as ophthalmoplegia, or neurological compromise due to compression by the lesion; a lesion abutting the optic nerves or chiasm; pituitary apoplexy with visual disturbance; or if the incidentaloma is a hypersecreting tumor other than a prolactinoma.

Panhypopituitarism secondary to a macroprolactinoma manifesting with pancytopenia: case report and literature review

OBJECTIVE

To present a case of pancytopenia associated with hypopituitarism secondary to a macroprolactinoma.

METHODS

We report the clinical features on presentation and results of laboratory investigation. Findings on magnetic resonance imaging are illustrated. The response to hormone replacement therapy is summarized.

RESULTS

A 46-year-old man was referred with pancytopenia and secondary hypothyroidism. Laboratory investigation revealed hypopituitarism and a substantially increased prolactin level. Magnetic resonance imaging of the head demonstrated a macroprolactinoma. Hematologic investigation disclosed no other cause for the pancytopenia. Hormone replacement therapy was initiated with hydrocortisone, levothyroxine, and testosterone. Cabergoline was used to induce regression of the prolactinoma. A rapid improvement was seen in the cytopenias, with normalization of the blood cell counts after 8 months of treatment. This result has been sustained during 29 months of follow-up.

CONCLUSION

Pancytopenia associated with hypopituitarism has been reported in the literature as a rare occurrence limited to isolated case reports, predominantly associated with Sheehan syndrome. To our knowledge, this is the first reported case of pancytopenia associated with a macroprolactinoma. This finding is noteworthy because prolactin alone has been reported to support hematopoiesis in animal studies.

Hypopituitarism caused by carotid cavernous fistula

Here we report a 79-year-old woman who presented with a 7-day history of headache, nausea, vomiting, and was found to have proptosis and ptosis. Laboratory findings showed hyponatremia, hypocortisolism, secondary hypothyroidism and low follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels. CT angiography (CTA) showed a vascular lesion in sella causing a mass affect on the pituitary gland which proved to be a carotid cavernous fistula (CCF) by conventional angiography. The lesion was subsequently treated with coil placement and patient's hyponatremia was successfully treated with corticosteroid and thyroid hormone replacement. Though rare, CCF should be considered in the differential diagnosis of sellar lesions. Also, in patients with CCF hyponatremia, hypotension or signs of hypothyroidism should warrant a work-up for pituitary function.

Symptomatic hypopituitarism revealing primary suprasellar lymphoma

BACKGROUND

The most common cause of hypopituitarism is pituitary adenoma. However, in the case of suprasellar masses different etiologies are possible. We report an unusual case of primary suprasellar lymphoma presented with hypopituitarism.

CASE PRESENTATION

A 26 year old woman presented with amenorrhea, galactorrhea and neurological disorders. Also, the laboratory work-up revealed partial hypopituitarism. The magnetic resonance imaging of the head showed a suprasellar mass. A presumptive diagnosis of granulomatous processes was made and the patient was given steroid therapy. Repeated brain MRI detected new lesions in the brain with regression of the suprasellar mass. Stereotactic biopsy of the paraventricular lesion revealed the diagnosis of B-cell lymphoma.

CONCLUSION

This case presentation reports a rare cause of hypopituitarism. Primary suprasellar lymphoma is extremely rare and represented a real diagnostic challenge. Besides, suprasellar masses are varied in aetiology and can present diagnostic problems for a radiologist. Also, because of the increased incidence of PCNSL, lymphoma must be kept in mind in the differential diagnosis of lesions in the suprasellar region.

Immunoglobulin D Multiple Myeloma Involving the Sella Manifesting as Oculomotor Palsy

OBJECTIVE

Immunoglobulin D multiple myeloma (IgD MM) is an uncommon type of MM characterized by an aggressive clinical behavior and a short survival time. We report a rare case in which oculomotor palsy caused by a sellar lesion was the initial manifestation of IgD MM; systemic treatments were beneficial in this case.

CLINICAL PRESENTATION

A 61-year-old man presented with diplopia, left-sided ptosis, and retro-orbital pain. An examination revealed left cranial nerve (CN) III and IV palsies. CT scanning demonstrated a mass in the sellar and parasellar regions and partial destruction of the left side of the dorsum sellae. MRI revealed that the mass extended into the left cavernous sinus with minimal suprasellar extension. An endocrinologic evaluation did not reveal any abnormality. At the time of admission, the patient had no symptoms of MM.

INTERVENTION

A transsphenoidal resection was performed. Histopathologic examination revealed a tumor consisting of plasma cells. Appropriate laboratory studies, a bone scan, and a bone marrow biopsy led to a diagnosis of IgD lambda-type MM. High-dose chemotherapy followed by autologous peripheral blood stem cell transplantation was therapeutically beneficial. The patient's symptoms were gradually relieved.

CONCLUSION

This case demonstrates that an unusual sellar tumor might be the first manifestation of IgD MM. Careful observation can suggest a possible non-pituitary etiology for a tumor, leading to appropriate diagnostic and therapeutic procedures.

Solitary metastatic tumor within the optic chiasm--case report

A 61-year-old female, previously treated for lung cancer, presented with a rare case of metastasis directly to the optic chiasm manifesting as visual deficits. Magnetic resonance imaging revealed a suprasellar mass similar to an optic glioma. At surgery, the optic chiasm appeared swollen with hypervascularity over the surface. The bilateral optic nerves and the pituitary stalk appeared normal. A small incision was made on the superior surface of the chiasm and biopsy specimens were taken. The histological diagnosis was adenocarcinoma, which was consistent with the primary lung cancer. She received whole brain irradiation, resulting in mild improvement of her vision. Suprasellar metastatic tumors to the pituitary gland, pituitary stalk, and hypothalamus are well documented, but solitary metastasis within the optic chiasm should be considered as one of several differential diagnoses of suprasellar tumors, in patients with or without a history of treated cancer.

Incidentally discovered pituitary masses: pituitary incidentalomas

With the widespread use of computed tomography and MRI, the incidental discovery of pituitary incidentalomas is increasing in frequency. The most common cause of a pituitary mass is a pituitary adenoma (90% of all pituitary masses); however, the differential diagnosis remains extensive. The challenge is to distinguish those that can or will cause morbidity/mortality from those that will not. Opinions on approaching management of these lesions vary. This article will review current data regarding the prevalence, natural history and potential morbidity associated with this entity and describe an epidemiological approach based on four questions: does an incidental mass put the patient at increased risk for an adverse outcome? Can individuals with treatable syndromes be accurately diagnosed? Is the treatment of these syndromes more effective in presymptomatic patients? And do the beneficial effects of presymptomatic detection and treatment of these patients justify the costs incurred? We recommend the following approach: recognizing that one size does not fit all and that the approach should be tailored to the needs of the particular case. If the mass was discovered on a computed tomography, an enhanced MRI is recommended. Detailed history and physical examination should be carried out to look for signs of functional or 'subclinically' functional tumor. Size and structure should be assessed, especially proximity to the optic chiasm. Laboratory evaluation with a serum prolactin for small tumors is cost effective, other lab testing is indicated if metabolic problems are present. Care should be taken to assess for hypopituitarism, clinically and biochemically, if the mass is large, that is, more than 1 cm, visual field testing is also recommended. Note that the vast majority of patients with pituitary incidentalomas that are microadenomas die with them, not from them.

Panhypopituitarism apparently caused by hypophysitis masking a rapid development of a craniopharyngioma. A case report

We report the case of a 39-year-old male presenting with panhypopituitarism and diabetes insipidus. MR imaging showed focal thickening of the pituitary infundibulum and infiltration of the anterior pituitary lobe, suggesting hypophysitis. Hormonal replacement therapy induced a pronounced amelioration of general well-being. Eight months later the subject developed visual disturbances. MR imaging now showed a cystic sellar mass. Surgical drainage was performed. A second operation was necessary six weeks Later because of recurrent visual field defects. Diagnosis of papillary craniopharyngioma was finally made. This case demonstrates the remarkably rapid development of a craniopharyngioma, which initial radiological appearance was suggestive of hypophysitis. It also emphasizes the need of repeat MR examination in case of unusual presentation of hypopituitarism.

Primary sellar lymphoma: intravascular large B-cell lymphoma diagnosed as a double cancer and improved with chemotherapy, and literature review of primary parasellar lymphoma

Lymphoma is one of the causative factors of hypothalamus-pituitary dysfunction, and intravascular large B-cell lymphoma (IVLBCL) is a subtype of primary extranodal neoplasm. A 69-year-old woman visited our hospital because of general fatigue. We diagnosed her with presumable non-functional primary pituitary adenoma and subsequent dysfunction. Eight months after, the patient revisited our hospital because of dyspnea. Though we conducted systemic investigations including chest and abdomen enhanced computer tomography, transbronchial lung biopsy, and bone marrow biopsy, the diagnosis was not confirmed. Inadvertently, a breast cancer was found, and the surgical specimen proved that the patient had double cancer-adenocarcinoma and IVLBCL. Rituximab, cyclophosphamide, adriamycin, vincristine, and prednisolone regimen was initiated, and complete remission was achieved. Notably, the sellar mass returned to normal size with improved function. We reviewed 32 patients with primary parasellar lymphoma. In affected sites, both sellar and pituitary stalk (6.7%), both hypothalamus and pituitary stalk (6.7%), only sellar (63.3%), only pituitary stalk (6.7%), only hypothalamus (13.3%), and only clivus (3.3%) were observed. In hypothalamus-pituitary dysfunction, both anterior and posterior dysfunction (20.7%), only anterior dysfunction (58.6%), only posterior dysfunction (3.4%), and no dysfunction (17.2%) were observed. It seemed that hypothalamic lesion is related to both anterior and posterior dysfunction, while sellar lesion is related to mainly anterior dysfunction. In cranial nerve dysfunction, 2nd nerve dysfunction (45.2%) and 6th nerve dysfunction (35.5%) were frequently observed. It seemed that sellar lesion is related to both 2nd and 6th nerve dysfunction, while hypothalamic lesion is related to mainly 2nd nerve dysfunction.

Autoimmune hypophysitis: expanding the differential diagnosis to CTLA-4 blockade

Autoimmune hypophysitis is an increasingly recognized disorder that enters in the differential diagnosis of nonfunctioning pituitary masses. The differential diagnosis of these conditions is challenging because of similar clinical presentations and radiological signs. This review describes the essential features of hypophysitis and the other nonfunctioning pituitary masses. It also emphasizes a recently described feature of hypophysitis: its appearance with unexpectedly high frequency in patients receiving treatments that abrogate the function of cytotoxic T lymphocyte antigen 4.

A radiologic score to distinguish autoimmune hypophysitis from nonsecreting pituitary adenoma preoperatively

BACKGROUND AND PURPOSE

Autoimmune hypophysitis (AH) mimics the more common nonsecreting pituitary adenomas and can be diagnosed with certainty only histologically. Approximately 40% of patients with AH are still misdiagnosed as having pituitary macroadenoma and undergo unnecessary surgery. MR imaging is currently the best noninvasive diagnostic tool to differentiate AH from nonsecreting adenomas, though no single radiologic sign is diagnostically accurate. The purpose of this study was to develop a scoring system that summarizes numerous MR imaging signs to increase the probability of diagnosing AH before surgery.

MATERIALS AND METHODS

This was a case-control study of 402 patients, which compared the presurgical pituitary MR imaging features of patients with nonsecreting pituitary adenoma and controls with AH. MR images were compared on the basis of 16 morphologic features besides sex, age, and relation to pregnancy.

RESULTS

Only 2 of the 19 proposed features tested lacked prognostic value. When the other 17 predictors were analyzed jointly in a multiple logistic regression model, 8 (relation to pregnancy, pituitary mass volume and symmetry, signal intensity and signal intensity homogeneity after gadolinium administration, posterior pituitary bright spot presence, stalk size, and mucosal swelling) remained significant predictors of a correct classification. The diagnostic score had a global performance of 0.9917 and correctly classified 97% of the patients, with a sensitivity of 92%, a specificity of 99%, a positive predictive value of 97%, and a negative predictive value of 97% for the diagnosis of AH.

CONCLUSIONS

This new radiologic score could be integrated into the management of patients with AH, who derive greater benefit from medical as opposed to surgical treatment.

Silent subtype 3 pituitary adenoma: a clinicopathologic analysis of the Mayo Clinic experience

BACKGROUND

Macroadenomas represent 50% of pituitary tumours and are often (30%) nonfunctioning. Their immunophenotype suggests differentiation toward a specific pituitary cell line. A substantial proportion of tumours with particularly aggressive behaviour are so called 'silent subtype 3 adenoma'. Its diagnosis requires ultrastructural confirmation. Although once included among silent corticotroph adenomas, this aggressive, morphologically distinctive tumour is now recognized as a major form of plurihormonal adenoma and, in fact, some patients might present with clinical hormonal excess. The cytogenesis and pathobiology of silent subtype 3 adenomas is unsettled.

OBJECTIVE

We undertook a systematic clinicopathologic examination of the Mayo Clinic experience with this poorly understood tumour.

DESIGN

This retrospective, single institution study found 27 confirmed examples of silent subtype 3 adenoma, a frequency of 0.9% of adenomas. Despite histologic and immunophenotypic variation, their ultrastructural features were diagnostic and the sole basis for case inclusion.

RESULTS

The study group was comprised of 16 men (59%) and 11 women (41%); two patients (7%) had definitive diagnosis of multiple endocrine neoplasia type 1 (MEN1). Three tumours (11%) were discovered incidentally. Nine patients each (38%) presented with headaches or visual field loss. Endocrine hyperfunction was noted in eight cases (30%), including GH excess in five (19%) and clinically significant PRL elevation in three (11%). Hypogonadism was noted in 17 cases (63%) and growth arrest in one (4%). All tumours were macroadenomas; 16 (60%) showed radiographic evidence of invasion. Most tumours were plurihormonal, featuring immunoreactivity for PRL (17), GH (15), TSH (16) or ACTH (3); only one lesion was immunonegative. Although a gross total resection was achieved in 19 cases (70%), re-operation for recurrence(s) was required in seven of these (37%). Follow-up (mean, 69 months) showed a high (59%) rate of persistent or recurrent of tumour. Overall, 14 patients (54%) underwent radiotherapy after surgical treatment: three patients (12%) for substantial residual tumour, eight (31%) as adjuvant therapy and three (12%) for tumour regrowth.

CONCLUSION

Silent subtype 3 adenoma, a plurihormonal tumour, is rare and aggressive in nature. This adenoma must be considered in the differential of often clinically nonfunctioning but plurihormonal adenomas featuring variable cytologic atypia. Electron microscopy is required for confirmation of the diagnosis. The cytogenesis of silent subtype 3 adenoma remains unsettled.

Multiple intracranial melanoma metastases: case report and review of the literature

Although intracerebral metastases of malignant melanoma are common, those located in the sellar region and within the pontocerebellar area are extremely rare. Furthermore, to our knowledge, there is no report about melanoma metastasis to the epiphysis published so far. We report here a 46-year-old patient who had metastatic lesions in the sellar region, cerebellopontine area and epiphysial gland, preceded by a primary melanoma at her left shoulder. The diagnosis of sellar metastasis was confirmed histopathologically following a stereotactic biopsy. The patient received whole-brain irradiation therapy combined with chemotherapy. After 10 months, she died from a severe hemorrhage in the cerebellopontine angle. Autopsy findings confirmed melanoma metastases both in the cerebellopontine angle and additionally in the epiphysial gland. To our knowledge, this is the first case of multiple intracranial melanoma metastases including the suprasellar region, the pontocerebellar and epiphysial area.

Radiotherapy of other sellar lesions

Radiotherapy has been used as primary or adjuvant treatment in a number of non-adenomatous masses arising from within the sella. It is particularly important in the therapeutic algorithm of craniopharyngiomas and meningiomas and has also been used in chordomas/chordosarcomas and less commonly, in other lesions. This review describes the place of irradiation in the management of these masses.

Primary sellar melanocytic tumor: report of new case and literature review

CONTEXT

Primary sellar melanocytic tumors are extremely rare, and they can mimic hormonally inactive pituitary macroadenoma both clinically and radiologically.

OBJECTIVES

The aim of this study was to describe a new case of primary sellar melanocytic tumor, and place it in the context of published literature.

DESIGN

This is a case report.

PATIENT

The case of a 61-year-old woman presenting with a 2-month history of fatigue and progressive bitemporal hemianopia is described. Endocrine investigation revealed anterior pituitary insufficiency and hyperprolactinemia without diabetes insipidus. Magnetic resonance imaging demonstrated a sellar tumor mass with suprasellar extension compressing the optic chiasm, and intense gadolinium enhancement. Transsphenoidal surgical excision of the pituitary tumor was undertaken. Histological examination showed a melanocytic tumor. An extensive search failed to find evidence of any other primary or secondary site. Due to the presence of significant tumor residue at 3-month follow-up, another surgical resection was done followed by post-operative stereotactic radiotherapy of the sellar region.

CONCLUSION

Primary sellar melanocytic tumors are exceptional lesions presenting most often as a tumor syndrome and/or anterior pituitary insufficiency mimicking a non-secreting pituitary macroadenoma. The management of these tumors consists of surgical removal of the tumor. However, surgery is often incomplete and stereotactic fractionated radiotherapy is frequently indicated.

Primary central nervous system lymphoma mimicking pituitary apoplexy: case report

Lymphoma involving the pituitary gland is very rare and usually results from metastatic spread of systemic lymphoma. We present a case of primary central nervous system (CNS) large B cell lymphoma that manifested as pituitary apoplexy. A 45-year-old woman presented with headache, and then rapidly developed a third nerve palsy and bitemporal hemianopsia. Imaging suggested a pituitary macroadenoma, with spontaneous necrosis, extending into the suprasellar region, compressing the optic chiasm and invading the right cavernous sinus. The patient underwent transsphenoidal resection which revealed a vascular, firm tumor. An aggressive decompression of the optic chiasm was performed with complete resolution of both visual fields and third nerve palsy. Final pathology showed B cell lymphoma. Systemic work-up including bone marrow aspiration and CSF studies showed no other foci of lymphoma, and the patient was HIV-negative. Chemotherapy with methotrexate, vincristine, procarbazine, and dexamethasone was administered for primary CNS lymphoma. This is an uncommon diagnosis of which the clinician should be aware in order to tailor surgical intervention and provide early institution of proper therapy.

Primary pituitary lymphoma: a histological, immunohistochemical, and ultrastructural study with literature review

We report the case of a 62-year-old man with headache and left sixth cranial nerve palsy. A computerized tomography scan revealed an osteolytic process involving the sella turcica and clivus. A partial tumor resection was achieved via an endoscopic transsphenoidal approach. Morphologic investigation revealed a diffuse large B cell lymphoma involving pituitary parenchyma. No systemic disease was found upon staging. Primary pituitary lymphoma is extremely rare. An accurate histologic diagnosis is key to successful treatment and a favorable prognosis. The literature is reviewed.