Tissue factor expressed in pituitary adenoma cells contributes to the development of vascular events in pituitary adenomas

Approach to the Patient: Differential Diagnosis of Cystic Sellar Lesions

Cystic lesions arising in the sellar region are not uncommon and encompass cystic pituitary adenomas, Rathke cleft cysts, craniopharyngiomas, and arachnoid cysts. Their clinical presentation may be similar, including headache, visual field defects, and anterior pituitary hormone deficits, which makes differential diagnosis challenging. On the other hand, imaging features may indicate certain pathologies. In this approach to the patient, we describe the case of a patient who presented with right temporal hemianopsia and a sellar/suprasellar cystic lesion, which was determined to be Rathke cleft cyst. We discuss the imaging characteristics that may suggest a particular diagnosis between Rathke cleft cyst, cystic pituitary adenoma, craniopharyngioma, and arachnoid cyst and propose a flowchart for aiding in the imaging differential diagnosis.

Patients With MEN1 Are at an Increased Risk for Venous Thromboembolism

BACKGROUND

Multiple endocrine neoplasia type 1 (MEN1) is a rare inherited disorder predisposing the development of multiple functional and nonfunctional neuroendocrine tumors (NETs). Only uncommon MEN1-associated functional NETs such as glucagonomas (<1%) and adenocorticotropic hormone-producing tumors (<5%) are known to be associated with hypercoagulability. It is unknown if patients with MEN1 generally have an increased risk of venous thromboembolism (VTE).

METHODS

We queried a prospective natural history study of germline mutation-positive MEN1 patients (n = 286) between 1991 and 2019 for all lifetime events of VTE. The search terms were: DVT, thromb, embol, PE, pulmonary embolism, clot, hematology consult, anticoagulant, coumadin, lovenox, xarelto, warfarin, aspirin, rivaroxaban, and apixaban. Incidence rates were calculated, accounting for age and sex. Comparisons were made to published incidence rates in healthy populations, different types of cancer, and Cushing's syndrome.

RESULTS

Thirty-six subjects (median age 45 years, range 16-75) experienced a VTE event, yielding a prevalence rate of 12.9%. The age-sex adjusted incidence rate of VTE is 9.11 per 1000 patient-years, with a sex-adjusted lifetime incidence rate of 2.81 per 1000 patient-years. MEN1-associated lifetime incidence rates are ~2-fold higher than the estimated annual incidence rate in the general population and are comparable to the known risk in the setting of various types of cancer. Approximately 80% of patients who had a VTE were diagnosed with pancreatic NETs, of which 24% were insulinomas. Fourteen patients (42%) experienced perioperative VTE events.

CONCLUSIONS

MEN1 patients have an increased risk of VTE. Further mechanistic investigation and validation from other MEN1 cohorts are needed to confirm the increased prevalence of VTE in MEN1.

Treatment Strategy for Recurrent Hemorrhage from Meningioma: Case Report and Literature Review

We came across a rare case of recurrent hemorrhage from a meningioma. Here, we describe this case and discuss the treatment strategies for recurrent hemorrhage from a meningioma using a literature review. A 61-year-old woman with a history of two episodes of hemorrhage from a meningioma originating from the left falx cerebri, presented to our outpatient clinic. She was asymptomatic, and MRI revealed a small tumor along the falx cerebri; however, we decided to remove the hemorrhagic meningioma. No abnormal vascular structures were recognized on preoperative angiography and on intraoperative evaluation. The tumor was easily removed along the falx cerebri (Simpson grade I). The pathological diagnosis was transitional meningioma, World Health Organization grade I. The patient experienced no recurrence of tumor or hemorrhage for up to 15 months after surgery. The incidence of repeated bleeding from meningiomas is very rare and is seldom reported, because the mortality associated with hemorrhage in meningiomas is high (28-50%). Immediate diagnosis and surgical treatment with both hematoma evacuation and tumor removal are crucial to avoid inadequate and delayed treatment that may cause mortality.

Evaluation of Clinical and Magnetic Resonance Imaging Profile of Pituitary Macroadenoma: A Prospective Study

Background

Pituitary macroadenoma is a common tumor of middle-aged people. Magnetic resonance imaging (MRI) is the investigation of choice for its evaluation. Various parameters regarding the extent, consistency, and contrast uptake can be studied and a noninvasive diagnosis is possible.

Aims and Objectives

To study the MRI features and extent of pituitary macroadenomas.

Materials and Methods

We studied clinical and MRI features of 33 patients of all age groups and both sexes with pituitary macroadenomas who presented to Dayanand Medical College and Hospital, Ludhiana from January 2014 to June 2015. MRI was carried out on MAGNETOM Avanto 18 Channel 1.5 Tesla Machine by Seimens India Ltd. The dedicated sellar protocol consisted of sagittal and coronal T1-weighted image (TI-WI) and T2-WI without intravenous contrast using thin slices (3 mm) and a field of view of <200 mm.

Results

On analysis of the 33 cases, we observed that patients of pituitary macroadenoma showed an almost equal sex incidence and average age group of 50-60 years. The common presenting complaints were headache and decreased vision. Superior and inferior extent of the lesion was beyond the defined boundaries of sella in most cases, but the lateral extent was limited, resulting in characteristic "snowman-like" appearance. The imaging characteristics showed solid to predominantly solid consistency, appearing mostly heterogeneously hyperintense on T2-WI, and hypo to isointense on T1-WI with intense postcontrast enhancement. Hemorrhage is less common. Pituitary apoplexy is rare and can result in spontaneous resolution.

Conclusions

We conclude that the knowledge of clinical and imaging profile of pituitary macroadenoma can help the radiologists to diagnose these sellar lesions, and hence their therapeutic approach can be defined timely.

Pituitary apoplexy: a rare cause of cerebral infarction. A case report

Pituitary apoplexy is usually the result of hemorrhagic infarction in pituitary adenoma. The clinical presentation of pituitary apoplexy varies widely and includes asymptomatic hemorrhage, classical pituitary apoplexy and even sudden death. Few cases of cerebral infarction associated with pituitary apoplexy have been reported in the literature. Pituitary apoplexy can cause narrowing of intracranial vessels by mechanical obstruction due to mass effect or by vasospasm resulting in cerebral ischemia. We report a case of pituitary apoplexy associated with cerebral infarction and the putative mechanisms.

Assessment of hemorrhage in pituitary macroadenoma by T2*-weighted gradient-echo MR imaging

BACKGROUND AND PURPOSE

Intratumoral hemorrhage occurs frequently in pituitary macroadenoma and manifests as pituitary apoplexy and recent or old silent hemorrhage. T2*-weighted gradient-echo (GE) MR imaging is the most sensitive sequence for the detection of acute and old intracranial hemorrhage. T2*-weighted GE MR imaging was used to investigate intratumoral hemorrhage in pituitary macroadenomas.

MATERIALS AND METHODS

Twenty-five consecutive patients who underwent total or subtotal resection of pituitary macroadenoma with heights from 17 to 53 mm, including 1 patient with classic pituitary apoplexy, underwent MR imaging before surgery, including T2*-weighted GE MR imaging. For histologic assessment of the hemorrhage in whole surgical specimens, we used hematoxylin-eosin staining.

RESULTS

T2*-weighted GE MR imaging detected various types of dark lesions, such as "rim," "mass," "spot," and "diffuse" and combinations, indicating clinical and subclinical intratumoral hemorrhage in 12 of the 25 patients. The presence of intratumoral dark lesions on T2*-weighted GE MR imaging correlated significantly with the hemorrhagic findings on T1- and T2-weighted MR imaging (P < .02 and <.01, respectively), and the surgical and histologic hemorrhagic findings (P < .001 and <.001, respectively).

CONCLUSION

T2*-weighted GE MR imaging could detect intratumoral hemorrhage in pituitary adenomas as various dark appearances. Therefore, this technique might be useful for the assessment of recent and old intratumoral hemorrhagic events in patients with pituitary macroadenomas.

Massive stroke in a patient with pituitary apoplexy, cervical carotid artery stenosis and hypotension

We report a case of massive cerebral infarct in the early stage of pituitary apoplexy. The case is unique because the stroke was delayed and occurred only after the patient developed severe arterial hypotension superimposed on a tandem internal carotid artery stenosis by both the sellar mass on the siphon and an unknown homolateral atheromatous cervical lesion. Illustrated with MRI and specifically by diffusion-weighted imaging, this case reinforces the idea that a low apparent diffusion coefficient in a non-enhancing sellar mass may indicate the presence of pituitary apoplexy and help in the early adequate management of such patients.

Expression of tissue factor pathway inhibitor in human fetal and placental tissues

The coagulation system differs markedly between fetuses, neonates, and adults, and fetal and neonatal thrombotic abnormalities are poorly understood. Tissue factor pathway inhibitor (TFPI) is an important inhibitor of the extrinsic pathway of coagulation. To begin examining the role of TFPI in the maternal-fetal relationship, TFPI expression in human fetal and placental tissues was studied by immunohistochemical staining. TFPI was widely expressed in human fetal tissues from 8-24 weeks gestation, particularly in epithelial and endothelial tissues. Fetal liver, lung, kidney, and intestine were notably positive for TFPI staining. Within the tissues, TFPI was expressed in pneumocytes, hepatocytes, renal tubular and glomerular cells, muscle fibers, and enterocytes. In placental tissues, TFPI was expressed in syncytiotrophoblasts, cytotrophoblasts, vascular endothelium, and extravillus trophoblasts from 10 weeks through term. Advancing gestation had little effect on TFPI expression. Further studies are needed to determine the functional role of TFPI in fetal and placental tissues and to define perturbations in its expression during fetal and neonatal disease states.