Sellar Lesions/Pathology

What to report in sellar tumor MRI? A nationwide survey among German pituitary surgeons, radiation oncologists, and endocrinologists

PURPOSE

While MRI has become the imaging modality of choice in the diagnosis of sellar tumors, no systematic attempt has yet been made to align radiological reporting of findings with the information needed by the various medical disciplines dealing with these patients. Therefore, we aimed to determine the prevailing preferences in this regard through a nationwide expert survey.

METHODS

First, an interdisciplinary literature-based catalog of potential reporting elements for sellar tumor MRI examinations was created. Subsequently, a web-based survey regarding the clinical relevance of these items was conducted among board certified members of the German Society of Neurosurgery, German Society of Radiation Oncology, and the Pituitary Working Group of the German Society of Endocrinology.

RESULTS

A total of 95 experts (40 neurosurgeons, 28 radiation oncologists, and 27 endocrinologists) completed the survey. The description of the exact tumor location, size, and involvement of the anatomic structures adjacent to the sella turcica (optic chiasm, cavernous sinus, and skull base), occlusive hydrocephalus, relationship to the pituitary gland and infundibulum, and certain structural characteristics of the mass (cyst formation, hemorrhage, and necrosis) was rated most important (> 75% agreement). In contrast, the characterization of anatomic features of the nasal cavity and sphenoid sinus as well as the findings of advanced MRI techniques (e.g., perfusion and diffusion imaging) was considered relevant by less than 50% of respondents.

CONCLUSION

To optimally address the information needs of the interdisciplinary treatment team, MRI reports of sellar masses should primarily focus on the accurate description of tumor location, size, internal structure, and involvement of adjacent anatomic compartments.

Ultra-Early Treatment of Neurosurgical Emergencies with Endoscopic Endonasal Approach: Experience from Three Italian Referral Centers

PURPOSE

the aim of this multicenter study is to preliminarily assess the role of the Endoscopic Endonasal Approach (EEA) in ultra-early (i.e., within 12 h) management of selected neurosurgical emergencies in terms of clinical and radiological outcomes.

METHODS

26 patients affected by sellar/parasellar pathologies with rapid progression of symptoms were managed with EEA within 12 h from diagnosis in three Italian tertiary referral Centers from January 2016 to December 2019. Both clinical and radiological data have been collected preoperatively as well as post-operatively in order to perform retrospective analysis.

RESULTS

The average time from admission to the operating room was 5.5 h (±2.3). The extent of resection was gross-total in 20 (76.9%), subtotal in 6 (23.1%) patients. One patient experienced re-bleeding after a subtotal removal of a hemorrhagic lesion. Patients with a longer time from admission (>4 h) to the operatory room (OR) experienced stable impairment of the visual acuity (p = 0.033) and visual field (p = 0.029) in the post-operative setting.

CONCLUSIONS

The Endoscopic Endonasal Approach represents a safe, effective technique that can be efficiently used with good results in the management of selected neurosurgical emergencies in centers with adequate experience.

Pituitary adenoma consistency affects postoperative hormone function: a retrospective study

BACKGROUND

Tumor consistency recently emerged as a key factor in surgical planning for pituitary adenomas, but its impact on postoperative endocrine function is still unclear. Our study aimed to evaluate the impact of tumor consistency on the development of postoperative pituitary deficiencies.

METHODS

Single-center, retrospective analysis of consecutive pituitary surgeries performed between January 2017 and January 2021 at Policlinico Umberto I in Rome. All patients underwent radiological and biochemical evaluations at baseline, and hormone assessments 3 and 6 months after pituitary surgery. Postoperative MRI studies were used to determine resection rates following surgery. Data on tumor consistency, macroscopic appearance, neurosurgical approach, and intraoperative complications were collected.

RESULTS

Fifty patients [24 women, mean age 57 ± 13 years, median tumor volume 4800 mm³ [95% CI 620-8828], were included. Greater tumor volume (χ² = 14.621, p = 0.006) and male sex (χ² = 12.178, p < 0.001) were associated with worse preoperative endocrine function. All patients underwent transsphenoidal adenomectomy. Fibrous consistency was observed in 10% of patients and was associated with a Ki-67 greater than 3% (χ² = 8.154, p = 0.04), greater risk of developing postoperative hormone deficiencies (χ² = 4.485, p = 0.05, OR = 8.571; 95% CI: 0.876-83.908), and lower resection rates (χ2 = 8.148, p = 0.004; OR 1.385, 95% CI; 1.040-1.844). Similarly, worse resection rates were observed in tumors with suprasellar extension (χ2 = 5.048, p = 0.02; OR = 6.000, 95% CI; 1.129-31.880) and CSI (χ2 = 4.000, p = 0.04; OR = 3.857, 95% CI; 0.997-14.916).

CONCLUSIONS

Tumor consistency might provide useful information about postoperative pituitary function, likely due to its impact on surgical procedures. Further prospective studies with larger cohorts are needed to confirm our preliminary findings.

Imaging of pituitary tumors: an update with the 5th WHO Classifications-part 2. Neoplasms other than PitNET and tumor-mimicking lesions

Many types of tumors can develop in the pituitary gland. In the recently revised 5th editions of the World Health Organization (WHO) classifications (2021 WHO Classification of Central Nervous System Tumors and the 2022 WHO Classification of Endocrine and Neuroendocrine Tumors), various changes have been made to the tumors other than pituitary neuroendocrine tumor (PitNET)/pituitary adenoma, as well as PitNET. Adamantinomatous craniopharyngioma and papillary craniopharyngioma are now considered separate tumors in the 5th edition of the WHO classification. Tumors positive for thyroid transcription factor 1, a marker of posterior pituitary cells, are now grouped together in the pituicyte tumor family in the 5th edition of the WHO classification of Endocrine and Neuroendocrine Tumors. Poorly differentiated chordoma is newly listed in the 5th edition of the WHO Classification of Endocrine and Neuroendocrine Tumors. In this paper, we present the latest WHO classification of pituitary tumors (adamantinomatous craniopharyngioma, papillary craniopharyngioma, pituitary blastoma, pituicyte tumor family, tumors of pituitary origin other than those of the pituicyte tumor family, germinoma, meningioma, chordoma, metastatic tumors, lymphoma, and pituitary incidentaloma), review diseases requiring differentiation from tumors (pituitary abscess, hypophysitis, pituitary hyperplasia, Rathke's cleft cyst, arachnoid cyst, and aneurysm), and discuss diagnoses based on imaging findings.

Preoperative 3D volume reconstruction of the posterior wall of the sphenoid sinus with Horos: A free, simple and reliable tool in endoscopic endonasal trans-sphenoidal surgery

BACKGROUND

The purpose of the study was to create computer-aided design models of the sphenoid sinus with a free-source software in order to perform a preoperative planning during trans-sphenoidal endoscopic surgery (TES) and clarify the three-dimensional anatomical features of the sphenoid sinus and its surrounding structures.

METHODS

For each patient a 3D volume rendering of the sphenoid sinus was obtained from a thin slice head and maxilla-facial CT scan using a free-source DICOM viewer. The 3D models obtained preoperatively were examined preoperatively by six neurosurgeons in order to identify the boundaries of the sella.

RESULTS

For the main anatomical landmark, all of the observers were able to recognize the anatomical structure at a rate ranging from 80 to 98%, 28 to 60% and 25 to 58% for expert (n=3), inexpert (n=3) and the entire group of observers (n=6), respectively. The analysis of the data shows that both observation groups presented a lower recognition rate of the following parameters: right and left medial and lateral optocarotid recesses and tumor prominence, however, the sellar prominence, clival recess, planum sphenoidalis, right and left ICA prominence, right and left optic prominences represent the main anatomical landmarks to be recognized during TES immediately before the opening of the sellar floor.

CONCLUSIONS

The use of a preoperative 3D imaging is not in itself a novelty in the literature, however the fact that a simple tool obtained with a free-source software like Horos can represent a considerable help in surgical practice without resorting to the use of more complex software and expensive represents the real utility of this work.

Neoplastic nerve lesions

Though metastasis and malignant infiltration of the peripheral nervous system is relatively rare, physicians should have a familiarity with their presentations to allow for prompt diagnosis and initiation of treatment. This article will review the clinical presentations, diagnostic evaluation, and treatment of neoplastic involvement of the cranial nerves, nerve roots, peripheral nerves, and muscle. Due to the proximity of the neural structure traversing the skull base, metastasis to this region results in distinctive syndromes, most often associated with breast, lung, and prostate cancer. Metastatic involvement of the nerve roots is uncommon, apart from leptomeningeal carcinomatosis and bony metastasis with resultant nerve root damage, and is characterized by significant pain, weakness, and numbness of an extremity. Neoplasms may metastasize or infiltrate the brachial and lumbosacral plexuses resulting in progressive and painful sensory and motor deficits. Differentiating neoplastic involvement from radiation-induced injury is of paramount importance as it dictates treatment and prognosis. Neurolymphomatosis, due to malignant lymphocytic infiltration of the cranial nerves, nerve roots, plexuses, and peripheral nerves, deserves special attention given its myriad presentations, often mimicking acquired demyelinating neuropathies.

Optical coherence tomography and visual evoked potentials in evaluation of optic chiasm decompression

Chiasmal compression is a known cause of visual impairment, often leading to surgical decompression of the optic chiasm (OC). A prospective study was held at University Hospital in Hradec Králové to explore sensitivity of optical coherence tomography (OCT) and visual evoked potentials (VEPs) to OC compression and eventual changes after a decompression. 16 patients with OC compression, caused by different sellar pathologies, were included. The main inclusion criterion was the indication for decompressive surgery. Visual acuity (VA), visual field (VF), retinal nerve fibre layer (RNFL) and ganglion cell layer (GCL) thickness, and peak time and amplitude of pattern-reversal (P-VEPs) and motion-onset VEPs (M-VEPs) were measured pre- and postoperatively. The degree of OC compression was determined on preoperative magnetic resonance imaging. For M-VEPs, there was a significant postoperative shortening of the peak time (N160) (p < 0.05). P100 peak time and its amplitude did not change significantly. The M-VEPs N160 amplitude showed a close relationship to the VF improvement. Thinner preoperative RNFL does not present a statistically important limiting factor for better functional outcomes. The morphological status of the sellar region should be taken into consideration when one evaluates the chiasmal syndrome. M-VEPs enable detection of functional changes in the visual pathway better than P-VEPs.

Imaging of the sellar and parasellar regions

Although a wide variety of pathologies can occur in the limited anatomic space within and surrounding the sella turcica only a few are common. This review aims to briefly summarize pituitary and parasellar anatomy and provide a focused description of the imaging features of both common and rare pituitary pathologies. Diagnoses of imaging findings with important implications for clinical management are highlighted. MR is the primary diagnostic modality for evaluation of this anatomic region. CT supplements MR in the evaluation of pathologies involving the bony sella turcica while angiography or nuclear medicine plays a limited clinical role. Despite the wide array of pathologies, imaging and basic clinical history will frequently yield a specific diagnosis or narrow differential. In certain pathologies such as hypophysitis or pituitary hyperplasia, proper imaging interpretation may obviate the need for surgical biopsy or resection. The two key elements to diagnosis in the pituitary region are localization of the abnormality and recognition of characteristic imaging features for different pathologies. Localization is particularly important in separating parasellar masses such as meningiomas, skull base tumors, carotid aneurysms, craniopharyngiomas, or sphenoid sinus tumors from pituitary masses. Imaging features are often variable and in some cases such as craniopharyngioma or epidermoid, can be almost pathognomonic. In cases of neoplastic pathology, imaging both provides diagnostic information and guides planning of surgical biopsy or resection. In most cases, biopsy or resection is performed though a trans-sphenoidal endoscopic route, and identifying invasion or the suprasellar cistern, skull base, or cavernous sinuses is critical.

Sellar and parasellar lesions: multidisciplinary management

Introduction

The endoscopic endonasal transsphenoidal approach to the sella and parasellar regions is now increasingly used for removal of a variety of lesions localized in the ventral skull base. The advantage of the endoscope is enhanced visualization and improved panoramic view that can result in more complete removal of the tumor. An extensive knowledge of the anatomy is mandatory to approach this region.

Materials and methods

From February 2009 to March 2020, the endoscopic endonasal approach was used in 153 patients with sellar and parasellar lesions, at our Institution: 136 pituitary adenomas, 7 craniopharyngiomas, 3 Rathke’s cysts, a tuberculum sellae meningioma, an aneurysm of the internal carotid artery (ICA), a clivus chordoma, a papillary glioneuronal tumor, an histiocytosis, a pituitary metastasis from breast cancer and a chondrosarcoma.

Results

The most common surgical complications were cerebral spinal fluid leak (9), bleeding (2), pituitary abscess (2). Among endocrinological complications, the most important were diabete insipidus (23) and panhypopituitarism (3). Two patients complicated with meningitis. There were no visual worsening and no operative mortality. We had persistence of disease in 20 cases. Twelve patients underwent surgical revision for recurrence of the disease.

Conclusions

Pre-operative planning and collaboration with several specialists are necessary in order to offer the patient the best treatment, minimizing complications.

A comparative study of functioning and non-functioning pituitary adenomas

Pituitary tumors commonly cause visual impairment and the degree of impairment can depend on the size, location, and type of the tumor. However, no studies have been made regarding the differences caused by functioning pituitary adenoma (FPA) and non-functioning pituitary adenoma (NFPA). We aimed to investigate the relationship between clinical characteristics and visual impairment in patients with FPA and NFPA.This case series study included 73 pituitary adenoma patients. All patients underwent ophthalmic evaluations, and we retrospectively reviewed their medical records. Tumor types were confirmed by histological analysis, and the tumor volume was calculated. Magnetic resonance imaging was used to determine the tumor diameter. The observation indices of the two groups were compared. The correlation between the visual field and tumor volume was analysed using scatter plots.We enrolled 30 patients in the FPA group and 43 in the NFPA group. The first symptoms presented in the eyes in 23% of FPA patients and 41.9% of NFPA patients. The best-corrected visual acuity of the FPA group was better than that of the NFPA group, and 34 (56.7%) and 73 (84.9%) eyes in these groups had visual field defects, respectively. The visual field defects of the FPA patients were lighter than those of the NFPA patients. Except for the anteroposterior diameter, there were no differences in the other parameters of tumor diameter between the groups. The tumor volume of the FPA group was smaller than that of the NFPA group. The tumor size was positively correlated with the mean deviation and negatively correlated with the mean sensitivity in both groups.There was a longer delay between the onset of signs and symptoms and treatment in the FPA group than in the NFPA group. Future studies should focus on visual field defects caused by FPA and NFPA.

Sellar Tumors

Sellar region lesions include a broad range of benign and malignant neoplastic as well as non-neoplastic entities, many of which are newly described or have recently revised nomenclature. In contrast to other intracranial sites, imaging features are relatively less specific, and the need for histopathological diagnosis is of paramount importance. This review will describe pituitary adenomas, inflammatory lesions, and tumors unique to the region (craniopharyngioma) as well as tumors which may occur in but are not exclusively localized to the sellar location (schwannoma, metastasis, etc.).

Clinical efficacy of optical coherence tomography in sellar mass lesions: a meta-analysis

PURPOSE

Although optical coherence tomography (OCT) of the eyes has been studied to detect and monitor sellar masses, there is no recommendation for selecting the most effective measurement of OCT in clinical practice. Thus, we conducted a meta-analysis to examine the efficacy of OCT in sellar mass lesions.

METHODS

We conducted a literature search in PubMed and EMBASE through April 26, 2020. The primary outcomes were the thickness of the peripapillary retinal nerve fiber layer (pRNFL) and the macular ganglion cell complex (mGCC). The secondary outcomes included the thickness of the macular ganglion cell and inner plexiform layer (mGCIPL) and macular thickness. Random-effects models were used in all meta-analyses. Additionally, we conducted meta-regressions and subgroup analyses.

RESULTS

We included 22 studies, involving 1347 eyes of patients and 1198 eyes of controls. When compared with the control group, the reductions in pRNFL, mGCC and macular thickness in the patient group were significantly different, whereas significant thinning of the mGCIPL was restricted to the nasal hemiretina. Furthermore, we found that before visual field (VF) defects occurred, significant thinning of the pRNFL and mGCC thickness could be detected by OCT. The change in OCT parameters also showed different patterns in different types of pituitary adenomas.

CONCLUSIONS

Sellar mass lesions were associated with the changes in OCT measurements. The characteristic patterns of the OCT parameters may refine the diagnostic accuracy. Moreover, the alterations of OCT metrics before VF defects indicate the efficacy of OCT in early detection. Different types of pituitary adenomas may vary in OCT measurements, and their specific features warrant further research efforts.

Xanthogranulomatous Pituitary Adenoma in a Dog with Typical Hyperadrenocorticism

Xanthogranuloma of the sellar region has been reported in both humans and animals. The lesion is rare, and its aetiology and pathogenesis are not fully understood. The association of sellar xanthogranuloma with an adenoma, known as xanthogranulomatous pituitary adenoma (XPA), is an extremely rare condition in humans and is usually associated with anterior pituitary insufficiencies, headache, vomiting and visual deficits. We present the first report of XPA in an animal. A 7-year-old male neutered Labrador Retriever was presented for investigation of progressive lethargy, vomiting and hyporexia, having been previously diagnosed with chronic kidney disease, pituitary-dependent hyperadrenocorticism and hypoparathyroidism. The dog was euthanized due to lack of response to medical treatment and post-mortem examination revealed XPA. Although rare, xanthogranulomatous lesions should be considered in patients with pituitary disease.

Clinical and pathological features of 124 patients with indistinguishable sellar lesions and central diabetes insipidus

BACKGROUND

Sellar lesions with central diabetes insipidus have a wide range of causes, and diagnosis is relatively difficult. The indication and clinical value of biopsy are still controversial.

OBJECTIVE

To describe the etiology, demographic characteristics, manifestations, laboratory tests and imaging findings of this disease and to explore the clinical value and safety of endoscopic transsphenoidal biopsy.

METHODS

Retrospective analysis of 124 patients with sellar lesions and central diabetes insipidus who underwent endoscopic transsphenoidal biopsy at the Neurosurgery Department, Peking Union Medical College Hospital, from 2011 to 2019.

RESULTS

The main etiology includes congenital diseases, inflammatory/infectious diseases and tumor diseases. The most common diseases were germ cell tumors, Langerhans cell histiocytosis, lymphocytic hypophysitis, and Rathke's cleft cysts. Except for the age at the time of biopsy of patients with tumor diseases, which was significantly lower than that of the other two, the other clinical manifestations of the three types of diseases were not significantly different. Among the 124 patients, biopsy was performed via an endoscopic transsphenoidal approach for 101 with intrasellarly available lesions or via an endoscopic extended transsphenoidal approach for 23 with intrasellarly unavailable lesions. 6 patients had central nervous system infections after surgery, and 3 had cerebrospinal fluid rhinorrhea, of which 2 were surgically repaired. These incidences were basically the same as those of classic surgery. 2 patients had worse visual acuity, 2 had worse visual field, and 2 had worse eye movement. Excepting one patient, all of whom have recovered after treatment.

CONCLUSIONS

Noninvasive examination is difficult for identifying the common causes of this type of disease. Endoscopic transsphenoidal biopsy is relatively safe and effective, helps doctors to select the best treatment for patients, and is worth promoting.

Suprasellar pituitary adenomas: a 10-year experience in a single tertiary medical center and a literature review

BACKGROUND

Suprasellar pituitary adenomas (SPAs) are a special type of pituitary adenoma. Although dozens of SPA cases have been reported, the exact definition and the characteristics of SPA have not been exhaustively discussed before.

METHODS

In a retrospective electronic medical records review, 13 patients with SPA were identified in our hospital between January 2010 and December 2019. A literature review was performed by searching the online database PubMed, and 39 cases conformed to the criteria based on the previous literature. Data regarding clinical symptoms, imaging manifestations, surgical information and follow-ups were analyzed.

RESULTS

The mean age at diagnosis of 52 patients with SPA was 36.73 years, and most of the patients were female (61.5%). The most common hormone-secreting subtypes of SPA were nonfunctioning (36.5%) and ACTH-secreting (34.6%) SPA. Macroadenomas (68.9%) were more common than microadenomas (31.1%). The origins of the SPAs included the intrasellar pituitary gland (type I), the subdiaphragmatic (type IIa) and supradiaphragmatic (type IIb) part of the pituitary stalk, and the suprasellar peri-infundibular region (type III). The most common anatomic subtype of SPA was type III, and type IIb was also common. The most common presentations of SPA were visual symptoms, especially for type III SPA. In addition, 64.7% and 73.1% of type IIb and III SPAs, respectively, were suspected to be of suprasellar origin based on presurgical imaging examination. Patients with tumors of suspected suprasellar origin were more likely to receive transcranial surgery (TCS) initially than those with tumors of suspected intrasellar origin (70.6% vs. 22.2%, p = 0.0013). The intact rate for the pituitary stalk after surgery for type II SPA was lower than that for type I and III SPA (52.6% vs. 92.6%, p = 0.0036). More patients with type II SPA experienced postoperative central diabetes insipidus (CDI) than those with type I and III SPA (57.9% vs. 11.1%, p = 0.0011). There was no significant difference in the incidence of postoperative CDI between transsphenoidal surgery (TSS) and TCS (p = 0.1304). Nine patients in our hospital received extended endoscopic TSS; only one experienced tumor recurrence, and no severe complications occurred after surgery.

CONCLUSIONS

SPAs could be defined as pituitary adenomas completely or partially located in the suprasellar region. There were both similarities and differences among the different anatomic subtypes of SPA. For patients who were suspected of having SPAs, visual field tests, pituitary hormone evaluation and MRI were necessary. Because imaging examination is not a reliable method, surgery is the only way to confirm the tumor origin. Extended endoscopic TSS might be a safe and efficient approach to remove these tumors, but more studies are needed to verify this conclusion. For type II SPA, the pituitary stalk should be carefully protected during surgery, and postoperative CDI should be monitored.

Collision sellar lesions: coexistence of pituitary adenoma and Rathke cleft cyst-a single-center experience

PURPOSE

Collision sellar lesions represent the coexistence of distinct histopathological lesions found in the sella turcica. They are uncommon entities and have mainly been reported as pituitary adenoma (PA) associated to Rathke cleft cyst (RCC). Pre- and perioperative diagnosis is difficult, since most of the cases appear clinically, radiologically, and macroscopically as solitary cystic sellar lesion.

METHODS

A retrospective study of histological reports from patients operated for PA from 2013 to 2018 in a single neurosurgery reference center was performed. Patients who also exhibited RCC in the histological sections were included. Clinical and biochemical data were collected from medical files. MRI scans and histopathological slides were also reviewed.

RESULTS

Among 554 PA, five patients (0.9%) presented the association of PA and RCC. At diagnosis, patients had median age of 60 years (33-78) with, at least, one pituitary dysfunction, and visual field loss and/or headache. There was a female predominance (n = 3). All patients had nonfunctioning PA. MRI studies showed a predominantly cystic lesion and were unable to distinguish both lesions. The definitive diagnosis was made by histopathology.

CONCLUSION

The association of PA and RCC is extremely rare. On MRI, they appear as a solid-cystic or cystic sellar tumors. RCC can rupture causing granulomatous reaction with cholesterol crystal formation, which can be mistaken for craniopharyngiomas during surgery. Therefore, collision sellar lesion must be included in the differential diagnosis of cystic sellar lesions. The definitive diagnosis is made by histological study.

Deep Learning for Automatically Visual Evoked Potential Classification During Surgical Decompression of Sellar Region Tumors

Purpose

Detection of the huge amount of data generated in real-time visual evoked potential (VEP) requires labor-intensive work and experienced electrophysiologists. This study aims to build an automatic VEP classification system by using a deep learning algorithm.

Methods

Patients with sellar region tumor and optic chiasm compression were enrolled. Flash VEP monitoring was applied during surgical decompression. Sequential VEP images were fed into three neural network algorithms to train VEP classification models.

Results

We included 76 patients. During surgical decompression, we observed 68 eyes with increased VEP amplitude, 47 eyes with a transient decrease, and 37 eyes without change. We generated 2,843 sequences (39,802 images) in total (887 sequences with increasing VEP, 276 sequences with decreasing VEP, and 1680 sequences without change). The model combining convolutional and recurrent neural network had the highest accuracy (87.4%; 95% confidence interval, 84.2%–90.1%). The sensitivity of predicting no change VEP, increasing VEP, and decreasing VEP was 92.6%, 78.9%, and 83.7%, respectively. The specificity of predicting no change VEP, increasing VEP, and decreasing VEP was 80.5%, 93.3%, and 100.0%, respectively. The class activation map visualization technique showed that the P2-N3-P3 complex was important in determining the output.

Conclusions

We identified three VEP responses (no change, increase, and decrease) during transsphenoidal surgical decompression of sellar region tumors. We developed a deep learning model to classify the sequential changes of intraoperative VEP.

Translational Relevance

Our model may have the potential to be applied in real-time monitoring during surgical resection of sellar region tumors.

Using sellar region tumor's size as a predictor of psychophysical and electrophysiological perimetric visual losses: a logistic regression approach

BACKGROUND

Sellar region tumor growth represents an important cause of visual loss due to mechanical compression of the optic nerve apparatus. Many investigations have used non-invasive tools to evaluate the visual field consequences of this damage, and good associations have been reported between psychophysical and electrophysiological perimetries. Few reports have considered the tumor size as a predictor of visual field loss.

AIMS

In the present study, we evaluated the association between the visual perimetry measured by Humphrey visual field analyzer and multifocal visual evoked cortical potential (mfVECP) and the tumor size.

METHODS

Our sample was composed of 14 patients diagnosed with sellar tumors by magnetic resonance imaging. We accounted the number of sectors with negative visual responses for both methods. A simple logistic regression analysis was used to evaluate the association between the tumor dimensions and the visual field features RESULTS: Three patients had preserved visual fields, three patients showed hemianopic defects, and eight patients had generalized visual field losses at both evaluations. We observed that the three maximum diameters of the tumor and total tumor volume had different predictive abilities regarding the extent of visual field loss when using psychophysical and mfVECP data. The maximum craniocaudal diameter of the tumor was the better predictor of the psychophysical measurements, whereas for the mfVECP results, all tumor dimensions and volumes had similar values that predict visual field losses.

CONCLUSION

Tumor size as a predictor of visual loss has potential to assist in the clinical intervention and to prevent the irreversible visual impairment caused by tumors of the sellar region.

A systematic review on machine learning in sellar region diseases: quality and reporting items

INTRODUCTION

Machine learning methods in sellar region diseases present a particular challenge because of the complexity and the necessity for reproducibility. This systematic review aims to compile the current literature on sellar region diseases that utilized machine learning methods and to propose a quality assessment tool and reporting checklist for future studies.

METHODS

PubMed and Web of Science were searched to identify relevant studies. The quality assessment included five categories: unmet needs, reproducibility, robustness, generalizability and clinical significance.

RESULTS

Seventeen studies were included with the diagnosis of general pituitary neoplasms, acromegaly, Cushing's disease, craniopharyngioma and growth hormone deficiency. 87.5% of the studies arbitrarily chose one or two machine learning models. One study chose ensemble models, and one study compared several models. 43.8% of studies did not provide the platform for model training, and roughly half did not offer parameters or hyperparameters. 62.5% of the studies provided a valid method to avoid over-fitting, but only five reported variations in the validation statistics. Only one study validated the algorithm in a different external database. Four studies reported how to interpret the predictors, and most studies (68.8%) suggested possible clinical applications of the developed algorithm. The workflow of a machine-learning study and the recommended reporting items were also provided based on the results.

CONCLUSIONS

Machine learning methods were used to predict diagnosis and posttreatment outcomes in sellar region diseases. Though most studies had substantial unmet need and proposed possible clinical application, replicability, robustness and generalizability were major limits in current studies.

Ectopic Pituitary Adenoma Presenting as a Clival Mass

Pituitary adenomas are well described in the literature and are frequently observed and treated in clinical practice by neurosurgeons. On the other hand, ectopic adenomas are a diagnostic enigma; a good understanding of anatomy and radiological characteristics is crucial for the successful management of such pathologies. In this paper, we describe the case of a 77-year-old woman who presented with a clival mass invading the left cavernous sinus; we also discuss the associated diagnostic techniques, approaches, imaging options, and characteristics.

Neurocytoma mimicking macroadenoma

Background

Intraventricular and extraventricular central neurocytomas (CN) are equally frequent among 20-40-year-old men and women. However, sellar and suprasellar extraventricular CN are extremely rare, with only 12 reported cases.

Case Description

The authors report the case of a Brazilian 27-year-old man who presented with progressive vision loss during the last 4 years and serious bilateral keratoconus. We also review the epidemiological, clinical, radiological, pathological, and treatment features of the 12 reported cases. The patient developed left amaurosis and right temporal hemianopsia after undergoing bilateral corneal transplantation, which was detected during campimetry testing, and subsequently underwent magnetic resonance imaging, which revealed a huge hypophyseal tumor. Endocrinological evaluation revealed complete loss of pituitary function. The patient was referred to our department and underwent a two-step surgery (using transsphenoidal approach and cranio-orbital zygomatic approach) based on the diagnosis of an extraventricular central nervous system neurocytoma. Tumor removal was successful, and the patient was discharged at 3 weeks after admission to our department.

Conclusion

Although extraventricular neurocytomas of the brain are rare, careful preoperative consideration of its anatomy, pathophysiological features, and radiological features can enhance the treatment outcomes.

Intraoperative Magnetic Resonance Imaging-Guided Biopsy in the Diagnosis of Suprasellar Langerhans Cell Histiocytosis

BACKGROUND

Magnetic resonance imaging (MRI)-guided biopsy is an emerging diagnostic technique that holds great promise for otherwise difficult to access neuroanatomy.

CASE DESCRIPTION

Here we describe MRI-guided biopsy of a suprasellar lesion located posterior and superior to the pituitary stalk. The approach was implemented successfully in a 38-year-old woman who had developed progressive visual deterioration.

CONCLUSION

Intraoperative MRI revealed the need for trajectory adjustment due to an unintended, minor deviation in the burr hole entry point, demonstrating the benefit of an MRI-guided approach. Langerhans cell histiocytosis was diagnosed after biopsy, and the lesion regressed after cladribine treatment. Technical nuances of the case are reviewed in the context of the available literature.