Intrasellar pituitary gangliocyto-adenoma presenting with acromegaly: case report

Mixed gangliocytoma-pituitary adenoma in the sellar region: a large-scale single-center experience

BACKGROUND

Mixed gangliocytoma-pituitary adenoma is an extremely rare tumor occurring in the sellar region, histologically composed of both gangliocytic and pituitary adenomatous architectures. The histogenesis of these tumors remains unknown, and the diagnosis, treatment, and prognosis are yet to be fully understood.

METHODS

We retrospectively reviewed the clinical, radiological, and histopathological profiles from a series of 20 patients with sellar mixed gangliocytoma-pituitary adenomas. All patients underwent surgical tumorectomy via an endoscopic or microscopic transsphenoidal approach. Perioperative magnetic resonance imaging (MRI) and computed tomography (CT) data were reviewed. Immunohistochemical stains and electron microscopy examination were performed. Follow-up outcomes were presented.

RESULTS

This case series consisted of 13 females and seven males (age range, 20-59 years; mean age, 42.3 ± 11.2 years). Preoperative endocrine examination showed elevated growth hormone (GH) in nine patients and hyperprolactinemia in eight patients. The tumors were positive for GH in 15 cases, prolactin in 13 cases, adrenocorticotropic hormone in three cases, and thyroid-stimulating hormone in one case. Gross total resection was achieved in 15 patients, and subtotal resection in five patients. During an average follow-up period of 42.5 ± 29.0 months, no recurrence was noted.

CONCLUSIONS

The clinical and neuroimaging features of sellar mixed gangliocytoma-pituitary adenomas are non-specific, and invasion into the cavernous sinus is common. Surgical resection via a transsphenoidal approach is the preferred treatment, and the surgical outcomes are favorable. Moreover, our histopathological findings are more likely to support the theory that mixed gangliocytoma-pituitary adenoma originates from the neuronal transdifferentiation of adenomatous cells.

Pituitary adenoma with gangliocytic component: report of 5 cases with focus on immunoprofile of gangliocytic component

INTRODUCTION

Pituitary adenomas with gangliocytic component are rare tumors of the sellar region that are composed of pituitary adenoma cells and a ganglion cell component. Their histogenesis and hence nosology is not yet resolved because of the small number of cases reported and lack of large series in the literature.

METHODS

Herein we report five cases of pituitary adenoma with gangliocytic component to add knowledge to this rare neoplasm.

RESULTS

Three cases are functional mammosomatotroph adenomas, one case is functional sparsely granulated somatotroph adenoma and the other is functional corticotroph adenoma. Gangliocytic component showed immunohistochemical expression of hormones in three cases. The ganglion cells were prolactin immunoreactive in case 1, GH and TSH immunoreactive in case 5 and showed expression of prolactin, TSH, ACTH and FSH in case 4. Three cases had undergone more than one surgery of which two had gangliocytic cells only in the recurrent tumors whereas the third case showed gangliocytic cells only in the initial tumor.

DISCUSSION

The cases are discussed with clinical and histological features and a brief review of the literature considering the histogenesis is included.

Pituitary adenoma with gangliocytoma: Report of two cases

Worldwide, cases of pituitary adenoma with gangliocytoma are rarely reported. The current study reports the cases of two 47-year-old females who presented with masses in the sellar region following a general examination and radiological imaging. The two patients underwent sellar region tumor resection via the trans-naso-sphenoid approach. The histopathological examination confirmed the diagnosis of a hormone-free pituitary adenoma with gangliocytoma. The two patients were in good condition and experienced no specific discomfort subsequent to the follow-up after surgery. Gangliocytoma is a slowly growing and non-metastasizing tumor. A biopsy is required to differentiate a gangliocytoma from a malignant neuroblastoma, and excision is usually curative.

Growth hormone-producing pituitary adenoma regrowing as pituitary adenoma with neuronal choristoma 14 years after tumor removal

BACKGROUND

We report a case of an uncommon association of pituitary adenoma with neuronal choristoma that usually is diagnosed at initial surgery.

CASE DESCRIPTION

A 50-year-old woman with acromegaly and bitemporal hemianopsia underwent removal of a pituitary adenoma via the transsphenoidal approach. Histologic examination of the first surgical specimen demonstrated only adenoma, which was eosinophilic and expressed growth hormone. Fourteen years later, bitemporal hemianopsia recurred, and magnetic resonance imaging revealed regrowth of the residual tumor.

DISCUSSION

The patient underwent removal of the regrown tumor via the transsphenoidal approach. Histologic examination of the second surgical specimen revealed gangliocytoma and a small component of pituitary adenoma.

CONCLUSIONS

The present case report supports the theory that pituitary adenoma with neuronal choristoma might represent the result of neuronal differentiation from pituitary adenoma.

An unusual collision tumor comprising a prolactinoma and a plasmocytoma originating from the sellar region

A 58-year-old previously healthy man presented with diplopia of rapid onset over a few days. Examination demonstrated bilateral sixth and right fourth cranial nerve palsy. MR imaging showed a large sellar mass with significant destruction of the pituitary fossa. Laboratory tests revealed very high serum prolactin (2,483 ng/dl, reference range 3-13 ng/dl). Dopamine agonist therapy was initiated with significant decline in PRL levels; however, nausea, fatigue, and anorexia developed. Within a few weeks the patient developed renal failure and hypercalcemia. Urine protein electrophoresis revealed large free monoclonal kappa peaks while extensive plasmocytosis was evident in bone marrow aspirates. On bone scan numerous lytic lesions were present. A transsphenoidal excisional biopsy was performed which demonstrated two distinct populations of cells, corresponding to a plasma cell tumor and a lactotroph adenoma. Treatment for multiple myeloma was initiated along with radiotherapy for the sellar tumor. Only a few cases of solitary plasmocytomas of the pituitary region have been reported. Few cases of prolactinomas coexisting with other sellar tumors has been described. We discuss in this report possible pathogenic and functional connections between these two tumors. We suggest that in the presence of extensive cranial nerve involvement, atypical imaging findings for a pituitary adenoma and severe hyperprolactinemia, the possibility of a collision tumor should lead the physician to consider excisional tumor biopsy or surgery in addition to dopamine agonist therapy.

An unusual association of a sellar gangliocytoma with a prolactinoma

The simultaneous occurrence of a hypothalamic and sellar gangliocytoma with a pituitary prolactinoma is very rare. The explanation for such an association is not known. We describe the case of a woman who had a coexisting adjacent pituitary prolactinoma and gangliocytoma within the same sellar mass. The tumor cells of the gangliocytoma demonstrated expression of enkephalin, a product of proopiomelanocortin known to be a prolactin secretagogue. We postulate that in this patient there may be a link between gangliocytoma enkephalin and prolactin hypersecretion.

Combined sellar fibrosarcoma and prolactinoma with neuronal metaplasia: report of a case unassociated with radiotherapy

We report the occurrence of a primary pituitary fibrosarcoma causally unrelated to radiotherapy, admixed in association with a prolactin cell pituitary adenoma showing neuronal metaplasia. These unique findings were associated with multiple endocrine neoplasia type 1 (MEN 1). Primary fibrosarcoma involving the sella is a very rare tumor. The majority of cases have been associated with prior irradiation of either a pituitary adenoma or a craniopharyngioma. Pituitary adenoma with neuronal metaplasia is also rare and usually occurs in the setting of acromegaly. Despite the intimate association of both elements in our lesion, no transition of adenoma to sarcoma was demonstrable by immunohistochemistry or in situ hybridization studies.

January 2002: 59-year-old woman with an intrasellar lesion

An intrasellar lesion resembling a hormone-inactive pituitary adenoma was resected in a 59-year-old woman. The well-differentiated benign tumor was composed of ganglion-like cells, clusters of adenohypophyseal tissue as well as a GH-expressing adenoma. In addition, small cells exhibited an intermediate neuronal and epithelial immunoreactivity. Surrounding the tumor was a spindle cell component that histologically resembled Antoni A areas of a schwannoma, but showed a mixed immunohistochemical profile. Final diagnosis was intrasellar glioneuronal hamartoma with GH-cell pituitary adenoma.

Gangliocytoma masquerading as a prolactinoma. Case report

The authors describe the case of a 36-year-old man who presented with bitemporal hemianopsia and a serum prolactin concentration of 1440 ng/ml. Magnetic resonance imaging of the pituitary revealed a presumed macroadenoma with suprasellar and temporal lobe extension. Although the patient's prolactin level was lowered to 55 ng/ml by bromocriptine therapy, no tumor shrinkage occurred. Fourteen months later, progression of visual field defects necessitated transsphenoidal resection, which was incomplete. Immunocytochemical analysis of the biopsy tissue was positive for prolactin and, in view of the clinical picture, more detailed analysis was not performed. External-beam radiotherapy was given 2 years later because of enlargement of residual tumor. Subsequently, despite a fall in the serum prolactin concentration to less than 20 ng/ml in response to the course of bromocriptine, the mass displayed further extension into the temporal lobe. Nine years after the patient's initial presentation, he underwent transfrontal craniotomy for sudden deterioration in visual acuity caused by hemorrhage into the mass. No adenohypophyseal tissue was identified in the resected tissue. The mass was composed of dysplastic neurons that were strongly immunoreactive for synaptophysin and neurofilament (indicating neural differentiation) and prolactin. Review of the original biopsy specimen indicated that the prolactin-positive cells had striking neuronal morphological characteristics. The final diagnosis in this case is prolactin-secreting gangliocytoma. Although exceedingly rare, this disease must be added to the differential diagnosis in cases of "prolactinoma" when bromocriptine therapy is followed by a marked decline in serum prolactin that is not accompanied by significant tumor shrinkage. Furthermore, in such instances, consideration should be given to "obtaining a biopsy sample prior to electing for radiotherapy.