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Campana C, Nista F, Castelletti L, Caputo M, Lavezzi E, Marzullo P, Ferrero A, Gaggero G, Canevari FR, Rossi DC, Zona G, Lania A, Ferone D, Gatto F. Clinical and radiological presentation of parasellar ectopic pituitary adenomas: case series and systematic review of the literature. J Endocrinol Invest 2022; 45:1465-1481. [PMID: 35147925 DOI: 10.1007/s40618-022-01758-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/30/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Parasellar ectopic pituitary adenomas (pEPAs) are extremely rare tumors located out of the sella turcica. PEPAs are heterogeneous entities in terms of anatomical localization and secretion of anterior pituitary hormones. METHODS Multicenter retrospective study. Clinical charts' consultation of patients diagnosed with parasellar lesions, to identify all subjects fulfilling the diagnostic criteria of parasellar EPAs. Systematic review of the literature focused on the medical management of prolactin-secreting pEPAs and on the prevalence of radiological bone invasion in pEPAs. RESULTS We identified four cases of pEPAs: (1) 54-year-old female with a prolactin-secreting suprasellar EPA successfully treated with cabergoline; (2) 74-year-old male with a non-functioning EPA of the sphenoidal sinus treated with endoscopic transsphenoidal surgery; (3) 75-year-old female with a giant lesion of the skull base (maximum diameter 7.2 cm) diagnosed as a non-functioning EPA after biopsy; (4) 49-year-old male with a silent corticotroph EPA of the sphenoidal sinus and clivus. Three out of four cases had radiological evidence of invasion of the surrounding bone structures. A systematic review of the literature highlighted that medical therapy can be effective in prolactin-secreting pEPAs. Overall, we found mention of local invasiveness in 65/147 cases (44.2%), confirmed by radiological signs of bone invasion/erosion. CONCLUSION Our experience confirms the heterogeneity of pEPAs in terms of clinical and radiological presentation, as well as hormone secretion. PEPAs show a high frequency of radiological bone invasion, though similar to that of sellar pituitary adenomas. Although extremely rare, pEPAs need to be considered in the differential diagnosis of parasellar lesions.
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Affiliation(s)
- C Campana
- Endocrinology Unit, Department of Internal Medicine and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - F Nista
- Endocrinology Unit, Department of Internal Medicine and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - L Castelletti
- Department of Radiology, Ospedale di Lavagna, Lavagna, Italy
| | - M Caputo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - E Lavezzi
- Endocrinology Unit, IRCCS Humanitas Research Hospital and Humanitas University, Rozzano, Italy
| | - P Marzullo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Laboratorio di Ricerche Metaboliche, IRCCS Istituto Auxologico Italiano, Piancavallo, Verbania, Italy
| | - A Ferrero
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - G Gaggero
- Department of Clinical Pathology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - F R Canevari
- Unit of Otorhinolaryngology-Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - D C Rossi
- Division of Neurosurgery, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - G Zona
- Division of Neurosurgery, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - A Lania
- Endocrinology Unit, IRCCS Humanitas Research Hospital and Humanitas University, Rozzano, Italy
| | - D Ferone
- Endocrinology Unit, Department of Internal Medicine and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, 16132, Genoa, Italy
| | - F Gatto
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, 16132, Genoa, Italy.
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Zhang Y, Wu D, Wang R, Luo M, Wang D, Wang K, Ai Y, Zheng L, Zhang Q, Shi L. Ectopic Adrenocorticotropic Hormone-Secreting Pituitary Adenoma in the Clivus Region: A Case Report. Onco Targets Ther 2022; 15:913-918. [PMID: 36062163 PMCID: PMC9439651 DOI: 10.2147/ott.s378353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/23/2022] [Indexed: 12/05/2022] Open
Abstract
Ectopic pituitary adenoma (EPA) is a pituitary adenoma unrelated to the intrasellar component and is an extremely rare disease. EPA resembles typical pituitary adenomas in morphology, immunohistochemistry, and hormonal activity, and it may present with specific or non-specific endocrine manifestations. Here, we report a rare case of ectopic adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma in the clival region. Only three patients with ACTH-secreting pituitary adenomas occurring in the clivus have been previously reported, and the present case was diagnosed as a clivus-ectopic ACTH-secreting pituitary macroadenoma. Thus, in addition to the more common organs, such as the lung, thymus, and pancreas, in the diagnosis of ectopic ACTH syndrome, special attention should be paid to the extremely rare ectopic ACTH-secreting pituitary adenoma of the clivus region.
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Affiliation(s)
- Yan Zhang
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
| | - Danrong Wu
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
| | - Ruoqiu Wang
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
| | - Min Luo
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
| | - Dong Wang
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
| | - Kaiyue Wang
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
| | - Yi Ai
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
| | - Li Zheng
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
| | - Qiao Zhang
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
- Correspondence: Qiao Zhang; Lixin Shi, Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China, Tel/Fax +86 851-86277666, Email ;
| | - Lixin Shi
- Department of Endocrinology and Metabolism, Guiqian International General Hospital, Guiyang, People’s Republic of China
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3
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Abdali A, Astafeva LI, Trunin YY, Chernov IV, Sidneva YG, Abdilatipov AA, Kalinin PL. [Modern aspects of surgery for cushing's disease]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:111-117. [PMID: 34463458 DOI: 10.17116/neiro202185041111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cushing's disease is a severe neuroendocrine disorder caused by chronic hypersecretion of ACTH by pituitary adenoma (corticotropinoma). Surgical resection is a gold standard for this disease resulting stable remission in about 65-95% of cases. Despite benign nature of corticotropinoma, recurrence rate is still higher (25-35%) even in specialized neurosurgical centers. Modifications in surgical strategy can prolong recurrence-free period.
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Affiliation(s)
- A Abdali
- Peoples' Friendship University of Russia, Moscow, Russia
| | | | | | - I V Chernov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | - P L Kalinin
- Burdenko Neurosurgical Center, Moscow, Russia
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Zhu J, Wang Z, Zhang Y, Li X, Liu J, Deng K, Lu L, Pan H, Wang R, Yao Y, Zhu H. Ectopic pituitary adenomas: clinical features, diagnostic challenges and management. Pituitary 2020; 23:648-664. [PMID: 32757141 DOI: 10.1007/s11102-020-01071-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Ectopic pituitary adenomas (EPAs) are extremely rare pituitary adenomas located outside the sella turcica without any connection with intrasellar components. This study aims to review all the reported cases to date and describe the clinical characteristics of EPAs. METHODS In a retrospective chart review, 14 patients were identified with EPAs in our hospital. A literature review was performed, and 166 cases in the literature met the criteria. Clinical data were analyzed. RESULTS Of 180 patients with EPAs, the mean age at diagnosis was 45.4 years, and 66.5% of the patients were females. EPAs were mainly located in the sphenoid sinus (34.4%) and suprasellar region (25.6%), followed by the clivus (15.6%), cavernous sinus (13.3%) and nasopharynx (5.6%). Adrenocorticotropic hormone (ACTH)-secreting (38.9%) and nonfunctioning (27.2%) adenomas were predominant. Patients with suprasellar EPAs were more likely to present menstrual disorders and visual changes, while patients with clival EPAs were more likely to suffer from headaches. EPAs in the cavernous sinus and suprasellar space were more likely to be initially misdiagnosed as a suspicious intrasellar mass on imaging examination. The complete tumor resection rates for EPAs in the sphenoid sinus, suprasellar region, clivus, cavernous sinus and nasopharynx were 72.3%, 88.6%, 45.0%, 73.3% and 88.9%, respectively. CONCLUSIONS EPA clinical characteristics varied across different tumor locations and hormone-secreting types. In addition to comprehensive hormone evaluation and careful review of imaging data, nuclear medicine and surgical biopsy should also be considered when facing differential difficulty. EPA management should be individualized.
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Affiliation(s)
- Jianyu Zhu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Zhicheng Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yi Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Xiaoxu Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Jie Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Lin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Hui Pan
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
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Riccio L, Donofrio CA, Tomacelli G, De Blasi R, Melatini A. Ectopic GH-secreting pituitary adenoma of the clivus: systematic literature review of a challenging tumour. Pituitary 2020; 23:457-466. [PMID: 32504302 DOI: 10.1007/s11102-020-01057-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE Acromegaly is usually due to growth hormone (GH)-secreting pituitary adenomas, but it may be exceptionally caused by GH-secreting ectopic pituitary adenomas (EPA). EPA are defined as extra-sellar pituitary tumours, extra- or intra-cranially sited, entirely separated from the pituitary stalk and gland. The aim of the study is to address the challenges in the management of clival GHEPA. METHODS We reported a case of a 53-year-old acromegalic patient with a primary clival GHEPA and reviewed systematically the relevant English literature between 1975 and 2019, in keeping with the PRISMA guidelines. RESULTS Four cases of primary clival GHEPA have been described in literature apart from ours. All patients presented with acromegalic features, elevated circulating GH and/or insulin-like growth factor-1 levels. Hyperprolactinemia and empty sella were described in two cases, respectively. These tumours show the typical imaging characteristics of pituitary adenomas, but their neuroradiological diagnosis may be challenging due to their sizes and the difficulty in defining the absence of connections with the pituitary fossa. CONCLUSION Although primary clival GHEPA are exceedingly rare, even if likely under-reported in literature, they should be considered in the differential diagnosis of clival tumours because of their specific management. Surgery represents the first-line treatment option, while medical and radiation therapies can be adopted as neo-adjuvant, adjuvant or primary treatments according to tumour and patient characteristics.
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Affiliation(s)
- Lucia Riccio
- Department of Neurosurgery, Ospedale "Vito Fazzi", Piazza F. Muratore, 1, 73100, Lecce, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - Carmine Antonio Donofrio
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | | | - Roberto De Blasi
- Department of Radiology, Azienda Ospedaliera "Cardinale Giovanni Panico", Tricase, Italy
| | - Alessandro Melatini
- Department of Neurosurgery, Ospedale "Vito Fazzi", Piazza F. Muratore, 1, 73100, Lecce, Italy
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Zhu J, Lu L, Yao Y, Chen S, Li W, You H, Feng F, Feng M, Zhang Y, Wang Z, Sun X, Li X, Zhu H, Wang R, Lu Z. Long-term follow-up for ectopic ACTH-secreting pituitary adenoma in a single tertiary medical center and a literature review. Pituitary 2020; 23:149-159. [PMID: 31838612 DOI: 10.1007/s11102-019-01017-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ectopic ACTH-secreting pituitary adenoma (EAPA) are a rare cause of Cushing's disease. Due to the lack of consensus and experience in terms of the diagnosis and treatment of EAPAs, preoperative identification and optimal treatment remain challenging. PURPOSE To investigate the characteristics of EAPAs and offer some proposals for the diagnosis and management of this uncommon disease, the EAPA patients admitted to our center and all of the EAPA cases reported in the literature were reviewed. METHODS In a retrospective electronic medical chart review, 6 patients (0.39%) with EAPAs were identified from 1536 consecutive patients who were admitted to our hospital with a diagnosis of Cushing's syndrome between January 2000 and August 2019. A literature review was performed on the online databases PubMed and EMBASE, and 52 cases conformed to the criteria. The data regarding biochemical tests, imaging examinations and follow-ups were analyzed. RESULTS The mean age of patients with EAPAs was 37.7 years old, and an obvious female predominance (3.5: 1) was demonstrated. The most common location of EAPAs was the cavernous sinus (34.5%), followed by the sphenoid sinus (31.0%) and the suprasellar region (20.7%). No significant differences in the biochemical test results were found among tumors in different locations. Except for sex, no risk factors related to remission were found. Although no significant differences among different locations were found, the tumors in the cavernous sinus had a relatively higher rate of invisibility in terms of imaging and a higher non-remission rate than tumors in other locations. CONCLUSIONS In patients with negative intrasellar findings, the uncommon disease of EAPA should be considered. Due to the endocrine similarity between intrasellar pituitary corticotrophin adenoma and EAPA, the preoperative identification of EAPA depends on a careful review of the imaging examinations. Locations such as the cavernous sinus, sphenoid sinus and suprasellar region should be considered first. Tumor resection is recommended when the diagnosis is confirmed.
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Affiliation(s)
- Jianyu Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Lin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Shi Chen
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Wei Li
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yi Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Zhicheng Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Xu Sun
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Xiaoxu Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Zhaolin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
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Gatto F, Perez-Rivas LG, Olarescu NC, Khandeva P, Chachlaki K, Trivellin G, Gahete MD, Cuny T. Diagnosis and Treatment of Parasellar Lesions. Neuroendocrinology 2020; 110:728-739. [PMID: 32126547 DOI: 10.1159/000506905] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
The parasellar region, located around the sella turcica, is an anatomically complex area representing a crossroads for important adjacent structures. Several lesions, including tumoral, inflammatory vascular, and infectious diseases may affect this area. Although invasive pituitary tumors are the most common neoplasms encountered within the parasellar region, other tumoral (and cystic) lesions can also be detected. Craniopharyngiomas, meningiomas, as well as Rathke's cleft cysts, chordomas, and ectopic pituitary tumors can primarily originate from the parasellar region. Except for hormone-producing ectopic pituitary tumors, signs and symptoms of these lesions are usually nonspecific, due to a mass effect on the surrounding anatomical structures (i.e., headache, visual defects), while a clinically relevant impairment of endocrine function (mainly anterior hypopituitarism and/or diabetes insipidus) can be present if the pituitary gland is displaced or compressed. Differential diagnosis of parasellar lesions mainly relies on magnetic resonance imaging, which should be interpreted by neuroradiologists skilled in base skull imaging. Neurosurgery is the main treatment, alone or in combination with radiotherapy. Of note, recent studies have identified gene mutations or signaling pathway modulators that represent potential candidates for the development of targeted therapies, particularly for craniopharyngiomas and meningiomas. In summary, parasellar lesions still represent a diagnostic and therapeutic challenge. A deeper knowledge of this complex anatomical site, the improvement of imaging tools, as well as novel insights into the pathophysiology of presenting lesions are strongly needed to improve the management of parasellar lesions.
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Affiliation(s)
- Federico Gatto
- Endocrinology Unit, Department of Specialist Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luis G Perez-Rivas
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Nicoleta Cristina Olarescu
- Section of Specialized Endocrinology, Department of Endocrinology, Medical Clinic, Oslo University Hospital, and University of Oslo, Oslo, Norway
- Department of Medical Biochemistry, Oslo University, Oslo, Norway
| | - Pati Khandeva
- Endocrinology Research Center, Moscow, Russian Federation
| | - Konstantina Chachlaki
- Inserm, Laboratory of Development and Plasticity of the Neuroendocrine Brain, Jean-Pierre Aubert Research Centre, UMR-S 1172, Lille, France
| | - Giampaolo Trivellin
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Manuel D Gahete
- Maimónides Institute of Biomedical Research of Córdoba (IMIBIC), Córdoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Córdoba, Córdoba, Spain
- Reina Sofía University Hospital, Córdoba, Spain
- CIBER Pathophysiology of Obesity and Nutrition (CIBERobn), Córdoba, Spain
| | - Thomas Cuny
- Department of Endocrinology, Hospital La Conception, Aix Marseille University, APHM, INSERM, MMG, Marseille, France,
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Flitsch J, Schmid SM, Bernreuther C, Winterberg B, Ritter MM, Lehnert H, Burkhardt T. A pitfall in diagnosing Cushing's disease: ectopic ACTH-producing pituitary adenoma in the sphenoid sinus. Pituitary 2015; 18:279-82. [PMID: 25129688 DOI: 10.1007/s11102-014-0591-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To show a rare case of Cushing's disease and possible cause of failed transsphenoidal surgery. METHOD We report on a 50-year-old woman suffering from ACTH-dependent Cushing's syndrome. Endocrinological work-up including low-dose/high-dose dexamethasone test (Liddle-test) and CRH test were clearly compatible with pituitary origin. Although an MRI showed no pituitary tumor, CRH-stimulated petrosal sinus sampling revealed a significant central-peripheral gradient in ACTH concentrations, rendering Cushing's disease very likely. The patient underwent transsphenoidal surgery with negative exploration of the pituitary gland. After intraoperative re-evaluation of the preoperative MRI, a "polyp" at the bottom of the sphenoid sinus was identified. The intraoperative microscopic aspect as well as instantaneous sections and cytology of a biopsy confirmed an adenoma, which was then removed. Histological analysis demonstrated an ACTH-producing pituitary adenoma adjacent to respiratory mucous membrane consisting of ciliated epithelium with submucous connective tissue. Postoperatively, ACTH concentrations were decreased and intermittent hydrocortisone substitution treatment was initiated. At the 3-month follow up, Cushing's stigmata were found to be alleviated and the hydrocortisone dosage could be reduced. CONCLUSION Ectopic pituitary adenoma tissue causing Cushing's disease is extremely rare but a potential cause for surgical failure or re-evaluation.
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Affiliation(s)
- J Flitsch
- Department of Neurosurgery, Bereich Hypophysenchirurgie, Neurochirurgische Klinik, University Medical Center Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Germany,
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9
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Johnston PC, Kennedy L, Weil RJ, Hamrahian AH. Ectopic ACTH-secreting pituitary adenomas within the sphenoid sinus. Endocrine 2014; 47:717-24. [PMID: 24927792 DOI: 10.1007/s12020-014-0313-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 05/21/2014] [Indexed: 12/15/2022]
Abstract
Ectopic pituitary adenomas are defined by the presence of adenomatous pituitary tissue outside the sella and distinctly separate from the pituitary gland. Ectopic ACTH-secreting pituitary adenomas (EAPAs) are a rare cause of Cushing's syndrome. Detecting these radiologically can prove difficult, in part, due to their typically small size and unpredictable anatomical location. In ACTH-dependent Cushing's syndrome, if, despite comprehensive testing, the source of excess ACTH remains occult (including negative work up for ectopic ACTH syndrome) thought should be given to the possibility of the patient harboring an EAPA. In most cases, ectopic ACTH pituitary adenomas within the sphenoid sinus will manifest with symptoms of hormonal excess, have an obvious sphenoid sinus mass on pre-operative imaging and will demonstrate resolution of hypercortisolism after surgical excision if located and removed. Twenty cases of EAPAs have been reported in the literature to date. This paper will review the current literature on all previously reported EAPAs within the sphenoid sinus in addition to the current case.
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Affiliation(s)
- Philip C Johnston
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Foundation, 9500 Euclid Avenue Desk F20, Cleveland, OH, 44195, USA
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10
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Regan J, Watson J. Selective use of peri-operative steroids in pituitary tumor surgery: escape from dogma. Front Endocrinol (Lausanne) 2013; 4:30. [PMID: 23508065 PMCID: PMC3600533 DOI: 10.3389/fendo.2013.00030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 03/03/2013] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Traditional neurosurgical practice calls for administration of peri-operative stress-dose steroids for sellar-suprasellar masses undergoing operative treatment. This practice is considered critical to prevent peri-operative complications associated with hypoadrenalism, such as hypotension and circulatory collapse. However, stress-dose steroids complicate the management of these patients. It has been our routine practice to use stress steroids during surgery only if the patient has clinical or biochemical evidence of hypocortisolism pre-operatively. We wanted to be certain that this practice was safe. METHODS We present our retrospective analysis from a consecutive series of 114 operations in 109 patients with sellar and/or suprasellar tumors, the majority of whom were managed without empirical stress-dose steroid coverage. Only patients who were hypoadrenal pre-operatively or who had suffered apoplexy were given stress-dose coverage during surgery. We screened for biochemical evidence of hypoadrenalism as a result of surgery by measuring immediate post-operative AM serum cortisol levels. RESULTS There were no adverse events related to the selective use of cortisol replacement in this patient population. CONCLUSION Our experience demonstrates that selective use of corticosteroid replacement is safe; it simplifies the management of the patients, and has advantages over empiric "dogmatic" steroid coverage.
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Affiliation(s)
- Jacqueline Regan
- Department of Neurosciences, Inova Health SystemsFalls Church, VA, USA
- *Correspondence: Jacqueline Regan, Department of Neurosciences, Inova Health Systems, 3300 Gallows Road, Falls Church, VA 22042, USA. e-mail:
| | - Joseph Watson
- Department of Neurosciences, Inova Fairfax Hospital, Virginia Commonwealth UniversityFalls Church, VA, USA
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Abstract
The management of adrenocorticotropic hormone (ACTH)-dependent Cushing's disease implies difficulties in the differential diagnosis, in the detection of minute pituitary adenomas, as well as in the radical removal of invasive adenomas. Magnetic resonance imaging (MRI) is unspecific and often negative in minute adenomas of three or less millimeters diameter. The trias of detectable ACTH, suppression of cortisol in the high-dose dexamethasone test, and stimulation in the corticotropin-releasing-hormone (CRH)-test has a high accuracy to prove pituitary dependency. In unclear cases, the use of inferior petrosal sinus sampling (IPSS) or cavernous sinus sampling (CSS) for the exclusion of ectopic ACTH-syndrome is currently advised especially in cases where cranial MRI is negative. The reliability of these methods to localize the mostly lateralized microadenomas is still discussed. Transsphenoidal microsurgical adenomectomy, the accepted primary therapy of Cushing's disease, has been published from experienced pituitary centers with remission rates ranging from 70% to 98% in the last decade. False diagnosis (pseudo-Cushing, ectopic ACTH-syndrome), incorrect adenoma localization by IPSS or CSS, and the rate of minute or non-resectable invasive tumors influence the results. The handling of minute specimen implies problems for surgeon and pathologist. Intraoperative tumor localization was improved by ACTH measurement from the cavernous sinus and the adenoma itself, by cytology, and frozen sections. The histology of the anterior lobe (rate of Crooke's cells) bears information of clinical relevance. Invasive macroadenomas may deserve repeat microsurgery, medical treatment, and radiosurgery.
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Affiliation(s)
- D K Lüdecke
- Department of Neurosurgery, University Hospital Hamburg-Eppendorf, Germany
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