Intrasellar chordomas mimicking pituitary adenoma

Intrasellar chordoma masquerading as a pituitary neuroendocrine tumor: Illustrative case

Background

Chordomas are rare, locally aggressive neoplasms recognized as derivatives of the notochord vestiges. These tumors typically involve the midline axial skeleton, and intracranial chordomas exhibit proclivity for the spheno-occipital region. However, purely intrasellar occurrences are extremely rare. We report a case of intrasellar chordoma, which masqueraded as a pituitary neuroendocrine tumor.

Case Description

An 87-year-old female presented with an acutely altered mental state after a few-week course of headaches and decreased left vision. Adrenal insufficiency was evident, and magnetic resonance imaging revealed an intrasellar lesion with heterogeneous contrast enhancement and marked T2 hyperintensity. Central adrenal insufficiency due to an intrasellar lesion was suspected. Cortisol replacement was initiated, and transsphenoidal surgery was performed. Anterosuperior displacement of the normal pituitary gland and the absence of the bony dorsum sellae were notable during the procedure. Histological examination led to a diagnosis of conventional chordoma, and upfront adjuvant stereotactic radiosurgery was executed. She has been free from tumor progression for 12 months.

Conclusion

This case and literature review suggested that the pathognomonic features of intrasellar chordoma were heterogeneous contrast enhancement, marked T2 hyperintensity, osteolytic destruction of the dorsum sellae, and anterosuperior displacement of the pituitary gland. Clinical outcomes seemed slightly worse than those of all skull base chordomas, which were the rationale for upfront radiosurgery in our case. Neurosurgeons should include intrasellar chordomas in the differential diagnosis of intrasellar lesions, carefully dissect them from the adjacent critical anatomical structures, and consider upfront radiosurgery to achieve optimal patient outcomes.

Clinical Grading System, Surgical Outcomes and Prognostic Analysis of Cranial Base Chordomas

Objective

Cranial base chordomas are rare, but their treatment is challenging. Tumor recurrence is still common despite improvements in microsurgical techniques and postoperative radiotherapy. We retrospectively analyzed the course of treatment, overall survival, and recurrence/progression of chordomas over the past 10 years.

Methods

We retrospectively reviewed 50 patients who underwent surgery at Tianjin Huanhu Hospital between 2010 and 2020 and were pathologically diagnosed with chordomas. Tumor resection was performed within the maximum safe range in all patients; the extent of resection was evaluated by imaging; and the incidence of complications, recurrence or progression, and overall survival were assessed.

Results

Fifty patients were divided into the low-risk group (LRG) and high-risk group (HRG) based on the cranial chordoma grading system (CCGS). The Karnofsky Performance Scale scores and gross total resection rate of the LRG were significantly higher than those of the HRG (p<0.05). The incidence of complications and mortality in the LRG were lower than those of HRG. The analysis of cumulative survival and cumulative recurrence free survival/progression free survival (RFS/PFS) showed no statistical differences in the extent of resection for survival, recurrence, or progression. Univariate and multivariate analyses showed that Ki-67 was significantly associated with tumor recurrence and was an independent hazard factor (p=0.02).

Conclusion

The CCGS can help neurosurgeons anticipate surgical outcomes. Pathological results are important in evaluating the possibility of tumor recurrence, and postoperative radiotherapy improves overall survival and RFS/PFS.

Skull Base Chordomas and Chondrosarcomas

Skull base chordomas account for less than 0.2% and chondrosarcomas for less than 0.15% of all intracranial tumors. Although their clinical and imaging presentations are similar, they derive from different origins. Chordomas arise from embryonic remnants of the primitive notochord and chondrosarcomas from primitive mesenchymal cells or from the embryonic rest of the cranial cartilaginous matrix. Both entities are characterized by infiltration and destruction of the surrounding bone and soft tissue and a high locoregional recurrence rate. Chondrosarcomas, when treated with similar complex strategies, display a much better prognosis than chordomas. The overall survival is approximately 65% for chordomas and 80% for chondrosarcomas at 5 years and 30 and 50%, respectively, at 10 years. Chordomas are divided into the following 3 histological types: classical (conventional), chondroid, and dedifferentiated. Chondrosarcomas have conventional, mesenchymal, clear cell, and dedifferentiated subgroups. Both tumor entities often present with nonspecific symptoms, and headaches are the most reported initial symptom. Computed tomography and magnetic resonance imaging are required to determine the tumor localization and the extent of tumor growth. The treatment philosophy is to maximize tumor resection, minimize morbidity, and preserve function. Neurosurgical approaches commonly used for the resection of intracranial chordomas and chondrosarcomas are transsphenoidal, transbasal, cranio-orbitozygomatic, transzygomatic extended middle fossa, transcondylar, and transmaxillary approaches. Chordomas and chondrosarcomas are not sensitive to chemotherapy and there are no approved drugs for their treatment. The present treatment concept is a combination of surgical resection with a maximal excision and preserving patients' quality of life by adjuvant radiotherapy for both chordomas and chondrosarcomas.

Chordoma of the corpus callosum: case report

Chordomas are neoplasms that typically arise from midline skeletal structures and rarely originate within the intradural compartment of the CNS. A chordoma arising from the corpus callosum has not been previously described. The authors report the surgical management of a chordoma originating within the splenium of the corpus callosum. To determine the incidence and distribution of intracranial intradural chordoma, a literature search for additional cases was performed. MEDLINE was searched using the MeSH keyword "chordoma," yielding 2010 articles. These articles were screened for cases of primary intradural chordoma rostral to the craniocervical junction, which led to the identification of 46 relevant articles. The authors report the case of a 69-year-old man who initially presented with nonspecific neurological symptoms including spatial disorientation and cognitive decline. These symptoms eventually prompted intracranial imaging, including MRI, which revealed a ring-enhancing, heterogeneous, cystic mass localized within the splenium of the corpus callosum and extending into the bilateral ventricles. The lesion was believed to represent a high-grade glioma and the patient underwent a left interhemispheric approach and subtotal resection. After pathologic evaluation confirmed a diagnosis of an anaplastic chordoma, the patient underwent further resection. A gross-total resection (GTR) was achieved with a transfalcine approach to the contralateral portion of the tumor. Postoperatively, the patient had a partial left homonymous quadrantanopsia, but was otherwise at his neurological baseline. Proton beam radiotherapy was performed to the resection cavity but diffuse intraventricular disease ensued. The results of a literature search suggest that a chordoma arising in the corpus callosum has not been previously described. The present case demonstrates that chordomas can occur in the corpus callosum, and illustrates the utility of a transfalcine approach for GTR of lesions in this location, as well as the need for improved strategies to prevent intraventricular dissemination.

Clinical classification of clival chordomas for transnasal approaches

Endoscopic endonasal approaches (EEAs) are ideal for most chordomas, but there is little information regarding the practical clinical classification of clival chordomas to guide surgery with EEAs. This article investigates a relatively concise and practical clinical classification system for clival chordomas and summarizes the clinical characteristics and operative key points of different clinical types. Here, 55 patients with clival chordomas treated through EEAs from 2012 to 2017 were retrospectively reviewed. Depending on the origin of the notochord and the growth pattern of the tumor, with our introduced Wang's line, these cases of clival chordoma were divided into types I-IV. There were 14 cases of type I-A, 7 cases of type I-B, 10 cases of type II, 10 cases of type III-A, 7 cases of type III-B, and 7 cases of type IV. The gross total resection (GTR) rate of primary and recurrent type I tumors was 64% and 25%, and residual tumors were found mainly in cases with involvement of the cavernous sinus or the posterior upper part of the dorsum sella. The GTR rate of primary and recurrent type II tumors was 85% and 66.6%, respectively. Residual tumors were found in cases with involvement of the petrous apex. The GTR rate of primary and recurrent type III tumors was 75% and 20%, and residual tumors were found in cases with involvement of the parapharyngeal space and dorsal side of C1-2. Residual type I-B and type III-B tumors were found when there was BA or VA adhesion or brain stem invasion. Our new classification method proposed here can be used to guide the resection of clival chordomas through EEAs.

Non-adenomatous sellar lesions: single-centre 10-year experience

OBJECTIVE

A minority of lesions found in the sellar region are non-adenomatous neoplastic, inflammatory, or cystic masses. Our study aims to describe the prevalence and characteristics of these lesions in a multidisciplinary pituitary outpatient clinic.

DESIGN

We conducted an observational study which included 36 patients (15.9% of those followed up in this outpatient clinic between 2006 and 2016 who had pituitary surgery) submitted to pituitary surgery with histological results showing a non-adenomatous sellar lesion. We evaluated clinical, radiological, and biochemical (pituitary function) characteristics during the pre-operative and post-operative period.

RESULTS

Thirty-six patients (50% female) with a mean age of 41.3 ± 21.9 years and a mean follow-up duration of 8.0 ± 9.0 years were included. Histologic diagnoses were divided into benign neoplasms (80.6%), malignant neoplasms (11.1%), inflammatory lesions (5.6%), and cystic masses (2.8%). The most common clinical presentation was headache (66.7%) and visual defects (61.1%). Forty-seven percent of patients had at least one pituitary axis insufficiency at the time of diagnosis. In the majority of cases (58.3%), a transsphenoidal approach was used for the initial pituitary surgery. Thirteen patients had more than one pituitary surgery and eight also had radiotherapy. At the time of data retrieval, five patients had no pituitary hormonal insufficiency and 13 patients had some visual defect improvement.

CONCLUSIONS

Although rare, non-adenomatous sellar lesions may be associated with significant causes of morbidity, such as hypopituitarism and visual defects, per se or due to the various treatment modalities employed. Moreover, since the lesions are difficult to distinguish from adenomas, these patients require a careful multidisciplinary approach.

Differentiating skull base chordomas and invasive pituitary adenomas with conventional MRI

Background It is difficult to distinguish between invasive pituitary adenomas (IPAs) and skull base chordomas based on tumor location and clinical manifestations. Purpose To investigate the value of the apparent diffusion coefficient (ADC), T2-weighted (T2W) imaging, and dynamic contrast enhancement (DCE) in differentiating skull base chordomas and IPAs. Material and Methods Data for 21 patients with skull base chordomas and 27 patients with IPAs involving the paranasal sinus were retrospectively reviewed, and all diagnoses were pathologically confirmed. Each patient underwent conventional 3.0 T magnetic resonance imaging (MRI), including, ADC, T2W imaging, and DCE sequences. Regions of interest were drawn in the mass and in normal white matter on ADC maps and T2W imaging. The mean ADC, normal ADC, T2W imaging signal intensity (SI), and relative T2-weighted (rT2W) imaging values were measured. DCE parameters, including types of time signal-intensity curves (TIC), enhancement peak (EP), and maximum contrast enhancement ratio (MCER), were calculated. Differences between skull base chordomas and IPAs were evaluated using the independent samples t-test. Receiver operating characteristic (ROC) curve analyses were also performed. Results When comparing IPAs and chordomas, there were significant differences in mean ADC, normal ADC, rT2W imaging values, TIC, EP, and MCER ( P < 0.01). The areas under curves in the ROC analyses for normal ADC, mean ADC, T2W imaging, rT2W imaging, TIC, EP, and MCER were 1.0, 0.996, 1.0, 0.81, 0.987, and 0.987, respectively. Conclusion ADC, T2W imaging SI, and DCE-related parameters can contribute to the differential diagnosis of skull base chordomas and IPAs.

Presentation, Treatment, and Long-Term Outcome of Intrasellar Chordoma: A Pooled Analysis of Institutional, SEER (Surveillance Epidemiology and End Results), and Published Data

BACKGROUND

Chordoma that occurs primarily in the sella turcica is rare and presents unique treatment challenges.

OBJECTIVE

The purpose of this study was to determine common features, treatment approaches, and survival characteristics of intrasellar chordoma.

METHODS

Institutional databases, the SEER (Surveillance Epidemiology and End Results) database, and PubMed/EMBASE were queried for chordoma with a primarily intrasellar component. The SEER database was also queried for adult skull base chordoma. Patient-level data were extracted where available. Kaplan-Meier survival analyses were conducted.

RESULTS

Among 80 cases, the mean age at presentation was 55.6 (standard deviation, 15.9), with a female predominance (1.16:1.00). Patients experienced symptoms for a mean duration of 19.0 months, including cranial nerve deficits, hypopituitarism, and hyperprolactinemia. Among patients receiving treatment, 77.5% underwent surgery. In addition, less than half of the patients (n = 34, 47.3%) received adjuvant radiation therapy. The 5-year overall survival (OS) of intrasellar chordoma was 60.0% (standard error [SE], 6.9). Patients aged 40 years and younger had a 5-year OS of 80.8% (SE, 12.2), compared with patients older than 40 years, who had an OS of 55.4% (SE, 7.7) (Mantel-Cox, P = 0.044). Males experienced a lower 5-year OS (44.0; SE, 9.7) than did females (76.8; SE, 8.5), (Mantel-Cox, P = 0.003). Median OS was greater in patients with skull base chordoma than in patients with intrasellar chordoma (Mantel-Cox, P = 0.046).

CONCLUSIONS

Intrasellar chordoma presents frequently with visual disturbances and hyperprolactinemia and has a slightly higher incidence in females. Young age predicts a better prognosis. Intrasellar chordoma has a lower overall survival than has skull base chordoma.

A Case of Coincidental Intrasellar Chordoma and Pituitary Adenoma

Although chordomas are midline tumors, primarily intrasellar chordomas are extremely rare. In this report, the authors describe the case of a 68-year-old female with partial abducens nerve palsy in the right eye due to the intrasellar cystic tumor. After endonasal trans-sphenoidal surgery, intraoperative and histopathological findings confirmed the co-occurrence of an entirely intrasellar chordoma and pituitary adenoma. To our knowledge, the present case is the third reported case of an intrasellar chordoma with a pituitary adenoma.

Preoperative Evaluation of Sellar and Parasellar Macrolesions by [18F]Fluorodeoxyglucose Positron Emission Tomography

OBJECTIVE

Various diseases can occur in the sellar and suprasellar regions. The potential of [¹⁸F]fluorodeoxyglucose (FDG) positron emission tomography (PET) for the preoperative evaluation of sellar and parasellar lesions was investigated.

METHODS

A total of 49 patients aged 8-82 years with sellar and parasellar macroscopic lesions (≥10 mm) underwent FDG PET. Twenty-two patients had pituitary adenomas, including 14 nonfunctioning and 8 growth hormone-secreting adenomas. Eleven patients had craniopharyngiomas, including 5 adamantinomatous and 6 squamous-papillary types. Eight patients had chordoma, 4 had meningioma, and 4 had a Rathke cleft cyst. The maximum standardized uptake value (SUV_max), and the ratio of the SUV_max in the tumor to the mean standardized uptake value in the normal cortex (T/N ratio) or in the normal white matter (T/W ratio) were calculated. The relationships between SUV_max, T/N ratio, and T/W ratio, and lesion disease were evaluated.

RESULTS

Uptakes of FDG, including SUV_max, T/N ratio, and T/W ratio, were lower in chordoma and Rathke cleft cyst compared with pituitary adenoma. SUV_max, T/N ratio, and T/W ratio of nonfunctioning adenoma were significantly higher than those of growth hormone-secreting adenoma. SUV_max, T/N ratio, and T/W ratio of squamous-papillary type were significantly higher than those of the adamantinomatous type of craniopharyngioma.

CONCLUSIONS

FDG PET is useful for the preoperative diagnosis of sellar and parasellar macrolesions. High uptake in nonfunctioning pituitary adenoma, and low uptake in chordoma are significant. The difference in FDG uptake dependent on the histologic subtype may be related to the specific genetics of the craniopharyngioma subtype.

Classification and surgical approaches for transnasal endoscopic skull base chordoma resection: a 6-year experience with 161 cases

The aim of this study is to retrospectively analyze 161 cases of surgically treated skull base chordoma, so as to summarize the clinical classification of this tumor and the surgical approaches for its treatment via transnasal endoscopic surgery. Between August 2007 and October 2013, a total of 161 patients (92 males and 69 females) undergoing surgical treatment of skull base chordoma were evaluated with regard to the clinical classification, surgical approach, and surgical efficacy. The tumor was located in the midline region of the skull base in 134 cases, and in the midline and paramedian regions in 27 cases (extensive type). Resection was performed via the transnasal endoscopic approach in 124 cases (77%), via the open cranial base approach in 11 cases (6.8%), and via staged resection combined with the transnasal endoscopic approach and open cranial base approach in 26 cases (16.2%). Total resection was achieved in 38 cases (23.6%); subtotal resection, 86 cases (53.4%); partial resection of 80-95%, 29 cases (18%); and partial resection <80%, 8 cases (5%). The clinical classification method used in this study seems suitable for selection of transnasal endoscopic surgical approach which may improve the resection degree and surgical efficacy of skull base chordoma. Gross total resection of skull base chordoma via endoscopic endonasal surgery (with addition of an open approach as needed) is a safe and viable alternative to the traditional open approach.

Adjuvant Stereotactic Radiosurgery and Radiation Therapy for the Treatment of Intracranial Chordomas

Objective Chordomas are locally aggressive, highly recurrent tumors requiring adjuvant radiotherapy following resection for successful management. We retrospectively reviewed patients treated for intracranial chordomas with adjuvant stereotactic radiosurgery (SRS) and stereotactic radiation therapy (SRT). Methods A total of 57 patients underwent 83 treatments at the UCLA Medical Center between February 1990 and August 2011. Mean follow-up was 57.8 months. Mean tumor diameter was 3.36 cm. Overall, 8 and 34 patients received adjuvant SRS and SRT, and the mean maximal dose of radiation therapy was 1783.3 cGy and 6339 cGy, respectively. Results Overall rate of recurrence was 51.8%, and 1- and 5-year progression-free survival (PFS) was 88.2% and 35.2%, respectively. Gross total resection was achieved in 30.9% of patients. Adjuvant radiotherapy improved outcomes following subtotal resection (5-year PFS 62.5% versus 20.1%; p = 0.036). SRS and SRT produced comparable rates of tumor control (p = 0.28). Higher dose SRT (> 6,000 cGy) (p = 0.013) and younger age (< 45 years) (p = 0.03) was associated with improved rates of tumor control. Conclusion Adjuvant radiotherapy is critical following subtotal resection of intracranial chordomas. Adjuvant SRT and SRS were safe and improved PFS following subtotal resection. Higher total doses of SRT and younger patient age were associated with improved rates of tumor control.

Experimental study on differences in clivus chordoma bone invasion: an iTRAQ-based quantitative proteomic analysis

Although a bone tumor, significant differences in the extent of bone invasion exist in skull base chordoma, which directly affect the extent of surgical resection, and have an impact on its prognosis. However, the underlying mechanism of the phenomenon is not clearly understood. Therefore, we used an iTRAQ-based quantitative proteomics strategy to identify potential molecular signatures, and to find predictive markers of discrepancy in bone invasion of clivus chordoma. According to bone invasive classification criteria, 35 specimens of clivus chordoma were calssified to be either endophytic type (Type I) or exophytic type (Type II). An initial screening of six specimens of endophytic type and six of exophytic was performed, and 250 differentially expressed proteins were identified. Through the GO and IPA analysis, we found evidence that the expression of inflammatory activity-associated proteins up-regulated in endophytic type, whereas the expression of cell motility-associated proteins up-regulated in exophytic ones. Moreover, TGFβ1 and mTOR signal pathway seemed to be related with bone invasion. Thus, TGFβ1, PI3K, Akt, mTOR, and PTEN were validated in the following 23 samples by immune histochemistry and Western blot. The expression levels of TGFβ1 and PTEN were significantly lower in the endophytic type than in the exophytic ones. It was found that TGFβ1 may play an important role in its bone invasion. The mechanisms may be related with conducting an increased inflammatory cell response and a decline in cytoskeletal protein expression. PTEN is confirmed to be associated with the degree of bone invasion. The PI3K/AKT/mTOR signaling pathway might be associated with the bone invasion, but still needs a larger sample size to be verified These results, for the first time, not only demonstrate the biological changes that occur in different growth patterns from the perspective of proteomics, but also provide novel markers that may help to reveal the mechanisms behind clivus chordomas.

Sellar Chordoma Presenting as Pseudo-macroprolactinoma with Unilateral Third Cranial Nerve Palsy

We described a 61-year-old female with a sellarchordoma, which presented as pseudo-macroprolactinoma with unilateral third cranial nerve palsy. Physical examination revealed that her right upper lid could not be raised by itself, right eyeball movement limited to the abduction direction, right pupil dilated to 4.5 mm with negative reaction to light, and hemianopsia in bitemporal sides. CT scanning showed a hyperdense lesion at sellar region without bone destruction. Magnetic resonance imaging (MRI) revealed the tumor was 2.3 cm×1.8 cm×2.6 cm, with iso-intensity on T1WI, hyper-intensity on T2WI and heterogeneous enhancement on contrast imaging. Endocrine examination showed her serum prolactin level increased to 1,031.49 mIU/ml. The tumor was sub-totally resected via pterional craniotomy under microscope and was histologically proven to be a chordoma. Postoperatively, she recovered uneventfully but ptosis and hemianopsia remained at the 6th month.

Intra et parasellar chordoma

A rare case of giant intra and parasellar chordoma, mimicking a pituitary prolactinoma is presented. The tumor involving pituitary fossa and surrounding structures was removed via a bifrontal approach. The pathology exhibited the typical histological patterns of a chordoma. The authors present a rare case of a giant sellar and parasellar chordoma and review the literature on that.

Solitary fibrous tumor of the central nervous system: a 15-year literature survey of 220 cases (August 1996-July 2011)

We reviewed the world literature on solitary fibrous tumors of the central nervous system from August 1996 to July 2011, focusing on both clinicopathological features and diagnostic findings. The anatomical distribution of the 220 cases reported so far reveals that most are intracranial and just over one-fifth are intraspinal. In decreasing frequency, intracranial tumors involve the supratentorial and infratentorial compartments, the pontocerebellar angle, the sellar and parasellar regions, and the cranial nerves. Intraspinal tumors are mainly located in the thoracic and cervical segments. Although most solitary fibrous tumors of the central nervous system are dural based, a small subset presents as subpial, intraparenchymal, intraventricular, or as tumors involving the nerve rootlets with no dural connection. Preoperative imaging and intraoperative findings suggest meningioma, schwannoma or neurofibroma, hemangiopericytoma, or pituitary tumors. Immunohistochemistry is critical to establish a definitive histopathological diagnosis. Vimentin, CD34, BCL2, and CD99 are the most consistently positive markers. The usual histologic type generally behaves in a benign manner if complete removal is achieved. Recurrence is anticipated when resection is subtotal or when the tumor exhibits atypical histology. The proliferative index as assessed by MIB1 labeling is of prognostic significance. Occasionally, tumors featuring conventional morphology may recur, perhaps because of minimal residual disease left behind during surgical extirpation. Rare extracranial metastases and tumor-related deaths are on record. Surgery is the treatment of choice. Stereotactic and external beam radiation therapy may be indicated for postsurgical tumor remnants and for unresectable recurrences. Long-term active surveillance of the patients is mandatory.

Intrasellar chondroid chordoma: a case report

Chordomas are tumors derived from cells that are remnants of the notochord, particularly from its proximal and distal extremes, they are mainly midline and represent approximately 1% of all malignant bone tumors and 0.1 to 0.2% of intracranial neoplasms. Chordomas involving the sellar region are rare. Herein, we describe a 57-year-old male patient presenting with a history of retro-orbital headache, progressive loss of vision, and clinical features of hypopituitarism, for over 2 months. During evaluation, the CT scan revealed a large contrast-enhancing intrasellar tumor with a 3.6-cm largest diameter. The patient underwent transsphenoidal partial resection of the tumor, and histological examination was consistent with the diagnosis of chondroid chordoma. Although chordomas are rare, they may be considered to constitute a differential diagnostic of pituitary adenomas, especially if a calcified intrasellar tumor with bone erosion is diagnosed.

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

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

Rare sellar lesions

Sellar masses are associated most commonly with pituitary adenomas. Many other neoplastic, inflammatory, infectious, and vascular lesions, however, may affect the sellar region and mimic pituitary tumors. These lesions must be considered in a differential diagnosis. This article describes the characteristics of rare sellar masses that provide clues to their differential diagnosis.

Tumor-biology and current treatment of skull-base chordomas

Chordomas are rare, slow growing tumors of the axial skeleton, which derive from the remnants of the fetal notochord. They can be encountered anywhere along the axial skeleton, most commonly in the sacral area, skull base and less commonly in the spine. Chordomas have a benign histopathology but exhibit malignant clinical behavior with invasive, destructive and metastatic potential. Genetic and molecular pathology studies on oncogenesis of chordomas are very limited and there is little known on mechanisms governing the disease. Chordomas most commonly present with headaches and diplopia and can be readily diagnosed by current neuroradiological methods. There are 3 pathological subtypes of chordomas: classic, chondroid and dedifferentiated chordomas. Differential diagnosis from chondrosarcomas by radiology or pathology may at times be difficult. Skull base chordomas are very challenging to treat. Clinically there are at least two subsets of chordoma patients with distinct behaviors: some with a benign course and another group with an aggressive and rapidly progressive disease. There is no standard treatment for chordomas. Surgical resection and high dose radiation treatment are the mainstays of current treatment. Nevertheless, a significant percentage of skull base chordomas recur despite treatment. The outcome is dictated primarily by the intrinsic biology of the tumor and treatment seems only to have a secondary impact. To date we only have a limited understanding this biology; however better understanding is likely to improve treatment outcome. Hereby we present a review of the current knowledge and experience on the tumor biology, diagnosis and treatment of chordomas.

Synovial sarcoma of the sellar region

Primary sarcomas of the sellar region are uncommon, although a wide variety have been reported. To date, no cases of primary synovial sarcoma have been described as occurring at this site. We report an immunohistochemically and molecular genetically confirmed primary synovial sarcoma involving the sellar/parasellar region and cavernous sinus in an adult male. Subtotal resection and radiosurgery proved to be efficacious. The spectrum of primary sellar region sarcomas is summarized.

Chordoma in the sella turcica

A 75-year-old man presented with a rare case of chordoma in the sella turcica of the skull base. He had been treated for hypertension and chronic renal failure since 1990. Computed tomography detected a tumor in the sella turcica in 1994, but the patient had no clinical complaints and the serum pituitary hormone levels were normal. He died of disseminated intravascular coagulation, myocardial infarction, pulmonary infection, and multiple cerebral infarctions in 2000. At autopsy, the tumor in the sella turcica was 3.1 cm in greatest diameter and had compressed the pituitary gland posteriorly. Histological examination found oval cells and vacuolated short spindle-shaped cells which showed morphological changes similar to myxoma cells. The tumor was lobulated by narrow connective tissues. The tumor did not contain any cartilaginous tissue components, and was stained positively for epithelial membrane antigen but negatively for S-100 protein. The final diagnosis was chordoma. There was no association between the tumor and the cause of death.

[Hormonal dysfunction of nonpituitary lesions from midline and perisellar area]

OBJECTIVE

To analyse clinical and/or laboratorial preoperative hormonal dysfunction, of the nonpituitary intracranial lesions from midline and parasellar area.

METHOD

Forty-four patients were evaluated with nonpituitary intracranial lesions, who had images studies (computed tomography or magnetic resonance) and preoperative basal hormonal level; 16 had preoperative hypothalamus-hypophysial function tests (megatests). These patients were divided in two groups. Group I - 34 lesions from midline: 11 craniopharyngiomas, 8 meningiomas, 3 germinomas, 3 tumors of sphenoid sinus, 2 empty sella syndrome, 2 pylocitic astrocytomas, 1 giant aneurysm, 2 mucoceles, 1 III ventricle diverticulum and 1 Rathke's cleft cyst; Group II - 10 lesions from parasellar area: 9 meningiomas and 1 giant aneurysm.

RESULTS

In group I, 25/34 (73.5%) patients showed laboratorial hormonal deficit (14 without clinical manifestations) 18/34 (52.9%) hyperprolactinemia (5 with galactorreia) and 8 (53.3%) showed growth hormone deficiency in 15 megatests available in this group; 3 (8.8 %) patients presented central diabetes insipidus (CDI). In group II, 6/10 (60%) patients showed laboratorial hormonal deficit (5 without clinical manifestations), 1 (10%) hyperprolactinemia and 1 growth hormone deficiency (single megatest realized in this group); no patient had preoperative CID.

CONCLUSIONS

The presence of nonspecific or poorly valorized clinical manifestations, does not indicate absence of hormonal dysfunction; in this present serie, 19/38 (50%) patients with laboratorial abnormalities, didn't show clinical manifestations. Hormonal dysfunction is frequent in sellar and perisellar nonpituitary lesions, specially involving midline.

Skull base chordomas: overview of disease, management options, and outcome

Cranial base chordomas are locally invasive tumors that, from a midline, clival location, extend in different directions and display various patterns of skull base invasion. Although histologically benign, their invasive nature makes true “oncological” resection virtually impossible to achieve in most cases, despite modern skull base surgical techniques. Moreover, because of the tumor's location and proximity to critical neural and vascular structures, surgery-related morbidity can be significant when an aggressive resection is undertaken. Cytoreductive surgery assumes a critical role in the management of these lesions. The choice of surgical approach and the extent of resection are dependent on several factors: location and extension of the tumor, the surgeon's philosophy and familiarity with a specific approach, and the patient's preexisting clinical status. Proton-beam radiotherapy seems to be effective as an adjunct to surgery in achieving local tumor control. The timing of radiation therapy, however, remains controversial. Gamma knife surgery has been proposed as an adjunctive therapy, but the limited experience and short follow-up periods do not permit formulation of meaningful conclusions at this time. Recurrences are common, although in a subset of patients prolonged disease-free survival is demonstrated.