An audit of the use of CT pituitary scans to exclude a pituitary macroadenoma

BACKGROUND

Pituitary imaging is often required to exclude an adenoma suspected clinically or biochemically. Although magnetic resonance (MR) is the gold standard, computerised tomography (CT) is faster, cheaper and induces less claustrophobia. Our audit at Auckland City Hospital, New Zealand, investigated whether the use of CT of the pituitary as the first line imaging to assess for a pituitary macroadenoma reduces the need for MR.

METHODS

We investigated the usefulness of CT pituitary imaging in the exclusion of pituitary macroadenoma between 2012 and 2020. A re-audit was then undertaken for a period of one year between March 2021 and March 2022 to assess outcomes once a departmental policy change was implemented. At Auckland City Hospital, 32 patients across eight years were eligible for this analysis, of which 31 had data available. In our re-audit, 29 patients were eligible for this analysis. We collected data on patient demographics, relevant hormone levels, indication for imaging and imaging results and subsequent management.

RESULTS

After CT pituitary imaging, 28/31 (90%) of patients did not require further imaging because the clinical question had been addressed. One year after routine initial CT pituitary imaging was implemented by the Auckland City Hospital Endocrinology Department, 29 CT pituitary scans were performed to exclude a pituitary macroadenoma. Of these patients one required further imaging due to the finding of an expanded pituitary sella but not a pituitary macroadenoma.

CONCLUSION

CT pituitary imaging to exclude a pituitary macroadenoma is a useful test that may reduce the need for MR pituitary scans.

TRIAL REGISTRATION

Not applicable. This was an audit as defined by the New Zealand National Ethics Advisory Committee guidelines. Please see 'Declarations' section.

Preoperative Magnetic Resonance Elastography (MRE) of Skull Base Tumours: A Review

Conventional magnetic resonance imaging (MRI) can detect tumors consistency, but it can't predict tumor stiffness or adherence of the tumor to nearby structures. Magnetic resonance elastography (MRE) is a known non-invasive MRI based imaging technique used to assess the viscoelasticity of the tissues particularly liver fibrosis. This study discussed the importance of preoperative MRE in skull base tumors and the future implications of this new imaging modality. We did review of the English literature (by searching PubMed) regarding the use of MRE in preoperative assessment of skull base tumours stiffness and adherence to surrounding tissues. Recent research demonstrated that MRE can detect the stiffness and adherence of skull base tumors to surrounding structures by recording the spread of mechanical waves in the different tissues. In addition to non-radiation exposure, this technique is fast and can be incorporated into the conventional (MRI) study. MRE can palpate skull base tumours by imaging, allowing the stiffness of the tumour to be assessed. Preoperative assessment of brain tumours consistency, stiffness, and adherence to surrounding tissues is critical to avoid injury of important nearby structures and better preoperative patient counselling regarding surgical approach (endoscopic or open), operative time, and suspected surgical complications. However, the accuracy of MRE is less in small and highly vascular tumors. Also, MRE can't accurately detect tumour-brain adherence, but the new modality (slip-interface imaging) can. Hence, adding MRE to the conventional MRI study may help in preoperative diagnosis and treatment of skull base tumours.

Pituitary macroadenoma apoplexy as a rare complication of Bruton tyrosine kinase inhibitor in chronic lymphoid leukaemia

BACKGROUND

Pituitary apoplexy is a neurosurgical emergency and is a known yet rare complication of pituitary macroadenoma. Patients typically present with visual field defects, headache and altered sensorium. There are multiple risk factors for this complication and a thorough drug history is essential to exclude iatrogenic causes of disease. We present an extremely rare case of newly diagnosed pituitary insufficiency unveiled by ibrutinib therapy (a Bruton tyrosine kinase inhibitor). Furthermore, after initial withdrawal of ibrutinib because of the erroneous diagnosis of Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH), its re-administration led to the development of classical pituitary apoplexy 4 months after treatment was restarted.

CASE PRESENTATION

A male patient in his 60s with a background of chronic lymphocytic leukaemia (CLL) on ibrutinib and venetoclax presents with acute confusion and deranged electrolytes. He is found to be hyponatraemic and is diagnosed with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) and treated with fluid restriction. He represents again 3 weeks later with hyponatraemia and further investigations reveal pituitary insufficiency and macroadenoma. He was restarted on ibrutinib and venetoclax at the time of discharge. Four months later, he presents with sudden retro-orbital headache associated with vomiting. Clinical findings include cranial nerve III, IV and XI palsy. Humphrey's visual field examination revealed a left visual field index (VFI) of only 1% while the right was 64% with temporal hemianopia. Both pupils were mid-dilated and poorly reactive to light. MRI pituitary with contrast showed features of pituitary apoplexy and optic nerve compression. He was urgently referred to the neurosurgical team and underwent an emergency trans-sphenoidal hypophysectomy with circumferential excision of the macroadenoma. Post-operative recovery was uneventful with marked improvement in vision bilaterally. The patient was restarted on ibrutinib and venetoclax 2 weeks post-operatively. Approximately 1 year post-treatment, he remains in radiological, clinical and biochemical remission from CLL and all medications have been withdrawn.

CONCLUSIONS

This is a unique and rare case of pituitary macroadenoma apoplexy following the commencement of ibrutinib for CLL. Central nervous system haemorrhage is a rare side effect of ibrutinib due to its platelet dysfunction effects. A thorough assessment is required to assess the risks and benefits of using ibrutinib in patients with pituitary macroadenoma to avoid serious complications.

Comparison of the Novel Two-Hand Technique Using the Saraj Endocath with the Traditional Three-Hand Technique in Transnasal Endoscopic Pituitary Surgery: An Innovation for the Future

BACKGROUND

Endoscopic surgery has become the preferred treatment of sellar lesions because of its minimally invasive nature. Visualization is frequently obscured as a result of the frequent contact of the lens with blood and tissue debris. We seek to alleviate these problems and increase the efficiency and safety of neuroendoscopic surgery by introducing a new device (Saraj Endocath) combining the major function of suction with the endoscope.

METHODS

A total of 75 patients with pituitary macroadenoma who were eligible for transnasal transsphenoidal endoscopic excision were included in the study between January 2020 and January 2023. Forty-one patients were operated on by the traditional 3-hand technique and 34 patients were operated on using the Saraj Endocath. The duration of surgery, in-out frequency of the endoscope, number of wipes needed to clean the endoscopic lens, and outcomes were assessed. A questionnaire regarding assistance, ergonomics, and instrument handling compared the Saraj Endocath procedure with the traditional technique.

RESULTS

The 3-hand technique was converted into the 2-hand technique. The mean operative time using the novel technique with the Saraj Endocath was reduced significantly compared with the traditional technique. The mean number of in-out movements of the endoscope and the number of wipes per hour decreased significantly using the Saraj Endocath. There was no dependency on the assistant's expertise and skills.

CONCLUSIONS

The use of the Saraj Endocath can effectively reduce the mean operative time by decreasing the frequency of in-out movement and wiping off the lens of the endoscope. It reduces fatigue, avoids clustering of instruments and hands, and minimizes the dependency on assistants.

Acromegaly with initial negative oral glucose tolerance test: a case report

BACKGROUND

Acromegaly can be diagnosed by a growth hormone value ≥ 1 µg/L following an oral glucose tolerance test. However, normal growth hormone suppression following oral glucose tolerance test may not exclude acromegaly.

CASE PRESENTATION

We present a case of a 55-year-old Chinese man with pituitary macroadenoma incidentally noted after a traffic accident. He reported feet enlargement in the past few years. At the beginning, elevated insulin-like growth factor-1 was noted with growth hormone value < 1 µg/L after oral glucose tolerance test. Fracture-related high insulin-like growth factor-1 was suspected. Insulin-like growth factor-1 decreased gradually but was still above the upper limit of normal . However, he suffered from dizziness 1 year later and insulin-like growth factor-1 increased again. Besides, secondary hypocortisolism developed. The size of the pituitary macroadenoma was stationary. Follow-up oral glucose tolerance test showed a growth hormone value > 1 µg/L. Endoscopic endonasal approach to the remove pituitary macroadenoma was performed subsequently. After the resection of the pituitary macroadenoma, pathology showed positive staining of growth hormone and prolactin. Insulin-like growth factor-1 normalized as well.

CONCLUSIONS

Suppressed growth hormone after oral glucose tolerance test cannot exclude acromegaly, and some patients may have only mild or no clinical presentation of acromegaly. Patients with pituitary microadenoma or macroadenoma and elevated insulin-like growth factor-1 should be closely monitored for signs/symptoms of acromegaly and hypopituitarism.

Anatomy and Pathology of the Skull Base: Malignant and Nonmalignant Lesions

The skull base (SB) is the osseous foundation of the cranial vault. It contains many openings that allow communication between the extracranial and intracranial structures. This communication is crucial in normal physiologic processes yet may also arrow spread of disease. This article provides a comprehensive review of SB anatomy including important landmarks and anatomic variants relevant to SB surgery. We also illustrate the diverse pathologies affecting the SB.

A retrospective cohort study assessing geometrical parameters related to visual deterioration in pituitary macroadenoma

PURPOSE

We aim to identify specific parameters that will allow identification of those patients at greater risk of vision loss, specifically variables such as geometry, volume and size of the pituitary tumour.

METHODOLOGY

Volume measurements were made with both manual (using the formula width × height × length × 0.5) and video size, sub-voxel interpolation using Brainlab software. The shape of the tumour was divided into four categories, ovoid, dumbbell, pyramidal and other. Chiasmal compression was divided into central and lateral compression and the chiasm location was classified based on pre/post and normal fixed chiasm in relation to the tuberculum sella. We used a visual impairment score ranging from (0-100), which was then further subdivided in to four grades: Grade I - 0-25 (mild); Grade II - 26-50 (moderate); Grade III - 51-75 (severe); Grade IV - 76-100 (subtotal or complete).

RESULTS

Univariate analysis of variables related to vision loss found tumour volume, suprasellar growth and lateral chiasmal compression related to pre-operative vision loss. On multivariate regression analysis tumour volume and lateral chiasmal compression remained significant (p < 0.008). In relation to post-operative vision, univariate analysis indicated that variables such as giant macroadenoma, pre-operative visual impairment score and suprasellar growth were significant. Multivariate analysis showed pre-operative visual impairment and suprasellar growth as the only statistically significant variables.

CONCLUSION

Our ROC analysis suggests tumours with suprasellar extension 16 mm (sensitivity 85 %, specificity 67 %) in sagittal plane are more likely to result in moderate to severe grade vision loss (VIS grade ≥ 2).

Radiation Therapy for Recurrent or Residual Pituitary Macroadenoma Invading Extrasellar Structures

PURPOSE

This study aimed to evaluate the efficacy of radiation therapy (RT) for recurrent or residual pituitary macroadenoma (PMA) invading extrasellar regions.

MATERIALS AND METHODS

Patients from 2000 to 2020 who received RT with conventional fractionation for recurrent or residual PMA were included. The patients were divided according to the type of tumor [functioning (fx) or non-fx] and the aim of RT (salvage RT alone, immediate postoperative RT, delayed postoperative RT). Local and biochemical failure-free rates (FFR) were calculated using the Kaplan-Meier method.

RESULTS

With a median follow up of 82 months (IQR; 42-132 months), 36 patients treated with conventional RT (total 45-54 Gy in 1.8 or 2 Gy per fraction) for recurrent or residual PMA were analyzed. The 10-year local FFRs after RT for non-fx and fx tumor were 100% and 74.4%, respectively (p=0.047). In the immediate postoperative RT group, the 10-year local FFR was 100%, which was higher than the 90% FFR for salvage RT alone or 80% FFR for the delayed postoperative RT group (overall p=0.043, immediate vs. salvage; p=0.312, immediate vs. delayed; p=0.072). The local FFR was compared according to size of tumor with a cut-off value of 4 cm, and there was no significant difference (10-year local FFR 100% vs. 84.7% for >4 cm vs. <4 cm, p=0.320). The extents of extrasellar region invasion were not predictive of local failure after RT. We found no grade ≥3 acute toxicities or newly developed visual impairments as a late toxicity of RT.

CONCLUSION

Conventional RT is safe and effective for the local control of recurrent or residual PMA. Our data suggest that immediate postoperative RT can be beneficial in recurrent or residual PMA, although further studies to evaluate risk factors of treatment failure in terms of treatment and disease characteristics are required.

A study on clinical outcomes of Rathke's cleft cyst in patients managed conservatively

OBJECTIVES

The primary objective was to investigate the clinical presentation, hormonal dysfunction, imaging characteristics and natural history of RCCs that were managed conservatively. Secondary objective was to identify factors associated with cyst progression.

METHODS

A retrospective review of patients with the clinical diagnosis of RCC-identified from word search from radiology reports that were followed up from January 1999 to March 2019 was performed. The demographics, clinical data, radiological features and outcomes were reviewed and analyzed.

RESULTS

105 patients were identified with a median follow up of 6 years. 68 patients (64.8%) were managed conservatively from diagnosis till last follow up while 37 patients (35.2%) underwent surgery, with 26 operated at time of diagnosis and 11 operated upon monitoring. For patients managed conservatively from diagnosis till last follow up, incidental finding was the most common presentation. 19.1% had either one or more axes of hormonal dysfunction, with hypogonadism and hypocortisolemia being the commonest ones. Imaging features were variable. 66.2% of patients had T2W hyperintensity on MRI. Pathognomonic feature of intracystic nodule was present in only 14.7% of patients. Among the 79 patients with repeated MRI imaging (68 from conservative group and 11 from surgical group), 32.9% of patients developed cyst progression while 67.1% had either static disease or regression in size of RCC. Median time to progression of cyst was 14 months. Longer median follow up duration and presence of pituitary stalk displacement at presentation were associated with cyst progression. Only one patient developed new endocrine dysfunction.

CONCLUSION

2/3 of the RCCs had static disease or even regression in the size of the cyst. They rarely gave rise to additional endocrine dysfunction by adopting observant approach. Cyst progression was demonstrated in 1/3 of patients. Conservative treatment remained a reasonable treatment for patients without significant symptoms.

Solid tumor size for prediction of recurrence in large and giant non-functioning pituitary adenomas

A subset of large non-functioning pituitary adenomas (lNFPA) and giant non-functioning pituitary adenomas (gNFPA) undergoes early progression/recurrence (P/R) after surgery. This study revealed the clinical and image predictors of P/R in lNFPA and gNFPA, with emphasis on solid tumor size. This retrospective study investigated the preoperative MR imaging features for the prediction of P/R in lNFPA (> 3 cm) and gNFPA (> 4 cm). Only the patients with a complete preoperative brain MRI and undergone postoperative MRI follow-ups for more than 1 year were included. From November 2010 to December 2020, a total of 34 patients diagnosed with lNFPA and gNFPA were included (median follow-up time 47.6 months) in this study. A total of twenty-three (23/34, 67.6%) patients had P/R, and the median time to P/R is 25.2 months. Solid tumor diameter (STD), solid tumor volume (STV), and extent of resection are associated with P/R (p < 0.05). Multivariate analysis showed large STV is a risk factor for P/R (p < 0.05) with a hazard ratio of 30.79. The cutoff points of STD and STV for prediction of P/R are 26 mm and 7.6 cm³, with AUCs of 0.78 and 0.79 respectively. Kaplan-Meier analysis of tumor P/R trends showed that patients with larger STD and STV exhibited shorter progression-free survival (p < 0.05). For lNFPA and gNFPA, preoperative STD and STV are significant predictors of P/R. The results offer objective and valuable information for treatment planning in this subgroup.

Optic neuritis concomitant with pituitary macroadenoma in a patient with active COVID-19 infection: A case report

Introduction and importance

Several neuro-ophthalmic manifestations have been reported with coronavirus disease 2019 (COVID-19) infection. However, isolated optic neuritis was infrequently reported in humans with COVID-19. If it occurred, optic neuritis was usually a part of a demyelinating syndrome.

Case presentation

In this paper, we report a case of optic neuritis concomitant with an undiagnosed pituitary macroadenoma discovered during active COVID-19 infection. The case was a 33-year-old woman with infertility who was recently found to have a pituitary macroadenoma secreting prolactin. During active COVID-19 infection, the patient developed optic neuritis that responded well to corticosteroids. Brain imaging and hormonal profile negated the presence of any demyelinating disease or pituitary apoplexy.

Clinical discussion

A dilemma of whether optic neuritis occurring concomitantly with pituitary macroadenoma is just a coincidence, or there is an association remains unresolved. Whether COVID-19 infection might precipitate optic neuritis in patients with pituitary macroadenoma or not remains an issue to be answered by observing data from future case reports about similar findings.

Conclusion

Optic neuritis in concomitant with pituitary macroadenoma following COVID-19 infection represents a dilemma of whether the visual symptoms are attributed to the tumor or COVID-19 infection.

Virtual magnetic resonance elastography has the feasibility to evaluate preoperative pituitary adenoma consistency

PURPOSE

To evaluate the use of preoperative virtual Magnetic Resonance Elastography (vMRE) for patients undergoing transsphenoidal resection of pituitary adenomas (PA).

METHODS

Ten patients (60.2 ± 19.6 years; 8 males) were prospectively examined with the vMRE-method prior to transsphenoidal surgery. vMRE-images, reflecting tissue stiffness were reconstructed. From these images, histograms as well as the mean stiffness values over the tumor body were extracted. Finally, vMRE-data was compared with the PA consistency at surgery blinded to vMRE.

RESULTS

In all patients, successful vMRE-examination was performed enabling evaluation of even small PAs. For tumors with homogenous tissue, the mean stiffness value increased with surgical consistency grading. For heterogenous tumors, however, the mean stiffness value did not consistently reflect the grading at surgery. On the other hand, the vMRE-images and histograms were found to be able to characterize the tumor heterogeneity and display focal regions of high stiffness that were found to affect the surgery outcome in these PAs. The vMRE-images and histograms showed great promise in characterizing the consistency at surgery for these PAs.

CONCLUSION

Evaluation of PA consistency in preparation for surgery seems to be feasible using the vMRE-method. Our findings also address the need for high resolution diagnostic methods that can non-invasively display focal regions of increased stiffness, as such regions may increase the difficulty of transsphenoidal PA-resection.

Endoscopic transsellar transdiaphragmatic approach for extensive suprasellar pituitary macroadenomas

OBJECTIVE

In pituitary macroadenomas with extensive suprasellar extension (SSE), suprasellar region can be approached by extending exposure either anteriorly by adding bone removal of the tuberculum sellae and planum sphenoidal or posteriorly from inside the sellar cavity through diaphragma sella. The later approach has been rapidly regressed in favor of the anteriorly extended approach, mainly due to the inadequate angled illumination. Benefiting from the continuous evolution of visualization, authors, in current series, tried to revive this technique in form of pure endoscopic trans-sellar trans-diaphragmatic approach (ETSDA) for extra-capsular resection of pituitary macroadenomas with extensive SSE.

METHODS

A prospective review including 10 patients of pituitary macroadenomas with extensive SSE more than 10 mm underwent extra-capsular resection via the ETSDA. The detailed technical nuances and surgical outcome of this approach were evaluated.

RESULTS

Six of 10 patients had SSE > 10 mm and 4 patients had SSE > 20 mm, grade B and C, respectively. Gross total resection was achieved in all cases. Postoperatively, visual field deficit was ameliorated to varying degrees in all patients. There were no serious intraoperative complications, and the clinically overt postoperative CSF rhinorrhea was not observed in any case.

CONCLUSION

Extra-capsular resection of pituitary macroadenomas with extensive SSE can be effectively and safely achieved using the ETSDA. Thus, it may be more preferable to the anteriorly extended approach that may potentially increase the risk for postoperative CSF rhinorrhea.

The Chiasmal Compression Index: An Integrative Assessment Tool for Visual Disturbances in Patients with Pituitary Macroadenomas

OBJECTIVE

Visual status is routinely evaluated by neuro-ophthalmologic examination and computerized visual field (VF) tests in patients with chiasmal compression secondary to pituitary macroadenoma. Currently, no relevant data exists to accurately quantify the extent of optic apparatus compromise to further guide clinical decision-making. We aimed to assess for a possible quantitative correlation between optic chiasm geometric properties on magnetic resonance imaging (MRI) and VF deficits.

METHODS

Visual assessments and concurrent MRI scans were retrospectively reviewed from patients treated for pituitary macroadenoma in a single medical institution. Chiasm width, chiasm minimal and maximal height, and chiasm angle were measured on MRI coronal plane images by 3 independent reviewers (for the sake of variability analysis). VF numerical summary parameters were also retrieved.

RESULTS

A total of 30 patients were included in the final analysis. Average VF index was 70% (±30), and averaged mean deviation was 10.0 db (±9). Chiasm angle and width (which together represents the bending and stretching of the chiasm by the upward directed compression; both of which demonstrated high inter- and intraobserver agreement) showed strong correlation with VF loss. Chiasmal compression index derived from those parameters showed even stronger correlation.

CONCLUSIONS

The strong correlation demonstrated by our results of this relatively simple radiologic measurement with VF status, despite the relatively small cohort, calls for further investigation in this promising direction, and may facilitate with basic assessment and clinical decision-making for patients with equivocal neuro-ophthalmologic evaluation, as well as with poor compliance.

Preoperative vascular heterogeneity and aggressiveness assessment of pituitary macroadenoma based on dynamic contrast-enhanced MRI texture analysis

PURPOSE

To assess the vascular heterogeneity and aggressiveness of pituitary macroadenomas (PM) using texture analysis based on Dynamic Contrast-Enhanced MRI (DCE-MRI).

METHOD

Fifty patients with pathologically confirmed PM, including 32 patients with aggressive PM (aggressive group) and 18 patients with non-aggressive PM (non-aggressive group), were included in this study. The preoperative DCE-MRI and clinical data were collected from all patients. The features based on Ktrans, Ve, and Kep were generated using Omni-Kinetics software. Independent-samples t-test and Mann-Whitney U test were used for comparison between two groups. Logistic regression analysis was used to determine the optimal model for distinguishing aggressive and non-aggressive PM.

RESULTS

Six features related to tumor morphology, 24 features in Ktrans, 20 features in Ve, and 3 features in Kep were significantly different between the aggressive and non-aggressive groups. Volume count, gray-level non-uniformity in Ktrans, voxel value sum in Ve and run-length non-uniformity in Kep (AUC = 0.816, 0.903, 0.785, 0.813) were considered the best feature for tumor diagnosis. After modeling, the diagnosis efficiency of mean model and total model was desirable (AUC = 0.859 and 0.957), and the diagnostic efficiency of morphological, Ktrans, Ve and Kep features model was improved (AUC = 0.845, 0.951, 0.847, 0.804).

CONCLUSIONS

Texture analysis based on DCE-MRI elucidates the vascular heterogeneity and aggressiveness of pituitary adenoma. The total model could be used as a new noninvasive method for predicting the aggressiveness of pituitary macroadenoma.

Pituitary Dysfunction Among Men Presenting with Hypogonadism

PURPOSE OF REVIEW

Hypogonadism is a common endocrine dysfunction. This review focuses on the most up-to-date guideline for evaluation of pituitary function among men presenting with signs and symptoms of hypogonadism.

RECENT FINDINGS

The clinician must differentiate between primary (testicular) and secondary (pituitary-hypothalamic or central) hypogonadisms and be aware of adult-onset hypogonadism. If gonadotropins are low or inappropriately normal, the clinician must consider potential reversible causes in the hypothalamus-pituitary axis. Also, it is critical to understand the pitfalls of testosterone testing. When clinically indicated, evaluation of other pituitary hormone functions as well as pituitary magnetic resonance imaging may be necessary. Furthermore, it is essential to recognize that pituitary incidentalomas are common. Patients with microprolactinoma are more likely to present with symptoms of sexual dysfunction while those with macroprolactinoma are more likely to present with symptoms of mass effect. Some functional pituitary tumors respond to drug therapy while other nonfunctional tumors require surgical intervention. It is important for the clinician to understand the proper work-up of the hypogonadal patient with pituitary dysfunction and when necessary to refer to an endocrinologist or a neurosurgeon.

Simultaneous Resection of Pituitary Macroadenoma and Sphenoid Sinus Inverted Papilloma: The Challenge of Operating Sinonasal and Skull Base Pathologies Through a Single-Stage Endoscopic Endonasal Approach

BACKGROUND

Coexistence of sinonasal and skull base tumors is uncommon but possible, and the endonasal route seems to be the best option to manage both lesions simultaneously. We report the first case in the English literature of concomitant sphenoid sinus inverted papilloma and pituitary macroadenoma treated through an endoscopic endonasal approach.

CASE DESCRIPTION

A 68-year-old man presented with a history of progressive visual loss and nasal obstruction. Clinical examination disclosed bitemporal hemianopsia. Computed tomography scan and magnetic resonance imaging obtained on admission showed a large sellar/suprasellar enhancing lesion with a marked mass effect on the optic chiasm. Imaging also showed a second mass extending from the sphenoid sinus to the left nasal cavity with obstruction of the maxillary sinus ostium and development of maxillary sinus mucocele. Both tumors were entirely resected by an endoscopic endonasal approach. Additionally, middle meatal antrostomy and marsupialization with drainage of the maxillary mucocele was performed. Biopsy confirmed the coexistence of a pituitary macroadenoma and sphenoid sinus inverted papilloma.

CONCLUSIONS

This case and the literature suggest that patients with concomitant nasal and skull base pathologies can be simultaneously managed. The otolaryngologist plays an essential role in removing the sinonasal lesion to ensure a safe surgical corridor before entering the intracranial cavity and for planning for the skull base reconstruction.

Pituitary macroadenoma presenting as severe hyponatremia: a case report

Background

Hyponatremia is defined as a serum sodium level of less than 135 mEq/L in a patient. Although hyponatremia is not an uncommon laboratory finding, especially in the elderly, hunting for the etiology is a challenging issue for any clinician. The three first-line investigations that are required for further analysis are urine osmolality, serum osmolality, and urinary sodium levels in addition to clinical assessment of volume status.

Case presentation

A 69-year-old previously well Sinhalese man presented with lethargy, loss of appetite, vomiting, and altered behavior of 1 week’s duration. An examination revealed Glasgow Coma Scale of 13/15 and marginally low blood pressure. Initial serum sodium level was 104 mmol/L, and plasma and urinary osmolalities were 251 mOsm/kg and 305 mOsm/kg, respectively. His urinary sodium level of 158 mmol/L was suggestive of a clinical picture of a syndrome of inappropriate secretion of antidiuretic hormone. Even after correction of hyponatremia with intravenously administered 3% saline, a persistent altered behavior necessitated cerebral imaging that confirmed the presence of pituitary macroadenoma. Meanwhile, his hormone profile showed very low serum cortisol and low free tetraiodothyronine levels. An ultrasound scan of his abdomen affirmed the presence of normal adrenal glands. With intravenously administered hydrocortisone and orally administered levothyroxine replacement, he showed marked clinical improvement that supported the diagnosis of hypopituitarism.

Conclusion

Hyponatremia in the elderly is not an uncommon presentation. However, etiological diagnosis is a challenging task as there are multiple overlapping differential diagnoses.

MR textural analysis on contrast enhanced 3D-SPACE images in assessment of consistency of pituitary macroadenoma

OBJECTIVES

To explore the value of magnetic resonance textural analysis (MRTA) in assessing consistency of pituitary macroadenoma (PMA) based on contrast enhanced (CE) three-dimensional sampling perfection with application-optimized contrasts by using different flip angle evolution (3D-SPACE) images.

MATERIALS AND METHODS

Fifty-three patients with PMAs that underwent CE 3D-SPACE scanning by 3.0 T MRI and endoscopic trans-sphenoidal surgery were included in the present study. Consistency levels of PMAs were evaluated intraoperatively by two neurosurgeons. Each resection specimen was stained with H&E and anti-collagen IV. MRTA was conducted and texture features were calculated. An unpaired t-test was used to analyze the differences of texture features between soft and hard PMAs. ROC curves by individual and combined features were used to calculate the diagnostic accuracy of MRTA in predicting PMA consistency.

RESULTS

First-order energy and second-order correlation negatively correlated with hard PMAs, while first-order entropy and second-order variance, sum variance, and sum entropy positively correlated with stiffness. All showed significant differences between soft and hard PMAs (P < 0.05). Diagnostic accuracy of combined negative features could achieve an AUC of 0.819, sensitivity of 88.9%, specificity of 61.5%, PPV of 70.6%, NPV of 84.2% and positive features could achieve an AUC of 0.836, sensitivity of 85.2%, specificity of 69.2%, PPV of 74.2%, NPV of 81.8% (P < 0.001).

CONCLUSION

MRTA using CE 3D-SPACE images is helpful for assessing PMA consistency preoperatively and noninvasively.

Pituicytoma with Significant Tumor Vascularity Mimicking Pituitary Macroadenoma

A 19-year-old man presented with bitemporal hemianopsia and was found to have a large sellar and suprasellar tumor, resembling a pituitary macroadenoma. Emergency transsphenoidal approach was attempted because of rapid visual deterioration with headache. However, the approach was complicated and stopped by uncontrolled hemorrhage from the tumor. After conventional cerebral angiography and recognition of an unusual pathology, transcranial approach was achieved to prevent permanent visual loss. The final pathological diagnosis was pituicytoma with epithelioid features. Pituicytoma is a rare low-grade tumor (WHO Grade I) of pituicytes involving the sellar and suprasellar region, and originating from special glial cells of the neurohypophysis. Because of the high vascularity, the firm consistency, and invasion to surrounding neurovascular structures, a pituicytoma should be included in the differential diagnosis of a mass in the sellar and suprasellar area if the tumor shows high enhancement with vascular components. We report a case of rare pituicytoma mimicking a pituitary macroadenoma with massive hemorrhage to disturb surgery.

Predictive role of dynamic contrast enhanced T1-weighted MR sequences in pre-surgical evaluation of macroadenomas consistency

PURPOSE

Our hypothesis was that pituitary macroadenomas show different areas of consistency detectable by enhanced magnetic resonance imaging (MRI) with Dynamic study during gadolinium administration.

MATERIALS AND METHODS

We analysed 21 patients with pituitary macroadenomas between June 2013 and June 2015. All patients underwent trans-sphenoidal surgery and neurosurgeon described macroadenomas consistency. Similarly, two neuroradiologists manually drew regions of interest (ROIs) inside the solid-appearing portions of macroadenoma and in the normal white matter both on dynamic and post-contrast acquisitions. The ratio between these ROIs, defined as Signal Intensity Ratio (SIR), allowed obtaining signal intensity curves over time on dynamic acquisition and a single value on post-contrast MRI. SIR values best differentiating solid from soft macroadenoma components were calculated and correlated with pathologic patterns. A two-sample T test and empiric receiver operating characteristic (ROC) curve of SIR was performed.

RESULTS

According to ROC analysis, the SIR value of 1.92, obtained by dynamic acquisition, best distinguished soft and hard components. All the specimens from soft components were characterized by high cellularity, high representation of vascularization and micro-haemorrhage and low percentage of collagen content. The reverse was evident in hard components.

CONCLUSIONS

We demonstrated that dynamic MRI acquisition could distinguish with good accuracy macroadenomas consistency.

Radiotherapy with concurrent temozolomide for the management of extraneural metastases in pituitary carcinoma

BACKGROUND

Pituitary carcinomas (PC) are uncommon neuroendocrine tumors, accounting for 0.1 % of all pituitary tumors. The diagnosis of PC is based on the presence of metastases from a pituitary adenoma, and not by local invasion or pathological features alone. PC is typically resistant to therapy, with a median overall survival of only 31 months. There is no standard treatment for PC, but maximal safe resection and radiation are performed when possible. Encouraging preliminary data on the use of temozolomide (TMZ)-based therapy has been previously reported.

METHODS

We report the response to therapy and safety of radiation with concurrent temozolomide (RT/TMZ) in 2 adult patients with heavily pretreated PC and extraneural metastases.

RESULTS

Both patients had prior history of pituitary macroadenoma. At the time of diagnosis of PC, Ki-67 % was 24.2 and 10 %, with positive p53 staining in one case. Metastatic sites included lymph nodes, liver and bone. Case-1 received RT/TMZ to the tumor bed in the skull base and to the metastases in the cervical lymph nodes. Case-2 received RT/TMZ to recurrent tumor involving portacaval lymph nodes. Both patients achieved excellent long-term control of the sites of treated extraneural metastases, with no significant acute or delayed toxicity.

CONCLUSIONS

RT/TMZ was safely delivered and might provide sustained control of extraneural metastases in PC. Although this retrospective report has limitations, RT/TMZ can be considered as a therapeutic option for the management of extraneural metastases in PC.

Magnetic resonance elastography detects tumoral consistency in pituitary macroadenomas

INTRODUCTION

Most pituitary macroadenomas (PMA) are soft and suckable allowing transsphenoidal resection. A small percentage of PMA are firm, which significantly alters the time, technical difficulty, and effectiveness of transsphenoidal surgery. No current imaging technology can reliably assess PMA viscoelastic consistency in preparation for surgery. Magnetic resonance elastography (MRE) is an MRI-based technique that measures the propagation of mechanically induced shear waves through tissue to calculate stiffness. We prospectively evaluated MRE in 10 patients undergoing transsphenoidal resection of PMA to determine feasibility and potential usefulness.

METHODS

10 patients with PMA > 2.0 cm in maximum diameter were prospectively imaged with MRE prior to transsphenoidal surgery. Mean patient age was 59.5 ± 16.2 (22-78) years. Five were female and five male. MRE was performed with a modified single-shot spin-echo echo-planar-imaging pulse sequence on a 3T MRI. MRE values were independently calculated. The surgeon, blinded to the MRE results, graded tumor consistency at surgery as soft, intermediate, or firm. Chi-squared test compared surgical grading and MRE stiffness values.

RESULTS

MRE was accomplished in all patients with excellent resolution. By surgical categorization, six tumors were soft and four intermediate. The mean MRE value for soft tumors was 1.38 ± 0.36 (1.08-1.87) kPa, while for intermediate tumors it was 1.94 ± 0.26 (1.72-2.32) kPa (p = 0.020).

CONCLUSION

Determination of PMA stiffness is feasible with MRE. There was a statistically significant difference in MRE values between soft and intermediate PMAs. Further study in a larger series is ongoing to determine whether MRE will prove useful in preoperative planning for PMA.

Pure Intrasellar Meningioma Mimicking Pituitary Macroadenoma: Magnetic Resonance Imaging and Review of the Literature

Intrasellar meningioma originating from the sellar floor is extremely rare and is often indistinguishable from pituitary macroadenoma, both clinically and radiologically. Here, we report a case involving a 68-year-old patient with intrasellar meningioma possibly originating from the sellar floor and present a brief review of all previous cases reported in the English literature.

Splitting of the Optic Nerve by a Pituitary Macroadenoma

BACKGROUND

Splitting of the optic nerve by a pituitary adenoma is an extremely unusual condition with only 3 cases reported to date.

CASE DESCRIPTION

A 41-year-old woman presented with visual loss as a result of an aggressive pituitary macroadenoma causing the splitting of the right optic nerve. Possible mechanisms of this condition are discussed, and the literature is reviewed.

CONCLUSIONS

In aneurysm and tumor cases, awareness of the exact anatomy is particularly important to preserve function. An overlooked duplication or penetration of cranial nerves may result in inadvertent injury to important structures and loss of function.

Preoperative somatostatin analogs treatment in acromegalic patients with macroadenomas. A meta-analysis

BACKGROUND

Several studies have investigated the biochemical remission rate of presurgical somatostatin analogs treatment on acromegaly, but the remission criteria were diversed and the results were contradicting.

OBJECTIVE

Aim of this paper is to provide enhanced evidence for the effectiveness of preoperative SSA treatment to improve on surgical results of macroadenomas in acromegaly.

DATA SOURCE

Literature is cited from the PubMed, Embase and Cochrane Library, dating from December, 1985 to August, 2013.

STUDY ELIGIBILITY CRITERIA

Eligibility criteria included patients with acromegaly caused by GH-secreting pituitary macroadenomas, patients pretreated with somatostatin analogs versus direct surgery and a stricter remission criteria defined as the GH nadir<1μg/l during an oral glucose tolerance test (OGTT) and the age- and sex- adjusted IGF-1 concentration was normal. Primary end points included Short term and long term postoperative biochemical remission.

STUDY APPRAISAL AND SYNTHESIS METHODS

A total of 1421 publications were found by the electronic search. After full-text review, 8 were included in our study. 7 of them focus on the postoperative remission in short term; 3 of them focus on the outcomes in long term. For the analysis of the postoperative biochemical remission, a random effect model was used to account for differences.

RESULTS

The meta analysis shows that patients in the SSA pretreatment groups have had a more significantly cure rate than those in the direct surgery groups (RR=1.72, 95%CI: 1.14-2.60, P=0.009) with a short term follow-up. Subgroup analysis proves benefit from lanreotide pretreated groups (RR=2.27, 95%CI: 1.34-3.84, P=0.002) but not octreotide pretreated groups (RR=1.51, 95%CI: 0.82-2.75, P=0.183). No significant differences appeared between the two groups (RR=1.03, 95%CI: 0.86-1.24, P=0.751) with a long term follow-up.

LIMITATIONS

2 Retrospective trial was included and most of the trials included was designed as single-center study.

CONCLUSIONS

Based on the analysis of this paper, the preoperative SSA treatment was beneficial in the group with short-term follow-up, while it was not advantageous in the group with long-term follow-up. For the limitations in this study, to drawn more solid conclusions, further large, randomized, multi-center, and long-term follow-up trials were required.

Large intracranial aneurysm after transsphenoidal surgery for pituitary macroadenoma

Uncontrolled cerebrospinal fluid (CSF) leakage after transsphenoidal surgery (TSS) for pituitary adenoma can lead to meningitis. Intracranial mycotic pseudoaneurysm is a rare complication in central nervous system infection. Large single pseudoaneurysm is more uncommon. Most mycotic aneurysms occur due to endocarditis. The present patient had no heart problem and was infected by CSF leakage after transsphenoidal surgery. We present a case of large ruptured mycotic pseudoaneurysm as a complication of cerebral infection after TSS for pituitary macroadenoma.

Non-functioning pituitary macroadenomas: Benefit from early growth hormone substitution after surgery

PURPOSE

Data suggests that substitution of GH in GH-deficient patients may improve quality-of-life and reduce insufficiency-associated-symptoms. Unlike in corticotroph, thyreotroph, or gonadotroph-insufficiency, GH-substitution is usually not started within the first 6-12months after surgery. We aimed to investigate the effect of early-GH-substitution on body-composition, metabolic and pituitary-laboratory-tests, and quality-of-life.

METHODS

Data was reviewed from 21 adult-patients who were diagnosed with insufficiency of GH-axis using insulin-hypoglycemia-test. We retrospectively assessed body-composition, metabolic and pituitary-laboratory-tests and quality-of-life for a period of 52-weeks after pituitary-surgery in patients with early GH-substitution (= treated-group, 11-patients) and no GH-substitution (= untreated group, 10-patients).

RESULTS

Follow-up-IGF-I-levels of the treated-group stayed within the normal range and differed significantly from the untreated-group. Bioelectrical-impedance-analysis showed a significant decrease of impedance, a significant increase of lean-body-mass and a significant difference in health status in the treated group (p<0.05). Average increase in HDL-level was 2.1mg/dl in the untreated compared to an average decrease of 0.2mg/dl in the treated-group. Lp(a)-levels were reduced by 4.1mg/dl in the treated and by 2.7mg/dl in the untreated-group. Both groups showed an initial-mean-life-satisfaction below average (-0.9 and -1.2). Within one year after surgery mean-health-status improved in both groups. The difference in health-status after 1-year compared to the health-status of the previous year was statistically different between both groups with a greater benefit in the treated-group. Finally there was a trend detectably pointing towards an improvement in pituitary-function (LH- and FSH-recovery) if GH was substituted.

CONCLUSION

Early GH-substitution leads to a significant improvement in quality-of-life and body-composition after pituitary-surgery. It is possible that pituitary-function recovers more with early-GH-substitution.

The volume of tumor mass and visual field defect in patients with pituitary macroadenoma

PURPOSE

We used the Swedish interactive threshold algorithms (SITA) standard strategy of Humphrey perimetry, to analyze the pattern of visual field (VF) defects and evaluate the quantitative correlation between the tumor volume and severity of VF defects in patients with pituitary macroadenoma.

METHODS

We reviewed 50 patients with pituitary macroadenoma who received VF test and 11 patients were excluded. VF analysis was performed with Humphrey perimeter using the SITA standard strategy. The tumor volume was assessed radiologically via brain magnetic resonance images and was calculated using Cavalieri's principle. We used the mean deviation (MD) and pattern standard deviation (PSD) of the Humphrey parameter to measure VF defect severity, and then analyzed the correlation of tumor volume with VF defects.

RESULTS

Twenty nine patients (74%) showed abnormal VF and bitemporal field changes, which were the most common field defects on presentation. Seven patients (18%) had unilateral VF defects, 22 patients (56%) had bilateral VF defects. The tumor volume of the patients with VF defects was significantly larger than that of patients with normal VF (p = 0.006). The tumor volume exhibited significant negative correlation with MD (r = -0.693; p < 0.001) and significant positive correlation with PSD (r = 0.589; p < 0.001).

CONCLUSIONS

In patients with pituitary macroadenoma, there was a variety of VF defects and a high correlation between the tumor volume and the severity of VF defects. SITA standard strategy can be a fast and quantitative method for evaluating central VF defects.