Granular Cell Tumor and Spindle Cell Oncocytoma of the Pituitary Gland: Imaging and Intraoperative Cytology Diagnostic Dilemmas and Management Challenges

2021 ◽  
Author(s):  
Sandeep Kandregula ◽  
Abhinith Shashidhar ◽  
Shilpa Rao ◽  
Manish Beniwal ◽  
Dhaval Shukla ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Gland ◽  
Vision Loss ◽  
Spindle Cell ◽  
Pituitary Tumors ◽  
Granular Cell ◽  
Preoperative Imaging ◽  
Posterior Pituitary ◽  
Intraoperative Cytology ◽  
Transcranial Approach

Abstract Background Tumors arising from the posterior pituitary gland are rare and closely resemble pituitary adenoma in presentation and imaging. Most of them come as a histopathologic surprise. We have analyzed the posterior pituitary tumors managed in our institute and have discussed the dilemmas in imaging, challenges in intraoperative squash cytology, and surgical management. Methods We retrospectively reviewed our operative database of pituitary tumors over the past 10 years, which included five posterior pituitary tumors (three granular cell tumors [GCTs] and two spindle cell oncocytomas [SCOs]). Clinical, imaging, and endocrine characteristics; intraoperative details; histopathologic features; and postoperative outcomes were collected and analyzed. Results The mean age of the patients was 47 years. All patients presented with varying degrees of vision loss. Radiology revealed a sellar / suprasellar lesion with the pituitary gland seen separately in two of three GCTs, whereas a separate pituitary gland could not be identified in both the SCOs. Pituitary adenoma was a radiologic diagnosis in only two of five cases. Three patients underwent a transsphenoidal surgery, whereas two underwent surgery by the transcranial approach. Intraoperative cytology was challenging, though a possibility of posterior pituitary tumor was considered in three of four cases, whereas one was considered meningioma. All the tumors were very vascular and influenced the extent of resection. Conclusions GCTs and SCOs are relatively uncommon tumors that are difficult to diagnose on preoperative imaging. Intraoperative squash cytology too can pose challenges. A preoperative suspicion can prepare the surgeon for surgery of these hypervascular tumors. The transcranial approach may be necessary in cases of uncertainty in imaging.

scholarly journals Pituitary spindle cell oncocytoma: illustrative case

2021 ◽  
Vol 2 (14) ◽  
Author(s):  
Taha M. Taka ◽  
Chen Yi Yang ◽  
Joshua N. Limbo ◽  
Alvin Y. Chan ◽  
Jordan Davies ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Spindle Cell ◽  
Pituitary Tumors ◽  
World Health ◽  
Preoperative Imaging ◽  
Illustrative Case ◽  
Structure Damage ◽  
Secondary Hypothyroidism ◽  
Increased Risk ◽  
Spindle Cell Oncocytoma

BACKGROUND Spindle cell oncocytoma (SCO) of the pituitary gland is an extremely rare nonfunctional World Health Organization grade I tumor. SCOs are often misdiagnosed as nonfunctional pituitary adenomas on the basis of preoperative imaging. They are often hypervascular and locally adherent, which increases hemorrhage risk and limits resection, leading to increased risk of recurrence. The authors report a case of SCO treated at their institution and provide a review of the current literature. OBSERVATIONS SCO of the pituitary gland can be a rare cause of progressively growing pituitary tumors that presents similarly to nonfunctional pituitary adenoma. Endoscopic transsphenoidal resection of the tumor by a multidisciplinary team allowed total resection despite local adherence of the tumor. Postoperatively, the patient’s visual symptoms improved with persistence of secondary adrenal insufficiency and secondary hypothyroidism. LESSONS Careful resection is needed due to SCO’s characteristic hypervascularity and strong adherence to minimize local structure damage. Long-term follow-up is recommended due to the tendency for recurrence.

scholarly journals Clinical-Pathological, Immunohistochemical, and Genetic Characterization of a Series of Posterior Pituitary Tumors

2020 ◽  
Vol 80 (1) ◽  
pp. 45-51
Author(s):  
Valeria Barresi ◽  
Michele Simbolo ◽  
Marco Gessi ◽  
Sabrina Rossi ◽  
Maria Caffo ◽  
...  
Keyword(s):  
Loss Of Heterozygosity ◽  
Pituitary Tumors ◽  
Granular Cell ◽  
Genetic Alterations ◽  
Homozygous Deletion ◽  
Posterior Pituitary ◽  
Chromosome 1P ◽  
Genetic Features ◽  
Older Subjects

Abstract Posterior pituitary tumors are supposed to represent the morphological spectrum of a single entity. Herein, we report the clinical-pathological, immunohistochemical, and genetic features of 5 spindle cell oncocytomas (SCOs), 3 pituicytomas, and 1 granular cell tumor (GCT). SCOs had the highest local invasiveness and affected older subjects. The 3 histotypes differed in the content of spindle cells (predominant in pituicytoma and absent in GCT), presence of lymphocytic infiltrate (in SCO and GCT, but not in the pituicytoma) and EMA/GFAP staining (negative in GCT; EMA-positive/GFAP-negative in 4/5 SCO and GFAP-positive in 3/3 pituicytomas). Three SCOs and 1 pituicytoma analyzed with next-generation sequencing had no mutations in 409 genes. However, 1 SCO had previously unreported homozygous deletion of CDKN2A/B and another of SMARCA4, SMARCB1, and NF2. All 3 SCOs had loss of heterozygosity of chromosome 1p, while the pituicytoma had chromosome 19 homozygous loss and chromosomes 10, 13q, and 18q loss of heterozygosity. Since 1p and 13q losses were previously reported in 1 pituicytoma and 1 SCO, respectively, our data demonstrate that posterior pituitary tumors share common genetic alterations. The possibility that posterior pituitary tumors are SMARCA4/SMARCB1-deficient should be kept in mind in the differential diagnosis toward other entities.

Cushing’s disease due to mixed pituitary adenoma-gangliocytoma of the posterior pituitary gland presenting with Aspergillus sp. sinus infection

2013 ◽  
Vol 32 (09) ◽  
pp. 377-383 ◽  
Author(s):  
Mark Bridenstine ◽  
Janice M. Kerr ◽  
Kevin O. Lillehei ◽  
Bette K. Kleinschmidt-DeMasters
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Gland ◽  
Posterior Pituitary ◽  
Sinus Infection ◽  
Posterior Pituitary Gland ◽  
Aspergillus Sp

scholarly journals Endoscopic Endonasal Transoculomotor Triangle Approach for the Resection of a Pituitary Adenoma with Ambient Cistern Extension

2018 ◽  
Vol 79 (S 03) ◽  
pp. S283-S283
Author(s):  
Georgios Zenonos ◽  
Eric Wang ◽  
Juan Fernandez-Miranda
Keyword(s):  
Pituitary Adenoma ◽  
Clinical Outcome ◽  
Outcome Measures ◽  
Vision Loss ◽  
Pituitary Tumors ◽  
Recurrence Free Survival ◽  
Endoscopic Endonasal ◽  
Free Survival ◽  
Ambient Cistern

Objectives The current video presents the nuances of the endoscopic endonasal transoculomotor triangle approach for the resection of a pituitary adenoma with extension into the ambient cistern. Design The video analyzes the presentation, preoperative workup and imaging, surgical steps and technical nuances of the surgery, the clinical outcome, and follow-up imaging. Setting The patient was treated by a skull base team consisting of a neurosurgeon and an ENT surgeon at a teaching academic institution. Participants The case refers to a 62-year-old female who presented with vision loss and headaches, and was found to have a pituitary adenoma with extension into the ambient cistern. Main Outcome Measures The main outcome measures consist of the reversal of the patient symptoms (headaches), the recurrence-free survival based on imaging, as well as the absence of any complications. Results The patient's headaches improved. There was no evidence of recurrence. Conclusions The endoscopic endonasal transoculomotor triangle approach is safe and effective for addressing pituitary tumors which extend into the ambient cistern.The link to the video can be found at: https://youtu.be/EBLwEWhohxY.

scholarly journals Genetic and epigenetic characterization of posterior pituitary tumors

2021 ◽  
Author(s):  
Simone Schmid ◽  
David A. Solomon ◽  
Eilis Perez ◽  
Anne Thieme ◽  
Bette K. Kleinschmidt-DeMasters ◽  
...  
Keyword(s):  
Dna Methylation ◽  
Copy Number ◽  
Pituitary Tumors ◽  
Granular Cell ◽  
Genetic Alterations ◽  
Outcome Analysis ◽  
Posterior Pituitary ◽  
Single Entity ◽  
Molecular Features ◽  
Favorable Group

AbstractPituicytoma (PITUI), granular cell tumor (GCT), and spindle cell oncocytoma (SCO) are rare tumors of the posterior pituitary. Histologically, they may be challenging to distinguish and have been proposed to represent a histological spectrum of a single entity. We performed targeted next-generation sequencing, DNA methylation profiling, and copy number analysis on 47 tumors (14 PITUI; 12 GCT; 21 SCO) to investigate molecular features and explore possibilities of clinically meaningful tumor subclassification. We detected two main epigenomic subgroups by unsupervised clustering of DNA methylation data, though the overall methylation differences were subtle. The largest group (n = 23) contained most PITUIs and a subset of SCOs and was enriched for pathogenic mutations within genes in the MAPK/PI3K pathways (12/17 [71%] of sequenced tumors: FGFR1 (3), HRAS (3), BRAF (2), NF1 (2), CBL (1), MAP2K2 (1), PTEN (1)) and two with accompanying TERT promoter mutation. The second group (n = 16) contained most GCTs and a subset of SCOs, all of which mostly lacked identifiable genetic drivers. Outcome analysis demonstrated that the presence of chromosomal imbalances was significantly associated with reduced progression-free survival especially within the combined PITUI and SCO group (p = 0.031). In summary, we observed only subtle DNA methylation differences between posterior pituitary tumors, indicating that these tumors may be best classified as subtypes of a single entity. Nevertheless, our data indicate differences in mutation patterns and clinical outcome. For a clinically meaningful subclassification, we propose a combined histo-molecular approach into three subtypes: one subtype is defined by granular cell histology, scarcity of identifiable oncogenic mutations, and favorable outcome. The other two subtypes have either SCO or PITUI histology but are segregated by chromosomal copy number profile into a favorable group (no copy number changes) and a less favorable group (copy number imbalances present). Both of the latter groups have recurrent MAPK/PI3K genetic alterations that represent potential therapeutic targets.

scholarly journals PATH-36. SYNCHRONOUS TTF-1-POSITIVE TUMORS AND PITUITARY ADENOMAS. ARE WE SENDING INSUFFICIENT TUMOR TISSUE FOR PATHOLOGY?

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii172-ii172
Author(s):  
Franco Rubino ◽  
Daniel Eichberg ◽  
Ashish shah ◽  
Evan Luther ◽  
Victor Lu ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Tumor ◽  
Cushing Syndrome ◽  
Case Reports ◽  
Case Series ◽  
Pituitary Tumors ◽  
World Health ◽  
Low Grade ◽  
Posterior Pituitary ◽  
Female Ratio

Abstract BACKGROUND Tumors of the posterior pituitary are a distinct group of low-grade neoplasms arising from the sellar region. According to the most recent World Health Organization (WHO) guidelines, these tumors are grouped based on TTF-1 immunostain positivity. The coexistence of a posterior and anterior pituitary tumors is statistically extremely unlikely. OBJECTIVE In this study, we present a case of a 41-year-old woman suffering from Cushing syndrome with the presence of two pituitary masses on MRI. Also, the relevant literature is systematically reviewed. METHODS Two databases (PubMed and Google Scholar) and crossed references were systematically reviewed for TTF-1 pituitary tumors with coexisting pituitary adenoma or increased pituitary serum hormone levels. A literature review was performed according to PRISMA guidelines. Also, one patient from our institution is reported. Data regarding demographic features, type of anterior and posterior pituitary tumor, clinical features of the patients and lab results, MRI findings, and pathology results were extracted. RESULTS Seventeen retrospective case reports and case series were identified and included. Twenty-four patients were analyzed (including the reported case). The mean age was 46 ± 16 years, with a male-to-female ratio of 0.33:1. Pituicytomas and granular cell tumors were the only posterior pituitary tumors reported in 19 (79%) and 5 (21%) cases, respectively. There are only eight cases reported (including our patient) with a confirmed pituitary adenoma and a TTF-1 pituitary tumor (one GCT with GH-secreting adenoma, five pituicytoma with ACTH-secreting adenoma, one with GH-secreting adenoma and one with a null type adenoma). CONCLUSION We presented the eighth reported case of a TTF-1 pituitary tumor coexisting with a pituitary adenoma. We think that improving the amount of the tissue specimen available for pathology evaluation could increase the incidence of these very rare tumors.

Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors

2006 ◽  
Vol 104 (1) ◽  
pp. 7-19 ◽  
Author(s):  
Edward H. Oldfield ◽  
Alexander O. Vortmeyer
Keyword(s):  
Pituitary Gland ◽  
Surgical Techniques ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Surrounding Tissue ◽  
Maximum Diameter ◽  
Preoperative Imaging ◽  
Tumor Diameter ◽  
Cushing Disease ◽  
Pituitary Glands

Object The presence of a histological pseudocapsule around pituitary tumors was noted in the early 1900s. Since that time there has been no emphasis on the sequence of the stages of its development or on the relationship between these stages and the capacity to identify very small pituitary tumors at surgery in patients in whom preoperative imaging has been nondiagnostic. In addition, limited emphasis has been given to the pseudocapsule’s use for selective and complete resection of pituitary adenomas. Methods The development of the pseudocapsule was examined by performing histological analysis of portions of pituitary glands removed during 805 operations for Cushing disease. Twenty-five adenomas, each measuring between 0.25 and 4 mm in maximum diameter, were detected in the excised specimens; 17 were adenocorticotropic hormone–positive adenomas and eight were incidental tumors (four prolactin-secreting and four nonsecreting lesions). In 16 tumors the size of the adenoma could be established. The distribution of tumor size in relation to the presence of a histological pseudocapsule indicates a transition from the absence of a reticulin capsule (tumor diameter ≤ 1 mm) through the initial compression of surrounding tissue (tumor diameter 1–2 mm) to the presence of a multilayered reticulin capsule observed when adenomas become larger (tumor diameter 2–3 mm). Conclusions The absence of a reticulin capsule in cases of very small tumors may contribute to limited localization of these lesions during surgical exploration of the pituitary gland. In this article the authors describe surgical techniques in which the histological pseudocapsule is used as a surgical capsule during pituitary surgery. In their experience, recognition of this surgical capsule and its use at surgery has contributed to the identification of microadenomas buried in the pituitary gland, aided the recognition of subtle invasion of the pituitary capsule and contiguous dura mater, and enhanced the consistency of complete tumor excision with small and large tumors.

scholarly journals Comparing Mononostril, Binostril, and One and a Half Nostril Endoscopic Transsphenoidal Approach for Treating Pituitary AdenomaPituitary Adenoma

2021 ◽  
Vol 7 (1) ◽  
pp. 15-22
Author(s):  
Shahrokh Yousefzadeh-Chabok ◽  
◽  
Guive Sharifi ◽  
Mohammad Ghorbani ◽  
Mohammad Samadian ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Tumors ◽  
Surgical Instruments ◽  
Transsphenoidal Approach ◽  
Endoscopic Endonasal ◽  
Minimal Invasiveness ◽  
Transcranial Approach ◽  
Surgical Field ◽  
Surgical Corridor ◽  
Suprasellar Extension

Background and Aim: EETA (Endoscopic Endonasal Transsphenoidal Approach) is a preferred choice for pituitary tumors. EETA offers minimal invasiveness, fewer complications, and better outcomes than the sublabial or transseptal microscopic approach. EETA has three approaches: mononostril endoscopic transsphenoidal approach, binostril endoscopic transsphenoidal approach, and one and a half nostril approach. This study aims to compare three different EETAs and compare between microscopic transsphenoidal approach, transcranial approach and EETA. Methods and Materials/Patients: To provide up-to-date information, we concisely reviewed these three EETAs. Using the keywords of “neuroendoscopy”, “META” (Mononostril Endoscopic Transsphenoidal Approach), “OETA” (One and a half nostril Approach), “BETA” (Binostril Endoscopic Transsphenoidal Approach), “pituitary adenoma”, “EETA”, “endoscopy”, “transsphenoidal approach”, “transcranial approach for pituitary adenoma” and “microscopic transsphenoidal approach”. We retrieved all the relevant articles from Google Scholar, PubMed, and Medline. Then, we reviewed them and critically analyzed them. Results: In BETA there is free and easy movement of surgical instruments in the surgical field and a broader view of the sphenoid sinus and it is an excellent approach to resect large tumors. The META is suitable in tumors with limited involvement of the intra-sellar and supra-sellar area. The mononostril approach is not suitable and has some limitations for the following situations: a crowded narrow nasal cavity, a harder tumor with the invasive appearance or significant suprasellar extension, and lesions other than pituitary adenomas. The OETA provides a sufficient surgical corridor for a 2-surgeon/4 or 3-hands technique with a minimal injury of the nose and good operative results, free and easy movement of surgical instruments in the surgical field, low post-operative morbidity, and good post-operative quality of life. Conclusion: In EETA, knowing the size and consistency of tumor, general versus invasive pituitary adenoma, and the extent of parasellar and suprasellar extension, is essential. If we cannot reach a pituitary macroadenoma with a trans-sphenoidal approach, then we can use a transcranial approach for the removal of the tumor. The microscopic transsphenoidal approach is suitable for pediatric pituitary adenoma

Hypophysial transposition (hypophysopexy) for radiosurgical treatment of pituitary tumors involving the cavernous sinus

2003 ◽  
Vol 14 (5) ◽  
pp. 1-5 ◽  
Author(s):  
James K. Liu ◽  
Meic H. Schmidt ◽  
Joel D. Macdonald ◽  
Randy L. Jensen ◽  
William T. Couldwell
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Gland ◽  
Radiation Exposure ◽  
Cavernous Sinus ◽  
Tumor Resection ◽  
Pituitary Tumors ◽  
Residual Tumor ◽  
Normal Pituitary Gland ◽  
Fascia Graft ◽  
Normal Functional

Stereotactic radiosurgery (SRS) is performed with increasing frequency in the treatment of residual or recurrent pituitary adenomas. Its major associated risk in these cases of residual or recurrent pituitary tumor adjacent to normal functional pituitary gland is radiation exposure to the pituitary, which frequently leads to the development of hypopituitarism. The authors describe a technique of pituitary transposition to reduce the radiation dose to the normal pituitary gland in cases of planned radiosurgical treatment of residual pituitary adenoma within the cavernous sinus. A sellar exploration for tumor resection is performed, the pituitary gland is transposed from the region of the cavernous sinus, and a fat and fascia graft is interposed between the normal pituitary gland and the residual tumor in the cavernous sinus. The residual tumor may then be treated with SRS. The increased distance between the normal pituitary gland and the residual tumor facilitates treatment of the tumor with radiosurgery and reduces radiation exposure to the normal pituitary gland.

scholarly journals Xanthomatous Hypophysitis Mimicking a Pituitary Adenoma: Case Report and Review of the Literature

2010 ◽  
Vol 2010 ◽  
pp. 1-5 ◽  
Author(s):  
Laura Aste ◽  
Mattia Bellinzona ◽  
Veronica Meleddu ◽  
Graziella Farci ◽  
Cristina Manieli ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Gland ◽  
Diabetes Insipidus ◽  
Correct Diagnosis ◽  
Pituitary Tumors ◽  
Inflammatory Lesion ◽  
Postoperative Recovery ◽  
Cystic Mass ◽  
Uneventful Postoperative Recovery ◽  
High Level

Background. Hypophysitis is an inflammatory disease of the pituitary gland that may mimic pituitary tumors clinically and radiologically.Case Description. We report a case of a xanthomatous hypophysitis initially diagnosed as pituitary adenoma. A 31-year-old woman presented with headache, diabetes insipidus, and amenorrhea. A head CT scan showed no intrasellar changes, while an MRI scan showed a sellar cystic mass. An endocrinological work up revealed mild hypocortisolism and diabetes insipidus (DI). Transsphenoidal surgery was performed. The intraoperative histological examination suggested a pituitary adenoma. The removed tissue showed central necrosis surrounded by accumulation of foamy cells and xanthomatous epithelioid cells. The patient made an uneventful postoperative recovery, Nevertheless, DI persisted and the adenohypophysis hypofunction did not recover.Conclusion. We describe an unusual inflammatory lesion of the pituitary gland mimicking an adenoma. A high level of clinical suspicion of inflammatory disorders is necessary for correct diagnosis and optimal management.

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