A Unilateral Nasal Mass With Generalized Seizures: Potential Diagnostic Pitfalls in Giant Pituitary Adenoma

Giant pituitary adenomas are clinically nonfunctioning adenomas, and the clinical presentation is usually secondary to compression of the neighboring structures. Visual impairment and visual field defect are the most common preoperative symptoms, followed by headache. Generalized seizures may occur in giant pituitary adenomas when there is involvement of frontal lobes or medial temporal lobes. We present a case of a unilateral nasal mass with generalized seizures in a 55-year-old woman without prior episode of seizure and any predisposing factors. Imaging showed a sinonasal tumor with intracranial extension and histopathological examination confirmed a corticotroph adenoma. On seeing a patient with a unilateral nasal mass extending down from the roof of nasal cavity, olfactory neuroblastoma, or meningo-encephalocoele readily comes to mind. To avoid misdiagnosis and delay in treatment, imaging and, if possible, a biopsy should be considered. Giant pituitary adenoma although not common should be thought of as one of the differential diagnosis.

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NCOG-31. GIANT PITUITARY ADENOMA (GPA) SCORE: A NOVEL SCORING SYSTEM TO PREDICT POSTOPERATIVE OUTCOMES OF GIANT PITUITARY ADENOMAS

Neuro-Oncology ◽

10.1093/neuonc/noab196.621 ◽

2021 ◽

Vol 23 (Supplement_6) ◽

pp. vi158-vi158

Author(s):

Syed Ather Enam ◽

Fauzan Alam Hashmi ◽

Sanam Mir Ghazi ◽

Ahsan Ali Khan ◽

Muhammad Bilal Tariq ◽

...

Keyword(s):

Pituitary Adenoma ◽

Linear Regression ◽

Pituitary Adenomas ◽

Scoring System ◽

Tumor Resection ◽

Maximum Diameter ◽

Giant Pituitary Adenoma ◽

Giant Pituitary Adenomas ◽

The Mean ◽

Suprasellar Extension

Abstract BACKGROUND Giant pituitary adenomas (GPA) are uncommon and highly variable in morphology and extension. There is no scoring system that considers all the dimensions of adenoma invasion. We developed a new Giant Pituitary Adenoma score and report our surgical experience and evaluate outcomes after resection of these tumors in accordance with the preoperative score. METHODS We developed a novel scoring system for classifying giant pituitary adenomas, and 11-year data of GPA surgery at our center was collected retrospectively, based on this scoring system. GPA Score considered tumor’s parasellar extension, encasement of cavernous internal carotid artery (ICA), suprasellar extension > 2 cm, suprasellar extension > 4cm and retrosellar extension. Maximum possible score was 9. The scoring system was applied to 53 patients of GPA who underwent surgical resection between January 1, 2006, and December 2017. The Lundin-Pederson (ABC/2) method was used to calculate the tumor volume both pre- and post-resection and linear regression was used to assess the relationship between extent of tumor resection and GPA score. RESULTS The median age of the study population was 42.08 ± 16.49 years. The mean maximum diameter of the pituitary adenomas was 5.0 cm (range 4.0 cm-8.5cm) while the mean volume of the adenomas was 27.3 cm3 (range 10 cm3-149 cm3). There were 3 cases of score 2, 5 cases of score 3, 13 cases of score 4, 20 cases of score 5, 9 cases of score 6 and 3 cases of score 7. The range of tumor volumes of tumors for scores from 2-7 was 17.3 cm3 to 65.8 cm3 and GPA score was correlated with the percent residual tumor using linear regression that was statistically significant (p= 0.001). CONCLUSION GPA Score is a reliable scoring system to predict the extent and subsequent difficulty in tumor resection in GPA.

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Aggressive Cushing disease five years after the treatment of a nonfunctional pituitary adenoma

Problems of Endocrinology ◽

10.14341/probl201662577-78 ◽

2016 ◽

Vol 62 (5) ◽

pp. 77-78

Author(s):

Minodora Betivoiu ◽

Sorina Martin ◽

Iulia Soare ◽

Alexandra Nila ◽

Simona Fica

Keyword(s):

Pituitary Adenoma ◽

Gamma Knife ◽

Pituitary Adenomas ◽

Histopathological Examination ◽

Case Reports ◽

Dependent Diabetes Mellitus ◽

Ki 67 ◽

The Right ◽

Gamma Knife Therapy

Introduction. Cushing's disease (CD) represents 10%–12% of all pituitary adenomas and is seen predominantly in women, with a female-to-male ratio of 8:1. Although most patients with ACTH-secreting adenomas present with benign, small tumors, some have invasive macroadenomas. Rarely, nonfunctional pituitary adenomas (NFPAs) may gain secretory function, but there have been a few case reports of metamorphosis to CD.Case report. We report the case of a 59-year-old female diagnosed in 2007 with a NFPA and panhypopituitarism. She had two transsphenoidal surgeries and Gamma Knife therapy and started replacement treatment with levothyroxine 75mcg/day and prednisone 5mg/day. The postoperative course was favorable and imagistic follow-up between 2007-2014 showed progressive reduction of the residual tumor and empty sella. From personal history we note noninsulin-dependent diabetes mellitus, postmenopausal osteoporosis treated with bisphosphonates. In January 2015 she suffered visual loss on the right eye. Pituitary MRI showed supra and parasellar tumor recurrence of 27/24/17mm, infiltrating the right side of the cavernous sinus, extending around the right internal carotid artery and optic nerve, compressing the optic chiasm. In March 2015 a third transsphenoidal partial excision of the tumor was performed and in August Gamma Knife therapy was repeated. The histopathological examination was consistent with a pituitary adenoma but immunohistochemical staining for ACTH was positive, with Ki-67=25%. She had no non-specific cushingoid features. Laboratory test: glucose=116mg/dl, HbA1c=7.5%, FSH=3.34mIU/ml, LH=0.585mIU/ml TSH=0.044mcIU/ml, FT4=1.13ng/dl. Prednisone replacement therapy was stopped and CD was confirmed: 8AMcortisol=13.3mcg/dl, 23PMcortisol=11.3mcg/dl, ACTH=70.2pg/ml, 8AMcortisol after 1mg dexamethasone overnight=13.8mcg/dl. Ophthalmic exam: blindness in the right eye, slightly decreased visual field in the left eye. Pituitary MRI 8-month postsurgery revealed a 28/31/28mm invasive tumor. We started treatment with Cabergoline 3mg/week and recommended closely biological and imagistic follow-up, hoping for a good response to radiotherapy.Conclusions: Our case stresses the importance of regular, lifelong follow-up of patients with NFPAs. Chiloiro et al have reported that pituitary adenomas with Ki-67≥1.5% have a higher risk of recurrence. Although the characteristics of patients with CD have been well known for decades, the diagnosis and management of this disease are often challenging.

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Double pituitary adenomas in a large surgical series

Pituitary ◽

10.1007/s11102-019-00996-2 ◽

2019 ◽

Vol 22 (6) ◽

pp. 620-632

Author(s):

Grzegorz Zieliński ◽

Emir Ahmed Sajjad ◽

Maria Maksymowicz ◽

Monika Pękul ◽

Andrzej Koziarski

Keyword(s):

Pituitary Adenoma ◽

Cushing’S Disease ◽

Pituitary Adenomas ◽

Clinical Laboratory ◽

Histopathological Examination ◽

Cushing's Disease ◽

Imaging Data ◽

Tertiary Center ◽

Double Pituitary Adenomas ◽

Double Pituitary Adenoma

Abstract Purpose To explore the incidence of double pituitary adenomas in a tertiary center for pituitary surgery and asses their clinical, imaging and histopathological features. Methods The medical records of the patients operated on for pituitary tumors at the Department of Neurosurgery of Military Institute of Medicine in Warsaw, Poland between the years 2003 and 2018 were retrospectively analyzed. Among the 3270 treated patients, the diagnosis of double pituitary adenoma was established in 22 patients. Clinical, laboratory, detailed histopathological and diagnostics imaging data were collected and analyzed. Results There were 21 cases of synchronous and one case of asynchronous double pituitary adenoma. The main clinical finding was acromegaly (12/22) followed by Cushing’s disease (3/22). The diagnosis of synchronous double pituitary adenoma was suspected in the preoperative MRI in 11 patients. In the remaining patients the diagnosis of contiguous double pituitary adenoma was confirmed in the histopathological examination. There was no predilection for gender and the mean observation time was 74.2 months. In one case of Cushing’s disease the occurrence of double pituitary adenoma led to the initial failure of achieving hormonal remission. One patient presented with double pituitary adenomas as a manifestation of Carney complex. Conclusions Double pituitary adenoma is a rare entity that can pose a significant challenge especially in the setting of Cushing’s disease. Careful inspection of preoperative MRI and diagnostic work-up before transsphenoidal surgery and thorough histopathological microscopic examinations with immunohistochemical staining for all pituitary hormones is essential for establishing the diagnosis of double pituitary adenoma.

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Seesaw nystagmus caused by giant pituitary adenoma: case report

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2006000100030 ◽

2006 ◽

Vol 64 (1) ◽

pp. 139-141 ◽

Cited By ~ 3

Author(s):

Frederico Castelo Moura ◽

Allan Christian Pieroni Gonçalves ◽

Mário Luiz Ribeiro Monteiro

Keyword(s):

Pituitary Adenoma ◽

Visual Loss ◽

Rare Occurrence ◽

Resonance Imaging ◽

Large Tumor ◽

Giant Pituitary Adenoma ◽

Cranial Nerve Palsies ◽

Giant Pituitary Adenomas ◽

Endocrine Symptoms ◽

Bitemporal Hemianopia

Giant pituitary adenomas are uncommonly large tumors, greater than 4 cm in size that can produces endocrine symptoms, visual loss and cranial nerve palsies. We report the rare occurrence of seesaw nystagmus as the presenting sign of giant pituitary adenoma. A 50-year-old man presented with headache associated with visual loss and seesaw nystagmus. Perimetry revealed bitemporal hemianopia and magnetic resonance imaging showed a giant pituitary adenoma. After surgery, nystagmus disappeared. Our case is relevant in understanding its pathogenesis since it documents seesaw nystagmus in a patient bitemporal hemianopia due to a large tumor but without mesencephalic compression.

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Nonfunctioning Ectopic Pituitary Adenoma Presenting as Epistaxis: A Report of Two Cases

Otorhinolaryngology Clinics - An International Journal ◽

10.5005/jp-journals-10003-1175 ◽

2014 ◽

Vol 6 (3) ◽

pp. 130-133

Author(s):

Aparna Govindan ◽

Premkumar Sasi ◽

Suma Radhakrishnan ◽

Jacob Paul Alapatt ◽

KP Aravindan

Keyword(s):

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Sphenoid Sinus ◽

Histopathological Examination ◽

Third Ventricle ◽

Correct Diagnosis ◽

Final Diagnosis ◽

Extensive Literature ◽

Ectopic Pituitary Adenoma ◽

Suprasellar Region

ABSTRACT Ectopic pituitary adenomas are uncommon lesions and are found along the migratory pathway of the Rathke's pouch. Sites reported include suprasellar region, clivus, sphenoid sinus, nasopharynx, third ventricle, petrous temporal bone, hypo thalamus, etc. Compared to intrasellar adenomas, a higher proportion of the ectopic examples are functional and most commonly produce adenocorticotropic hormone (ACTH). The authors report two cases of ectopic pituitary adenoma in the sphenoid sinus in two male patients 36 and 40 years old, presenting with epistaxis. Both the patients did not have any endocrine abnor malities. The clinical and imaging findings were suggestive of sinonasal malignancy. The final diagnosis was made after histopathological examination and immunohistochemistry for cytokeratin, chromogranin and pituitary hormones. The diagnosis of ectopic pituitary adenomas is difficult especially in those tumors that are nonfunctioning. After extensive literature search, we could find only six cases of nonfunctioning adenomas reported in the sphenoid sinus and in all these cases the correct diagnosis could be made only by histopathology. How to cite this article Govindan A, Sasi P, Radhakrishnan S, Alapatt JP, Aravindan KP. Nonfunctioning Ectopic Pituitary Adenoma Presenting as Epistaxis: A Report of Two Cases. Int J Otorhinolaryngol Clin 2014;6(3):130133.

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Pituitary Adenomas: Presentations and Outcomes in a South Asian Country

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100008635 ◽

2008 ◽

Vol 35 (2) ◽

pp. 198-203 ◽

Cited By ~ 8

Author(s):

Muhammad Shahzad Shamim ◽

Muhammad Ehsan Bari ◽

Faraz Khursheed ◽

Rashid Jooma ◽

Syed Ather Enam

Keyword(s):

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Hormone Replacement ◽

Tumor Resection ◽

Residual Tumor ◽

Asian Country ◽

Developed Countries ◽

P Value ◽

Tumor Diameter ◽

Giant Pituitary Adenoma

Objective:: The purpose of this retrospective review of all operated cases of pituitary adenomas in the last decade, is to define the demographic patterns and characteristics of such tumors and to assess surgical outcomes with regards to safety and efficacy of trans–sphenoidal tumor removal in our institution.Methods:Surgically treated pituitary adenomas presenting from 1995 till 2005 were reviewed for different variables. Results were expressed as mean, standard deviation and median for continuous and number with percentage for categorical data. Chi square test was applied to measure differences and significance was taken at p value < 0.05.Results:One hundred and twenty–five patients were operated for pituitary adenoma. Sixty–three percent were male and mean age was 37 years. Sixty percent of the patients presented with headache and/or visual symptoms. Twelve percent presented with pituitary apoplexy and 28% presented with symptoms due to pituitary hyperfunction. Fifty–five percent of patients had functioning and 44% had nonfunctioning adenomas. Mean pre operative tumor diameter from 86 pre op MRI scans was 26.76 mm (3–78 mm). Eighty–four percent of patients underwent trans–sphenoidal tumor resection and three percent had craniotomy. Mean size of post op residual tumor as calculated from 76 available post operative scans was 5.3 mm (range 0–31 mm). 17.6% of the patients required hormone replacement beyond three months and 10% were re–operated. Overall mortality was 1.6%.Conclusion:In Pakistan, patients are more likely to present either with apoplexy or with a giant pituitary adenoma than patients reported from developed countries. Overall, our results have been satisfactory and comparable with the literature.

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