Magnetic Resonance Imaging (MRI) Evaluation of Sellar Region Tumors with Histopathological Correlation

MRI is a complex, rapidly evolving modality which has assumed an increasingly important role in the diagnosis of Sellar region tumors. It is now the preferred modality for the definitive evaluation and follow-up of the most sellar region tumors. Using different pulse sequence small lesion can be detected even without contrast. Gd-DTPA provides valuable information in MR imaging sellar region tumors, particularly in pre-operative evaluation. This study was conducted to elucidate the accuracy of MRI in pre-operative evaluation of sellar region tumors and its validity by determining sensitivity, specificity, positive and negative predictive value with histopathological correlation. This cross sectional observational study was carried out in the department of radiology and imaging in collaboration with department of Neurosurgery, Dhaka Medical college Hospital, Dhaka during the period of January 2008 to April 2009. MRI of brain was done on 42 patients referred for evaluation of sellar region tumors. The following result and observation were obtained. The age range of the patient was 20 to 80 years. The mean age (HSE) was 34.31(+2.80). Maximum patients were in age group 20-30 years and male-female ratio was 1.8:1. Most sellar region tumor located in the intrasellar with suprasellar extension. Out of 42 patients 37 (88%) patients were truly diagnosed by MRI as sellar region tumors. The sensitivity of MRI to diagnosed macro adenoma was 81.25%, specificity 80.76%, positive predictive value 72.2%, negative predictive value 87.5%, accuracy 80.95%. This study finds that MRI is a valid imaging modality in the diagnosis of pituitary adenoma and sellar region tumor. Bangladesh Med J. 2020 Sept; 49(3) : 1-10

Pituitary Metastasis of Lung Neuroendocrine Carcinoma Mimicking Pituitary Adenoma:Case Report and Literature Review

Pituitary metastasis is an unusual situation in clinical practice, while the incidence is increasing with age. Breast cancer for women and lung cancer for men were the most frequent primary origins of pituitary metastasis. Diagnosing asymptomatic patients with unknown primary malignant origin is difficult, thus pituitary metastasis may be diagnosed as primary pituitary adenoma. Here, we report a case of a 65-year-old patient with visual changes and diabetes insipidus, showing an extensive mass in the sellar region which was initially thought to be a primary pituitary adenoma. Patient corticotropic deficits were corrected, and transnasal transsphenoidal surgery was adopted, leading to total tumor resection. Tumor texture during surgical procedure was similar to that of pituitary adenoma. However, the histopathological and immunohistochemistry results suggested it as a pituitary metastasis from lung neuroendocrine tumor. Postoperative chest CT scan confirmed a pulmonary mass consistent with primary neoplasm. Abdominal CT further detected multiple metastases in liver, pancreas, and colon. Despite intensive treatment, the patient continued to show decreased level of consciousness due to cachexia, resulting in death 1 week after surgery. This case highlights the importance of differential diagnosis of invasive lesions of the sellar region, especially in individuals over 60 years of age with diabetes insipidus.

Juvenile Xanthogranuloma of the Sellar Region with a 5-Year Medical History: Case Report and Literature Review

<b><i>Introduction:</i></b> Xanthogranuloma of the sellar region is a rare benign lesion, and there are few cases reported in children. Its histogenesis is controversial, and it is difficult to strictly differentiate it from craniopharyngioma (CP), Rathke’s cleft cyst, or pituitary adenoma. <b><i>Case Presentation:</i></b> A 16-year-old boy presented with a rare xanthogranuloma of the sellar region after complaining of retardation of growth 5 years previously. The ophthalmologic evaluation revealed no visual field disturbance. Endocrinological examination revealed hypopituitarism. Magnetic resonance imaging showed an intrasellar mass extending into the suprasellar region and compressing the optic chiasma, which appeared mixed signals on T1-weighted images. Endonasal transsphenoidal resection of the tumor was performed. Histological analysis of the tumor sections demonstrated granulomatous tissue with cholesterol clefts, hemosiderin deposits, fibrous tissues, multinucleated giant cells, and lymphocyte. Thus, the tumor was pathologically diagnosed as xanthogranuloma of the sellar region, which is different from adamantinomatous CP. There was no epithelial tissue in any part of the tumor including tumor capsule but have focal necrosis and calcification. His endocrinological dysfunction did not recover, so a hormonal replacement was continuously required. <b><i>Conclusion:</i></b> Xanthogranuloma of the sellar region is a rare entity but must be considered in the differential diagnosis of lesions of the sellar region, even in pediatric population. We should think about this disease when dealing with children with stunted growth accompanied by a long medical history. Our case demonstrates the natural progression of the disease, suggesting that xanthogranuloma of the sellar region without epithelial components may be an independent disease.

Changes of Peripapillary Region Perfusion in Patients with Chiasmal Compression Caused by Sellar Region Mass

Purpose. To evaluate the peripapillary vessel density (pVD) and the peripapillary nerve fiber layer (pRNFL) thickness in patients with chiasmal compression caused by sellar region mass using optical coherence tomography angiography (OCTA). Methods. This is an observational, cross-sectional study of 31 patients (31 eyes) with chiasmal compression caused by sellar region mass and 34 healthy controls (34 eyes). Automated perimetry and OCTA were performed. The pVD and pRNFL thickness were compared between the two groups. The impact of tumor diameter, duration of symptoms, and cavernous sinus (CS) invasion on visual dysfunction, pVD, and pRNFL thickness was also analyzed. Furthermore, we divided the patients into two subgroups according to whether there was an absolute defect in the central visual field and evaluated their pVD and pRNFL thickness, respectively. Results. Compared to the healthy control group, there was a statistically significant decrease in pVD and pRNFL thickness in patients with chiasmal compression ( p < 0.05 ), especially in patients with substantial absolute defects in the central visual field. Tumor diameter, duration of symptoms, and CS invasion did not appear to be associated with pVD and pRNFL thickness. There was a significant positive correlation between the pVD and pRNFL thickness in patients with chiasmal compression ( p < 0.001 ). Conclusion. pVD and pRNFL thickness are significantly decreased in patients with chiasmal compression revealed by OCTA, especially in patients with more severe visual field defects. A significant correlation between pVD and pRNFL thickness was demonstrated, which provides a clue for the study of the mechanism of changes in retinal perfusion in compressive optic neuropathy. It requires considerable attention that OCTA may play an important role in disease monitoring of sellar region mass. Hence, further studies are needed to verify whether OCTA is helpful to predict the prognosis of visual function after decompression surgery.

Transsphenoidal endoscopic treatment of cysts of the chiasmo-sellar region

Introduction. Cysts of the chiasmo-sellar region include Rathke cleft cysts, colloid cysts, arachnoid cysts, dermoid cysts, and epidermoid cysts.The objective was to determine the specific features of surgical treatment for each type of cysts of the chiasmo-sellar region, allowing to achieve the best postoperative results.Methods and materials. During the period from 2009 to 2018, 57 patients with cysts of the chiasmo-sellar region were examined and treated. All patients underwent transsphenoidal endoscopic treatment of cysts of the chiasmo-sellar region.Results. Among 57 operated patients, follow-up observation revealed only 2 relapses.Conclusion. For each type of cysts of the chiasmal-sellar region, there are specific features of surgical treatment that allow to achieve the best postoperative results.

Development and Evaluation of Deep Learning-based Automated Segmentation of Pituitary Adenoma in Clinical Task

Purpose To create an automated segmentation method for the sellar region, several tools to extract invasiveness-related features, and evaluate their clinical usefulness by predicting the tumor consistency. Materials and Methods Patients included were diagnosed with pituitary adenoma at Peking Union Medical College Hospital. A deep convolutional neural network, called Gated-Shaped U-Net (GSU-Net), was created to automatically segment the sellar region into eight classes. Five MRI features were extracted from the segmentation results, including tumor diameters, volume, optic chiasma height, Knosp grading system, and degree of ICA contact. The clinical usefulness of proposed methods was evaluated by the diagnostic accuracy of the tumor consistency. Results 163 patients confirmed with pituitary adenoma were included as the first group and were randomly divided into a training dataset and test dataset (131 and 32 patients, respectively). 50 patients confirmed with acromegaly were included as the second group. The Dice coefficient of pituitary adenoma in important image slices was 0.940. The proposed methods achieved accuracies of over 80% for the prediction of five invasive-related MRI features. Methods derived from the automatic segmentation showing better performances than original methods and achieved AUCs of 0.840 and 0.920 for clinical models and radiomics models, respectively. Conclusion The proposed methods could automatically segment the sellar region and extract features with high accuracies. The outstanding performance of the prediction of the tumor consistency indicates their clinical usefulness for supporting neurosurgeons in judging patients’ conditions, predicting prognosis, and other downstream tasks during the preoperative period.

RARE-25. DISSECTING THE CONTEMPORARY EPIDEMIOLOGY OF PRIMARY AND SECONDARY BRAIN TUMORS IN INFANCY THROUGH CHILDHOOD

Introduction Herein we utilize national registry data to evaluate the epidemiology of primary and secondary pediatric brain tumors according to the WHO2016 classification. Methods Pediatric patients (age≤14) presenting between 2004–2017 with a brain tumor were identified by ICD-O-3 and brain metastasis (2010–2017) coding from the National Cancer Database (comprising &gt;70% of newly-diagnosed cancers in the U.S.), and categorized by NICHD age stages: infant (&lt;1yr; n=1,686), toddler (1-2yrs; n=1,732), early- (2-5yrs; n=6,712), middle- (6-11yrs; n=9,175), and late- (12-14yrs; n=5,042) childhood. Patients’ age, sex, race/ethnicity, and overall survival, and tumor location and size were evaluated by WHO2016 tumor type. Results 24,347 pediatric brain tumor patients were identified. Overall, other astrocytic tumors (24% of females, 20% of males), diffuse astrocytic/oligodendroglial gliomas (23% of females, 21% of males – 64% of which were midline), embryonal (13% of females, 19% of males), and sellar region tumors (12% of females, 8% of males) predominated. Embryonal tumors prevailed in infancy (24%) and toddlerhood (24%), declining to 9% in late childhood; only 40% were female. Ependymal tumors peaked at 15% in toddlerhood (6% overall), whereas choroid plexus tumors peaked at 11% in infancy (1.9% overall). A minority of brain tumors were of neuronal & mixed neuronal-glial (6.1%), germ cell (3.8%), cranial nerve (3.2%), mesenchymal non-meningothelial (2.4%), meningioma (1.6%), pineal (1.1%), hematological/histiocytic (0.5%), and other glioma (0.2%) types. Brain metastases were rare (1.5% overall; from 4.0% in infancy to 0.8% in late childhood; and only 41% were female) – 61% came from adrenal neuroblastoma, 16% from sarcomas, and 6% from malignant rhabdoid tumors/extracranial AT/RT. Conclusions Pediatric brain metastases overwhelmingly originate from adrenal neuroblastoma. Although, overall, diffuse astrocytic/oligodendroglial, other astrocytic, embryonal, and sellar region tumors predominate among pediatric brain tumors, together they only comprise 70% of cases and their distribution varies substantially by patients’ age and sex.

Hypothalamus-Pituitary Dysfunction as an Independent Risk Factor for Postoperative Central Nervous System Infections in Patients With Sellar Region Tumors

ObjectiveThe purpose of this study was to verify that hypothalamus-pituitary dysfunction is one of the risk factors for postoperative central nervous system infections (PCNSIs).MethodWe performed a retrospective analysis of all patients with sellar region lesions who underwent surgery between January 2016 and November 2019 at Peking Union Medical College Hospital. In total, 44 age− and sex-matched controls were enrolled. Univariate and multivariate analyses were performed to identify risk factors for PCNSIs.ResultWe enrolled 88 patients, 44 of whom had PCNSIs. Surgical approach (TCS) (P&lt;0.001), previous surgery on the same site (P=0.001), intraoperative cerebral spinal fluid (CSF) leakage (P&lt;0.001), postoperative adrenal insufficiency (P=0.017), postoperative DI (P=0.004) and the maximum Na+ levels(&lt;0.001) correlated significantly with PCNSIs. Multivariate analysis showed that Surgery approach (TCS)(OR: 77.588; 95%CI: 7.981-754.263; P&lt;0.001), intraoperative CSF leakage (OR: 12.906; 95%CI: 3.499-47.602; P&lt;0.001), postoperative DI (OR: 6.999; 95%CI:1.371-35.723; P=0.019) and postoperative adrenal insufficiency (OR: 6.115; 95%CI: 1.025-36.469; P=0.047) were independent influencing factors for PCNSIs.ConclusionTCS, intraoperative CSF leakage, postoperative DI and postoperative adrenal insufficiency are risk factors for PCNSIs in patients with sellar region tumors.