Pituitary Macroadenoma
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2021 ◽  
Shayan Sirat Maheen Anwar ◽  
Kiran Hilal ◽  
Anam Khan ◽  
Asra Ahmad

Abstract BACKGROUNDMagnetic resonance imaging (MRI) is regarded as the modality of choice in diagnosis of pituitary adenomas. Since surgery is the first line therapy for all pituitary adenomas with exception of prolactinoma, simple and reproducible MRI classification based on major directions of tumour growth is an essential tool providing the exact road map for right surgical approach and maximum safe resection.SIPAP MRI classification for pituitary adenomas is derived from KNOSP-STEINER classification of parasellar growth, to which has been added grading for superior, inferior, anterior and posterior tumour extension.We, therefore, propose to incorporate SIPAP classification in routine reporting template of pituitary adenomas, for ideal radiological description of tumour delineation, relationship to juxtasellar structures, and tumour size, hence facilitating greater success rate in surgical and subsequent clinical management.METHODSTwo radiologists retrospectively reviewed imaging of 49 patients with biopsy-proven pituitary macroadenoma and graded according to SIPAP classification. Study was conducted at Aga Khan University Hospital from 1st July 2019 to 30th June 2020. Data was analyzed using Stata version 15. Interobserver variability was calculated using Cohen’s Kappa. Comparison between grading before and after treatment was performed by Chi-square test. P values <0.05 were considered statistically significant.RESULTSSixty three percent patients were male and 37% female. Overall, maximum preoperative and postoperative volume was 71.82 cm3 and 49.50 cm3 respectively, with significant difference in pre and post-operative volumes (14.1±17.7 vs. 4.5±10.4, p-value <0.001). Length showed most significant difference pre and post-operatively (2.4±1.1 vs. 1.3±1.1, p-value <0.001). Individual tumour extensions according to SIPAP for pre- and post-operative grading showed significant difference (p-value <0.001), except for anterior extension. For suprasellar extension, 67.3% patients had pre-operative grade 3 and 63.3% had post-operative grade 0. For infrasellar extension, 51.0% had pre-operative grade 2 and 71.4% had post-operative grade 0. Anterior, posterior and parasellar extensions showed increased frequency in grade 0 in post-operative stage compared to pre-operative. Substantial inter-observer agreement was achieved for Superior, Inferior, Anterior and Posterior extent with all Kappa statistics values above 0.7 (p-value <0.001).CONCLUSIONWe propose incorporating simple and objective SIPAP classification in routine MR reporting for ideal pituitary tumour delineation, relationship to juxtasellar structures and tumour size.

Abhijit Goyal-Honavar ◽  
Sauradeep Sarkar ◽  
Geeta Chacko ◽  
Rajesh Balakrishnan ◽  
H. S. Asha ◽  

2021 ◽  
Vol 12 ◽  
Jinci Lu ◽  
Liam Chen

Pituitary sarcoma arising in association with pituitary adenoma is an uncommon finding. Most cases of secondary sarcoma have been noted to arise with a median interval of 10.5 years post radiation. In this case report, we describe a 77-year-old man with an incidental discovery of a pituitary macroadenoma on magnetic resonance imaging (MRI) and underwent radiotherapy. Three years after radiation treatment, there was an acute change in clinical symptoms and increase in tumor size and mass effect on the optic chiasm which prompted surgical resection. A pituitary adenoma along with a separate spindle-cell sarcomatous component was identified in histology. Immunohistochemical stain for muscle markers confirmed a development of pituitary rhabdomyosarcoma (RMS). Molecular profiling of the tumor identified mutations in TP53, ATRX, LZTR1, and NF1. Despite its rarity, characterization of pituitary RMS with immunohistochemistry and molecular studies may provide an insight to its pathophysiological relationship with pituitary adenoma.

Amalina Che Din ◽  
Celine Fong ◽  
Chon Sum Ong

The occurrence of symptomatic Rathke's cleft cyst (RCC) apoplexy is extremely rare. This is often misdiagnosed due to similar presentations to subarachnoid haemorrhage and pituitary apoplexy. This case highlights an excellent example of similar clinical presentation and serves as a learning case for clinicians. A 40-year-old lady presented to a district hospital with 9 days of worsening severe headache associated with blurring of vision, photophobia, stiff neck, nausea and vomiting. Nuchal rigidity and Brudzinski’s positive. Blood test showed hyponatremia, raised inflammatory markers and normal dynamic pituitary function test. CT Head demonstrated no evidence of space-occupying lesion or intracranial haemorrhage. Lumbar puncture showed xanthochromia positive consistent with subarachnoid haemorrhage. MRI head advised by Neurosurgery team and revealed a focal lesion involving anterior pituitary macroadenoma with mass effect on optic chiasm with possible haemorrhage within. Further assessment in tertiary hospital confirmed loss of visual acuity and field deficit. Patient underwent emergency endoscopic transnasal transsphenoidal resection of apoplectic tumour and repair of CSF leak with graft from thigh. Histopathology report showed a Rathke’s cleft cyst with squamous metaplasia. Post operatively, the patient developed sinusitis which fully recovered, and MRI showed good decompression. The author demonstrated a rare case of symptomatic RCC which was initially presumed to be pituitary apoplexy. Radiology imaging and treatment approach for both conditions are quite similar and can only be differentiated by histopathology. Further research is required to identify the causes and risk factors of RCC apoplexy to aid early detection and diagnosis.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S23

2021 ◽  
Vol 47 (1) ◽  
pp. 34-39
Patricia Lopez Gomez ◽  
David Mato Mañas ◽  
José María Navasa Mellado ◽  
Jaime Viera Artiles ◽  
Sergio Obeso Aguera ◽  

Cerebral vasospasm is an uncommon complication following transsphenoidal surgery (TSS) of a pituitary adenoma. Therefore, neither its physiopathology nor its management are clear. We present a case of vasospasm after TSS and we discuss about its etiology and treatment. A 52-year-old woman presented with hirsutism, without neurologic symptoms. A MRI showed a pituitary macroadenoma. The patient underwent an endoscopic transsphenoidal approach. Post-operative CT scan revealed an extensive subarachnoid haemorrhage (SAH). On postoperative 7th day, she developed an abrupt mixed aphasia. An urgent arteriography showed left middle cerebral artery vasospasm, so intra-arterial nimodipine was administered. After that, vasospasm disappeared and the patient recovered completely. The key to successful management of this rare complication is a high index of suspicion. The presence of postoperative SAH seems to definitely contribute to its apparition. Therefore, treatment in concordance with protocols for vasospasm due to aneurysmal SAH is recommended.

2021 ◽  
Vol 108 (Supplement_6) ◽  
E Tan ◽  
A Zammit

Abstract Pituitary abscesses are rare yet life-threatening entities. Most common presenting features are headache, hypopituitarism, and visual changes. Majority of patients are found to have a predisposing risk factor, such as a pre-existing pituitary lesion, recent pituitary surgery or irradiation, or a primary source of infection. We present the case of a 53-year-old male with a spontaneous pituitary abscess, who presented with an isolated bitemporal hemianopia, but was otherwise asymptomatic with no known risk factors. Magnetic resonance imaging showed a sellar and suprasellar mass, thought to be a pituitary macroadenoma. He underwent endoscopic transsphenoidal adenectomy and cystic fluid was seen intraoperatively. Microbiology analysis showed Staphylococcus Aureus, and a course of intravenous ceftriaxone was commenced. Histopathology reported no evidence of adenoma and impression was of a pituitary abscess. Following transsphenoidal resection and commencement of antibiotic therapy, the bitemporal hemianopia resolved. We therefore report a rare case of primary pituitary abscess and emphasise the importance of including this condition as a differential diagnosis in any patient with a visual deficit or new pituitary lesion.

2021 ◽  
Vol 36 (6) ◽  
pp. 1130-1131
Katelyn Yunes ◽  
Carolina Posada

Abstract Objective Arachnoid cysts (ACs) are typically cerebrospinal fluid-filled abnormalities that occur within the central nervous system. ACs are uncommon (prevalence rate of 1.2%), and typically occur within the left hemisphere middle cranial fossa or posterior fossa. Symptoms vary depending on location and size but often include headaches, weakness, cognitive changes, and hydrocephalus. We present an unusual case of a 68-year-old right-handed woman with 13 years of education who was admitted to the hospital following overdose. During a previous admission, Patient was found to have a large arachnoid cystic lesion and right-sided weakness, but was determined not to require acute intervention. Neuropsychology was consulted to assess current cognitive functioning. Method Patient was initially diagnosed with a severe major depressive episode with new-onset psychotic features following an overdose of baclofen and Tylenol. Suicide attempt was denied. Magnetic Resonance Imaging (MRI) confirmed previously identified arachnoid cystic lesion (Figure 1) causing mass effect. Patient’s MRI also revealed pituitary macroadenoma (Figure 2) that caused subtle distortion along the optic chiasm. Results The results (Table 1) suggested an abnormal cognitive profile characterized by deficits on measures of language, visuoperception, memory, and abstract reasoning in the context of relatively intact auditory attention and working memory. Conclusions The extent and severity of Patient’s deficits are likely attributable to the cystic lesion, with recent onset of visual hallucinations likely caused by location of pituitary macroadenoma. This case highlights the importance of having access to a neuropsychological inpatient consultation service to assist with clarification of symptom etiology and facilitation of appropriate diagnosis and intervention.

2021 ◽  
Vikas Shah ◽  
Bahman Rasuli

2021 ◽  
Vol 2021 ◽  
pp. 1-6
Silvia Ciancia ◽  
Silvia Cesari ◽  
Barbara Predieri ◽  
Sergio Bernasconi ◽  
Lorenzo Iughetti

In case of primary hypothyroidism, reactive pituitary hyperplasia can manifest as pituitary (pseudo) macroadenoma. We report the case of a 12-year-old boy who was evaluated for impaired growth velocity and increased body weight. Because of low insulin-like growth factor 1 levels and poor response to the growth hormone stimulation test, brain magnetic resonance imaging was performed and a pituitary macroadenoma was found. Treatment with levothyroxine was started, and thyroid function was evaluated approximately every 40 days to titrate the dosage. After few months of therapy, the size of the macroadenoma decreased and growth hormone secretion normalized. The pituitary returned to normal size in approximately 5 years. The boy went through puberty spontaneously and reached a normal adult height. In a patient affected by primary hypothyroidism, reactive pituitary hyperplasia can cause growth hormone deficiency; however, growth hormone secretion usually normalizes after starting levothyroxine treatment. Pituitary macroadenoma can be difficult to distinguish from severe pituitary hyperplasia; however, pituitary macroadenomas are rare in childhood, and our clinical case underlines how the hormonal evaluation is essential to achieve a correct diagnosis and prevent unnecessary surgery in a context of pituitary mass.

2021 ◽  
Vol 11 ◽  
Tao Xie ◽  
Xiaobiao Zhang ◽  
Chenghui Qu ◽  
Chen Li

BackgroundThe endoscopic endonasal approach and extra-pseudocapsule resection may be the main progress in modern pituitary surgery. However, for pituitary macroadenomas, discerning the pseudocapsule in the posterior plane of the tumor may be difficult. When the anterior-inferior debulking is performed, the early subsidence of the thinning normal pituitary gland and enlarged diaphragm may obstruct the surgical dissection view.MethodWe describe the technique of using a micro retractor for the endoscopic endonasal posterior pseudocapsule resection of pituitary macroadenomas. This micro retractor that was 2 mm in width was placed at the 12 o’clock position on the nostrils, and the end was fixed in the flexible arms of the self-retaining retractor system. The head of the micro retractor elevated the herniated diaphragm sellae in order to continue the posterior pseudocapsule resection of the pituitary macroadenoma.ResultThe technique was performed very easily and no complication was observed.ConclusionThe use of this micro retractor can increase the view of the posterior margin of the adenomas to facilitate the pseudocapsule dissection.

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