THE TRANSNASAL APPROACH TO SELLAR LESIONS. A NEUROSURGICAL EXPERIENCE AND PERSPECTIVE

The transnasal approach for pituitary lesions has been adopted increasingly by neurosurgeons for removing sellar lesions. It has made surgery in this region safer with fewer complications in experienced hands. However, the approach requires good knowledge of nasal anatomy and formal training to achieve good results since the territory is unfamiliar to most neurosurgeons. The approach has a somewhat steep learning curve. In our experience of 41 cases, we have presented here. We have discussed the history of this approach, technique and relevant complications and their avoidance.

Utility of Rescue Flap in the Reconstruction of Skull Base Defects Following Transnasal Endoscopic Excision of Sellar/Supra-sellar Lesions

Background: Naso-septal Rescue Flap(NSRF) technique involves the preservation of unilateral posterior septal artery pedicle without harvesting full Naso-Septal Flap (NSF). This enables usage of NSF flap when needed while allowing enough exposure to resect tumor completely. This also provides with added advantage of tailoring flap according to preference to cover the defect post tumor removal. This technique involves partial harvestation of only the most superior and posterior aspect of the flap to protect its pedicle, providing better instrumentation for the sphenoid sinus. At the end of the procedure, if there is unexpected CSF rhinorrhea or resultant bony defect is large then Nasoseptal flap is harvested from the rescue flap. As very few studies have been conducted for rescue flap technique in anterior skull base defect reconstruction following excision of sellar/supra-sellar lesions, the technique requires further validation, hence the present study is being undertaken. Objectives: To study the post-operative outcome of Nasal Septal Rescue Flap (NSRF) in terms of donor site morbidity and CSF leak. To study the post-operative outcome of posterior nasoseptal flap in terms of donor site morbidity and CSF leak. Methodology: A cross-sectional study will be conducted at Department of E.N.T, AVBRH, Sawangi Wardha, during a period of August 2020 to August 2021. A sample size of 20 within 18 -70 years of age with sellar/supra-sellar lesions will be included for the research. Results: The observations obtained will be analyzed statistically and will be discussed in light of literature available. Conclusion: This study will help in formulating the guidelines for the NSF harvest with the goal of preventing unnecessary harvest, thereby decreasing peri-operative and post-operative disadvantages as well as preserving the flap for reconstruction in patients requiring revision surgery.

Intrasellar Arachnoid Cyst, a Rare Radiological Finding: Report of a Case.

Intrasellar arachnoid cysts are uncommon radiological findings, generally incidental and clinically silent. We present the case of 70 year-old female who was treated of meningitis due to cerebrospinal fluid nasal fistulae. She was diagnosed of intrasellar arachnoid cyst and managed conservatively because no neurologic, hormonal, symptomatic either CSF fistulae appeared during follow-up. The origin of intrasellar arachnoid cysts is unclear; although an incomplete diaphragma sellae through basal arachnoid membrane herniates may be a plausible theory. Conservative treatment is the usual option, but if hormonal, visual or intracranial hypertension symptoms appeared, surgery may be the best therapy. This entity should be in the differential diagnosis of cystic sellar lesions with other benign cysts and tumors as craniopharyngioma.

Melanoma metastasis to a nonfunctioning pituitary macroadenoma: illustrative case

BACKGROUND Metastases to the central nervous system are often multiple in number and typically favor the gray-white matter junction. Collision tumors, defined as the coexistence of two morphologically different tumors, such as metastases to a known pituitary adenoma (PA), are exceedingly rare. Only a few reported cases of metastases to a PA exist in the literature. OBSERVATIONS The authors present the case of a 64-year-old man with a known history of stage IV metastatic melanoma who was found to have hypermetabolic activity in the sellar region on surveillance positron emission tomography. On laboratory evaluation, he had clear evidence of pituitary axis dysfunction without diabetes insipidus. Subsequent magnetic resonance imaging showed a 2.4-cm sellar mass with features of a pituitary macroadenoma and internal hemorrhage, although no clinical symptoms of apoplexy were noted. He underwent a transsphenoidal endoscopic endonasal approach for resection of the sellar lesion. Final pathology showed a collision tumor with melanoma cells intermixed with PA cells. LESSONS Histological analysis verified the rare presence of a collision tumor of a melanoma metastasis to a nonfunctional pituitary macroadenoma. Metastasis to a preexisting PA, although rare, should be considered in the differential diagnosis in patients with sellar lesions and a known cancer history.

Cystic lesion of the sella turcica: interesting case report and review of literature

<p class="western"><span><span><strong>ABSTRACT</strong></span></span></p><p class="western"><span><span>Intrasellar arachnoid cysts are rare entities. High index of suspicion and precise radiological evaluation are the cornerstone for appropriate diagnosis and treatment. We present a symptomatic case of a sellar cystic lesion in a 52-year-old lady, who had complaints of decreased vision associated with diplopia of three months duration. Clinical evaluation showed bitemporal hemianopia. Magnetic Resonance Imaging (MRI) of brain revealed features of sellar arachnoid cyst with the intracystic component similar to cerebrospinal fluid (CSF). She underwent endoscopic transnasal transsphenoidal excision of lesion. Her visual symptoms improved well on subsequent follow up.However infrequent, sellar arachnoid cyst should be borne in mind as differential diagnosis for any cystic sellar lesions, as they can mimic pituitary adenomas, either by impairment of pituitary hormonal function or by exerting pressure effects on optic chiasma. Evaluation modalities, therapeutic challenges and literature review are presented in this case report.</span></span></p><p class="western"> </p>

Salivary gland tissues and derived primary and metastatic neoplasms: unusual pitfalls in the work-up of sellar lesions. A systematic review

Purpose Salivary gland (SG) tissue and derived neoplasms may occur in the sellar region. As the current literature is mostly limited to case reports, the puzzling case of an inflammatory SG removed by transsphenoidal surgery (TS) and mimicking a prolactinoma prompted us to perform the first systematic review of these unusual conditions. Methods A systematic literature search was conducted according to the PRISMA guidelines. Forty-four individual cases—non-neoplastic enlarged salivary glands (NNESG, n = 15), primary benign (n = 7) and malignant (n = 8) ectopic salivary tumours (ST) and sellar metastasis from eutopic primary ST (n = 14)—were suitable for the analysis of clinical, radiological and pathological characteristics. Therapeutic outcome was reviewed as a secondary endpoint. Results All cases were diagnosed after surgery. NNESG commonly affected young and/or female patients, typically leading to headaches and hyperprolactinemia and originating close to the neurohypophysis. Submucosal SG should be excluded before concluding to an intrasellar NNESG after TS. No gender or age predominance was found for primary ectopic ST, which present as large tumors, with histological phenotypes similar to common ST. Hypopituitarism and diabetes insipidus were more frequent in ST than in NNESG. NNESG and benign ectopic ST rarely recur. Malignant ectopic ST should be distinguished from secondary localizations of eutopic ST reaching the sella by contiguity or metastatic spread; both share a frequent unfavorable outcome. Conclusion Sellar neoplasms derived from SG are rare but misleading conditions and pituitary dysfunction is likely to be more common than currently reported. Appropriate pathological evaluation and multidisciplinary approach are required.

A Potential Concomitant Sellar Embryonic Remnant-Associated Collision Tumor: Systematic Review

BackgroundDiagnosing the well-known concomitant Rathke’s cleft cyst (RCC) and differentiating it from other sellar lesions are difficult because RCC is and other sellar lesions are closely related and represent a continuum from simple RCCs to more complex lesions. The purpose of this study is to better understand the adeno- and neurohypophysis adjacent to the par intermedia remnants and their role in the origin of the coexistence of these two distinct tumor neoplasias; to assess the incidence in different age groups; to categorize the pathohistological subtype, which can be incorporated in predictive/prognostic models; and finally, to evaluate the current evidence on collision tumors of the sellar embryonic remnant tract in terms of their biological behavior and pathology.MethodsUtilizing the PubMed database, data were collected from 1920 to 2019. Information about demographics, clinical characteristics, and age was summarized and analyzed by using univariable and multivariable models. The same cell type was observed regardless of whether the tumor was only one type or mixed types, and their histologic patterns were assessed.ResultsThe incidence rates were similar among patients stratified into three age subgroups: 40–49 years (24.57%), 50–59 years (19.54%), and older than 60 years (22.98%). We found that various types of sellar lesions, namely, squamous metaplasia (SM) + goblet cells (GC) (HR 46.326), foamy macrophages (FM) (HR 39.625), epithelial cells and multinucleated giant cells or cholesterin (EM) (HR 13.195), a cavernous portion of the right internal carotid artery (CP-ICA) (HR 9.427), epithelial cells with ciliated cuboidal (EC-CC) (HR 8.456), were independently associated with RCC pathological status. These divergent AUCs (0.848 for Hypo as RCC, 0.981 for RCC co PA, 0.926 for CD and CP co RCC) and subtypes of PA (HR 4.415, HR 2.286), Hypo (HR 3.310), CD and CP (HR 2.467), EC and DC and PG and SGR (HR 1.068), coexisting with the risk of a comorbid RCC lesion, may reflect the etiologic heterogeneity of coderivation and the different effects of some risk factors on tumor subtypes. Our analyses suggested that the greatest accuracy was observed for the pituitary adenoma subtype, with an AUC of 0.981 (95% confidence interval [CI]: 0.959–1.005), while the poorest accuracy was observed for aneurysms, with an AUC of 0.531 (95% CI: 0.104–0.958). We separately analyzed and confirmed the above results. Sensitivity analysis revealed no evidence of systematic bias due to missing data.ConclusionThis study showed that the histopathological changes in patients with sellar embryonic remnant-associated collision tumors showed highly consistent epithelial cell replacement (renewal) (ciliated columnar epithelium to ciliated squamous epithelium to squamous epithelium) or accumulation, and the RCC cyst wall was similar in structure to the tracheobronchial airway epithelium, with progenitor cell characteristics. The collision accuracy between RCC and other tumors (PAs, craniopharyngioma, chordoma, etc.) is different; these characteristics constitute the theoretical basis for the postmigration development of the pharyngeal bursa.

Intraoperative MRI in trans-sphenoidal surgery using frameless stereotaxis

Background: Intraoperative magnetic resonance imaging (iMRI) has been used for pituitary surgery for approximately 20 years. The introduction of frameless stereotaxis allows efficient navigation for both the ENT and neurosurgeon. This allows flexibility in placement of the patients head to facilitate resection, efficient use of theater time and improves the safety profile of the operation. This is the first study to describe and investigate the use of frameless stereotaxis in conjunction with iMRI. Methods: Consecutive patients who underwent iMRI guided trans-sphenoidal debulking using frameless stereotaxis over a 3-year period, from January 2016 to June 2019, were included in this case series and reviewed retrospectively. The use of AxiEM (Medtronic, USA) tracker facilitated frameless stereotaxis in conjunction with iMRI for trans-sphenoidal debulking of sellar lesions based on the “twin-operating” model. Results: The cohort of 47 patients had a mean age of 55 years with a slight female predilection. The average lesion size measured 20 mm (3–46 mm) in maximal diameter with objective evidence of visual deterioration being the most common indication to consider surgery. The use of iMRI identified two patients with suboptimal decompression facilitating further resection in the same anesthetic and one hemorrhagic complication requiring evacuation and hemostasis to reduce postoperative morbidity. Conclusion: This study describes the procedural nuances in the use of frameless stereotaxis for iMRI in transsphenoidal surgery to further reduce morbidity and improve outcomes, as well as improving theater utilization and reducing cost.

Pituitary Abscess: Two Case Reports and Review of the Literature

Pituitary abscesses are infrequent entities, often forgotten and hence rarely included in the differential diagnosis of sellar lesions. However, given that they share the clinical manifestations of other more common pathologies in this region, the treatment of pituitary abscesses is usually performed correctly without demonstrating a relevant delay in therapeutic decisions when surgical options are considered as the alternative of choice. Two patients with intrasellar expansive processes and endocrinological alterations who were diagnosed intraoperatively as having pituitary abscesses are presented. In both cases, transsphenoidal surgery was performed; adjuvant antibiotic treatment was established for just one of them. Both patients are currently without symptoms due to mass-effect; one of the patients continues exhibiting residual endocrinological alteration and no signs of relapse in imaging studies.