Concomitant Pituitary Adenoma Research Articles

Challenging diagnosis of resistance to thyroid hormone in a patient with COVID-19, pituitary microadenoma and unusual response to octreotide long-acting release test.

The resistance to thyroid hormone syndrome (RTHβ) occurs uncommonly and requires a high level of clinical suspicion and specific investigations to reach a precise diagnosis and to avoid unnecessary and potentially harmful therapies. We report a case of a young male patient referred to our unit for SARS-CoV-2 infection and atrial fibrillation with elevated thyroid hormones and non-suppressed thyroid-stimulating hormone (TSH), for which antithyroid therapy was prescribed. A mood disorder was reported in the medical history. The family history was unknown as the patient was adopted. Thyroid-specific antibodies were undetectable, and thyroid ultrasound revealed a normal thyroid gland without nodules. After the resolution of SARS-CoV-2 infection, the diagnostic workup continued, and the pituitary MRI revealed a small area ascribable to a microadenoma. Due to atrial fibrillation, the execution of the T3 test was contraindicated. The octreotide long-acting release (LAR) test showed an initial reduction of free thyroid hormones levels at first administration, which was consistent with the presence of a TSH-secreting pituitary tumour, although an escape from the response was observed after the following two injections of octreotide LAR. Indeed, the genetic investigation revealed a variant in heterozygosity of the THRβ gene (Pro453Ser), thus leading to an RTHβ diagnosis, and, therefore, medical treatment with triiodothyroacetic acid was initiated. After 2 years from the SARS-CoV-2 infection, the patient continues the follow-up at our outpatient clinic, and no other medical interventions are needed. RTHβ is a rare genetic syndrome characterised by discrepant thyroid function tests and by a dissociation between the observed hormone levels and the expected patient signs and symptoms. Features of thyroid hormone deficiency in TR-ß dependent tissues (pituitary gland, hypothalamus, liver and neurosensitive epithelia), as well as thyroid hormone excess in TR-α-dependent tissues (heart, bone, skeletal muscle and brain), may coexist in the same individual. Clinical pictures can be different even when the same variant occurs, suggesting that other genetic and/or epigenetic factors may play a role in determining the patient's phenotype. Differentiating RTHβ from a TSH-secreting pituitary tumour is very difficult, especially when a concomitant pituitary adenoma is detected during diagnostic workup. The injection of long-acting somatostatin analogues can help differentiate the two conditions, but it is important to detect any interference in the dosage of thyroid hormones to avoid an incorrect diagnosis. Genetic testing is fundamental to prevent unnecessary and potentially harmful therapies. Medical treatment with triiodothyroacetic acid was demonstrated to be effective in reducing thyroid hormone excess and controlling symptoms.

GH-Producing pituitary adenoma and concomitant Rathke's cleft cyst: A case report

Abstract Introduction Rathke cleft cysts (RCCs) are commonly believed to be cysts formed from remnants of Rathke's pouch. It is usually asymptomatic, < 3mm in diameter, and found in 13–33% of normal pituitary glands. The coexistence of pituitary adenoma (PA) and RCC is rare (incidence rate of 0.51%-1.7%), and growth hormone hypersecretion has also been observed in a limited number of cases in these patients. Therefore, we aim to present a rare case of growth hormone- (GH-) producing PA with concomitant RCC. Clinical Case A 29-year-old female patient, due to primary amenorrhea, was diagnosed as having 46XY chromosomal Swyer syndrome from her previous visit, and she had bilateral salphengoopherectomy afterward. In clinical follow-ups, due to the presence of growth complaints in the hands and feet, insulin-like growth factor-1 (IGF-1) was found to be high. The basal serum GH value was 8.89 ng/mL, and IGF-1 was 369 ng/mL. The 75 gr oral glucose tolerance test (OGTT) result showed that the serum GH level was not suppressed below 1.0 μg/L, and the test was repeated twice. Other anterior pituitary hormone axes are normal. In the pituitary magnetic resonance imaging revealed a low-signal 4 mm Rathke cleft cyst is observed in the T1A image in the midsection of the pituitary gland and a high-signal intra-cystic nodule is observed within the cyst on the T1A image (Figure 1A). The fluid-fluid level is observed in the cyst on the T2A image (Figure 1B). Conclusion The relationship between RCC and PA is unclear and theoretical. The theory is “transitional pituitary tumor,” defined as the Rathke pouch forming the anterior lobe of the pituitary gland with a proliferation of the anterior wall. Moreover, PAs originate from the anterior lobe of the pituitary gland via clonal changes. This shows that RCCs originated from the remnant of the Rathke pouch, and PA has a common embryonic origin. Nevertheless, they rarely occur at the same time. Only 14 patients with GH-producing PA and concomitant RCC have been reported in the literature. Preoperative correct diagnosis of PA and RCC coexistence is difficult, because RCCs’ imaging characteristics (size, position, and intensity) are highly variable, and cystic degeneration occurs in 5% to 18% of PA cases. RCCs are often surrounded by the normal pituitary gland and are located in the nearby midline of the sellar region. MRI characteristics of sellar lesions for PAs existing concomitant with RCCs may present with variable intensity on T1-weighted imaging. If radiographic imaging shows that typical RCC and PA are not obvious at first glance, the possibility of concomitant PA still needs to be considered. If the PA in this patient had been nonfunctional, correct diagnosis of the concomitant PA would have been much more difficult. This case offers a reminder that although rare, RCC can accompany PA, and performing contrast-enhanced MRI is useful to detect RCC.

Unexpected concomitant pituitary adenoma and suprasellar meningioma: a case report and review of the literature

We report a case of a 75-year-old patient with hypopituitarism, bitemporal visual field deficits and a parasellar mass on pituitary MRI. During surgery, suspicion was raised that a non-functioning pituitary adenoma was accompanied by an abutting diaphragm sellae meningioma, which was confirmed at pathological examination. In retrospect, the initial MRI suggested two separate tumours on the basis of differing densities but this distinction was not seen on the last preoperative MRI.

Endoscopic Endonasal Resection of Concomitant Pituitary Adenoma and Rathke’s Cleft Cyst: A Case Report and Review of Literature

Endoscopic Endonasal Resection of Concomitant Pituitary Adenoma and Rathke’s Cleft Cyst: A Case Report and Review of Literature

Spontaneous pituitary adenoma occurring after resection of a Rathke’s cleft cyst

Rathke’s cleft cysts (RCC) are benign cystic lesions that originate from remnants of the epithelial lining of Rathke’s pouch. RCC are known rarely to occur together with a concomitant pituitary adenoma. Here, we report a patient with a pituitary adenoma arising in the same location as a previously-resected RCC, 3 years post-operatively, and review the literature of “collision” sellar lesions. Consecutive transsphenoidal operations from a single-center between 2008 and 2016 were reviewed to identify patients with pituitary adenoma arising after surgical resection of RCC, and a systematic search of the literature was also performed to identify such patient reports, as well as reports of concomitant pituitary adenoma and RCC. Of 837 transsphenoidal operations from our own experience, one patient with pituitary adenoma occurring after RCC resection was identified and is reported here. A systematic review of the literature resulted in identification of 34 patients with concomitant RCC and pituitary adenoma and no incidents of pituitary adenoma occurring after resection of RCC. Concomitant occurrence of RCC and pituitary adenoma was more commonly diagnosed in women (61%), at a median age of diagnosis of 44 years. The RCC histological analysis in these patients consistently described ciliated columnar or cuboidal epithelium. Although rare, the presence of a new, pathologically-distinct lesions in the sella after prior surgical treatment, is possible. During post-operative monitoring, physicians should consider that what appears as a “recurrent” lesion may actually be growth of a new and entirely different lesion.

Diagnosis of concomitant pituitary adenoma and Rathke's cleft cyst with magnetic resonance imaging

IntroductionThe diagnosis of concomitant pituitary adenoma (PA) and Rathke's cleft cyst (RCC) is difficult because PA and RCC cause similar symptoms. This study aimed to investigate magnetic resonance imaging (MRI) characteristics and surgical management of sellar lesions for concomitant PA and RCC. MethodsA retrospective study was performed in 18 patients with concomitant PA and RCC who visited our hospital between June 2008 and May 2014. MRI features, surgical management, histopathological diagnosis and prognosis of concomitant PA and RCC were summarized. ResultsOf the 18 patients, 3 cases were diagnosed with concomitant PA and RCC and 2 with concomitant PA and intermedia cyst by preoperative MRI. The remaining 8 cases were misdiagnosed as cystic formation of PA, 3 cases were bleeding of PA, and 2 cases were RCC. Surgery via the trans-sphenoidal route was performed in 17 cases and trans-frontal approach was chosen for one patient. All PAs resected were diagnosed by histological examination and the diagnosis of concomitant PA and RCC was histologically confirmed. ConclusionA non-enhancing cyst-like structure within the pars intermedia of PA usually located in the midline is a prominent MRI feature of coexisted PA and RCC. Total resection of coexisted RCC must be achieved and fat graft should be avoided during surgery because of high recurrence rate of RCC and complicated hypophysitis.

GH-Producing Pituitary Adenoma and Concomitant Rathke's Cleft Cyst: A Case Report and Short Review.

Concomitant pituitary adenoma (PA) and Rathke's cleft cyst (RCC) are rare. In some cases, such PA is known to produce pituitary hormones. A 53-year-old man was admitted to our hospital with a diagnosis of lacunar infarction in the left basal ganglia. Magnetic resonance imaging (MRI) incidentally showed a suprasellar mass with radiographic features of RCC. When he consulted with a neurosurgical outpatient clinic, acromegaly was suspected based on his appearance. A diagnosis of growth hormone- (GH-) producing PA was confirmed from hormonal examinations and additional MRI. Retrospectively, initial MR images also showed intrasellar mass that is compatible with the diagnosis of PA other than suprasellar RCC. The patient underwent endonasal-endoscopic removal of the PA. Since we judged that the RCC of the patient was asymptomatic, only the PA was completely removed. The postoperative course of the patient was uneventful and GH levels gradually normalized. Only 40 cases of PA with concomitant RCC have been reported to date, including 13 cases of GH-producing PA. In those 13 cases, RCC tended to be located in the sella turcica, and suprasellar RCC like this case appears rare. In a few cases, concomitant RCCs were fenestrated, but GH levels normalized postoperatively as in the cases without RCC fenestration. If radiographic imaging shows typical RCC, and PA is not obvious at first glance, the possibility of concomitant PA still needs to be considered. In terms of treatment, removal of the RCC is not needed to achieve hormone normalization.

Diagnostic Significance of Intracystic Nodules on MRI in Rathke’s Cleft Cyst

Background and Purpose. To explore strategies for the diagnosis and treatment of Rathke's cleft cyst (RCC). Methods. The medical records of 24 patients with sellar RCC were retrospectively reviewed. Two patients had concomitant pituitary adenoma, 2 underwent transcranial surgery, and 22 underwent transsphenoidal surgery. The clinical features, especially the findings of intracystic nodules on MRI, were evaluated and compared with the pathological findings. Results. Preoperatively, only 2 patients were diagnosed with RCC or suspected RCC. Pre- and postoperative MRI images revealed 10 intracystic nodules in 9 (37.5%) patients. Two nodules had bull's eyelike changes. The signal intensity of the intracystic nodules varied on T1- and T2-weighted images. Not all nodules on T2-weighted images were visualized. Postoperative MRI revealed recurrence or residual lesion in 5 patients; none had new symptoms and a second surgery was not required. Conclusions. Identifying intracystic nodules is important in patients with sellar cystic lesions. Bull's eyelike change in an intracystic nodule on MRI, which is reported here for the first time, potentially might have value for confirming the diagnosis.

Coexisting Rathke Cleft Cyst and Pituitary Adenoma Presenting with Pituitary Apoplexy: Report of Two Cases

The authors report two cases of coexisting Rathke cleft cyst (RCC) and pituitary macroadenoma. Both patients presented at the university hospital with pituitary apoplexy symptoms of sudden-onset headache while undergoing treatment with Coumadin (warfarin). Magnetic resonance imaging was consistent with a pituitary adenoma in one case and RCC in the other. Intraoperative findings and pathological work-up identified RCC along with adenomatous tissue displaying hemorrhagic pituitary adenoma in one and hemorrhagic RCC in the other. Clinical symptoms of pituitary apoplexy were present in both cases, making pituitary and RCC apoplexy clinically indistinguishable. RCC and concomitant pituitary adenoma are a rare intraoperative finding that must be considered as a differential diagnosis in patients with symptoms of pituitary adenoma apoplexy.

Resection of Fibrous Dysplasia of the Sphenoid Bone and a Concomitant Calcified Pituitary Adenoma via an Endoscopic Endonasal Transsphenoidal Approach

Background: Although pituitary adenomas have been described in association with polyostotic fibrous dysplasia in McCune-Albright Syndrome, no such relationship has been described with monostotic fibrous dysplasia. The authors describe a case of monostotic fibrous dysplasia of the sphenoid bone and concomitant pituitary adenoma in a 25-year-old male. To the authors’ knowledge this is the first such case reported in the literature. Clinical presentation, pathology, and surgical approach are described in detail. Case Description: A 25-year-old male initially presented with headaches, gynecomastia, and galactorrhea. Magnetic Resonance Imaging (MRI) revealed a sellar/suprasellar mass possibly consistent with a calcified pituitary adenoma or craniopharyngioma and a cranial base lesion obstructing the sphenoid sinus consistent with fibrous dysplasia. Both lesions were accessible via an endoscopic transnasal approach. The patient underwent resection of the affected sphenoid bone which allowed appropriate exposure for subsequent resection of the pituitary lesion without major complication. Pathology and immunohistochemical studies confirmed the diagnoses and postoperative imaging revealed gross total resection of the adenoma. Conclusions: The authors describe a case of monostotic fibrous dysplasia of the sphenoid bone and pituitary adenoma. Resection of such dual lesions can be both safe and efficacious via an endoscopic endonasal transsphenoidal approach.

A 70-Year-Old Man With Diplopia, Nausea, and Vomiting

A 70-year-old man who presented with diplopia was found to have an intrasellar unilocular cyst lined by ciliated columnar epithelium. The cyst showed suprasellar extension and measured 3 cm in greatest dimension. The intrasellar part of the cyst wall contained a pituitary adenoma. These findings are characteristic of Rathke cleft cyst with concomitant pituitary adenoma, an entity that must be distinguished from other intrasellar and suprasellar lesions.

A 70-year-old man with diplopia, nausea, and vomiting. Rathke cleft cyst concomitant with pituitary adenoma.

A 70-year-old man who presented with diplopia was found to have an intrasellar unilocular cyst lined by ciliated columnar epithelium. The cyst showed suprasellar extension and measured 3 cm in greatest dimension. The intrasellar part of the cyst wall contained a pituitary adenoma. These findings are characteristic of Rathke cleft cyst with concomitant pituitary adenoma, an entity that must be distinguished from other intrasellar and suprasellar lesions.

Concomitant pituitary adenoma and Rathke's cleft cyst.

We reviewed the clinical, radiological and surgical findings in patients with both pituitary adenoma and Rathke's cleft cyst. We retrospectively selected patients with both lesions from the 374 patients in whom a sellar/juxtasellar lesion was detected on MRI at 1.5 tesla. All patients received intravenous contrast medium. Concomitant pituitary adenoma and Rathke's cleft cyst were found in eight patients (2.1 %). The frequency of the combination was 3.5 % of pituitary adenomas and 11% of Rathke's cleft cysts. Symptoms were always due to the adenoma, secreting adrenocorticotrophin in two patients and growth hormone in six. The adenoma was larger in five patients, and the cyst in three. The cysts gave variable signal. The adenoma was adjacent to the cyst in seven patients, and enclosed it in the other patient. As a result of experience with MRI, concomitant pituitary adenoma and Rathke's cleft cyst are now known not to be as rare as thought previously. When a non-enhancing cyst-like structure is demonstrated in a patient with pituitary adenoma, the possibility of a coexisting Rathke's cleft cyst should be considered.

Intra- and suprasellar colloid cysts.

During the past 11 years 69 patients underwent transsphenoidal surgery for symptomatic intra- and suprasellar non-neoplastic cysts in our department. Eighteen of them harbored intra- and suprasellar colloid cysts. The most frequent presenting symptoms were oligomenorrhea, galactorrhea, and headaches. One patient presented with polydipsia. One male patient complained about mild hypogonadism and oligospermia. Two male patients presented with symptoms of panhypopituitarism. Endocrine assessment revealed hyperprolactinaemia in 72% of the female patients. Hypogonadism was found in 72%. Panhypopituitarism was found in two cases. During transsphenoidal surgery, a circumscribed collection of colloid material was removed in each case. Additional tumorous tissue was encountered in three cases that harbored a concomitant pituitary adenoma. Biopsies confirmed the surrounding tissue to be normal pituitary tissue. Postoperatively, regular menstrual cycles were found in 82% of the female patients with oligomenorrhea and headaches improved in 80%. Serum prolactin levels were restored in 92%, galactorrhea ceased in 89%. Only in one case deterioration of pituitary function occurred (diabetes insipidus). Symptomatic SIADH occurred in another one. There were no other post-operative complications. We conclude, that transsphenoidal surgery is a safe therapy for treating symptomatic intra- and suprasellar colloid cysts. Surgery is mainly indicated for female patients in childbearing age to restore fertility and to prevent further deterioration of pituitary function. The differential diagnosis is often unclear preoperatively, but a non-enhancing mass on MRI between anterior and posterior lobe may suggest the presence of an intra- and suprasellar colloid cyst.

Extradural temporopolar approach to lesions of the upper basilar artery and infrachiasmatic region.

Surgical access to the parasellar, infrachiasmatic, and posterior clinoid regions has traditionally been accomplished through an intradural pterional or subtemporal approach. However, for large or complex lesions in these locations, such traditional trajectories may not afford sufficient exposure for complete obliteration of the pathological process. The authors describe an anterolateral transcavernous approach to this region that includes the following components: 1) extradural removal of the sphenoid wing and exposure of the superior orbital fissure and foramen rotundum; 2) removal of the anterior clinoid process via the anterolateral route; 3) decompression of the optic canal; 4) extradural retraction of the temporal tip; 5) transcavernous mobilization of the carotid artery and third cranial nerve; and 6) removal of the posterior clinoid process. This method results in enhanced exposure with minimal brain retraction and preservation of the temporal tip bridging veins. This approach has been used in 22 patients: 10 with basilar top aneurysms, eight with craniopharyngiomas, one with a tuberculum sellae meningioma, and two with trigeminal neuromas; the last patient had a carotid-cavernous fistula and a concomitant pituitary adenoma. Complete clip ligation was performed for all 10 basilar artery aneurysms, and gross total resection was achieved with preservation of the pituitary stalk in all tumor cases. Microscopic total resection was not possible in two cases of craniopharyngioma due to hypothalamic invasion. Two patients suffered transient postoperative hemiparesis, and one patient has persisting weakness; however, no patient followed for more than 6 months suffered any persistent cranial nerve morbidity. It is concluded that this procedure can serve as an alternative to either the transsylvian or subtemporal approaches when cranial base pathologies are large or complex.