Sellar Magnetic Resonance Imaging Research Articles

Pituitary apoplexy associated with gram-negative meningitis following transsphenoidal surgery

BackgroundPituitary apoplexy (PA) is a rare but potentially life-threatening condition. While it is uncommon, it can present with findings that are clinically indistinguishable from acute bacterial meningitis. We report an unusual case of simultaneous coexistence of bacterial meningoencephalitis and pituitary apoplexy following transsphenoidal surgery (TSS) for pituitary macroadenoma, emphasizing the possibility of coexistence of the two entities.Case presentationA 62-year-old man was admitted with a moderate headache, gait disturbance, and progressively decreasing vision. Sellar magnetic resonance imaging showed a giant pituitary tumor of 4 × 5 cm with invasion of the cavernous sinus bilaterally, and a mass effect on the optic chiasm. The patient underwent a TSS and partial resection of a giant pituitary tumor. On postoperative day 11, he presented with an acute, severe headache and altered sensorium. An urgent computed tomography (CT) scan revealed hemorrhagic swelling of the residual. A complete analysis of the anterior pituitary hormones revealed panhypopituitarism. Administering steroid ameliorated the clinical features, but after decreasing the dose, the patient continued to deteriorate in his neurological status, a high fever, and marked stiffness were noted on postoperative day 14. Given the neck stiffness, leukocytosis, and high C-reactive protein level, acute meningitis was suspected, and the cerebrospinal fluid (CSF) was tested, which was consistent with acute bacterial meningitis. In the results of the bacterial cultures of the CSF, E. coli was identified and switched to ceftriaxone. The patient's neurological status and body temperature improved gradually. CSF test results returned to normal levels, and ceftriaxone was discontinued on day 10.ConclusionsThis is a report on a case of a giant pituitary tumor that developed late postoperative PA after having undergone a partial tumor resection. A postoperative CT scan showed hemorrhagic expansion of the residual tumor mass. Further, the patient exhibited typical symptoms of acute meningoencephalitis, the result of the cultures of the CSF was positive, and the patient's general condition deteriorated. In addition, laboratory findings indicated leukocytosis, an elevated C-reactive protein level, and neutrophilic pleocytosis. We highlighted diagnostic challenges and therapeutic delays arising as a result of rare concomitance.

The influence of pituitary volume on the growth response in growth hormone-treated children with growth hormone deficiency or idiopathic short stature.

Magnetic resonance imaging (MRI) can be used for assessing the morphology of the pituitary gland in children with short stature. The purposes of this study were: (1) to determine if pituitary volume (PV) can distinguish patients with growth hormone (GH) deficiency from those with idiopathic short stature (ISS), (2) to validate an association between PV and severity of GH deficiency, and (3) to compare PV between good and poor response groups in children with GH deficiency or ISS after 1 year of treatment. Data were collected from the medical records of 152 children with GH deficiency or ISS who underwent GH stimulation test, sella MRI, and GH treatment for at least 1 year. Estimated PVs were calculated using the formula of an ellipsoid. We compared the PVs in patients with GH deficiency with those of patients with ISS. In addition, we assessed the association between PV and severity of GH deficiency, and we assessed growth response after treatment. No difference was observed in PV between patients with GH deficiency and those with ISS. The severity of the GH deficiency seemed to be associated with PV (P=0.082), and the height of the pituitary gland was associated with severity of GH deficiency (P<0.005). The PV in the good response group was less than that of the poor response group in patients with GH deficiency (P<0.005), and PV showed no association with responsiveness to GH treatment in patients with ISS (P=0.073). The measurement of PV cannot be used for differential diagnosis between GH deficiency and ISS. In patients with GH deficiency, PV tended to be smaller as the severity of GH deficiency increased, but the difference was not significant. PV may be a good response predictor for GH treatment. Further studies, including a radiomics-based approach, will be helpful in elucidating the clinical implications of pituitary morphology in patients with short stature.

내시경적 경접형동 접근법에서의 중비갑개 부분 절제가 후각 기능에 미치는 영향

Background: There are controversies on whether endoscopic transsphenoidal approach (TSA) affects postoperative olfaction. This study aimed to compare olfactory function in regard of partial resection status of middle turbinate (MT) and analyze the amount of resection in images.&#x0D; Materials and Methods: This study retrospectively reviewed 46 patients who had undergone endoscopic TSA due to pituitary adenoma or Rathke’s cleft cyst from 2015 to 2019. MT preserva-tion (MTP) group was defined as the group of patients whose MTs were preserved. MT resection (MTR) group was defined as the group of patients whose MTs were partially resected unilaterally or bilaterally. Olfactory function was compared with pre- and postoperative 3-month Korean version of sniffing sticks test-II which was composed of threshold, discrimination, identification (TDI) scores each making 16 with correct answers. Pre- and postoperative images including paranasal computed tomography and sellar magnetic resonance imaging were analyzed using Picture Archiving and Communication System.&#x0D; Results: There were 41 pituitary adenomas and 5 Rathke’s cleft cysts. Male patients were 39.1% (n = 18) and mean age was 42.6. About 1/3 (31%) of MT was resected in MTR group (n = 13), which had the effect of increasing the cross-sectional area of the nasal cavity by 19%. Post-septectomy area was 6% of total septum. Preoperative TDI score was 27.34 and postoperative TDI score was 25.42. There were no significant differences of olfactory score in total, MTR and MTP groups 3 months after endoscopic TSA.&#x0D; Conclusions: Resection of lower third of MT may produce low morbidity in respect of olfactory function after endoscopic TSA.

Central diabetes insipidus following COVID-19 mRNA vaccination: a case report

The coronavirus disease 2019 (COVID-19) has been a major public health emergency worldwide. Vaccines were rapidly developed and approved to prevent the spread of viral infection. However, various side effects of the COVID-19 messenger RNA (mRNA) vaccines have been reported after their commercialization. A 24-year-old man visited our emergency department with polyuria and polydipsia that occurred after he received a COVID-19 mRNA vaccine 10 days beforehand. The initial laboratory findings showed very low urine osmolality with hyperosmolar hypernatremia. Based on these findings, diabetes insipidus was suspected, and sella magnetic resonance imaging showed an enlarged pituitary gland and the absence of posterior pituitary higher intensity. After 12 hours of using oral desmopressin acetate, urine volume decreased, and after 5 days of administration, serum electrolyte and serum osmolality improved. This case report of diabetes insipidus occurring after vaccination with the BNT162b2 mRNA COVID-19 vaccine is presented as a reminder that close monitoring is necessary for patients with polyuria and polydipsia after vaccination.

Missed pituitary microadenoma during endoscopic transsphenoidal surgery for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing with symptom relief: illustrative case.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is a rare headache disorder that has been associated with pituitary adenomas. Resection has been posited to be curative. A 60-year-old female presented with a 10-year history of SUNCT, which had been medically refractory. Sellar magnetic resonance imaging (MRI) showed a 2 × 2 mm nodule in the right anterolateral aspect of the pituitary. Endoscopic endonasal transsphenoidal resection of the pituitary microadenoma with neuronavigation was performed. The patient felt immediate relief from the headaches. Postoperative MRI showed persistence of the pituitary microadenoma and the resection tract to be inferomedial to the lesion. The right middle and partial superior turbinectomy site was close to the sphenopalatine foramen (SPF). The patient was discharged on postoperative day 1 and remained headache-free without any medications at the 4-month follow-up. Resection of pituitary lesions associated with SUNCT may not necessarily be the cause of SUNCT resolution. Manipulation of the middle and superior turbinate close to the SPF may lead to a pterygopalatine ganglion block. This may be the mechanism of cure for SUNCT in patients with related pituitary lesions who undergo endonasal resection.

Sustained hypercortisolemia after bilateral adrenalectomy in Cushing's disease

Abstract Introduction Cushing's disease caused by pituitary corticotropin (ACTH)-secreting tumors. These tumors are almost always benign and are usually microadenomas. In 30 to 40 percent, the microadenoma is so small that it is not detectable by magnetic resonance imaging (MRI). Primary therapy consists of transsphenoidal surgery or pituitary irradiation. Patients who fail this first approach can be treated either by repeat transsphenoidal surgery, medical therapy, radiotherapy, or, as a final resort, surgical or medical adrenalectomy. Clinical Case A 38-year-old male patient presented with headache and fatigue. The laboratory examinations reviewed ACTH depending Cushing's syndrome. A suspicious lesion in the pituitary with no contrast enhancement was observed in Sella MRI. Cavernous sinus sampling consistent with central sources. He was operated in 2018 for pituitary Cushing's disease. Reticulin framework disrupted compatible with adenoma but, ACTH could not be stained in immunohistochemical staining for technical reasons. Due to the high cortisol levels of the patient in the postoperative follow-up, the patient underwent bilateral adrenalectomy in 2019. Because of active Cushing's disease, patient was re-evaluated in 2022. In laboratory examinations, HGB 16.6 g/dL, WBC 6400 /uL, NEU 3200 /uL, PLT 228000 uL, cre 0.76 mg/dL, TSH 1.5 mIU/L, FT4 1.2 ng/dl, FSH 4.6 U/L, LH 7.98 U/L, PTH 23.7 ng/L, PRL 17 µg/L, Total Testosterone 571 ng/dl, Progesterone 0.06 µg/L, GH 0.04 ug/L, IGF1 83 µg/L were detected. Basal cortisol was 35 ug/dl and ACTH 67 ng/L. Cortisol with 1 mg of DST resulted in 28 ug/dl. 2 mg DST resulted in cortisol 38 ng/L. Free cortisol in the urine was found to be 281 mg/day (n&amp;lt;130 mg/day). Empty sella was observed in sella MR. No prominent contoured lesion was observed in the pituitary gland. Adrenal gland was not observed in the Abdominal MRI. No tumor was detected in Thorax CT. The patient's pasireotide 0.3 mg 1×1 treatment was continued. Metyropane 250 mg 2×1 was added to the treatment. Conclusion In Cushing's disease, the ACTH-secreting adenoma may be too small to be detected.

Difficulties in diagnosing acromegaly, acromegaly with apparently normal GH: Micromegaly

Abstract Introduction Acromegaly results from pathologically increased secretion of growth hormone (GH) from the pituitary somatotroph adenoma. If left untreated, it is associated with increased morbidity and mortality. We present a case of micromegaly, whose diagnosis is challenging for clinicians. Clinical Case A 40-year-old woman presented with complaints of enlarged facial features, hands and feet, and separation between teeth. She was using a salbutamol inhaler with the diagnosis of asthma. Her physical examination was unremarkable except for a body mass index of 28.7 kg/m2 and malocclusion. Insulin-like growth factor (IGF)-1 250 ng/mL (101–234) and GH 2.1 ng/mL was detected. 0, 1. and 2nd hour in oral glucose tolerance test (OGTT)-GH; hour GH/glucose values were 6.7/70, 1.5/98, 0.35 ng/ml /95 mg/dl, respectively. Sella magnetic resonance imaging (MRI) revealed an 8×5mm adenoma in the pituitary gland (Figure). Pseudoacromegaly causes such pachydermoperiostitis, severe insulin resistance, familial mandibular prognathism, use of phenytoin and minoxidil, and causes of false IGF-1 elevation such as pregnancy, puberty/adolescent period, thyrotoxicosis, glucocorticoid use were excluded. It was decided that the patient should be operated on. No adenoma was detected in the pathology tissue of the operated patient, but IGF-1 was detected at 201 ng/ml (101–234) and GH was 1,1 ng/ml in the 3rd postoperative month. The nadir GH was found to be 0.3 ng/ml in the OGTT-GH suppression test. Medical treatment was not started. The case has been followed for 2 years in remission. Conclusion Micromegaly describes a subset of patients with clinically evident acromegaly and elevated IGF-1 with apparently normal basal GH and often &amp;lt;0.4 ng/mL glucose suppressed GH. This condition is relatively rare in patients with acromegaly. As in our case, micromegaly should be considered in diagnosing patients with “normal” GH but with clinical signs, or even patients without clinical signs but with pituitary tumors and elevated IGF-1.

Desmopressin responding female nephrogenic diabetes insipidus: a case report

Nephrogenic diabetes insipidus, decreased ability to concentrate urine, with production of large amounts of urine, is caused by the refractory response of renal tubules to the action of antidiuretic hormone. This rare disorder, known as X-linked nephrogenic diabetes insipidus, is caused by a mutation in the arginine vasopressin receptor 2 gene. Because it is hereditary, most patients are male. This report highlights a case of nephrogenic diabetes insipidus in a 3-year 5-month-old female; upon presentation to the hospital, her symptoms included frequent urination and consumption of a significant amount of water, which had begun 2 years ago. The results of blood tests showed increased levels of serum antidiuretic hormone, and sellar magnetic resonance imaging showed no abnormality. The results of the water restriction test and the desmopressin administration test confirmed the diagnosis of nephrogenic diabetes insipidus showing a partial response to desmopressin. The results of genetic testing indicated the presence of an arginine vasopressin receptor 2 mutation, a heterozygous missense mutation (p.Val88Met), suggesting inheritance of X-linked nephrogenic diabetes insipidus. This report describes a significant case of symptomatic X-linked nephrogenic diabetes insipidus in a female patient who showed a partial response to desmopressin.

A Radiomics-Based Model with the Potential to Differentiate Growth Hormone Deficiency and Idiopathic Short Stature on Sella MRI.

PurposeWe hypothesized that a radiomics approach could be employed to classify children with growth hormone deficiency (GHD) and idiopathic short stature (ISS) on sella magnetic resonance imaging (MRI). Accordingly, we aimed to develop a radiomics prediction model for differentiating GHD from ISS and to evaluate the diagnostic performance thereof.Materials and MethodsShort stature pediatric patients diagnosed with GHD or ISS from March 2011 to July 2020 at our institution were recruited. We enrolled 312 patients (GHD 210, ISS 102) with normal sella MRI and temporally split them into training and test sets (7:3). Pituitary glands were semi-automatically segmented, and 110 radiomic features were extracted from the coronal T2-weighted images. Feature selection and model development were conducted by applying mutual information (MI) and a light gradient boosting machine, respectively. After training, the model’s performance was validated in the test set. We calculated mean absolute Shapley values for each of the selected input features using the Shapley additive explanations (SHAP) algorithm. Volumetric comparison was performed for GHD and ISS groups.ResultsTen radiomic features were selected by MI. The receiver operating characteristics curve of the developed model in the test set was 0.705, with an accuracy of 70.6%. When analyzing SHAP plots, root mean squared values had the highest impact in the model, followed by various texture features. In volumetric analysis, sagittal height showed a significant difference between GHD and ISS groups.ConclusionRadiomic analysis of sella MRI may be able to differentiate between GHD and ISS in clinical practice for short-statured children.

Demystifying the Relevance of Size Amongst Macro- and Micro-Corticotropinoma: Experience in 206 Patients.

Objective:In individuals with adrenocorticotrophic hormone (ACTH)-dependent Cushing’s syndrome (CS), to estimate the differences between micro-corticotropinoma (size ≤6 mm and 6-10 mm), macro-corticotropinoma (>10 mm) and ectopic Cushing’s syndrome (ECS), in relation to their epidemiological, clinical and biochemical parameters.Methods:In individuals with CS, the clinical and hormonal parameters, and magnetic resonance imaging of sella were collected from 1984 to 2019. A total of 138 cases of micro-corticotropinoma, 47 cases of macro-corticotropinoma and 21 cases of ECS were compared.Results:Except for size, there were no differences in biochemical and hormonal parameters of macro- and micro-corticotropinoma, irrespective of their size (≤6 mm, 6-10 mm and >10 mm). In comparison to Cushing’s disease (CD), individuals with ECS had a male predominance (F:M ratio of 2.4:1 vs. 0.5:1), shorter duration from onset of symptoms to diagnosis (24 vs. 12 months). They also had a higher ACTH (139 vs. 65.8 pg/ml), 0800h cortisol (1200 vs. 880 nmol/l), 2300h cortisol (1100 vs. 700 nmol/l) and cortisol levels after high dose dexamethasone suppression test (1050 vs. 244.5 nmol/l).Conclusion:The biochemical phenotype of macro-corticotropinoma resembles that of micro-corticotropinoma despite their larger tumour size, suggesting that the former is relatively less functional. Micro-corticotropinoma ≤6 mm and 6-10 mm have a similar clinical and biochemical profile. As compare to CD, ECS is characterised by a higher disease burden as reflected in their higher cortisol, more autonomicity and loss of rhythmicity.

Pituitary MRI Standard and Advanced Sequences: Role in the Diagnosis and Characterization of Pituitary Adenomas.

Pituitary adenomas (PAs) represent the most frequently found lesions in the sellar region; however, several other lesions may be encountered in this region, such as meningiomas, craniopharyngiomas, and aneurysms. High-quality imaging is fundamental for diagnosis, characterization, and guidance of treatment planning of PAs. Sellar magnetic resonance imaging (MRI) is considered the imaging modality of choice for the evaluation of lesions in the sella turcica. The sellar MRI standard protocol includes coronal and sagittal T1-weighted spin-echo sequencing with and without gadolinium-based contrast agent and coronal T2-weighted (T2w) fast-spin echo sequencing. A systematic MRI approach to the pituitary region generally provides information that includes the size and shape of the PA, the presence of cysts or hemorrhage within the tumor, its relationship with the optic pathways and surrounding structures, potential cavernous sinus invasion, sphenoid sinus pneumatization type, and differential diagnosis with other sellar lesions. The standard protocol is sufficient for the evaluation of most cases; however, some advanced techniques (susceptibility imaging, diffusion-weighted imaging, 3D T2w high-resolution sequences, magnetic resonance elastography, perfusion-weighted imaging) may render additional information, which may be important for some cases. In this "approach to the patient" manuscript, we will discuss the use of standard and advanced MRI sequences in the diagnosis and characterization of PAs, including MRI features associated with treatment response that may aid in presurgical evaluation and planning, and red flags that may point to an alternative diagnosis.

Application of artificial intelligence and radiomics in pituitary neuroendocrine and sellar tumors: a quantitative and qualitative synthesis.

To systematically review the literature regarding the application of machine learning (ML) of magnetic resonance imaging (MRI) radiomics in common sellar tumors. To identify future directions for application of ML in sellar tumor MRI. PubMed, Medline, Embase, Google Scholar, Scopus, ArxIV, and bioRxiv were searched to identify relevant studies published between 2010 and September 2021. Studies were included if they specifically involved ML of MRI radiomics in the analysis of sellar masses. Risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) Tool. Fifty-eight articles were identified for review. All papers utilized retrospective data, and a quantitative systematic review was performed for thirty-one studies utilizing a public dataset which compared pituitary adenomas, meningiomas, and gliomas. One of the analyzed architectures yielded the highest classification accuracy of 0.996. The remaining twenty-seven articles were qualitatively reviewed and showed promising findings in predicting specific tumor characteristics such as tumor consistency, Ki-67 proliferative index, and post-surgical recurrence. This review highlights the potential clinical application of ML using MRI radiomic data of the sellar region in diagnosis and predicting treatment outcomes. We describe future directions for practical application in the clinical care of patients with pituitary neuroendocrine and other sellar tumors.

Dedicated sellar magnetic resonance imaging protocols without contrast enhancement in girls with central precocious puberty: prevalence of pathologic lesions and clinical correlation.

Contrast-enhanced brain magnetic resonance imaging (MRI) is routinely performed in children with central precocious puberty (CPP). We evaluated the value of a dedicated sellar MRI protocol without contrast enhancement in girls with CPP. This study included 261 girls diagnosed with CPP. We performed sellar MRI scanning without gadolinium enhancement of the hypothalamic-pituitary area (HPA) at the pituitary level, including additional T2-weighted imaging of whole-brain scans to check for other lesions. We evaluated the prevalence of intracranial lesions via this MR protocol. In addition,the correlation between the clinical parameters and morphology of the pituitary gland on the images was assessed. Intracranial lesions were detected in 17 (6.5%) of the 261 girls. Of the 17 girls with abnormalities, 16 (94.1%) had findings in brain areas other than the HPA. The weight, height, Tanner stage of patients were significantly (p < 0.05) higher in the group with greater pituitary height. Patient weight and height, Tanner stage of breast development, and luteinizing hormone (LH) levels were significantly (p < 0.05) greater in those with a higher pituitary grade as determined on sellar MRI. A dedicated unenhanced sellar MRI protocol provides valuable information on brain lesions and pituitary morphology. We found a significantly low prevalence of brain lesions among girls with CPP. Analysis of the height or shape of the pituitary gland on sellar MRI revealed significant correlations with the weight, height, Tanner stage, and LH levels of the patients.

A challenging TSH/GH co-secreting pituitary adenoma with concomitant thyroid cancer; a\xa0case report and literature review

BackgroundThyroid stimulating hormone (TSH) secreting pituitary adenoma (TSHoma) with coexisting thyroid cancer is extremely rare, and proper treatment of both diseases may pose a unique clinical challenge. When TSHoma has plurihormonality, particularly involving the co-secretion of growth hormone (GH), management can be more complicated. Herein, we present a difficult-to-manage case of papillary thyroid cancer with an incurable TSH/GH-secreting pituitary adenoma.Case presentationA 59-year-old man was referred to our hospital due to memory impairment and inappropriate TSH level. Sella magnetic resonance imaging revealed a huge pituitary mass extending to the suprasellar area. Clinical diagnosis of TSH/GH co-secreting pituitary adenoma was made based on elevated free T4, total T3, serum α-subunit, insulin-like growth factor-1 levels and non-suppressible GH levels after oral glucose loading. Rectal cancer and multifocal papillary thyroid microcarcinoma (PTMC) were diagnosed during initial screening for internal malignancy; lower anterior resection was performed and close observation was planned for PTMC. Long-acting octreotide therapy was commenced, which resulted in a dramatic reduction in TSHoma size and facilitated control of hormonal excess. Total thyroidectomy and radioactive iodine (RAI) therapy were needed during follow up due to the growth of PTMC. After the surgery, the pituitary adenoma represented resistance to somatostatin analogue therapy and the tumor size gradually increased despite the addition of dopamine agonist therapy. Furthermore, TSH suppressive therapy with levothyroxine was impossible and an adequate TSH level for RAI therapy was unmountable. Late debulking pituitary surgery was ineffective, and the patient gradually deteriorated and lost to follow up.ConclusionWe report the first aggravated case of TSH/GH co-secreting pituitary tumor after total thyroidectomy for concomitant multifocal PTMC. Deferring of thyroid surgery until the TSHoma is well controlled may be the optimal therapeutic strategy in patients with TSHoma and coexistent thyroid cancer; ablative thyroid surgery may result in catastrophic pituitary tumor growth.

New developments and perspectives in acromegaly

Acromegaly is a rare but severe disorder which is usually due to an excessive secretion of growth hormone (GH) by a pituitary adenoma. Screening mainly relies on the measurement of insulin-like growth factor 1, and confirmatory diagnostics includes a GH suppression test. As delayed diagnosis results in increased morbidity and mortality, we here discuss recently published suggestions regarding the biochemical work-up of suspected cases and the follow-up of co-morbidities. Moreover, new analytical tools (such as automatic identification of typical facial changes using artificial intelligence) are presented, hopefully allowing for an earlier diagnosis in the future. So far, surgery is still regarded as therapy of first choice. In cases without postoperative remission, a new imaging approach (combining sellar magnetic resonance imaging and position emission tomography) may improve the results of repeated surgery. The pharmaceutical arsenal now includes the first orally available somatostatin analogue, and recent data on possible drug combinations and the outcome of radiotherapy are presented. Finally, special attention is paid to older and pregnant patients, as well as certain considerations during the COVID-19 pandemic (where appropriate diagnosis and management of acromegaly is particularly challenging).

Long-term response to cabergoline and multi-modal treatment in men with macroprolactinoma: Does size really matter?

To study the outcome of men with macroprolactinoma following cabergoline treatment based on tumour size. Retrospective cohort study. The study included 94 men, divided into three groups according to adenoma diameter: 10-19 mm (Group A, n = 36); 20-39 mm (Group B, n = 41); or ≥40 mm (Group C, giant prolactinomas, n = 17). Patients were followed for a mean of 7.5 years with sellar magnetic resonance imaging, visual fieldsand hormone measurements. Mean baseline prolactin was 767, 2090 and 24,806 ng/ml in Groups A, Band C, respectively (p < .01). Prolactin suppression below three times the upper limit of normal(ULN) was achieved in 34 (94%; mean weekly cabergoline dose of 1.2 mg), 37 (90%; cabergoline dose, 2.1 mg)and 15 (88%; cabergoline dose, 2.8 mg) men (p = .31) in each group. After excluding patients who underwent surgery and radiotherapy, cabergoline suppressed prolactinbelow three times ULN in 32/35 (91%), 29/37 (78%)and 11/14 (79%) men in Groups A, Band C, respectively (p = .27). Visual deficits were observed in 5 (14%), 12 (29%)and 10 (59%) patients (p < .01); improvement was achieved in 5/5 (100%), 11/12 (92%)and 10/10 (100%) of men in Groups A, Band C. Low baseline testosterone was measured in 26 (72%), 39 (95%)and 17 (100%) patients in the three groups (p < .01). Following multi-modal treatment, hypogonadism persisted in 3 (8%), 5 (12%)and 2 (12%) men, respectively (p = .85). Macroprolactinomas in men were controlled with cabergoline in 84% of cases, independent of tumour size. Pituitary surgery and adjuvant radiotherapy further improved long-term response to 91%.

Findings of Brain Magnetic Resonance Imaging in Girls with Central Precocious Puberty Compared with Girls with Chronic or Recurrent Headache.

In the present study, the results of brain magnetic resonance imaging (MRI) in girls with central precocious puberty (CPP) were compared those in with girls evaluated for headaches. A total of 295 girls with CPP who underwent sellar MRI were enrolled. A total of 205 age-matched girls with chronic or recurrent headaches without neurological abnormality who had brain MRI were included as controls. The positive MRI findings were categorized as incidental non-hypothalamic–pituitary (H–P), incidental H–P, or pathological. Positive MRI findings were observed in 39 girls (13.2%) with CPP; 8 (2.7%) were classified as incidental non-H–P lesions, 30 (10.2%) as incidental H–P lesions, and 1 (0.3%) as a pathological lesion (tuber cinereum hamartoma). The prevalence of positive MRI findings in girls with CPP did not differ from girls with headaches (13.2% vs. 12.2%, p = 0.74). The prevalence of incidental H–P lesions in girls with CPP <6 years of age, 6–6.9 years of age, and 7–7.9 years of age was 21.2%, 13.5%, and 9.6%, respectively (p = 0.21). Known pathological lesions were detected in only one (3.0%) girl with CPP aged <6 years and in no girls with CPP aged 6–7.9 years. Microadenomas were detected in no girls with CPP aged <6 years and in 5 (1.9%) girls with CPP aged of 6–7.9 years. Our findings call into question the routine use of brain MRI in girls with CPP, especially in girls 6 years or older. Current guidelines recommend a follow-up MRI in cases of microadenoma, but few data exist to support this recommendation for children.

A Rare Case of Sellar Metastastic Renal Cell Carcinoma Mimicking Pituitary Adenoma - a Case Report

Introduction: Metastatic sellar masses are very contributing to 2% of all sellar masses, and up to 0.87% of all metastases to the brain. Breast and lung cancer contribute for up to 60% of all sellar metastases but it is important to recognize other cancers that can also metastasize to pituitary gland. Renal Cell carcinoma (RCC) is number nine on that list. Here we present a case of rare RCC metastasis to pituitary which was mistaken as pituitary adenoma to emphasize early recognition and management of pituitary metastases which may result in better patient’s outcomes and prognosis. Case Presentation: 7 2 year-old male with a remote history of left sided RCC presented with worsening diplopia, blurry vision and headaches for 2 months. Physical exam was remarkable for right sided ptosis with right oculomotor, trochlear and abducens palsy. Computed Tomography Imaging (CT) of the brain showed hyperdense sellar/suprasellar fullness. Magnetic Resonance Imaging (MRI) with and without contrast of the brain showed 2.2 x 1.7 cm enhancing mass in the right cerebellopontine angle with local mass effect concerning for a pituitary tumor. Laboratory work-up was remarkable for hyperprolactinemia 36.5 ng/mL, low TSH <0.015 mU/L, and normal ACTH, FSH and LH levels. Patient underwent endoscopic trans-nasal resection of pituitary tumor. Surgical pathology of the tumor was consistent with metastatic renal cell carcinoma. He was discharged with appropriate multidisciplinary outpatient follow up with endocrinology, oncology and radiology. Discussion: Pituitary metastasis is very rare and often mistaken for pituitary adenoma. Only 7% of Pitutary metastases are symptomatic. Symptom presentation depends on the location of metastases. They include diabetes insipidus (45.2%), visual field defects (27.9%), hypopituitarism (23.6%), ophthalmoplegia (21%), headache (15.8%) and hyperprolactinemia (6.3%). Although, there is no gold standard imaging for sellar masses, both thin-section CT and MRI are beneficial. CT is used for visualizing bony destruction and calcification, on the other hand MRI demarcates lesions in that area. Due to its rarity, there is no standardized guideline therapy for pituitary metastasis and it should be individualized based on patient’s presentation, but it should be multidisciplinary approach of surgical resection, postoperative stereotactic radiosurgery, chemotherapy, and hormone replacement therapy. Prognosis of metastases to pituitary is very poor, with reported six to twenty-two months post resection survival. Factors contributing to prolonged survival are younger age, single/small metastases, and locally guided radiation therapy. Conclusion: This case is to shed light on early recognition of sellar metastasis as a challenging diagnosis especially in patients with rapidly growing pituitary mass and neurological symptoms with history of malignancy for better outcomes.

Treatment of Cushing’s disease with macroadenoma through transsphenoidal surgery

Cushing’s disease (CD) is a rare illness characterized by chronic hypercortisolism secondary to the overproduction of adrenocorticotropic hormone by a pituitary adenoma, which is associated with a high risk of developing serious complications, such as diabetes mellitus, cardiovascular disease, and emotional disorders. Endoscopic transsphenoidal surgery is performed for the treatment of CD, and was initially preferred over other types of treatments. However, the recurrence after pituitary surgery for CD is a common problem after an initial successful surgery. In microadenomas, the remission rates were higher than those of macroadenoma. This patient had a giant tumor that was greater than 4 cm in length on sella magnetic resonance imaging, and panhypopituitarism was detected using a combined pituitary stimulation test. After transsphenoidal surgery, the patient required temporary hormone replacement for a short period of time. After 1 year, he showed a normal cortisol response on the overnight dexamethasone suppression test and low morning cortisol levels. Therefore, we indicated that the patient was cured of giant macroadenoma with panhypopituitarism before surgery, and thus, reported this case. Key words: Cushing disease, Theasinensin A, Adenoma, Pituitary

Effectiveness of Cabergoline Treatment in Patients with Acromegaly Uncontrolled with SSAs: Experience of a Single Tertiary Center.

To evaluate the effectiveness of cabergoline and the parameters affecting cabergoline response as add-on treatment to somatostatin analaogues (SSA) in patients with acromegaly uncontrolled with SSAs. One hundred and twenty-nine acromegalic patients uncontrolled with SSA who had cabergoline added to their treatment were included in this retrospective study. Patients were divided into the SSAs + cabergoline-responsive (group 1) and non-responsive groups (group 2), and biochemical, pathologic, and radiologic parameters were assessed. IGF-1 normalization was achieved in 75 of 129 patients (58%) when cabergoline was added to the SSA treatment. Female patients were significantly higher in group 1 compared to group 2 (p=0.006). Group 1 had significantly smaller pre- and post-cabergoline tumor size (p=0.011, p=0.007 respectively), lower levels of IGF-1 in pre-and post-operative period (p=0.040, p=0.001), and lower levels of IGF-1 in pre- and post-cabergoline treatment (p<0.001). Cavernous invasion on sellar magnetic resonance imaging, dural invasion in pathologic examination were not significantly different between the groups. Sellar invasion in pathologic examination was significantly higher in group 1 (p=0.011). No significant difference was found in proliferation indices between two groups. The presence of fibrous bodies was significantly lower in group 1 (p=0.010). Cabergoline can be added to the treatment of acromegalic patients uncontrolled with SSAs due to its ease of use and low economic cost, especially in patients with acromegaly who have small adenomas and no fibrous bodies.