Suprasellar Location Research Articles

Role of bifrontal basal interhemispheric approach in recurrent suprasellar tumors; craniopharyngioma and pituitary tumors

Recurrent suprasellar tumors, including craniopharyngiomas and pituitary tumors, can be approached with minimal brain retraction, a wider operative field with better orientation and a good view of important neurovascular structures via a bifrontal basal interhemispheric approach (BFBIHA). The authors present their experience of using BFBIHA for removal of recurrent suprasellar tumors, during which they recorded the size and location of each tumor and the degree of tumor extension. Two hundred fifty-four cases of pituitary tumors and 80 cases of craniopharyngiomas were operated on. Recurrent cases were 25 (9.8%) in pituitary tumors and 14 (17.5%) in craniopharyngiomas. Among recurrent cases, nine patients (five recurrent pituitary tumors, four recurrent craniopharyngiomas) were included. Preoperatively, suprasellar extension of the tumors was measured with the aid of radiological images (MRI, MRA, CT). Using line C (mid-sella), the tumors were divided into three groups according to the direction of tumor growth. Group I (one case) contained those with a prechiasmatic location, group II (two cases), those with a suprasellar location, and group III (five cases), those with a retrochiasmatic location. All of the recurrent patients underwent operations by the same approach. All tumors but one were totally resected. There was no operative mortality. In our experience, recurrent suprasellar tumors were safely manipulated with this BFBIHA, preserving important neurovascular structures and hypothalamo–pituitary functions.

An entirely suprasellar Rathke's cleft cyst: case report and review of the literature

Rathke's cleft cysts usually present with an intrasellar or a combined intrasellar and suprasellar localization. In this report we present a 58-year-old man with a Rathke's cleft cysts in an entirely suprasellar location with intact diaphragm and intact sella. Although this presentation of a Rathke's cleft cyst is extremely rare, it belongs in the differential diagnosis of entirely suprasellar lesions. The relevant literature is discussed.

A pseudo-endocrine suprasellar tumour: review of primitive neuroectodermal tumours in adults

Primitive neuroectodermal tumours (PNETs) are very rare malignant brain tumours mostly affecting children. We report a 55-year-old female with a PNET, presenting with the clinical picture of a large suprasellar tumour. The patient complained of visual field defects, and had personality changes but no endocrine deficiencies or signs of hypothalamic disturbance. The diagnosis of craniopharyngioma was initially suspected on computerised tomography scan, but was not confirmed by magnetic resonance imaging, because of the presence of some perilesional oedema. The tumour was removed in two phases: first through a right frontal craniotomy to remove the suprasellar part and two weeks later through a transsphenoidal approach to remove tumour tissue from the sella turcica. The pathological examination of the first resected specimen revealed compact fields of small, rounded cells and hyperplasia of the interstitial connective tissue, compatible with an adamantinomatous craniopharyngioma. Pathological investigation after the second operation demonstrated perivascular pseudo-rosettes and immunoreactivity of tumour cells for synaptophysin, favouring the diagnosis of a PNET. After the surgery the patient retained a serious cognitive deficit. Staging examinations were not performed and the intention of systemic therapy was abandoned. She died six months later, in poor general condition, of a respiratory infection. Our case of PNET is the first to be reported with a suprasellar location in an adult patient and we suggest that this diagnosis should be included in the differential diagnosis of a hypothalamic tumour in adults. The epidemiology and therapy of this unusual

Radiation therapy of pineal region tumors: 25 new cases and a review of 208 previously reported cases

Purpose : Malignant pineal region tumors are rare neoplasms arising in midline structures of the brain. This report analyzes the influence of histology, tumor location, radiation dose, treatment volume, age and cerebrospinal fluid findings on freedom from relapse, freedom from spinal relapse and survival. Methods and Materials : Patient and treatment parameters of 25 cases of pineal region tumors managed at Stanford University are presented, and an additional 208 published cases were reviewed. Univariate and multivariate analysis were performed to delineate parameters predictive of freedom from relapse, freedom from spinal relapse, and survival for all 233 patients. Results : The 5- and 10-year freedom from relapse for Stanford patients was 63% and 46%, respectively. The 5-and 10-year survival for Stanford patients was 67% and 61%, respectively. The 5- and 10-year freedom from relapse for the total 233 cases was 66% and 61%, respectively. The 5- and 10-year survival for all patients was 74% and 68%, respectively. For the entire group, biopsy confirmed germinoma and non-biopsied tumors had superior freedom from relapse compared to non-germinoma germ cell tumors ( p = 0.03, p = 0.005, respectively). Non-biopsied patients had improved survival compared to non-germinoma germ cell tumors ( p = 0.004). Pineal parenchymal tumors had worse freedom from relapse compared to non-biopsied patients ( p = 0.04). For patients with suprasellar tumors, germinomas were associated with improved freedom from relapse compared to non-germinoma germ cell tumors ( p = 0.02). Simultaneous pineal and suprasellar tumors had superior survival compared to solitary tumors of pineal ( p = 0.04), suprasellar ( p = 0.03), or third ventricle location ( p = 0.03). Twenty-two patients (9.4%) developed isolated spinal relapse. Five- and 10-year spinal relapse rates for all patients were 11%n and 13%. Survival after spinal relapse was 19%. Pineal parenchymal tumors had lower freedom from spinal relapse compared to non-biopsied patients ( p = 0.001). For tumors located in the pineal gland, germinomas and pineal parenchymal tumors had lower freedom from spinal relapse than did non-biopsied patients ( p = 0.006, p = 0.004, respectively). Pineal germinomas had lower freedom from spinal relapse than germinomas with suprasellar location ( p = 0.04). Univariate and multivariate analysis identified tumor histology as the most significant predictor of freedom from relapse, freedom from spinal relapse and survival. Conclusion : Histologic type had the greatest impact on outcome. Treatment recommendations should be based on assessment of histologic type and extent of disease.

Clinical, radiographic, and pathological features of symptomatic Rathke's cleft cysts

The clinical, radiographic, and pathological findings in 155 patients with symptomatic Rathke's cleft cysts are discussed. Eight patients were treated by the authors and 147 were collected in a review of the literature. This lesion occurred more often in female than male patients by a 2:1 margin, and the mean age at presentation was 38 years. The average patient had been symptomatic for nearly 3 years at the time of treatment, with the most common symptoms and signs being pituitary dysfunction, visual disturbances, and headaches. Affected children generally were pituitary dwarfs. The sella was enlarged in 80% of cases, and the cyst was situated in both an intrasellar and a suprasellar location in 71%. Computerized tomography revealed a low-density cystic mass with capsular enhancement in one-half of the cases. A variable appearance was seen with magnetic resonance imaging. Partial excision and drainage of the cyst by the transsphenoidal approach is the recommended treatment, as the recurrence rate is low. Most symptoms and signs improved or resolved following surgery with the exception of hypopituitarism and diabetes insipidus. The cyst lining was usually composed of ciliated cuboidal or columnar epithelium. Theories as to the origin of Rathke's cleft cysts are also discussed.

Radiation therapy for pineal and suprasellar germ cell tumors

Radiation therapy (XRT) was used in the treatment of 25 patients with tumors of the pineal and suprasellar locations. A tissue diagnosis was obtained before XRT in 5 patients, and 20 were irradiated without histologic verification. The overall survival rate is 80% (76% with no evidence of disease [NED]). Megavoltage XRT was delivered to the entire neuraxis in 22 patients, and 86% (19/22) are alive from 4 to 88 months (median, 30 months) after treatment. In two of three patients treated only to local fields, tumor recurred in the spine; both are dead of disease. Biopsy-proven germinomas and multiple midline tumors responded favorably to XRT, whereas solitary pineal tumors and teratomas with marker positivity (human chorionic gonadotropin, alpha-fetoprotein) did not respond as well. The endocrinologic presentation, tumor marker status, and early response to radiation measured on computed tomography are useful means for selecting patients for radiation therapy.