Pituitary adenoma and meningioma in the same patient. Report of three cases

A Cohort Study of CNS Tumors in Multiple Endocrine Neoplasia Type 1

PURPOSE

Multiple endocrine neoplasia type 1 (MEN1) is thought to increase the risk of meningioma and ependymoma. Thus, we aimed to describe the frequency, incidence, and specific clinical and histological features of central nervous system (CNS) tumors in the MEN1 population (except pituitary tumors).

EXPERIMENTAL DESIGN

The study population included patients harboring CNS tumors diagnosed with MEN1 syndrome after 1990 and followed up in the French MEN1 national cohort. The standardized incidence ratio (SIR) was calculated based on the French Gironde CNS Tumor Registry. Genomic analyses were performed on somatic DNA from seven CNS tumors, including meningiomas and ependymomas from patients with MEN1, and then on 50 sporadic meningiomas and ependymomas.

RESULTS

A total of 29 CNS tumors were found among the 1,498 symptomatic patients (2%; incidence = 47.4/100,000 person-years; SIR = 4.5), including 12 meningiomas (0.8%; incidence = 16.2/100,000; SIR = 2.5), 8 ependymomas (0.5%; incidence = 10.8/100,000; SIR = 17.6), 5 astrocytomas (0.3%; incidence = 6.7/100,000; SIR = 5.8), and 4 schwannomas (0.3%; incidence = 5.4/100,000; SIR = 12.7). Meningiomas in patients with MEN1 were benign, mostly meningothelial, with 11 years earlier onset compared with the sporadic population and an F/M ratio of 1/1. Spinal and cranial ependymomas were mostly classified as World Health Organization grade 2. A biallelic MEN1 inactivation was observed in 4/5 ependymomas and 1/2 meningiomas from patients with MEN1, whereas MEN1 deletion in one allele was present in 3/41 and 0/9 sporadic meningiomas and ependymomas, respectively.

CONCLUSIONS

The incidence of each CNS tumor was higher in the MEN1 population than in the French general population. Meningiomas and ependymomas should be considered part of the MEN1 syndrome, but somatic molecular data are missing to conclude for astrocytomas and schwannomas.

Collision Tumor Composed of Nonfunctioning Pituitary Adenoma and Meningioma in the Sellar Region: Report of a Case and Literature Review

Background  The coexistence of two histologically distinct neoplasms in the same area without histological admixture or an intermediate cell population zone represents a rare tumor type called collision tumor. Collision tumor of pituitary adenoma and meningioma has been reported years later following irradiation to pituitary adenoma. However, collision tumor of pituitary adenoma and meningioma in absence of irradiation therapy is extremely uncommon. Case Description  We report an unusual case of collision tumor involving diaphragma sella meningioma and pituitary adenoma in a 50-year-old lady without prior radiation therapy. She presented with visual blurring and impaired field of vision. Her preoperative magnetic resonance imaging (MRI) was suggestive of pituitary adenoma. Total excision of the lesion was performed through endoscopic transsphenoidal route. Histological diagnosis was consistent with collision tumor of pituitary adenoma and meningioma. Conclusion  Collision tumor comprising of nonfunctioning pituitary adenoma and meningioma is extremely rare. Preoperative MRI may not always be able to distinguish these histologically distinct neoplasms. Hence, histopathological examination is necessary to establish the diagnosis. Endoscopic transsphenoidal approach may suffice in excision of these collision tumors. Close follow-up is necessary to detect tumor recurrence. Though the association of these tumors can be coincidental, casual relationship between the occurrence of collision tumors cannot be totally excluded.

Case report: Two unique cases of co-existing primary brain tumors of glial origin in opposite hemispheres

Background

Primary CNS tumors are rare. Coexistence of two glial tumors of different histological origins in the same patient is even rarer. Here we describe two unique cases of coexisting distinct glial tumors in opposite hemispheres.

Cases

Patient 1 is a 38-year-old male who presented with a seizure in February/2016. MRI showed a left parietal and a right frontal infiltrating nonenhancing lesions. Both lesions were resected revealing an oligodendroglioma WHO grade-2 and an astrocytoma WHO grade-2. Patient 2 is a 34-year-old male who presented with a seizure in November/2021. MRI showed a left frontal and a right mesial temporal lobe infiltrating nonenhancing lesions. Both lesions were resected revealing an oligodendroglioma WHO grade-2 and a diffuse low-grade glioma, MAPK pathway-altered (BRAF V600E-mutant). Patient 1 underwent adjuvant treatment. Both patients are without recurrence to date.

Discussion

Two histologically distinct glial tumors may coexist, especially when they are non-contiguous. Pathological confirmation of each lesion is imperative for appropriate management. We highlight the different management of gliomas based on the new CNS WHO 2021 classification compared to its 2016 version, based on NCCN guidelines. Although more molecular markers are being incorporated into glioma classification, their clinical impact of it is yet to be determined.

Coexistence of meningioma and other intracranial benign tumors in non-neurofibromatosis type 2 patients: A case report and review of literature

BACKGROUND

The coexistence of meningioma and other intracranial primary benign tumors is rare, especially in non-neurofibromatosis type 2, and there is limited guidance for the management of such patients. Here, we report a series of 5 patients with concomitant meningioma and other intracranial benign tumors, including subependymoma and pituitary adenoma.

CASE SUMMARY

Five non-neurofibromatosis type 2 patients with simultaneous occurrence of meningioma and other intracranial benign tumors were retrospectively reviewed. The patients had no history of previous irradiation. The clinical features, pre- and postoperative imaging, surgical procedure and pathological findings were extracted from electronic medical records. There were 4 female patients (80%) and 1 male patient (20%). The mean age was 42.8 years (range: 29-52 years). The coexisting tumors included subependymoma in 1 case (20%) and pituitary adenoma in 4 cases (80%). The most common clinical symptom was headache (3/5, 60%). Four patients (80%) underwent craniotomy. One patient (20%) underwent transsphenoidal surgery followed by transcranial operation. All tumor diagnoses were confirmed by histopathological examination. The mean follow-up was 38.8 mo (range: 23-96 mo), and all 5 patients were in a stable condition at the last follow-up.

CONCLUSION

The simultaneous occurrence of meningioma and other intracranial benign tumors is a rare clinical event. Histological examination is necessary for the accurate diagnosis. Neurosurgeons should select the appropriate surgical strategy according to the clinical features of each patient, which may provide a more favorable prognosis for individual patients.

Endoscopic endonasal resection of coexisting pituitary adenoma and meningioma: Two cases' report and literature review

INTRODUCTION

The coexistence of pituitary adenoma (PA) and para/suprasellar meningioma is an extremely rare event, which generally occurs in previous case reports. Literature on the endonasal endoscopic approach (EEA) to treat such synchronous tumours remains sparse.

CASE DESCRIPTION

Two cases of concomitant sellar and supra/parasellar tumours are reported. A 62-year-old woman with a PA and a tuberculum sellae meningioma and a 56-year-old woman with a PA and a cavernous sinus (CS) meningioma. Both coexisting tumours were resected through a single extended EEA and achieved a good prognosis. To the best of our knowledge, endoscopic endonasal resection of coexisting PA and CS meningioma has not been previously reported in the literature.

CONCLUSION

Our reports add to the literature two cases of coexisting PA and meningioma, with different consistence in sellar and para/suprasellar regions. Furthermore, the present case adds to the evidence that in the rare situation of coexisting sellar and suprasellar tumours located in the same sagittal plane, an extended EEA allows adequate exposure and safe removal of both tumours. However, for tumours coexisting in the sellar and parasellar region in the same coronal plane, we should draw attention to this rare situation for differential diagnosis of synchronous PA and CS meningioma to avoid unnecessary surgery and to decide the best strategy for treatment.

Multiple, Primary Brain Tumors with Diverse Origins and Different Localizations: Case Series and Review of the Literature

Background:

Multiple, primary brain tumors with different histological types occurring in the same patient are extremely rare. Several hypotheses have been proposed, and the pathophysiology of coexisting tumors has long been debated; however, due to low incidence, standard practices for this scenario are still inconclusive.

Case Description:

The authors describe 6 cases of coexisting tumors. By conducting a literature research focused on the computed tomography (CT) era and patients without prior radiation or phakomatosis. Sixty-five such reported cases were identified. In addition, the authors summarize their experience in 6 patients including histopathological features, chronological presentations, outcomes, mortality, and management from their series as well as from previous cases from the reported literature.

Conclusion:

The coexistence of multiple, primary brain tumors is an interesting condition. Surgical management remains the major treatment; malignant histology has a poor prognostic factor.

Simultaneous Occurrence of a Pituitary Adenoma and a Foramen Magnum Meningioma: Case Report

The coexistence of a pituitary adenoma and a meningioma is a rare event. In all previously reported cases, only 1 of these 2 tumors was symptomatic. We present the case of 61-year-old woman with no significant medical history who was treated for a simultaneously symptomatic pituitary nonfunctioning adenoma and foramen magnum meningioma. Such an association has not been reported previously.

Endoscopic endonasal resection of a synchronous pituitary adenoma and a tuberculum sellae meningioma: technical case report

OBJECTIVE

The presence of a sellar macroadenoma with a concomitant tuberculum sellae meningioma typically requires a craniotomy for extirpation of the meningioma. We describe a single endoscopic approach for resection of both lesions.

PRESENTATION

A 52-year-old woman with complaints of continuous headache and right temporal visual field loss was found to have a 1.9 x 2.1 x 1.7-cm enhancing sellar mass on magnetic resonance imaging scans associated with a second enhancing extra-axial lesion at the planum sphenoidale measuring 1.0 x 0.6 cm and encroaching on the right optic nerve.

INTERVENTION

After the endoscopic transnasal resection of the pituitary tumor, the planum sphenoidale was drilled and the underlying dura was incised. The suprasellar tumor was identified and completely resected. Histological evaluation confirmed the concomitant presence of a meningioma and pituitary adenoma.

CONCLUSION

With advances in endoscopic and image-guidance technology and increasing understanding of the endoscopic anatomy of the sellar region, surgeons are capable of reaching both intrasellar and suprasellar/anterior cranial base region tumors through a single endoscopic approach. The use of endoscopes in transsphenoidal approaches may obviate the need for additional craniotomies in properly selected patients.

MRI finding of simultaneous coexistence of growth hormone-secreting pituitary adenoma with intracranial meningioma and carotid artery aneurysms: report of a case

Coexistence of pituitary adenoma, intracranial meningioma and cerebral aneurysm has never been described. We report on a patient with GH-secreting pituitary macroadenoma associated with a right frontal meningioma and with two intracavernous asymptomatic aneurisms. A 61-year-old woman was referred to our Endocrine Unit 13 years after a right frontal craniotomy for a pituitary tumour. Endocrine investigation showed high levels of IGF-1 (560 ng/ml) and increased basal serum GH (56 ng/ml) levels, not suppressed after OGTT. MRI showed persistence of a homogeneously enhancing intra- and suprasellar lesion, compressing the visual pathways, with bilateral intracavernous invasion and simultaneous coexistence of a right intracavernous internal carotid artery (ICA) aneurysm in direct contact with the pituitary tumour. Somatostatin analog treatment normalized GH and IGF-1 levels. Eight months later, the patient underwent a balloon ICA occlusion with disappearance of the right ICA aneurysm. One year later, a new MRI confirmed the presence of the pituitary mass showing also a right intracranial frontal meningioma and a new ICA aneurysm on the left side. Previous studies have suggested that prolonged GH hypersecretion could play a role in the genesis of intracranial aneurysms, inducing atherosclerotic and/or degenerative modification of the arterial walls. Other aetiological factors include a mechanical effect due to a direct contact between adenoma and aneurysm. Coexistence of pituitary adenoma and intracranial meningioma is a rare event, but also for this association it has been suggested that GH or other growth factors could play a role in appearance or in growth of meningioma. In our case, meningioma appeared and grew, despite the effective treatment of acromegaly.

Meningiomas may be a component tumor of multiple endocrine neoplasia type 1

PURPOSE

Recently, an increased incidence of some nonendocrine tumors are reported in patients with multiple endocrine neoplasia type 1 (MEN 1). There are rare reports of meningiomas and other central nervous system tumors in these patients, but it is unknown if they are more frequent or if allelic loss of the MEN1 gene is important in their pathogenesis. The aim of this study was to address these two latter questions.

EXPERIMENTAL DESIGN

Results from a prospective study of 74 MEN 1 patients with suspected/proven pancreatic endocrine tumors (PETs) were analyzed, as well as molecular studies performed on a resected meningioma. All patients had serial brain imaging studies (computed tomography, magnetic resonance imaging, and octreoscanning since 1994) and yearly studies evaluating MEN 1 involvement with a mean follow-up of 7.2 years. Results were compared with 185 patients with sporadic Zollinger-Ellison syndrome.

RESULTS

Six patients (8%) had meningiomas. Meningiomas were single and found late in the MEN 1 course (mean age = 51 years). Magnetic resonance imaging/computed tomography were more sensitive than octreoscanning. Their diagnosis averaged 18 years after the onset of hyperparathyroidism, 10-15 years after pituitary disease or PETs. Meningiomas were 11 times more frequent in patients with PETs with MEN 1 than without MEN 1 (P = 0.017). No clinical, laboratory, or MEN 1 feature distinguished patients with meningiomas. Meningiomas were asymptomatic and 60% showed no growth. A resected meningioma showed loss of heterozygosity at 11q13 and 1p, including at p73 and ARHI/NOEY2 locus, but not at the neurofibromatosis 2 gene locus.

CONCLUSIONS

These results show meningiomas are not an infrequent occurrence in MEN 1, and loss of the function of the MEN1 gene product plays a role in their pathogenesis in these patients.

Intrasellar meningioma: case report and review of the literature

BACKGROUND

Intrasellar meningioma is a rare clinical entity, and surgical resection may be difficult when it is hypervascularized.

METHODS

A case of subdiaphragmatic hypervascular intrasellar meningioma with attachment to the dura of the anterior wall of the sella turcica is described. Literature review of 18 cases with operatively confirmed intrasellar meningioma discloses unexpected intraoperative bleeding and relatively low resectability of the tumor are also described.

RESULTS

We used preoperative endovascular embolization of feeding arteries, and resected a hypervascular intrasellar meningioma by a combined transsphenoidal-transcranial approach safely and without massive bleeding.

CONCLUSIONS

Preoperative endovascular embolization of feeding arteries and combined transsphenoidal-transcranial approach are useful for the surgical resection of hypervascular intrasellar meningiomas.

Diaphragma sellae meningiomas

Despite their unique clinical, radiological, and surgical considerations, diaphragma sellae meningiomas remain largely undistinguished from tuberculum sellae meningiomas. On the basis of our experience with 12 patients with diaphragma sellae meningiomas and our review of the literature, we classify these tumors into three groups: Type A, originating from the upper leaf of the diaphragma sellae anterior to the pituitary stalk; Type B, originating from the upper leaf of the diaphragma sellae posterior to the pituitary stalk; and Type C, originating from the inferior leaf of the diaphragma sellae. Each type has specific clinical symptoms. Type A mainly presents with unilateral visual disturbances and visual field defects resembling those of tuberculum sellae meningiomas, although preoperative diabetes insipidus occurred in patients with large tumors. Type B causes fewer visual disturbances, but memory disturbance and hypopituitarism occur. Type C closely resembles nonfunctioning pituitary adenomas; bitemporal hemianopsia and hypopituitarism are common. Multiplanar magnetic resonance images can accurately diagnose the tumor and establish its type. Surgical approaches include the cranio-orbital approach for Types A and B and the transcranial-transsphenoidal approach for Type C. Surgery is more difficult than for tuberculum sellae meningiomas because of the deep location and the difficulty of dissecting Types A and B from the pituitary stalk. Repair of the sphenoid sinus to prevent cerebrospinal fluid leakage is mandatory for Type C tumors.

Coexistence of growth hormone-secreting pituitary adenoma and intracranial meningioma: a case report and review of the literature

The simultaneous occurrence of a pituitary adenoma and an intracranial meningioma is a rare event. We report the coexistence of an eosinophilic pituitary adenoma and a endotheliomatous meningioma, in the sellar region, and evaluate their endocrine, neuro-radiological and immunohistochemical pattern. A 47-year-old woman affected by acromegaly was referred to us. Serum GH level was 82 ng/ml and remained unresponsive to both OGTT (75 g per os) and iv. GHRH 1-29 (100 micrograms); IGF-1 was 807 ng/ml. Eight hours after acute sc administration of octreotide (100 micrograms) GH returned to normal levels (2.3 ng/ml). CT scan showed a large intra- and suprasellar mass involving the right cavernous sinus, with a retrosellar extension along the tentorium. A slight and inhomogeneous enhancement, with a periferal rim of bright signal was apparent at MRI. Conversely, the retrosellar component showed a bright homogeneous enhancement. The patient, therefore, underwent neurosurgery. Histological examination revealed the coexistence of 2 types of tissue: areas of endotheliomatous meningioma were interspersed among sheets of acidophilic adenoma tissue. Immunohistochemical analysis was performed in order to determine the relationship between the two masses: a positive staining for GH was shown in the areas of adenoma, as against for GHRH, neither in the adenomatous tissue nor in the slices of meningioma. Although MRI showed a latero-sellar post-surgical residual of meningioma, serum GH value was < 1 ng/ml. In conclusion, the relationship between the GH-secreting adenoma and the meningioma is unclear; however the GH-hypersecretion is not induced by a hypothetic GHRH-activity from the meningioma.

Coexisting corticotroph and lactotroph adenomas: case report with reference to the relationship of corticotropin and prolactin excess

A 57-year-old obese woman with hypertension, diabetes mellitus, osteoporosis, and a 40-year history of secondary amenorrhea was diagnosed with corticotropin-dependent Cushing's syndrome. Dynamic endocrine testing and radiological evaluation did not reveal definitively the source of the excess corticotropin. Bilateral adrenalectomy was performed with resolution of the signs and symptoms of hypercortisolism. Four years later, the patient was noted to have rising serum corticotropin levels and an enlarging pituitary mass; hyperprolactinemia also was documented. A diagnosis of Nelson-Salassa syndrome was made, and she underwent a transsphenoidal adenomectomy. A histological examination of the specimen revealed two distinct, albeit contiguous, adenomas: a corticotroph adenoma and a lactotroph adenoma. Postoperatively, the serum prolactin and corticotropin levels decreased significantly. Although the stalk section effect resulting from compression by a pituitary adenoma can raise serum prolactin levels, a concurrent lactotroph adenoma should be considered in patients with nonfunctional or functional pituitary adenomas of other types associated with significantly elevated prolactin levels. The mechanisms underlying simultaneous adrenocorticotropic hormone and prolactin excess are discussed.