Case report of sarcoma of the sella caused by postoperative radiotherapy for a prolactin-producing pituitary adenoma

Case report: Spindle cell sarcoma and pituitary adenoma in the sella region-a rare collision tumor

Background

Collision tumors are defined as two or more distinctly bordered, mutually invasive tumors in the same anatomical region. Characterized by low incidence and lack of specificity, they often pose a significant challenge to disease diagnosis. Among these, collision tumors in the sella region are incredibly rare.

Case description

On 13 June 2023, the Department of Neurosurgery at Drum Tower Hospital admitted a patient with a pituitary adenoma in the sella region complicated by spindle cell sarcoma. After reviewing the literature, no related cases were reported. A patient presenting with complex clinical symptoms and preoperative imaging showing occupancy in the sella region is considered to have a recurrence of pituitary adenoma. After thorough preoperative evaluation and discussion, a trans-sphenoidal approach (with the aid of an endoscope) was performed to resect the pituitary lesions. Combined with postoperative pathological tissue and imaging, the patient was diagnosed with a pituitary adenoma (postoperative recurrence) in the sella region complicated by spindle cell sarcoma. The patient made a fair recovery and was discharged on the 8th postoperative day.

Conclusion

This case report aims to elucidate and discuss the diagnosis and screening of rare collision tumors in the sella region to reduce the misdiagnosis rate and provide accurate treatment.

Sarcomas of the sellar region: a systematic review

PURPOSE AND METHODS

Sarcomas of the sellar region are uncommon and unexpected tumors. Here, we review the cases reported in literature via a systematic search.

RESULTS

Ninety-four patients, 58.5% male with mean age of 39.2 ± 17.2 years were included. Fifty-seven (62%) had soft tissue sarcomas (STS) and 35 (38%) bone sarcomas (BS). Sarcoma was a primary tumor in 66%, developed after radiotherapy in 31.9% and 7.4% were metastatic. Median time between radiotherapy and sarcoma development was 10.5 (11) years. Main presentation symptoms were visual disorders (87.9%), headache (61.5%) and III cranial nerve palsy (24.1%). After surgery, sarcoma persisted or recurred in 82.3% and overall mortality reported was 44.6% with 6.5 (14) months of median survival. Tumor appeared earlier in BS compared to STS (34.4 ± 15.1 vs. 42.6 ± 17.6 years), p = 0.034 and complete tumor resection was achieved more often (41.3% vs. 4.4%), p =  < 0.001. Condrosarcoma and rhabdomyosarcoma were more frequent subtypes among primary tumors while fibrosarcoma was among post-radiation sarcomas. Tumor size was larger in radiation associated sarcomas (mean maximum diameter 46.3 ± 9.3 vs. 29.1 ± 8.0 mm, p = 0.004) and persistency/recurrence was similar in both groups (70.1 vs. 73.3%, p = 0.259).

CONCLUSION

Sarcomas appear as mass effect symptoms in the middle aged population, mainly as primary tumors, but one third is associated with radiotherapy. Surgery is commonly not curative, mortality rate is high and death ensues shortly after diagnosis.

The diagnosis and management of primary and iatrogenic soft tissue sarcomas of the sella

PURPOSE

Soft tissue sarcoma (STS) of the sella is exceptionally rare. We conducted a case series, literature review, and nationwide analysis of primary and iatrogenic (radiation-associated) STS of the sella to define the clinical course of this entity.

METHODS

This study employed a multi-institutional retrospective case review, literature review, and nationwide analysis using the National Cancer Database (NCDB).

RESULTS

We report five patients who were diagnosed at three institutions with malignant STS of the sella. All patients presented with symptoms related to mass effect in the sellar region. All tumors extended to the suprasellar space, with the majority displaying extension into the cavernous sinus. All patients underwent an operation via a transsphenoidal approach with a goal of maximal safe tumor resection in four patients and biopsy for 1 patient. Histopathologic evaluation demonstrated STS in all patients. Post-operative adjuvant radiotherapy and chemotherapy were given to 2 and 1 out of 4 patients with known post-operative clinical course, respectively. The 1-year and 5-year overall survival rates were 100% (5/5) and 25% (1/4). Twenty-two additional reports of primary, non-iatrogenic STS of the sella were identified in the literature. Including the three cases from our series, treatment included resection in all cases, and adjuvant radiotherapy and chemotherapy were utilized in 50% (12/24) and 17% (4/24) of cases, respectively. The national prevalence of malignant STS is estimated to be 0.01% among all pituitary and sellar tumors within the NCDB.

CONCLUSIONS

We report the prevalence and survival rates of STS of the sella. Multimodal therapy, including maximal safe resection, chemotherapy, and radiotherapy are necessary to optimize outcomes for this uncommon pathology.

Unusual Course of an Aggressive Pituitary Prolactinoma: Case Report and Review of the Literature

Pituitary carcinomas are rare tumors with heterogeneous behaviors. Their carcinogenesis is still unknown. Consequently, treatment is multimodal and not standardized. Dopamine (DA) agonists are used as first-line treatments, while radiotherapy and surgery may be used for local control of invasive tumors. We describe the case of a 35-year-old male who presented with an invasive prolactinoma, managed initially with a transsphenoidal resection, postsurgical radiotherapy and DA agonists. The patient posteriorly presented a sole metastatic lesion to the lumbar spine that was later managed with local radiotherapy. Due to pituitary recurrence of the lesion, multiple surgical resections were needed until further treatment was declined. The clinical course in this patient was unusual. He lived for 13 years after initial diagnosis, with a very invasive tumor without systemic chemotherapy. Radiotherapy is used in pituitary tumors in which surgery fails; we hypothesize that it contributed to the malignant transformation and the late resistance to DA agonists in our patient. Several biomarkers in tumoral tissue have been evaluated regarding their association with malignancy and aggressive behaviors, although more studies are still needed. Therapeutic strategies are limited, without evidence on the impact on overall survival and prognosis. Risk factors associated with early malignancy in pituitary prolactinomas include recurrent behavior, increase in prolactin levels with a stable sellar mass, and secondary development of DA agonist resistance. However, there are still no conclusive answers as to whether physicians should rigorously follow up these patients or provide direct therapy with aggressive approaches.

Broad clinical spectrum and diverse outcomes of prolactinoma with pediatric onset: medication-resistant and recurrent cases

Prolactinoma is a benign tumor of the pituitary gland that rarely occurs in children and adolescents; thus, the clinical spectrum and long-term prognosis in these patients remain unknown. This study was performed to investigate the long-term outcomes of medical treatment and the prognostic factors for remission and relapse in children and adolescents with prolactinoma. Three male subjects and four female subjects between the ages of 7- and 17-years-old were included in this study. The mean initial serum prolactin level was 443 ± 251.8 ng/mL (range, 152-946 ng/mL). During the follow-up period (range, 0.6-20 years), a dopamine agonist was administered, and surgery or radiotherapy was performed in cases of resistance to medical treatment or relapse. Unlike female subjects with macroadenoma who often exhibit a good clinical course, two male subjects with early onset macroadenoma presented with visual disturbances. These subjects showed resistance to medical therapy and relapsed, eventually requiring surgical removal and radiotherapy; one of the subjects manifested a metastatic thrombus in the internal jugular vein. In conclusion, pediatric prolactinoma exhibits a broad clinical spectrum, a relatively high incidence of macroadenoma, resistance to medical therapy, and frequent tumor relapses. In addition, a poor prognosis appears to be correlated with male sex, age at disease onset, and histopathological characteristics.

Extended transsphenoidal approach for pituitary adenomas invading the cavernous sinus using multiple complementary techniques

PURPOSE

Transsphenoidal surgery is the treatment of choice for most pituitary adenomas (PA), except prolactinomas. Difficulties achieving radical resection with this method are encountered in patients with PAs invading the cavernous sinus (CS), due to the inability of the standard transsphenoidal approach to expose all tumors adequately. This study analyzed methods to resect PAs invading the CS and factors influencing the degree of tumor resection and occurrence of complications.

METHODS

Outcomes were retrospectively analyzed in 52 patients with PA invading the CS who underwent surgery via the extended transsphenoidal approach utilizing multiple techniques, including microscopy, endoscopy, neuronavigation, and intraoperative Doppler ultrasonography.

RESULTS

Gross-total resection (GTR) was achieved in 33 patients (63.5 %). GTR rate was significantly higher in patients with Knosp Grade 3 than Knosp Grade 4 (92.3 vs. 53.8 %) and in patients undergoing initial surgery than reoperation (77.1 vs. 35.3 %). One patient (2.9 %) undergoing initial surgery experienced transient cranial nerve palsy, without other postoperative complications. Postoperative complications were significantly higher after reoperation. Firm tumor consistency was significantly more frequent in patients undergoing reoperation than initial surgery (52.9 vs. 8.6 %).

CONCLUSION

Extended transsphenoidal surgery incorporating multiple complementary techniques was highly effective for PAs invading the CS. Postoperative complications rates were relatively low, especially for patients undergoing initial surgery and those with Knosp Grade 3 tumors. Total resection of PAs invading the CS remains challenging, especially in patients undergoing reoperation or having firm tumors.