Primary tumors of the posterior pituitary: A systematic review

Posterior pituitary tumors: an entity unto itself

Posterior pituitary tumors (PPT) are rare, benign tumors but may lead to compromised hypothalamic and pituitary function. A new study by Kremenevski et al. presents a single institution experience of these tumors, namely, pituicytomas, spindle cell oncocytomas, and granular cell tumors. They incorporate the revised 2022 WHO classification and highlight the preoperative and postoperative endocrine, metabolic, and radiologic outcomes of PPT. This study adds to our knowledge in this rare subset of tumors and underscores the need for ongoing surveillance for hypopituitarism and hypothalamic obesity.

Hypopituitarism in non-neuroendocrine pituitary tumors: a systematic review

The existing evidence on pituitary function impairment in non-neuroendocrine pituitary tumors (non-PitNETs) is limited and scattered. We performed a systematic review using PubMed, Embase, Scopus, and Cochrane of all reported studies that evaluated pituitary function in craniopharyngiomas, meningiomas, germinomas, pituitary lymphomas, pituicytomas, granular cell tumors, spindle cell oncocytomas, and pituitary metastases over the past 35 years. A total of 5,614 patients from 114 studies were analyzed. The weighted mean age was 35.01 ± 2.7 years (95% CI: 34.9-35.1) and 47.5 ± 14.1% (95% CI: 47.1-47.8) were women. The overall weighted proportion of hypopituitarism was 49.1 ± 24.2% (95% CI: 48.4-49.7) and arginine vasopressin deficiency (AVD) was 18.43 ± 16.6% (95% CI: 17.9-18.9). According to tumor type, prevalence of hypopituitarism was 67.3 ± 8.1% (95% CI: 66.5-68.9) for germinomas, 61.4 ± 20.8% (95% CI: 58.8-64.1) for metastases, 58.7 ± 22.2% (95% CI: 46.2-71.3) for lymphomas, 54.4 ± 30.8% (95% CI: 45.6-63.3) for pituicytomas, 53.8 ± 12.3% (95% CI: 47.5-59.8) for oncocytomas, 49.1 ± 17.2% (95% CI: 48.6-49.6) for craniopharyngiomas, 29.7 ± 16.6% (95% CI: 22.4-36.9) for granular cell tumors, and 11.5 ± 9.1% (95% CI: 10.8-12.3) for meningiomas. When comparing the most prevalent non-PitNETs, the weighted prevalence of hypopituitarism was higher in metastases compared to craniopharyngiomas (χ2 = 696.8, df = 1), p < 0.0001. Similarly, the weighted prevalence of hypopituitarism in craniopharyngiomas was higher compared to meningiomas (χ2 = 16,278.13, df = 1), p < 0.0001. In conclusion, non-PitNETs result in hypopituitarism in approximately half of the cases and AVD in nearly one-fifth. Pituitary metastases and craniopharyngiomas demonstrate greater local aggressiveness and a higher likelihood of disrupting hypothalamic-pituitary function compared to meningiomas.

Preoperative Prediction of Non-functional Pituitary Neuroendocrine Tumors and Posterior Pituitary Tumors Based on MRI Radiomic Features

Compared to non-functional pituitary neuroendocrine tumors (NF-PitNETs), posterior pituitary tumors (PPTs) require more intraoperative protection of the pituitary stalk and hypothalamus, and their perioperative management is more complex than NF-PitNETs. However, they are difficult to be distinguished via magnetic resonance images (MRI) before operation. Based on clinical features and radiological signature extracted from MRI, this study aims to establish a model for distinguishing NF-PitNETs and PPTs. Preoperative MRI of 110 patients with NF-PitNETs and 55 patients with PPTs were retrospectively obtained. Patients were randomly assigned to the training (n = 110) and validation (n = 55) cohorts in a 2:1 ratio. The lest absolute shrinkage and selection operator (LASSO) algorithm was applied to develop a radiomic signature. Afterwards, an individualized predictive model (nomogram) incorporating radiomic signatures and predictive clinical features was developed. The nomogram's performance was evaluated by calibration and decision curve analyses. Five features derived from contrast-enhanced images were selected using the LASSO algorithm. Based on the mentioned methods, the calculation formula of radiomic score was obtained. The constructed nomogram incorporating radiomic signature and predictive clinical features showed a good calibration and outperformed the clinical features for predicting NF-PitNETs and PPTs (area under the curve [AUC]: 0.937 vs. 0.595 in training cohort [p < 0.001]; 0.907 vs. 0.782 in validation cohort [p = 0.03]). The decision curve shows that the individualized predictive model adds more benefit than clinical feature when the threshold probability ranges from 10 to 100%. Individualized predictive model provides a novel noninvasive imaging biomarker and could be conveniently used to distinguish NF-PitNETs and PPTs, which provides a significant reference for preoperative preparation and intraoperative decision-making.

Clinical, surgical, and endocrine outcome following treatment of posterior pituitary tumors: a retrospective cohort study

PURPOSE

This study evaluates the clinical presentation, endocrine dysfunction, surgical outcome, and long-term prognosis in patients with histologically confirmed posterior pituitary tumors (PPTs).

METHODS

A retrospective cohort study was conducted on 19 patients treated for PPTs at a single center between 2000 and 2023. Data on clinical, endocrine, and surgical outcomes were collected and analyzed.

RESULTS

The cohort included 3 pituicytomas (PCs), 8 granular cell tumors (GCTs), and 8 spindle cell oncocytomas (SCOs) patients, with a female predominance (58%) and a mean age of 57.2 ± 13.2 years. Symptoms leading to diagnosis were headache (31.6%), visual impairment (21%), and sexual dysfunction (10.5%). GCT patients had higher preoperative BMI (34.49 ± 5.72) compared to PC (22.12 ± 2.40) and SCO (24.74 ± 4.24) patients (p < 0.01). Postoperative BMI increased across all groups, with GCTs patients showing the steepest rise (p < 0.01). Endocrine dysfunction largely persisted or worsened after surgery, with limited recovery at follow-up. Surgical approaches included transsphenoidal (48%) and transcranial (52%), achieving gross total resection in 58% of cases. Tumor recurrence occurred in 16% of patients, all requiring adjuvant radiation therapy. Tumor-specific survival at 5 years was 100% with an overall survival rate of 80% where non-tumor-related comorbidities accounted for the observed mortality.

CONCLUSION

PPTs are rare tumors with significant endocrine and metabolic consequences. While surgical management is associated with favorable tumor-specific survival, persistent endocrine dysfunction and postoperative progressive BMI underscore the need for long-term follow-up and targeted interventions. These findings contribute to the understanding of PPT biology and support the development of optimized management strategies.

Oncocytic pituicytoma in a patient with Cushing's disease: a case report and narrative literature review

Background

Posterior pituitary tumors (PPTs) are extremely rare, with fewer than 400 cases reported to date. In 2022, the World Health Organization (WHO) classified four types of tumors originating from the posterior pituitary: traditional pituicytoma, oncocytic pituicytoma, granular pituicytoma, and ependymal pituicytoma. To our knowledge, only one subject with coexistence of Cushing's disease and oncocytic pituicytoma (spindle cell oncocytoma) has been reported, but the clinical features of this patient were not described in detail.

Case presentation

We presented a case of a patient with Cushing's syndrome and a pituitary mass. Transsphenoidal surgery was performed, and pathologic examination revealed two distinct tumors: a corticotroph adenoma with a diameter of less than 2 mm and a larger oncocytic pituicytoma. Post-surgery serum cortisol was 51 nmol/L, indicating complete remission. Corticotroph adenoma or corticotroph hyperplasia was identified after surgery in less than half of the subjects with Cushing's disease and PPT.

Conclusions

Our study indicates that Cushing's disease in patients with PPT may be caused by the existence of collision lesions, with corticotroph adenoma or hyperplasia being difficult to detect due to their small dimensions.

Posterior pituitary tumors and other rare entities involving the pituitary gland

Non-neuroendocrine tumors account for around 10% of all primary neoplasms of the sella. If meningiomas, craniopharyngiomas, and germ cell tumors are excluded, the remaining lesions include a broad spectrum of uncommon, benign, and aggressive, often diagnostically challenging lesions. This review aims to summarize the essential clinicopathological features of tumors of the posterior pituitary gland, infundibulum spectrum expressing thyroid transcription factor 1, and primary sellar atypical rhabdoid teratoid tumor, and provide the criteria for their diagnosis and management.

Neuropathology Entities Involving the Sinonasal Tract

Neuropathologic entities uncommonly involve the sinonasal tract via several mechanisms: (1) ectopic tissue remnants or defects during embryologic development (anterior encephalocele, extracranial meningioma, ectopic pituitary adenoma); (2) extension of benign tumors from structures exiting the brain or in the sellar region (pituitary adenoma, craniopharyngioma, schwannoma, meningioma); and (3) invasion from high-grade intracranial tumors (glioblastoma, atypical teratoid/rhabdoid tumor of sella, anaplastic meningioma, solitary fibrous tumor). Because these entities are not always restricted to the intracranial space, it is important for surgical pathologists to consider them in the differential diagnoses of unusual sinonasal lesions.

A Steerable Microcatheter Effectively Worked in Tumor Embolization

Objective

A Leonis Mova (LM; SB Kawasumi, Kanagawa, Japan), one of the steerable microcatheters, has a remote-controlled flexible catheter tip manipulated with a dial in the hand grip, which enables operators to overcome complicated branching in endovascular surgeries. We report a case of a pituitary tumor in which the LM worked effectively as a distal access catheter (DAC) in tumor embolization.

Case Presentation

A female patient in her 70s complained of bitemporal hemianopsia, and an MRI revealed a pituitary tumor that appeared hypervascular. The right internal carotid artery angiography demonstrated a prominent stain from a tumor vessel derived from the meningohypophyseal trunk (MHT). Tumor embolization was scheduled before its removal due to the hypervascularity. In the tumor embolization, the tip of the LM was bent toward the orifice of the right MHT, through which a 1.3F-1.8F 155 cm microcatheter along with a 0.010-inch 200 cm microguidewire was advanced. Locking the LM tip provided good support for the microcatheter and the microguidewire to proceed to the tumor vessel. Successful tumor embolization was achieved with an injection of 0.21 ml of 12.5% n-butyl-cyanoacrylate. Thanks to the tumor embolization, gross total removal of the pituitary tumor was transshenoidally accomplished with the least blood loss. Histopathological diagnosis of pituicytoma was made, and the intraoperative blood loss of 100 ml seemed small for this histology. The patient recovered from the bitemporal hemianopsia and was discharged without a blood transfusion.

Conclusion

This is the first report in which the LM was used and well worked in tumor embolization as a DAC.

Pituicytoma: A rare tumor of the sella. A case report and review of literature for diagnosis and management

Background

Pituicytomas are rare tumors of the pituitary gland derived from the ependymal cells and line the pituitary stalk and posterior lobe. These tumors are located in the vulnerable regions of the brain: Either in the sellar or suprasellar area. The location marks the difference in the clinical features of the tumor. Here, we report a case of histopathologically diagnosed pituicytoma of the sellar region. Literature is also reviewed and discussed to gain a better understanding of this rare disease.

Case Description

A 24-year-old female presented to the outpatient department with complaints of headache, diplopia, dizziness, and decreased vision in the right eye for 6 months. Computed tomography scan brain without contrast showed a well-defined hyperdense lesion in the sella without associated bony erosion. Her magnetic resonance imaging showed well defined rounded lesion in the pituitary fossa which was isointense on T1-weighted image and hyperintense on T2-weighted images. A presumptive diagnosis of pituitary adenoma was made. She underwent endoscopic endonasal transsphenoidal resection of pituitary mass. Intraoperatively, normal pituitary gland was visualized and there was a grayish-green-colored, jelly like tumor which was pulled gently. On 9^th postoperative day, she presented with cerebrospinal fluid (CSF) rhinorrhea. She underwent endoscopic CSF leak repair. Her histopathology was concluded to be Pituicytoma.

Conclusion

Pituicytoma is an uncommon diagnosis. The surgical aim is to completely excise the tumor which results in complete cure, but incomplete resection may be performed due to high vascularity of this tumor. In case of incomplete excision, recurrence is common and adjuvant radiotherapy may be administered.

Neuroimaging of pediatric tumors of the sellar region-A review in light of the 2021 WHO classification of tumors of the central nervous system

Sellar/suprasellar tumors comprise about 10% of all pediatric Central Nervous System (CNS) tumors and include a wide variety of entities, with different cellular origins and distinctive histological and radiological findings, demanding customized neuroimaging protocols for appropriate diagnosis and management. The 5th edition of the World Health Organization (WHO) classification of CNS tumors unprecedently incorporated both histologic and molecular alterations into a common diagnostic framework, with a great impact in tumor classification and grading. Based on the current understanding of the clinical, molecular, and morphological features of CNS neoplasms, there have been additions of new tumor types and modifications of existing ones in the latest WHO tumor classification. In the specific case of sellar/suprasellar tumors, changes include for example separation of adamantinomatous and papillary craniopharyngiomas, now classified as distinct tumor types. Nevertheless, although the current molecular landscape is the fundamental driving force to the new WHO CNS tumor classification, the imaging profile of sellar/suprasellar tumors remains largely unexplored, particularly in the pediatric population. In this review, we aim to provide an essential pathological update to better understand the way sellar/suprasellar tumors are currently classified, with a focus on the pediatric population. Furthermore, we intend to present the neuroimaging features that may assist in the differential diagnosis, surgical planning, adjuvant/neoadjuvant therapy, and follow-up of this group of tumors in children.

Synchronous Posterior and Anterior Pituitary Tumors: A Case Report of a Hypothetic Paracrine Relationship

Tumors of the posterior pituitary are a distinct group of low-grade sellar neoplasms. Furthermore, the coexistence with an anterior pituitary tumor is extremely unlikely and could not be a mere coincidence and could be a paracrine relationship. Here, we present a case of 41-year-old woman with Cushing syndrome and two pituitary masses on magnetic resonance imaging. Histologic examination shows two distinct lesions. The first consisted of a pituitary adenoma with intense adrenocorticotropic hormone immunostaining and the second lesion consisted of a proliferation of pituicytes arranged in vague fascicles or pituicytoma. After a narrative review of the literature, we found that synchronous pituitary adenoma and a thyroid transcription factor 1 (TTF-1) pituitary tumor were only reported eight times in the past. These patients included two granular cell tumors and six pituicytomas and all of them coexisted with pituitary adenomas, seven functioning and one nonfunctioning. We analyze the hypothesis of a possible paracrine relationship for this concomitance, but this exceedingly rare situation is still a matter of debate. To the best of our knowledge, our case represents the ninth case of a TTF-1 pituitary tumor coexisting with a pituitary adenoma.

Neoplasms and tumor-like lesions of the sellar region: imaging findings with correlation to pathology and 2021 WHO classification

The sellar region represents a complex anatomical area, composed of multiple structures of different embryological derivation, including the skull base and the pituitary gland, along with vascular, nervous, and meningeal structures. Masses arising in this region include benign and malignant lesions arising from the pituitary gland itself, but also from vestigial embryological residues or surrounding tissues, that may require different therapeutic approaches. While assessing sellar region masses, the combination of clinical presentation and imaging features is fundamental to define hypotheses about their nature. MR represents the imaging modality of choice, providing information about the site of the lesion, its imaging features, and relation with adjacent structures, while CT is useful to confirm the presence of lesion calcifications or to reveal tumor invasion of bony structures. The aim of this pictorial review is to provide an overview of the common neoplasms and tumor-like conditions of the sellar region, according to the 2021 WHO Classification of Tumors of the Central Nervous System (fifth edition), with an emphasis on the radiologic-pathologic correlation. After a brief introduction on the anatomy of this region and the imaging and pathological techniques currently used, the most relevant MRI characteristics, clinical findings, and pathological data, including histologic and molecular features, will be shown and discussed, with the aim of facilitating an appropriate differential diagnosis among these entities.

Imaging of pituitary tumors: an update with the 5th WHO Classifications-part 2. Neoplasms other than PitNET and tumor-mimicking lesions

Many types of tumors can develop in the pituitary gland. In the recently revised 5th editions of the World Health Organization (WHO) classifications (2021 WHO Classification of Central Nervous System Tumors and the 2022 WHO Classification of Endocrine and Neuroendocrine Tumors), various changes have been made to the tumors other than pituitary neuroendocrine tumor (PitNET)/pituitary adenoma, as well as PitNET. Adamantinomatous craniopharyngioma and papillary craniopharyngioma are now considered separate tumors in the 5th edition of the WHO classification. Tumors positive for thyroid transcription factor 1, a marker of posterior pituitary cells, are now grouped together in the pituicyte tumor family in the 5th edition of the WHO classification of Endocrine and Neuroendocrine Tumors. Poorly differentiated chordoma is newly listed in the 5th edition of the WHO Classification of Endocrine and Neuroendocrine Tumors. In this paper, we present the latest WHO classification of pituitary tumors (adamantinomatous craniopharyngioma, papillary craniopharyngioma, pituitary blastoma, pituicyte tumor family, tumors of pituitary origin other than those of the pituicyte tumor family, germinoma, meningioma, chordoma, metastatic tumors, lymphoma, and pituitary incidentaloma), review diseases requiring differentiation from tumors (pituitary abscess, hypophysitis, pituitary hyperplasia, Rathke's cleft cyst, arachnoid cyst, and aneurysm), and discuss diagnoses based on imaging findings.

Approach to a case with an unusual cause of hypopituitarism

Hypopituitarism refers to insufficiency of one or more hormones of the pituitary and can be due to myriad causes. The clinical and radiological spectrum of the condition is heterogeneous, based on the age, gender, clinical setting and/or other past medical history. Hypopituitarism includes central hypocortisolism, hypothyroidism, hypogonadism and growth hormone deficiency. Both hypo- and hyperprolactinemia can be associated with hypopituitarism, with low prolactin signifying more extensive pituitary damage. Posterior pituitary insufficiency (arginine vasopressin deficiency), occurs either in isolation or with anterior pituitary hormone deficiency. Clinical symptomatology of hypopituitarism is usually non-specific and insidious in onset and progression. Overall, the most common cause of hypopituitarism is a pituitary adenoma and/or its management (surgery, radiotherapy, pharmacotherapy or a combination of these). However, it is this subset of patients which is more likely to be identified and managed timely, possibly alleviating the premature mortality associated with hypopituitarism. What is more challenging is the recognition of hypopituitarism in less common settings, which may be either due to direct involvement of the pituitary (infection, traumatic brain injury, or infiltrative causes) or indirectly as a consequence of the primary process (thalassemia, vasculotoxic snakebite, subarachnoid hemorrhage). These entities are often under-recognised, and increased awareness can help in greater recognition of the problem burden. Further, pituitary insufficiency in most of these settings is dynamic, which may progress, or rarely, show recovery of function. This renders complexity to the problem, but makes it even more imperative to suspect, screen and appropriately manage patients with less common causes of hypopituitarism.

Pituicytoma Associated with Suspected Cushing’s Disease: Two Case Reports and a Literature Review

(1) Background: Pituicytomas are rare gliomas located in the neurohypophysis or infundibulum. A misdiagnosis of pituicytoma as pituitary adenoma is common because of similar location and occasional endocrine disturbances. (2) Case presentation: We present two cases with the comorbidity of pituicytoma and Cushing’s disease (CD). Case 1 is that of a 51-year-old woman, the first reported case of the comorbidity of pituicytoma, CD, and central diabetes insipidus. She received a diagnosis of CD and central diabetes insipidus. After transsphenoidal surgery, histopathology confirmed the diagnosis of pituicytoma and adrenocorticotropin-secreting microadenoma; case 2 is that of a 29-year-old man who received a biochemical diagnosis of CD, but he received a histopathological confirmation of only pituicytoma. Both patients achieved a remission of hypercortisolism without relapse during the follow-up, but they developed hypopituitarism after surgery. We also reviewed all published 18 cases with the comorbidity of pituicytoma and any pituitary adenoma. (3) Conclusions: Pituicytoma might present pituitary hyperfunction disorders such as CD or acromegaly, with or without pathologically confirmed pituitary adenoma. CD is the most common hyperpituitarism occurring concurrently with pituicytomas. The remission rate and hypopituitarism after surgery seem similar or slightly lower in CD than in common pituitary adenomas, but the long-term prognosis is unexplored.

Recommendation to improve the WHO classification of posterior pituitary tumors as a unique entity: evidence from a large case series

INTRODUCTION

Most studies reporting posterior pituitary tumors (PPTs) are small case series or single cases.

METHODS

Patients with a histological diagnosis of PPT from January 2010 to December 2021 in a tertiary center were identified. We reported clinical symptoms, endocrine assessments, radiological and pathological features, and surgical outcomes of PPTs.

RESULTS

A total of 51 patients (23 males, 51.3 ± 10.3 years old) with PPT were included in this study. Major symptoms were visual defects, headache, and hypopituitarism, while diabetes insipidus was uncommon (9.8%). The typical radiological feature was homogeneous enhancement (84.3%) of a regular-shaped mass on T1 contrast imaging without cystic change, calcification, or cavernous sinus invasion. We achieved gross total resection in 38/51 patients (74.5%). Pathologically, all tumors showed thyroid transcription factor 1 immunoreactivity. Among 29 patients with suprasellar PPTs, postoperative hemorrhage due to tumor residue was encountered in 2/15 cases in the transcranial group and 0/14 in the endoscopy group. Patients with spindle cell oncocytoma (SCO) were more likely to be surgically treated (25% vs 0%, P = 0.018), harbor a higher Ki-67 index (16.7% vs 0% > 5% P = 0.050), and present a lower 2-year recurrence-free survival rate (67.5% vs 90.9%) compared with patients with pituicytoma or granular cell tumor.

CONCLUSION

PPTs should be considered in the differential diagnosis of patients with sellar and suprasellar masses with a regular lesion with homogeneous enhancement. SCOs had high proliferation activity and risk of recurrence.

Sellar, suprasellar, and parasellar masses: Imaging features and neurosurgical approaches

The sellar, suprasellar, and parasellar space contain a vast array of pathologies, including neoplastic, congenital, vascular, inflammatory, and infectious etiologies. Symptoms, if present, include a combination of headache, eye pain, ophthalmoplegia, visual field deficits, cranial neuropathy, and endocrine manifestations. A special focus is paid to key features on CT and MRI that can help in differentiating different pathologies. While most lesions ultimately require histopathologic evaluation, expert knowledge of skull base anatomy in combination with awareness of key imaging features can be useful in limiting the differential diagnosis and guiding management. Surgical techniques, including endoscopic endonasal and transcranial neurosurgical approaches are described in detail.

Genetic and epigenetic characterization of posterior pituitary tumors

Pituicytoma (PITUI), granular cell tumor (GCT), and spindle cell oncocytoma (SCO) are rare tumors of the posterior pituitary. Histologically, they may be challenging to distinguish and have been proposed to represent a histological spectrum of a single entity. We performed targeted next-generation sequencing, DNA methylation profiling, and copy number analysis on 47 tumors (14 PITUI; 12 GCT; 21 SCO) to investigate molecular features and explore possibilities of clinically meaningful tumor subclassification. We detected two main epigenomic subgroups by unsupervised clustering of DNA methylation data, though the overall methylation differences were subtle. The largest group (n = 23) contained most PITUIs and a subset of SCOs and was enriched for pathogenic mutations within genes in the MAPK/PI3K pathways (12/17 [71%] of sequenced tumors: FGFR1 (3), HRAS (3), BRAF (2), NF1 (2), CBL (1), MAP2K2 (1), PTEN (1)) and two with accompanying TERT promoter mutation. The second group (n = 16) contained most GCTs and a subset of SCOs, all of which mostly lacked identifiable genetic drivers. Outcome analysis demonstrated that the presence of chromosomal imbalances was significantly associated with reduced progression-free survival especially within the combined PITUI and SCO group (p = 0.031). In summary, we observed only subtle DNA methylation differences between posterior pituitary tumors, indicating that these tumors may be best classified as subtypes of a single entity. Nevertheless, our data indicate differences in mutation patterns and clinical outcome. For a clinically meaningful subclassification, we propose a combined histo-molecular approach into three subtypes: one subtype is defined by granular cell histology, scarcity of identifiable oncogenic mutations, and favorable outcome. The other two subtypes have either SCO or PITUI histology but are segregated by chromosomal copy number profile into a favorable group (no copy number changes) and a less favorable group (copy number imbalances present). Both of the latter groups have recurrent MAPK/PI3K genetic alterations that represent potential therapeutic targets.

Pituitary spindle cell oncocytoma: illustrative case

BACKGROUND

Spindle cell oncocytoma (SCO) of the pituitary gland is an extremely rare nonfunctional World Health Organization grade I tumor. SCOs are often misdiagnosed as nonfunctional pituitary adenomas on the basis of preoperative imaging. They are often hypervascular and locally adherent, which increases hemorrhage risk and limits resection, leading to increased risk of recurrence. The authors report a case of SCO treated at their institution and provide a review of the current literature.

OBSERVATIONS

SCO of the pituitary gland can be a rare cause of progressively growing pituitary tumors that presents similarly to nonfunctional pituitary adenoma. Endoscopic transsphenoidal resection of the tumor by a multidisciplinary team allowed total resection despite local adherence of the tumor. Postoperatively, the patient’s visual symptoms improved with persistence of secondary adrenal insufficiency and secondary hypothyroidism.

LESSONS

Careful resection is needed due to SCO’s characteristic hypervascularity and strong adherence to minimize local structure damage. Long-term follow-up is recommended due to the tendency for recurrence.

Treatment and prognostic factors of pituicytoma: a single-center experience and comprehensive literature review

PURPOSE

Preoperative diagnosis of pituicytomas is difficult, and management and prognostic factors remain ambiguous. The purpose of this study was to elucidate the radiological characteristics of pituicytoma, to assess the risk factors affecting tumor progression, and to propose the optimal treatment regimen based on comprehensive analysis.

METHODS

We reviewed the clinical data of 22 patients with pituicytoma confirmed pathologically in our institution. In addition, 93 cases of pituicytoma in the previous literature were recruited. The individual data of 115 patients were analyzed to evaluate the adverse factors affecting pituicytoma progression.

RESULTS

In the combined cohort, 3 of 61 patients who underwent gross-total resection (GTR) developed recurrence (4.9%); of the 54 patients who received non-GTR, 19 progressed (35.2%). Univariate and multivariate Cox regression analysis verified male gender (HR 2.855, 95% CI 1.008-8.089; p = 0.048), TS (transsphenoidal surgery; HR 3.559, 95% CI 1.015-12.476; p = 0.047), and non-GTR (HR 4.388, 95%CI 1.240-15.521; p = 0.022) were independent unfavorable factors for pituicytoma progression. A multivariate logistic regression model verified that tumor diameter ≥ 1.85 cm (OR 4.859, 95% CI 1.335-17.691; p = 0.016) was independent adverse factors for GTR. Compared with TS, OT (open transcranial) is more likely to have postoperative complications (OR 3.185, 95% CI 1.020-9.944; p = 0.046), especially vision deterioration (OR 37.267, 95% CI 4.486-309.595; p = 0.001).

CONCLUSION

Based on our findings, GTR was advocated as an optimal treatment for pituicytomas. However, in order to avoid damage to important structures, partial resection is acceptable. After that, adjuvant radiotherapy is recommended for male patients with high Ki-67 index, and the remaining patients can be followed up closely. When the tumor recurs or progresses, it is recommended to re-operate and remove the lesion completely as far as possible. If GTR is still not possible, postoperative radiotherapy for the residual tumor is recommended.

Posterior pituitary tumours: patient outcomes and determinants of disease recurrence or persistence

OBJECTIVE

Posterior pituitary tumours (PPTs) are rare neoplasms with the four recognised subtypes unified by thyroid transcription factor -1 (TTF-1) expression, according to the 2017 WHO classification. Though traditionally defined as low-grade neoplasms, a substantial proportion of them show recurrence/persistence following surgery.

METHODS

We selected patients with PPTs in our cohort of 1760 patients operated for pituitary tumours over the past 10 years (2010-2019). The clinical, radiological, hormonal, histopathological profiles and long-term outcomes of the three cases identified (two pituicytomas and one spindle cell oncocytoma, SCO) were analysed. Following a literature review, data of all published cases with documented TTF-1 positive pituicytomas and SCOs were analysed to determine the predictors of recurrence/persistence in these tumours.

RESULTS

Patients presented with compressive features or hypogonadism. Two had sellar-suprasellar masses. One had a purely suprasellar mass with a pre-operative radiological suspicion of pituicytoma. Two were operated by transsphenoidal surgery and one transcranially guided by neuronavigation. Histopathology confirmed spindle cells in a storiform arrangement and low Ki67 index. Immunohistochemistry showed positive TTF-1, S-100 expression and variable positivity for EMA, vimentin and GFAP. Re-evaluation showed recurrence/persistence in two patients. A literature review of recurrent/persistent pituicytoma (n = 17) and SCO (n = 9) cases revealed clinical clues (headache for pituicytomas, male gender for SCO), baseline tumour size (≥20.5 mm with sensitivity exceeding 80%) and longer follow-up duration as determinants of recurrence/persistence.

CONCLUSION

PPTs are rare sellar masses with quintessential TTF-1 positivity. Recurrent/persistent disease following surgery is determined by greater tumour size at baseline and duration of follow-up. This warrants intensive and long-term surveillance in these patients.

Sellar Tumors

Sellar region lesions include a broad range of benign and malignant neoplastic as well as non-neoplastic entities, many of which are newly described or have recently revised nomenclature. In contrast to other intracranial sites, imaging features are relatively less specific, and the need for histopathological diagnosis is of paramount importance. This review will describe pituitary adenomas, inflammatory lesions, and tumors unique to the region (craniopharyngioma) as well as tumors which may occur in but are not exclusively localized to the sellar location (schwannoma, metastasis, etc.).

Comprehensive Genomic Characterization of A Case of Granular Cell Tumor of the Posterior Pituitary Gland: A Case Report

Granular cell tumors of the pituitary belong to a rare family of neoplasms, arising from the posterior pituitary gland. Although considered benign, they may cause significant morbidity and residual disease after resection can lead to poor clinical outcomes. Currently, there is no known medical therapy for any posterior pituitary gland tumor, in part due to sparse molecular characterization of these lesions. We report data from whole exome sequencing of a case of granular cell tumor of the pituitary, performed under an institutional review board approved protocol. A 77 year-old female underwent resection of an incidentally diagnosed pituitary mass that was causing radiographic compression of the optic nerves with a subclinical temporal field defect and central hypothyroidism. The pathology of the resected specimen demonstrated a granular cell tumor of the posterior pituitary gland. Whole-exome sequencing revealed mutations predicted to be deleterious in key oncogenes, SETD2 and PAX8, both of which have been described in other cancers and could potentially be amenable to targeted therapies with existing approved drugs, including immune checkpoint inhibitors and histone deacetylase inhibitors, respectively. To our knowledge, this is the first comprehensive genomic characterization of granular cell tumor of the posterior pituitary gland. We report mutations in oncogenes predicted to be deleterious and reported in other cancers with potential for therapeutic targeting with existing pharmacologic agents. These data provide new insights into the molecular pathogenesis of GCT of the pituitary and may warrant further investigation.

Case Report: Sellar Ependymomas: A Clinic-Pathological Study and Literature Review

Ependymomas are primary glial tumors arising from cells related to the ependymal lining of the ventricular system. They are classified into at least nine different molecular subtypes according to molecular phenotype, histological morphology, and tumor location. Primary sellar ependymoma is an extremely rare malignancy of the central nervous system, with only 12 known cases reported in humans. We herein report a case of ependymoma located at the pituitary region in a 44-year-old female patient and discuss the molecular subtype, natural history, clinical presentation, radiological findings, histological features, immunohistochemical characteristics, ultrastructural examinations, treatment, and prognosis of sellar ependymoma. This case report may serve as a helpful reference for clinicians and radiologists in clinical practice.

Rare neurohypophyseal tumor presenting as giant pituitary macroadenoma with cavernous sinus invasion - A case report and review of literature

Background:

Granular cell tumors (GCTs) of the pituitary are rare tumors of posterior pituitary that can present as giant pituitary macroadenoma due to the slow indolent growth of the tumor. We are reporting this case due to the rarity of GCT and usually these tumors are confined to the suprasellar region since they are arising from the pituitary stalk. GCTs that attain such giant size with cavernous sinus invasion are still rarer.

Case Description:

A 38-year-old female who presented with progressive deterioration of vision and on evaluation by magnetic resonance imaging showed a giant pituitary macroadenoma with bilateral cavernous sinus invasion. The patient underwent pterional craniotomy and near-total excision of the lesion was done due to high vascularity and firmness of the tumor. Histopathology examination of the lesion showed spindle to globular cells with granular cytoplasm and was reported as GCT of the pituitary.

Conclusion:

GCTs are WHO grade1 non-neuroendocrine tumors arising from neurohypophysis and infundibulum. Complete excision is usually difficult due to the high vascularity, firm consistency, and local invasion of the tumor to the cavernous sinus and optic apparatus.

Adenohypophyseal hyperfunction syndromes and posterior pituitary tumors: prevalence, clinical characteristics, and pathophysiological mechanisms

Posterior pituitary tumors are rare nonneuroendocrine neoplasms originating in the neurohypophysis that lack hormonal secretory capacity. Surprisingly, these tumors are relatively frequently associated with adenohypophyseal syndromes of hormonal hypersecretion such as Cushing's disease and acromegaly. Fifteen cases of posterior pituitary tumor associated with hypercortisolism have been reported to date, 13 of them were pituicytomas (Pi) and 2 were granular cell tumors (GCT). Six patients with posterior pituitary tumor associated with acromegaly have been reported (4 Pi and 2 GCT). The main forms of clinical presentation and the possible pathophysiological mechanisms of this association are reviewed.

Neuroimaging of the Pituitary Gland: Practical Anatomy and Pathology

The pituitary gland is a small endocrine organ located within the sella turcica. Various pathologic conditions affect the pituitary gland and produce endocrinologic and neurologic abnormalities. The most common lesion of the pituitary gland is the adenoma, a benign neoplasm. Dedicated MR imaging of the pituitary is radiologic study of choice for evaluating pituitary gland and central skull region. Computed tomography is complimentary and allows for identification of calcification and adjacent abnormalities of the osseous skull base. This review emphasizes basic anatomy, current imaging techniques, and highlights the spectrum of pathologic conditions that affect the pituitary gland and sellar region.

Primary Tumors of the Posterior Pituitary Gland: A Systematic Review of the Literature in Light of the New 2017 World Health Organization Classification of Pituitary Tumors

OBJECTIVE

The rare clinical entity of primary posterior pituitary tumors (PPTs) includes pituicytomas, granular cell tumors, spine cell oncocytomas, and sellar ependymomas. The recent World Health Organization classification of PPTs based on thyroid transcription factor 1 positivity has led to more investigations into the epidemiology, clinical presentation, nature history, histologic features, and operative characteristics of these tumors. The aim of this review is to summarize the characteristics of primary PPTs.

METHODS

Our summary involved an in-depth review of the literature on PPTs. Our systematic review was carried out using the PubMed database and PRISMA guidelines.

RESULTS

An initial search identified 282 publications. After strict application of the inclusion criteria, we found 16 articles for case series of patients with primary PPT (N > 5), which were included in our table for literature review. An additional 10 articles were review articles on PPTs published in the last 20 years and were used as resource for our systematic review. An extensive analysis was then performed to extract relevant clinical data with respect to the clinical radiologic histopathologic profile of primary PPTs and their treatment outcome.

CONCLUSIONS

Primary PPTs are a rare group of pituicyte-derived low-grade nonneuroendocrine neoplasms that arise from the sellar region. The nondescript radiographic findings and subtle endocrine abnormalities also veil their accurate diagnostic prediction. As shown through the narrative as well as the literature review, there is still a lot to be understood about PPTs. A prospective multicenter registry of these rare tumors would benefit both the neurosurgical as well as the endocrinologic knowledge base.

Sellar surprises: a single-centre experience of unusual sellar masses

BACKGROUND

Most common incidentally detected sellar-suprasellar region (SSR) masses are pituitary adenomas, followed by craniopharyngioma, rathke's cleft cyst, hypophysitis, and meningioma. Besides these, certain unusual SSR lesions can sometimes present as diagnostic challenges, where diagnosis is often made post-operatively on histopathology, the pre-operative suspicion of which might have influenced the management strategies. Series describing such masses are few.

OBJECTIVE

To present clinical, biochemical, and radiological characteristics and management outcomes of rare SSR lesions other than pituitary adenomas, craniopharyngioma, rathke's cleft cyst, hypophysitis, and meningioma.

DESIGN, SETTING, PATIENTS

Retrospective case record analysis of patients with uncommon SSR masses (from January 2006 to December 2016).

RESULTS

Our series consisted of ten patients, five with neoplastic and five with non-neoplastic lesions. Neoplastic masses included granular cell tumor (n = 2), astrocytoma (n = 1), malignant peripheral nerve sheath tumor (MPNST, n = 1), and metastasis from occult papillary carcinoma of thyroid (n = 1), while non-neoplastic masses were aspergillus abscess (n = 1), sterile abscess (n = 1), and tubercular abscess (n = 1), aneurysm of left internal carotid artery (n = 1), and ruptured dermoid cyst (n = 1). All patients (except one) presented with headache and/or visual disturbance. Only one patient had acromegaly while most others had hypopituitarism. We describe detailed MRI characteristics of each of the lesion. Seven patients underwent trans-sphenoidal surgery. Post-operatively, five patients had permanent diabetes insipidus, while two patients died in early post-operative period.

CONCLUSION

Our series expand the differential diagnostic considerations of SSR lesions. Most of the rare SSR masses present with symptoms of mass effects and hypopituitarism. Except for some non-neoplastic lesions like sellar abscesses, aneurysms, and dermoid cysts which can have some specific imaging characteristics that can provide clue to pre-operative diagnosis, most of the other neoplastic masses have overlapping radiological features, and pre-operative suspicion remains difficult.

Surgical resection of granular cell tumor of the sellar region: three indications

PURPOSE

This case series evaluates the surgical management of granular cell tumor (GCT) of the sellar region. This rare entity presents a unique diagnostic and surgical challenge.

METHODS

Institutional neuropathology databases at Brigham and Women's Hospital and Massachusetts General Hospital were searched for cases with a tissue diagnosis of GCT, and with a location in the sellar region. Patient, treatment, tumor, and follow-up data were extracted.

RESULTS

Three patients had a diagnosis of GCT of the sellar region occurring over an 18-year period. All three patients were followed postoperatively at our multidisciplinary pituitary center (median follow-up = 30 months; range 12-30 months). Hormonal disturbances, an incidental lesion requiring diagnosis, and neurological symptoms were indications for surgery in these patients. Two patients underwent a craniotomy and one underwent endoscopic transsphenoidal surgery. All three patients were free of tumor recurrence at last follow-up. In one case tested, positive thyroid transcription factor-1 (TTF-1) immunohistochemistry was observed.

CONCLUSION

GCT is generally a benign tumor of the sellar region. Surgical resection is the standard treatment, more recently with transsphenoidal surgery when indicated. Surgical resection results in optimal outcome for patients.

COL6A6 interacted with P4HA3 to suppress the growth and metastasis of pituitary adenoma via blocking PI3K-Akt pathway

The role and mechanism of collagen type VI alpha 6 (COL6A6) on tumor growth and metastasis in pituitary adenoma (PA) was determined. COL6A6 was downregulated in PA tissues and cell lines, which was negatively associated with the expression of prolyl-4-hydroxylase alpha polypeptide III (P4HA3) in the progression of PA. Overexpression of COL6A6 significantly suppressed tumor growth and metastasis capacity in PA. In addition, P4HA3 worked as the upstream of the PI3K-Akt pathway to alleviate the antitumor activity of COL6A6 on the growth and metastasis of both AtT-20 and HP75 cells. Furthermore, the inhibitory effect of COL6A6 on cell proliferation, migration and invasion, and epithelial-mesenchymal transition (EMT) was reversed by P4HA3 overexpression or activation of the PI3K-Akt pathway induced by IGF-1 addition, which provided a new biomarker for clinical PA treatment.