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Uccella S, Dottermusch M, Erickson L, Warmbier J, Montone K, Saeger W. Inflammatory and Infectious Disorders in Endocrine Pathology. Endocr Pathol 2023; 34:406-436. [PMID: 37209390 PMCID: PMC10199304 DOI: 10.1007/s12022-023-09771-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
A variety of inflammatory conditions may directly involve the endocrine glands, leading to endocrine dysfunction that can cause severe consequences on patients' health, if left untreated. Inflammation of the endocrine system may be caused by either infectious agents or other mechanisms, including autoimmune and other immune-mediated processes. Not infrequently, inflammatory and infectious diseases may appear as tumor-like lesions of endocrine organs and simulate neoplastic processes. These diseases may be clinically under-recognized and not infrequently the diagnosis is suggested on pathological samples. Thus, the pathologist should be aware of the basic principles of their pathogenesis, as well as of their morphological features, clinicopathological correlates, and differential diagnosis. Interestingly, several systemic inflammatory conditions show a peculiar tropism to the endocrine system as a whole. In turn, organ-specific inflammatory disorders are observed in endocrine glands. This review will focus on the morphological aspects and clinicopathological features of infectious diseases, autoimmune disorders, drug-induced inflammatory reactions, IgG4-related disease, and other inflammatory disorders involving the endocrine system. A mixed entity-based and organ-based approach will be used, with the aim to provide the practicing pathologist with a comprehensive and practical guide to the diagnosis of infectious and inflammatory disorders of the endocrine system.
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Affiliation(s)
- Silvia Uccella
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanule, Milan, Italy
- Pathology Service IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Matthias Dottermusch
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lori Erickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN USA
| | - Julia Warmbier
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathleen Montone
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Rawanduzy CA, Winkler-Schwartz A, Couldwell WT. Hypophysitis: Defining Histopathologic Variants and a Review of Emerging Clinical Causative Entities. Int J Mol Sci 2023; 24:ijms24065917. [PMID: 36982990 PMCID: PMC10057821 DOI: 10.3390/ijms24065917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/10/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Inflammatory disease of the pituitary gland is known as hypophysitis. There are multiple histological subtypes, the most common being lymphocytic, and the pathogenesis is variable and diverse. Hypophysitis can be primary and idiopathic or autoimmune related, or secondary to local lesions, systemic disease, medications, and more. Although hypophysitis was previously accepted as an exceedingly rare diagnosis, a greater understanding of the disease process and new insights into possible etiologic sources have contributed to an increased frequency of recognition. This review provides an overview of hypophysitis, its causes, and detection strategies and management.
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Affiliation(s)
- Cameron A Rawanduzy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84112, USA
| | - Alexander Winkler-Schwartz
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84112, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT 84112, USA
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DeCou S, Recinos PF, Prayson RA, Karakasis C, Haider A, Patel N. Successful immunomodulatory treatment for recurrent xanthogranulomatous hypophysitis in an adolescent: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 4:CASE22191. [PMID: 36051774 PMCID: PMC9426350 DOI: 10.3171/case22191] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/09/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Xanthomatous lesions of the pituitary have been linked to ruptured or hemorrhagic Rathke’s cleft cysts. Most cases are reported to resolve following radical resection. When recurrence does occur, there is no established treatment regimen. High-dose glucocorticoids have been reported to be beneficial in several published cases; however, their effects are often not sustained once therapy is discontinued. OBSERVATIONS The authors report the case of an adolescent male who developed recurrent xanthogranulomatous hypophysitis associated with a Rathke’s cleft cyst despite two surgical interventions. He was treated with a short course of dexamethasone followed by a maintenance course of celecoxib and mycophenolate mofetil. This regimen proved to be safe and well-tolerated, and it successfully prevented another recurrence of his xanthogranulomatous hypophysitis. LESSONS This case demonstrates a novel nonsurgical approach to the management of recurrent xanthogranulomatous hypophysitis. It suggests a potential application of a combined corticosteroid-sparing immunosuppressive and anti-inflammatory regimen in other cases of refractory xanthogranulomatous hypophysitis.
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Affiliation(s)
- Sarah DeCou
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Pablo F. Recinos
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard A. Prayson
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Department of Anatomic Pathology, The Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christopher Karakasis
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio; and
| | - Anzar Haider
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Center for Pediatric Endocrinology, Cleveland Clinic Children’s, Cleveland, Ohio
| | - Neha Patel
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Pediatric Hematology Oncology and Bone Marrow Transplant, Cleveland Clinic Children’s, Cleveland, Ohio
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Xanthogranuloma of the Sellar Region: A Comprehensive Review of Neuroimaging in a Rare Inflammatory Entity. J Pers Med 2022; 12:jpm12060943. [PMID: 35743728 PMCID: PMC9225214 DOI: 10.3390/jpm12060943] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 11/17/2022] Open
Abstract
Xanthogranuloma of the sellar region is a rare chronic inflammatory lesion resulting from secondary hemorrhage, inflammation, infarction, and necrosis of an existing Rathke’s cleft cyst, craniopharyngioma, or pituitary adenoma. Sellar xanthogranulomas are challenging to differentiate from other cystic lesions preoperatively due to the lack of characteristic imaging features. We performed a literature overview of the clinical and paraclinical features, treatment options, and long-term outcomes of patients with sellar xanthogranuloma, focusing on the preoperative radiological diagnosis. The hyperintense signal in both T1- and T2-weighted sequences, cystic or partially cystic morphology, ovoid shape, sellar epicenter, intra- and suprasellar location, intratumoral calcifications, linear rim contrast enhancement, and the absence of cavernous sinus invasion suggest xanthogranuloma in the preoperative differential diagnosis. An endoscopic endonasal gross total resection without radiotherapy is the preferred first-line treatment. Given the low rate of recurrence rate and low chance of endocrinological recovery, a mass reduction with decompression of the optic apparatus may represent an appropriate surgical goal. Identifying the xanthogranulomas’ mutational profile could complement histopathological diagnosis and give insight into their histo-pathogenesis. A better preoperative neuroimagistic diagnosis of sellar xanthogranulomas and differentiation from lesions with a poorer prognosis, such as craniopharyngioma, would result in an optimal personalized surgical approach.
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Gezer E, Çabuk B, Bayrak BY, Cantürk Z, Çetinarslan B, Selek A, Sözen M, Köksalan D, Ceylan S. Xanthomatous Hypophysitis Secondary to a Ruptured Rathke's Cleft Cyst: A Case Report. Brain Tumor Res Treat 2022; 10:48-54. [PMID: 35118849 PMCID: PMC8819468 DOI: 10.14791/btrt.2022.10.e24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/25/2021] [Accepted: 11/12/2021] [Indexed: 11/20/2022] Open
Abstract
Hypophysitis (HP) is a rare disease which develops secondary to chronic or acute inflammation of the pituitary gland and may cause symptoms related to pituitary dysfunction and mass compression. Lymphocytic HP is the most common subtype of primary HP, while xanthomatous HP (XHP) is considered the rarest form, with 35 reported cases, to date. A 35-year-old woman was initially admitted to a Gynecology clinic with a 2-year history of amenorrhea and headache. She was started on cabergoline 0.5 mg twice a week for macroprolactinoma. Due to persistent amenorrhea with low gonadotropins, she was referred to our Endocrinology clinic. Her pituitary function profile revealed panhypopituitarism and a 13×11×12 mm sized sellar mass with diffuse enhancement which sustained toward the infundibulum and dura was observed on the gadolinium-enhanced pituitary MRI. The patient underwent an endoscopic endonasal transsphenoidal approach for tumor resection and thick yellowish fluid draining from the lesion was observed. The histopathological diagnosis was reported as a rupture of an Rathke’s cleft cyst and an XHP. The surgery did not improve the symptoms/pituitary functions, however, headache recovered immediately after the first dose of high dose methylprednisolone treatment. The inflammatory process in a xanthomatous lesion may actually be a secondary response to mucous fluid content release from a ruptured cyst, thus recommended to classify XHP as secondary hypophysitis. Since the differentiation of XHP from other pituitary tumors may be challenging preoperatively, surgery is the major diagnostic tool and also, the most recommended therapeutic option.
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Affiliation(s)
- Emre Gezer
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey.
| | - Burak Çabuk
- Department of Neurosurgery, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Büsra Yaprak Bayrak
- Department of Pathology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Zeynep Cantürk
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Berrin Çetinarslan
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Alev Selek
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Mehmet Sözen
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Damla Köksalan
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Savas Ceylan
- Department of Neurosurgery, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
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Yang MG, Cai HQ, Wang SS, Liu L, Wang CM. Full recovery from chronic headache and hypopituitarism caused by lymphocytic hypophysitis: A case report. World J Clin Cases 2022; 10:1041-1049. [PMID: 35127918 PMCID: PMC8790444 DOI: 10.12998/wjcc.v10.i3.1041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/05/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lymphocytic hypophysitis (LYH) is an important condition to consider in the differential diagnosis of patients with a pituitary mass. The main clinical manifestations of LYH include headache, symptoms related to sellar compression, hypopituitarism, diabetes insipidus and hyperprolactinemia. Headache, which is a frequent complaint of patients with LYH, is thought to be related to the occupying effect of the pituitary mass and is rapidly resolved with a good outcome after timely and adequate glucocorticoid treatment or surgery.
CASE SUMMARY Here, we report a patient with LYH whose initial symptom was headache and whose pituitary function assessment showed the presence of secondary hypoadrenalism, central hypothyroidism and hypogonadotropic hypogonadism. Pituitary magnetic resonance imaging showed symmetrical enlargement of the pituitary gland with suprasellar extension in a dumbbell shape with significant homogeneous enhancement after gadolinium enhancement. The size of the gland was approximately 17.7 mm × 14.3 mm × 13.8 mm. The pituitary stalk was thickened without deviation, and there was an elevation of the optimal crossing. The lesion grew bilaterally toward the cavernous sinuses, and the parasternal dural caudal sign was visible. The patient presented with repeatedly worsening and prolonged headaches three times even though the hypopituitarism had fully resolved after glucocorticoid treatment during this course.
CONCLUSION This rare headache regression suggests that patients with chronic headaches should also be alerted to the possibility of LYH.
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Affiliation(s)
- Mao-Guang Yang
- Department of Endocrinology, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Han-Qing Cai
- Department of Endocrinology, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Si-Si Wang
- Department of Endocrinology, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Lin Liu
- Department of Endocrinology, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Chun-Mei Wang
- Department of Radiology, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
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Langlois F, Varlamov EV, Fleseriu M. Hypophysitis, the Growing Spectrum of a Rare Pituitary Disease. J Clin Endocrinol Metab 2022; 107:10-28. [PMID: 34528683 PMCID: PMC8684465 DOI: 10.1210/clinem/dgab672] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Indexed: 01/13/2023]
Abstract
Hypophysitis is defined as inflammation of the pituitary gland that is primary or secondary to a local or systemic process. Differential diagnosis is broad (including primary tumors, metastases, and lympho-proliferative diseases) and multifaceted. Patients with hypophysitis typically present with headaches, some degree of anterior and/or posterior pituitary dysfunction, and enlargement of pituitary gland and/or stalk, as determined by imaging. Most hypophysitis causes are autoimmune, but other etiologies include inflammation secondary to sellar tumors or cysts, systemic diseases, and infection or drug-induced causes. Novel pathologies such as immunoglobulin G4-related hypophysitis, immunotherapy-induced hypophysitis, and paraneoplastic pituitary-directed autoimmunity are also included in a growing spectrum of this rare pituitary disease. Typical magnetic resonance imaging reveals stalk thickening and homogenous enlargement of the pituitary gland; however, imaging is not always specific. Diagnosis can be challenging, and ultimately, only a pituitary biopsy can confirm hypophysitis type and rule out other etiologies. A presumptive diagnosis can be made often without biopsy. Detailed history and clinical examination are essential, notably for signs of underlying etiology with systemic manifestations. Hormone replacement and, in selected cases, careful observation is advised with imaging follow-up. High-dose glucocorticoids are initiated mainly to help reduce mass effect. A response may be observed in all auto-immune etiologies, as well as in lymphoproliferative diseases, and, as such, should not be used for differential diagnosis. Surgery may be necessary in some cases to relieve mass effect and allow a definite diagnosis. Immunosuppressive therapy and radiation are sometimes also necessary in resistant cases.
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Affiliation(s)
- Fabienne Langlois
- Department of Medicine, Division of Endocrinology, Centre intégré universitaire de santé et de services sociaux de l’Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Elena V Varlamov
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Maria Fleseriu
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
- Correspondence: Maria Fleseriu, MD, Oregon Health & Science University, Mail Code CH8N, 3303 S Bond Ave, Portland, Oregon 97239, USA.
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de Vries F, van Furth WR, Biermasz NR, Pereira AM. Hypophysitis: A comprehensive overview. Presse Med 2021; 50:104076. [PMID: 34687912 DOI: 10.1016/j.lpm.2021.104076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
Hypophysitis is defined as inflammation of the pituitary gland. It is a heterogeneous condition as it can originate from different parts of the pituitary gland, can be caused by different pathophysiological processes, and can be isolated or the manifestation of a underlying systemic disease. Hypophysitis usually presents with endocrine deficiencies, including diabetes insipidus, with varying patterns. A subset of patients presents with mass effects. The last decades major progress has been made in the understanding of this disease. New forms are now recognized, new diagnostics are being developed, and specific treatments are proposed. This review provides an overview of the current knowledge on hypophysitis using an aetiology-based approach and provides the clinician with a stepwise approach to the patient with (suspected) hypophysitis.
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Affiliation(s)
- F de Vries
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - W R van Furth
- Department of Neurosurgery and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Leiden, the Netherlands
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Xanthomatous Hypophysitis Presenting in an Adolescent Girl: A Long-Term Follow-Up of a Rare Case and Review of the Literature. AACE Clin Case Rep 2021; 7:220-225. [PMID: 34095493 PMCID: PMC8165125 DOI: 10.1016/j.aace.2021.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 01/22/2023] Open
Abstract
Objective Primary hypophysitis refers to the isolated inflammation of the pituitary gland not associated with other secondary causes. Among its histopathologic subtypes, xanthomatous is the rarest. Methods We describe a 22-year-old woman with xanthomatous hypophysitis (XH), its clinical progression over 8 years as well as the treatment effects of prednisolone and azathioprine. Our patient was first referred for severe short stature and delayed puberty at the age of 14 years. Results Investigations revealed multiple pituitary deficiencies. Magnetic resonance imaging showed a pituitary mass whereby a partial resection was performed. A full resection was not feasible due to the location of the mass. The histopathologic analysis of the tissue was consistent with XH. The results of secondary workout for neoplasm, infection, autoimmune, and inflammatory disorders were negative. After surgery, a progressive enlargement of the mass was observed. Two courses of prednisolone were administered with a significant reduction in the mass size. Azathioprine was added due to the unsustained effects of prednisolone when tapered off and the concern of steroid toxicity with continued use. No further increase in the mass size was noted after 6 months on azathioprine. Conclusion Glucocorticoid and immunotherapy are treatment options for XH; however, more cases are needed to better understand its pathogenesis and clinical progression.
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Zhu J, Wang Z, Wang W, Fan J, Zhang Y, Li X, Liu J, Jiang S, Deng K, Duan L, Yao Y, Zhu H. Xanthomatous Hypophysitis: A Case Report and Comprehensive Literature Review. Front Endocrinol (Lausanne) 2021; 12:735655. [PMID: 34659121 PMCID: PMC8518622 DOI: 10.3389/fendo.2021.735655] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/15/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Xanthomatous hypophysitis (XHP) is an extremely rare form of primary hypophysitis for which there is a lack of clinical experience. A comprehensive understanding of its clinical characteristics, diagnosis and treatment is needed. METHODS Here, we report a case study and conduct a systematic review of XHP. Thirty-six cases were included, and their clinical manifestations, endocrine assessment, imaging features, treatment and follow-up data were collected and analyzed. RESULTS The mean age at diagnosis was 39.1 years, and females were predominant (75.0%). The most common symptom was headache (68.6%), and 66.7% of female patients presented menstrual disorders. The most common pituitary dysfunction was growth hormone (GH) deficiency. More than half of patients exhibited central diabetes insipidus (CDI). The majority of patients had an imaging presentation of a cystic lesion with peripheral enhancement. Pituitary stalk thickening was observed in half of the patients. Total lesion resection was achieved in 57.1% of cases. The recurrence rate after partial resection and biopsy was significantly higher than that after total lesion resection (57.1% vs. 0.0%, P = 0.0147). The most common pituitary hormone abnormalities to resolve after surgery were hyperprolactinemia (100.0%) and GH deficiency (91.7%). The typical pathological feature was inflammatory infiltration of foamy histiocytes, which showed positivity for CD68. CONCLUSION Diagnosis of XHP is difficult when relying on clinical symptoms and imaging features. Therefore, surgical histopathology is necessary. Based on the available evidence, total lesion resection is recommended for treatment. However, the long-term prognosis for this rare disease remains unclear.
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Affiliation(s)
- Jianyu Zhu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhicheng Wang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wenze Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jinghua Fan
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yi Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaoxu Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jie Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shenzhong Jiang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Yong Yao, ; Huijuan Zhu,
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Yong Yao, ; Huijuan Zhu,
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Kurokawa R, Ota Y, Gonoi W, Hagiwara A, Kurokawa M, Mori H, Maeda E, Amemiya S, Usui Y, Sato N, Nakata Y, Moritani T, Abe O. MRI Findings of Immune Checkpoint Inhibitor-Induced Hypophysitis: Possible Association with Fibrosis. AJNR Am J Neuroradiol 2020; 41:1683-1689. [PMID: 32763900 PMCID: PMC7583108 DOI: 10.3174/ajnr.a6692] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Hypophysitis is one of the well-known adverse effects of immune checkpoint inhibitors. Immune checkpoint inhibitor-induced hypophysitis frequently causes irreversible hypopituitarism, which requires long-term hormone replacement. Despite the high frequency and clinical significance, characteristic MR imaging findings of immune checkpoint inhibitor-induced hypophysitis have not been established. In the present study, we aimed to review and extract the MR imaging features of immune checkpoint inhibitor-induced hypophysitis. MATERIALS AND METHODS This retrospective international multicenter study comprised 20 patients with melanoma who were being treated with immune checkpoint inhibitors and clinically diagnosed with immune checkpoint inhibitor-induced hypophysitis. Three radiologists evaluated the following MR imaging findings: enlargement of the pituitary gland and stalk; homogeneity of enhancement of the pituitary gland; presence/absence of a well-defined poorly enhanced area and, if present, its location, shape, and signal intensity in T2WI; and enhancement pattern in contrast-enhanced dynamic MR imaging. Clinical symptoms and hormone levels were also recorded. RESULTS Enlargement of the pituitary gland and stalk was observed in 12 and 20 patients, respectively. Nineteen patients showed poorly enhanced lesions (geographic hypoenhancing lesions) in the anterior lobe, and 11 of these lesions showed hypointensity on T2WI. Thyrotropin deficiency and corticotropin deficiency were observed in 19/20 and 12/17 patients, respectively, which persisted in 12/19 and 10/12 patients, respectively, throughout the study period. CONCLUSIONS Pituitary geographic hypoenhancing lesions in the anterior lobe of the pituitary gland are characteristic and frequent MR imaging findings of immune checkpoint inhibitor-induced hypophysitis. They reflect fibrosis and are useful in distinguishing immune checkpoint inhibitor-induced hypophysitis from other types of hypophysitis/tumors.
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Affiliation(s)
- R Kurokawa
- From the Department of Radiology (R.K., W.G., E.M., S.A., Y.U., O.A.), Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Y Ota
- Division of Neuroradiology (Y.O., T.M.), Department of Radiology, Michigan Medicine, Ann Arbor, Michigan
| | - W Gonoi
- From the Department of Radiology (R.K., W.G., E.M., S.A., Y.U., O.A.), Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - A Hagiwara
- Department of Radiology (A.H.), Juntendo University School of Medicine, Tokyo, Japan
| | - M Kurokawa
- Department of Radiology (M.K.), Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - H Mori
- Department of Radiology (H.M.), Jichi Medical University, Tochigi-ken, Japan
| | - E Maeda
- From the Department of Radiology (R.K., W.G., E.M., S.A., Y.U., O.A.), Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - S Amemiya
- From the Department of Radiology (R.K., W.G., E.M., S.A., Y.U., O.A.), Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Y Usui
- From the Department of Radiology (R.K., W.G., E.M., S.A., Y.U., O.A.), Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - N Sato
- Department of Radiology (N.S.), Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Y Nakata
- Department of Radiology (Y.N.), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - T Moritani
- Division of Neuroradiology (Y.O., T.M.), Department of Radiology, Michigan Medicine, Ann Arbor, Michigan
| | - O Abe
- From the Department of Radiology (R.K., W.G., E.M., S.A., Y.U., O.A.), Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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12
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Presence of CD3 + and CD79a + Lymphocytes in the Pituitary Gland of Dogs at Post-mortem Examination. J Comp Pathol 2020; 176:116-121. [PMID: 32359623 DOI: 10.1016/j.jcpa.2020.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 11/22/2022]
Abstract
Hypophysitis has been reported occasionally in dogs, with most cases resembling primary lymphocytic hypophysitis in man. Although it is generally assumed that lymphocytes are not present normally in the canine pituitary gland, few studies have investigated this hypothesis. However, lymphocytes are recognized in the pituitary gland of people and horses without signs of pituitary disease. It is unknown to what degree lymphocyte infiltration of the pituitary gland might occur as an incidental finding in dogs. The aim of the present study was to investigate the presence and distribution of lymphocytes in the pituitary gland of dogs without clinical suspicion of pituitary disease. Twenty dogs were subjected to routine necropsy examination. Formalin-fixed and paraffin wax-embedded sections of pituitary were stained with haematoxylin and eosin (HE) or subjected to immunohistochemistry (IHC) using primary antibodies specific for the T-cell marker CD3 and the B-cell marker CD79a. The number of CD3+ and CD79a+ cells per area unit (CPA) was determined for different pituitary regions. Two dogs had extensive neoplastic lesions in the pituitary gland and were excluded from analysis. In the remaining 18 dogs, occasional scattered CD3+ cells were found in the pituitary gland. There was a significant difference in CD3+ CPA between pituitary regions (P = 0.001). The highest CD3+ CPA was found in the pars tuberalis (median 41.3 cells/mm2, interquartile range 20.9-50.5 cells/mm2). In six of the 18 dogs (33%), CD79a+ cells were detected in small number (median total cell number 0 cells/section, interquartile range 0-1.0 cells/section). This study shows that T cell, and fewer B cells, may be found in the pituitary gland of dogs without clinical suspicion of pituitary disease. Regional difference in T-cell density, with the highest CD3+ CPA in the pars tuberalis, may imply regional immunoregulatory functions in the canine pituitary gland.
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13
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Mathkour M, Zeoli T, Werner C, Scullen T, Garces J, Keen J, Ware M. Recurring Primary Xanthomatous Hypophysitis Behaving Like Pituitary Adenoma: Additional Case and Literature Review. World Neurosurg 2020; 138:27-34. [PMID: 32081821 DOI: 10.1016/j.wneu.2020.02.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/07/2020] [Accepted: 02/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Xanthomatous hypophysitis (XH) is the rarest histologic type of primary hypophysitis. It is nonlymphocytic and characterized by an infiltration of the pituitary gland by lipid-laden histiocytes and macrophages. The clinical and radiologic features overlap heavily with pituitary adenomas and are prone to misdiagnosis. We describe a rare case of XH recurrence at 1 year, treated surgically. Moreover, we provide an updated review of the literature to further elucidate useful management and detection strategies. CASE DESCRIPTION A 45-year-old woman presented with a history of menstrual irregularity for 9 months, amenorrhea, galactorrhea, and headache for 2 months duration. Preoperative endocrinologic studies showed increased prolactin levels. Magnetic resonance imaging of the sella showed a cystic lesion with suprasellar extension suggestive of a pituitary adenoma. The patient underwent transsphenoidal resection, showing a thick yellowish colloidal material. Histopathology showed necrotic tissue with no definitive diagnosis and no identified microorganisms. At 2 months after surgery, prolactin levels and menstrual cycle normalized. At 1 year after surgery, her menstrual cycle again became irregular. Repeat magnetic resonance imaging showed a recurrent mass and a second transsphenoidal resection was undertaken. Repeat histopathology was consistent with XH. The patient is 9 years postoperative and is doing well without evidence of recurrence. CONCLUSIONS XH presents similarly to nonfunctional adenomas and diagnosis remains difficult without surgical pathology, requiring meticulous immunohistochemistry to prevent misdiagnosis. Thus, XH should be considered as a rare cause in the differential of disease of the sellar region. Management can parallel that of pituitary neoplasm, with a focus on radiosurgery, re-resection, and high-dose steroids.
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Affiliation(s)
- Mansour Mathkour
- Ochsner Clinic Foundation Department of Neurosurgery, New Orleans, Louisiana, USA; Tulane Medical Center Department of Neurosurgery, New Orleans, Louisiana, USA.
| | - Tyler Zeoli
- Tulane Medical Center Department of Neurosurgery, New Orleans, Louisiana, USA
| | - Cassidy Werner
- Tulane Medical Center Department of Neurosurgery, New Orleans, Louisiana, USA
| | - Tyler Scullen
- Ochsner Clinic Foundation Department of Neurosurgery, New Orleans, Louisiana, USA; Tulane Medical Center Department of Neurosurgery, New Orleans, Louisiana, USA
| | - Juanita Garces
- St. Mary's Medical Center-Huntington, Huntington, West Virginia, USA
| | - Joseph Keen
- Ochsner Clinic Foundation Department of Neurosurgery, New Orleans, Louisiana, USA
| | - Marcus Ware
- Ochsner Clinic Foundation Department of Neurosurgery, New Orleans, Louisiana, USA
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14
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Angelousi A, Alexandraki K, Tsoli M, Kaltsas G, Kassi E. Hypophysitis (Including IgG4 and Immunotherapy). Neuroendocrinology 2020; 110:822-835. [PMID: 32126548 DOI: 10.1159/000506903] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
Hypophysitis is characterized by inflammation of the pituitary gland that can be primary (PH) or secondary (SH) to other diseases or following drug administration. It may also be classified according to anatomical and histopathological criteria, leading to variable degrees of hypopituitarism and/or compressive symptoms to nearby structures. There has recently been an increase in the number of hypophysitis cases, raising the interest on the spectrum of its pathogenesis, clinical, biochemical/endocrinological, and imaging features. However, the use of conventional biomarkers, including currently utilized pituitary autoantibodies, has relatively limited diagnostic accuracy. Lymphocytic hypophysitis (LH) is the commonest cause of PH, whereas IgG4-related hypophysitis is increasingly being recognized. Histiocytosis and granulomatous diseases are the most frequent causes of SH, although infections and lymphoma have also been reported. The increasing use of immune checkpoint inhibitors in oncology is associated with a high incidence of hypophysitis, providing further understanding of its pathogenesis. Hypophysitis can occur silently and be easily missed, potentially leading to substantial morbidity or mortality due to adrenal insufficiency, requiring a high index of clinical suspicion and timely initiation of appropriate treatment. In most cases of LH or drug-induced hypophysitis, active surveillance along with replacement of established hormonal deficiencies is needed. In the presence of compressive and/or evolving symptoms, treatment with glucocorticoids either alone or in combination with other immunosuppressive agents can be used. Surgical decompression is reserved for nonresponsive cases with threatened vital structures. Timely diagnosis and intervention are important to minimize disease-related morbidity and mortality. We aimed to review current concepts and recent developments in the pathogenesis, diagnosis, and management of hypophysitis.
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Affiliation(s)
- Anna Angelousi
- First Department of Internal Medicine, Laiko University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece,
| | - Krystallenia Alexandraki
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina Tsoli
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregory Kaltsas
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eva Kassi
- First Department of Propaedeutic Internal Medicine, Laiko University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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15
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Caranci F, Leone G, Ponsiglione A, Muto M, Tortora F, Muto M, Cirillo S, Brunese L, Cerase A. Imaging findings in hypophysitis: a review. Radiol Med 2019; 125:319-328. [PMID: 31863360 DOI: 10.1007/s11547-019-01120-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/28/2019] [Indexed: 12/24/2022]
Abstract
Hypophysitis (HP) is a rare acute or chronic inflammatory condition of the pituitary gland. The greatest challenge in the management of HP is establishing a diagnosis through clinical criteria and non-invasive methods and predicting the patients' clinical outcome. The aim of this review is to describe the neuroradiological findings of this rare disease, providing some information regarding the possible differential diagnosis in order to avoid unnecessary surgery. Gadolinium-enhanced pituitary magnetic resonance imaging (MRI) is considered the neuroradiological investigation of choice. The features suggestive for HP include an enlarged triangular- or dumbbell-shaped gland with a thickened and not obviously deviated stalk, further supported by the absence of posterior pituitary bright spot on T1weighted images, particularly in patients presenting with diabetes insipidus. Contrast enhancement pattern is quite variable; dural enhancement has been reported in some cases after intravenous contrast administration. The characterization of the unusual sellar mass is not straightforward and generally results in a wide differential. HP should be primarily differentiated from pituitary adenomas (including pituitary apoplexy), from pituitary metastases, and from other sellar and parasellar tumors, e.g., craniopharyngiomas, germinomas, gliomas, lymphomas, meningiomas, pituicytomas, chordomas, teratomas, dermoids and epidermoids, Rathke's cleft cysts, and abscesses. In patients suspected for secondary forms related to systemic pathology, additional imaging is helpful in identifying other involved sites. Neuroradiologists need to know MRI appearance of this rare disease, as well as its typical symptoms and serological markers. A strict collaboration with endocrinologists and neurosurgeons is mandatory in order to reach a definitive diagnosis, allowing to promptly initiating an appropriate treatment.
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Affiliation(s)
- Ferdinando Caranci
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy.
| | - Giuseppe Leone
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Andrea Ponsiglione
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Massimo Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy.,Department of Neuroscience and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Fabio Tortora
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Mario Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Sossio Cirillo
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy
| | - Alfonso Cerase
- Department of Neurological and Sensorineural Sciences, Azienda ospedaliero-universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
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16
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Singh K, Kanodia AK, Ross P, Torgersen A, Maclean J, Leese G, Hossain-Ibrahim K. Xanthomatous hypophysitis causing hypogonadotropic hypogonadism resulting in delayed presentation of slipped capital femoral epiphysis. Br J Neurosurg 2018; 36:286-289. [PMID: 30450996 DOI: 10.1080/02688697.2018.1525482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
An 18-year-old man who underwent bilateral pinning of his hip joints after a left unstable Slipped Capital Femoral Epiphysis (right pinned prophylactically) was noted to have delayed secondary sexual characteristics and post-operative diabetes insipidus. The patient also described a history of fatigue, headache and polydipsia for the past 4 years. Endocrine investigations revealed reduced androgen levels, hypocortisolism, a borderline normal Serum ACE and secondary hypothyroidism. Magnetic Resonance Imaging of the pituitary gland identified an enhancing mass and a thickened stalk which trans-nasal endoscopic biopsy found to be necrotic with pus. Histology confirmed a diagnosis of Xanthomatous Hypophysitis, an inflammatory condition likely related to a partial rupture of a Rathke cleft cyst. The patient was subsequently commenced on Androgen, Thyroxine, Desmopressin and Hydrocortisone therapy with on-going endocrine follow-up. Although endocrine dysfunction & hypogonadism has been recognised to be a risk factor for SCFE at an atypically older age, due to reduced androgen levels leading to a weakened physeal plate, this is the first known case of a Xanthomatous Hypophysitis resulting in pituitary dysfunction and eventual SCFE. This case highlights that an increased range of pituitary disorders should be considered in late presentations of SCFE; and vice versa the risk of SCFE should be considered in patients with prolonged hypogonadotropic hypogonadism.
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Affiliation(s)
- Kirit Singh
- a Department of Neurosurgery , NHS Tayside , Dundee , United Kingdom
| | | | - Peter Ross
- c Department of Ear, Nose & Throat Surgery , NHS Tayside , Dundee , United Kingdom
| | - Antonia Torgersen
- d Department of Neuropathology , NHS Lothian , Edinburgh , United Kingdom
| | - Jamie Maclean
- e Department of Trauma and Orthopaedics Neurosurgery , NHS Tayside , Dundee , United Kingdom
| | - Graham Leese
- f Department of Endocrinology , NHS Tayside , Dundee , United Kingdom
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17
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Joshi MN, Whitelaw BC, Carroll PV. MECHANISMS IN ENDOCRINOLOGY: Hypophysitis: diagnosis and treatment. Eur J Endocrinol 2018; 179:R151-R163. [PMID: 29880706 DOI: 10.1530/eje-17-0009] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/06/2018] [Indexed: 12/19/2022]
Abstract
Hypophysitis is a rare condition characterised by inflammation of the pituitary gland, usually resulting in hypopituitarism and pituitary enlargement. Pituitary inflammation can occur as a primary hypophysitis (most commonly lymphocytic, granulomatous or xanthomatous disease) or as secondary hypophysitis (as a result of systemic diseases, immunotherapy or alternative sella-based pathologies). Hypophysitis can be classified using anatomical, histopathological and aetiological criteria. Non-invasive diagnosis of hypophysitis remains elusive, and the use of currently available serum anti-pituitary antibodies are limited by low sensitivity and specificity. Newer serum markers such as anti-rabphilin 3A are yet to show consistent diagnostic value and are not yet commercially available. Traditionally considered a very rare condition, the recent recognition of IgG4-related disease and hypophysitis as a consequence of use of immune modulatory therapy has resulted in increased understanding of the pathophysiology of hypophysitis. Modern imaging techniques, histological classification and immune profiling are improving the accuracy of the diagnosis of the patient with hypophysitis. The objective of this review is to bring readers up-to-date with current understanding of conditions presenting as hypophysitis, focussing on recent advances and areas for future development. We describe the presenting features, investigation and diagnostic approach of the patient with likely hypophysitis, including existing conventional techniques and those in the research/development arena. Hypophysitis usually results in acute and persistent pituitary hormone deficiency requiring long-term replacement. Management of hypophysitis includes control of the inflammatory pituitary mass using a variety of treatment strategies including surgery and medical therapy. Glucocorticoids remain the mainstay of medical treatment but other immunosuppressive agents (e.g. azathioprine, rituximab) show benefit in some cases, but there is a need for controlled studies to inform practice.
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Affiliation(s)
- Mamta N Joshi
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Benjamin C Whitelaw
- Department of Endocrinology, Kings College Hospital NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College Hospital London, London, UK
| | - Paul V Carroll
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College Hospital London, London, UK
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18
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Lin W, Gao L, Guo X, Wang W, Xing B. Xanthomatous Hypophysitis Presenting with Diabetes Insipidus Completely Cured Through Transsphenoidal Surgery: Case Report and Literature Review. World Neurosurg 2017; 104:1051.e7-1051.e13. [DOI: 10.1016/j.wneu.2017.05.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 12/20/2022]
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19
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Kleinschmidt-DeMasters BK, Lillehei KO, Hankinson TC. Review of xanthomatous lesions of the sella. Brain Pathol 2017; 27:377-395. [PMID: 28236350 DOI: 10.1111/bpa.12498] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 12/28/2022] Open
Abstract
Xanthomatous lesions of the sellar region have traditionally been divided into two separate categories, xanthomatous hypophysitis (XH) and xanthogranuloma (XG) of the sellar region. The seminal article on XH, a condition typified by foamy histiocytes and lymphoplasmacytic infiltrates in the pituitary gland/sellar region, but usually little or no hemosiderin pigment, detailed three patients. However, most reports since that time have been single cases, making understanding of the entity difficult. In contrast, the seminal report on XG, characterized by sellar region cholesterol clefts, lymphoplasmacytic infiltrates, marked hemosiderin deposits, fibrosis, multinucleated giant cells around cholesterol clefts, eosinophilic granular necrotic debris, and accumulation of macrophages, included 37 patients, allowing more insights into etiology. Few examples could be linked to adamantinomatous craniopharyngioma, and although ciliated epithelium similar to that of Rathke cleft cyst (RCC) was identified up to 35% of the 37 cases, it could not be proven that XG was related to hemorrhage into RCC. Case reports since that time, however, occasionally linked XG to RCC when an etiology could be identified at all, and a few recognized that a spectrum exists in xanthomatous lesions of the sella. They review literature, adding 23 cases from our own experience, to confirm that overlap occurs between XH and XG, and that the majority-but not all-can be linked to RCC leakage/rupture/hemorrhage. It was suggested that progressive accumulation of hemosiderin pigment in the lesion, possibly caused by the multiple episodes of bleeding, could account for the transition of at least some cases of XH to XG.
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Affiliation(s)
- B K Kleinschmidt-DeMasters
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO.,Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO.,Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kevin O Lillehei
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO.,Morgan Adams Foundation Pediatric Brian Tumor Research Program
| | - Todd C Hankinson
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO.,Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
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20
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Clinical Interrogation for Unveiling an Isolated Hypophysitis Mimicking Pituitary Adenoma. World Neurosurg 2017; 99:735-744. [DOI: 10.1016/j.wneu.2016.07.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 01/29/2023]
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21
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Duan K, Asa SL, Winer D, Gelareh Z, Gentili F, Mete O. Xanthomatous Hypophysitis Is Associated with Ruptured Rathke's Cleft Cyst. Endocr Pathol 2017; 28:83-90. [PMID: 28120170 DOI: 10.1007/s12022-017-9471-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Xanthomatous hypophysitis is a rare inflammatory disease of the pituitary gland that can mimic a neoplastic lesion clinically and radiologically. Its pathogenesis remains largely unknown, although recent evidence suggests that pituitary inflammation may occur as a secondary reaction to mucous content released from a ruptured cyst. In a series of 1221 pituitary specimens, we identified seven cases of xanthomatous hypophysitis. Six patients had complete radiological and biochemical workup preoperatively: a cystic-appearing pituitary mass was identified in all six patients (100%) with a mean size of 2.0 cm (range 1.4-2.5 cm) on imaging, and pituitary endocrine dysfunction was noted in five patients (83.3%). In all cases, the pituitary mass was resected through an endoscopic transsphenoidal approach. Pathological examination revealed the presence of foamy macrophages admixed with variable amounts of giant cells and chronic inflammatory cells, confirming the diagnosis of xanthomatous hypophysitis. Additionally, all cases presented with concurrent findings of ruptured Rathke's cleft cyst, with the exception of one patient who had previous surgery for a Rathke's cleft cyst, followed by recurrence and diagnosis of xanthomatous hypophysitis. While accurate distinction of hypophysitis from a pituitary neoplasm can be problematic in the preoperative setting, the identification of a cystic lesion in the sella turcica should raise the possibility of such an entity in the clinical and radiological differential diagnosis. The current series provides further evidence that xanthomatous hypophysitis predominantly occurs as a secondary reaction to a ruptured Rathke's cleft cyst; thus, it is best classified as a secondary (reactive) hypophysitis.
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Affiliation(s)
- Kai Duan
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Sylvia L Asa
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Daniel Winer
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Zadeh Gelareh
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Neurosurgery, University Health Network, Toronto, ON, Canada
| | - Fred Gentili
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Neurosurgery, University Health Network, Toronto, ON, Canada
| | - Ozgur Mete
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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22
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Abstract
Hypophysitis is the acute or chronic inflammation of the pituitary gland. The spectrum of hypophysitis has expanded in recent years with the addition of two histologic subtypes and recognition as a complication of treatment with immune checkpoint inhibitors. Despite the increased number of published cases, the pathogenesis of hypophysitis is poorly understood, and treatment strategies are diverse and controversial. The diagnosis of hypophysitis generally requires histopathologic confirmation. The presentation and clinical course of hypophysitis varies. Hypophysitis can resolve spontaneously, relapse may occur, and some cases can be refractory to treatment.
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Affiliation(s)
- Alexander Faje
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
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23
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Oishi M, Hayashi Y, Fukui I, Kita D, Miyamori T, Nakada M. Xanthomatous hypophysitis associated with autoimmune disease in an elderly patient: A rare case report. Surg Neurol Int 2016; 7:S449-53. [PMID: 27500004 PMCID: PMC4960922 DOI: 10.4103/2152-7806.185773] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/16/2016] [Indexed: 11/04/2022] Open
Abstract
Background: Xanthomatous hypophysitis (XH) is an extremely rare form of primary hypophysitis characterized by infiltration of the pituitary gland by mixed types of inflammatory cells, including foamy cells, plasma cells, and small mature lymphocytes. XH manifests as varying degrees of hypopituitarism. Although several previous reports have denied a possible contribution of autoimmune mechanism, the exact pathogenesis of XH remains unclear. Case Description: We describe the case of a 72-year-old woman with a history of rheumatoid arthritis and Sjögren's syndrome who presented with panhypopituitarism and diabetes insipidus. At the time of her visit, she also experienced relapsed rheumatoid arthritis and Sjögren's syndrome, manifesting as arthralgia. Magnetic resonance imaging (MRI) showed a multicystic mass in the sellar and suprasellar regions. In the course of steroid replacement therapy for hypocortisolism, the patient's arthralgia diminished, and MRI revealed shrinkage of the mass. XH was diagnosed histologically following a transsphenoidal endoscopic biopsy, and it was the oldest case of XH. Conclusion: To the best of our knowledge, this patient is the oldest of reported patients diagnosed with XH. Steroid therapy may be effective to XH temporarily. XH should be considered when diagnosing pituitary cystic lesions in elderly patients with autoimmune disease.
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Affiliation(s)
- Masahiro Oishi
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yasuhiko Hayashi
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Issei Fukui
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Daisuke Kita
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Tadao Miyamori
- Department of Neurosurgery, Toyama City Hospital, Toyama, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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