Pharyngeal pituitary non-functioning adenoma with normal intra-sellar gland: massive tumor shrinkage on octreotide therapy

Clinical and radiological presentation of parasellar ectopic pituitary adenomas: case series and systematic review of the literature

PURPOSE

Parasellar ectopic pituitary adenomas (pEPAs) are extremely rare tumors located out of the sella turcica. PEPAs are heterogeneous entities in terms of anatomical localization and secretion of anterior pituitary hormones.

METHODS

Multicenter retrospective study. Clinical charts' consultation of patients diagnosed with parasellar lesions, to identify all subjects fulfilling the diagnostic criteria of parasellar EPAs. Systematic review of the literature focused on the medical management of prolactin-secreting pEPAs and on the prevalence of radiological bone invasion in pEPAs.

RESULTS

We identified four cases of pEPAs: (1) 54-year-old female with a prolactin-secreting suprasellar EPA successfully treated with cabergoline; (2) 74-year-old male with a non-functioning EPA of the sphenoidal sinus treated with endoscopic transsphenoidal surgery; (3) 75-year-old female with a giant lesion of the skull base (maximum diameter 7.2 cm) diagnosed as a non-functioning EPA after biopsy; (4) 49-year-old male with a silent corticotroph EPA of the sphenoidal sinus and clivus. Three out of four cases had radiological evidence of invasion of the surrounding bone structures. A systematic review of the literature highlighted that medical therapy can be effective in prolactin-secreting pEPAs. Overall, we found mention of local invasiveness in 65/147 cases (44.2%), confirmed by radiological signs of bone invasion/erosion.

CONCLUSION

Our experience confirms the heterogeneity of pEPAs in terms of clinical and radiological presentation, as well as hormone secretion. PEPAs show a high frequency of radiological bone invasion, though similar to that of sellar pituitary adenomas. Although extremely rare, pEPAs need to be considered in the differential diagnosis of parasellar lesions.

Ectopic pituitary adenomas: clinical features, diagnostic challenges and management

PURPOSE

Ectopic pituitary adenomas (EPAs) are extremely rare pituitary adenomas located outside the sella turcica without any connection with intrasellar components. This study aims to review all the reported cases to date and describe the clinical characteristics of EPAs.

METHODS

In a retrospective chart review, 14 patients were identified with EPAs in our hospital. A literature review was performed, and 166 cases in the literature met the criteria. Clinical data were analyzed.

RESULTS

Of 180 patients with EPAs, the mean age at diagnosis was 45.4 years, and 66.5% of the patients were females. EPAs were mainly located in the sphenoid sinus (34.4%) and suprasellar region (25.6%), followed by the clivus (15.6%), cavernous sinus (13.3%) and nasopharynx (5.6%). Adrenocorticotropic hormone (ACTH)-secreting (38.9%) and nonfunctioning (27.2%) adenomas were predominant. Patients with suprasellar EPAs were more likely to present menstrual disorders and visual changes, while patients with clival EPAs were more likely to suffer from headaches. EPAs in the cavernous sinus and suprasellar space were more likely to be initially misdiagnosed as a suspicious intrasellar mass on imaging examination. The complete tumor resection rates for EPAs in the sphenoid sinus, suprasellar region, clivus, cavernous sinus and nasopharynx were 72.3%, 88.6%, 45.0%, 73.3% and 88.9%, respectively.

CONCLUSIONS

EPA clinical characteristics varied across different tumor locations and hormone-secreting types. In addition to comprehensive hormone evaluation and careful review of imaging data, nuclear medicine and surgical biopsy should also be considered when facing differential difficulty. EPA management should be individualized.

Ectopic pituitary adenomas: common presentations of a rare entity

PURPOSE

Ectopic pituitary adenomas (EPA) are rare tumors thought to arise from embryological remnants along the route of normal pituitary migration. Clinically, these tumors vary in hormonal activity and can exert mass effect based on location and size.

METHODS

We performed a single-center retrospective analysis of patients with diagnosis of ectopic pituitary adenoma from 2001 to 2018.

RESULTS

Five patients were identified with EPA: a 48-year-old woman with suprasellar EPA treated with transsphenoidal removal of the tumor, a 44-year-old woman with cavernous EPA treated with transsphenoidal removal of the tumor, a 48-year-old woman with sphenoid EPA treated with cabergoline, a 45-year-old man with clival EPA treated with cabergoline and transsphenoidal surgical resection, and a 54-year-old man with clival EPA treated with cabergoline therapy.

CONCLUSIONS

EPA should be considered as a differential diagnosis of juxta-sellar lesions. Appropriate hormonal testing may lead to early diagnosis, avoidance of unnecessary biopsy or surgery, and improved outcomes.

MR Imaging of the Pituitary Gland and Postsphenoid Ossification in Fetal Specimens

BACKGROUND AND PURPOSE

A thorough knowledge of fetal growth and development is key to understanding both the normal and abnormal fetal MR imaging findings. We investigated the size and signal intensity of the normal pituitary gland and the intrasphenoidal ossification around the Rathke pouch in formalin-fixed fetuses on MR imaging.

MATERIALS AND METHODS

Thirty-two fetuses with undamaged brains were included in this study (mean age, 19.93 weeks; age range, 12-31 weeks). Visual inspection of the pituitary and ossification around the Rathke pouch in the sphenoid bone or the postsphenoid ossification was conducted. The extent of pituitary and postsphenoid ossification, pituitary/pons signal ratio, and postsphenoidal ossification/sphenoid bone signal ratio was compared according to gestational age.

RESULTS

The pituitary gland was identified as a hyperintense intrasellar structure in all cases, and postsphenoid ossification was identified as an intrasphenoidal hyperintense area in 27 of the 32 cases (84%). The mean pituitary/pons signal ratio was 1.13 ± 0.18 and correlated weakly with gestational age (R(2) = 0.243), while the mean postsphenoid ossification/sphenoid bone signal ratio was 2.14 ± 0.56 and did not show any increase with gestational age (R(2) = 0.05). No apparent change in the size of pituitary hyperintensity was seen with gestational age (R(2) = 0.001). Postsphenoid ossification showed an increase in size with gestational age (R(2) = 0.307).

CONCLUSIONS

The fetal pituitary gland was hyperintense on T1-weighted images and the pituitary/pons ratio and extent of postsphenoid ossification correlated weakly with gestational age.

Nasally located ectopic ACTH-secreting pituitary adenoma (EAPA) causing Nelson's syndrome: diagnostic challenges

PURPOSE

We report the first case of an Ectopic adrenocorticotrophin (ACTH)-secreting pituitary adenoma (EAPA) located within the posterior nasal septum associated with Nelson's syndrome, which eluded diagnosis for over a decade. In this report, we explore the reasons for such diagnostic difficulty and suggest ways in which an earlier diagnosis may be made.

METHODS AND RESULTS

A 19 years old Lebanese man presented in 2000, with overt Cushing's syndrome confirmed with markedly elevated urine free cortisols and failed dexamethasone suppression tests. An unsuppressed ACTH and a possible 5 mm adenoma on MRI (Magnetic Resonance Imaging) pituitary suggested Cushing's disease. The patient underwent trans-sphenoidal surgery (TSS), but histology revealed normal pituitary tissue and Cushing's syndrome persisted. A repeat MRI pituitary showed no anomaly, and extensive investigations failed to locate an ectopic lesion. Subsequently a bilateral adrenalectomy was performed. Over the ensuing years, the patient developed Nelson's syndrome with hyperpigmentation and markedly elevated ACTH levels. Repeated high dose dexamethasone suppression tests, corticotrophin releasing hormone (CRH) tests, and CRH stimulated inferior petrosal sinus samplings (IPSS) suggested a pituitary origin of the ACTH. Two further TSS were unsuccessful. The pituitary was irradiated. Subsequent review of his previous MRIs revealed an enlarging mass within the posterior nasal septum, which was excised in 2011. The histology confirmed the diagnosis of an EAPA within the nasal septum.

CONCLUSION

Ectopic ACTH-secreting pituitary adenomas can occur not only along the developmental route of Rathke's pouch, but other aberrant locations giving a clinical and biochemical picture identical to Cushing's disease or Nelson's syndrome. Clinicians should suspect an EAPA, when a central ACTH source seems to be apparent with no obvious pituitary adenoma. A detailed MRI involving possible EAPA sites aids in locating these unusual lesions.

Clival chordoma manifesting as nasal bleeding. A case report

Chordoma is a rare cartilaginous tumor, for which bleeding presentation is unusual. We report a case of rare hemorrhaged clival chordoma, which was diagnosed correctly by magnetic resonance imaging. A 32-year-old man presented with nasal bleeding. The tumor was totally removed via a trans-sphenoidal approach, from which the surgical specimen confirmed chordoma. Epistaxis seemed to be caused by the spreading of the intratumoral hemorrhage into the sphenoid sinus. This case demonstrates the importance of an exact differential diagnostic evaluation, including chordoma, by use of modern imaging techniques for nasal bleeding.

Ectopic neural and neuroendocrine neoplasms

Although neural and neuroendocrine tissues are distributed virtually ubiquitously throughout the body, the occurrence of selected neoplasms related to those lineages is extremely uncommon in some topographic sites. This review considers the clinicopathologic characteristics of heterotopic pituitary adenomas; neuroendocrine carcinomas in non-organ-based locations; ectopic (extraneuraxial) meningiomas and gliomas; visceral neuroblastic neoplasms and primitive neuroectodermal tumors; and paragangliomas arising outside the sympathoadrenal neural network. Practical approaches to differential diagnosis are emphasized.