Giant prolactinoma with progressive cranial settling and central herniation: a case report

BACKGROUND

Giant prolactinoma (size > 4 cm) is a rare condition and accounts for less than 1% of pituitary adenomas. In even rarer cases, these lesions may involve craniocervical structures requiring surgical intervention. The present case is the largest reported giant prolactinoma (99 × 72 × 57 mm). It led to cranial settling and significant central herniation at the foramen magnum, causing quadriparesis.

CASE PRESENTATION

The patient was a 39-year-old Iranian man from a village around Hamadan city who presented with quadriparesis and paresthesia as well as loss of libido and impotence. Magnetic resonance imaging and computed tomography showed a huge diffuse avid enhancing infiltrating osteolytic lesion at the skull base. It had spread predominantly extramurally into the skull base resulting in cranial deposition, significant central herniation, myelopathy, and acute exacerbation of quadriparesis. On the basis of the pathology, immunohistochemistry, and elevated serum prolactin levels, the diagnosis of giant prolactinoma was almost definite. In addition to urgent midline suboccipital craniotomy for the central herniation and quadriparesis, he was treated with cabergoline followed by occiput cervical fixation and fusion to control the progressive subsidence.

CONCLUSION

Prolactinoma that is treatable with dopamine agonists should be considered as a differential diagnosis of skull base lesions, even those that are extradural, diffuse, and infiltrative. Giant prolactinoma can lead to craniocervical settling and central herniation that requires surgery and multidisciplinary management.

Endoscopic resection of a giant colloid cyst in the velum interpositum: illustrative case

BACKGROUND

Colloid cysts are an unusual differential diagnosis for lesions in the lateral ventricles. Microsurgery is usually recommended for the treatment of giant colloid cysts. This case is the largest reported colloid cyst in this unusual location treated with an endoscope.

OBSERVATIONS

A 39-year-old woman with a history of pulsing headaches presented with nausea, vomiting, vision blurring, and paresthesia of the left leg. On the brain computed tomography, a huge, well-defined homogeneous hyperdense intraventricular lesion with hydrocephalus was observed. Magnetic resonance imaging showed a spherical lesion over the third ventricle inside the lateral ventricles, obstructing the Sylvius aqueduct. There was no enhancement and no diffusion restriction on diffusion-weighted images. Endoscopic third ventriculostomy was undertaken for hydrocephalus treatment. Then the lesion was resected grossly. The cyst wall was resected as much as it was safe. There was no clot or bloody product inside the lesion.

LESSONS

Colloid cyst is rarely encountered in the velum interpositum and lateral ventricles, but the authors' giant colloid cyst case along with similar cases led to considering it out of the third ventricle. According to their experience, endoscopic removal is a safe and efficient method for colloid cyst surgery, even in giant cases.

Joint application of biochemical markers and imaging techniques in the accurate and early detection of glioblastoma

Glioblastoma is a primary brain tumor with the most metastatic effect in adults. Despite the wide range of multidimensional treatments, tumor heterogeneity is one of the main causes of tumor spread and gives great complexity to diagnostic and therapeutic methods. Therefore, featuring noble noninvasive prognostic methods that are focused on glioblastoma heterogeneity is perceived as an urgent need. Imaging neuro-oncological biomarkers including MGMT (O⁶-methylguanine-DNA methyltransferase) promoter methylation status, tumor grade along with other tumor characteristics and demographic features (e.g., age) are commonly referred to during diagnostic, therapeutic and prognostic processes. Therefore, the use of new noninvasive prognostic methods focused on glioblastoma heterogeneity is considered an urgent need. Some neuronal biomarkers, including the promoter methylation status of the promoter MGMT, the characteristics and grade of the tumor, along with the patient's demographics (such as age and sex) are involved in diagnosis, treatment, and prognosis. Among the wide array of imaging techniques, magnetic resonance imaging combined with the more physiologically detailed technique of H-magnetic resonance spectroscopy can be useful in diagnosing neurological cancer patients. In addition, intracranial tumor qualitative analysis and sometimes tumor biopsies help in accurate diagnosis. This review summarizes the evidence for biochemical biomarkers being a reliable biomarker in the early detection and disease management in GBM. Moreover, we highlight the correlation between Imaging techniques and biochemical biomarkers and ask whether they can be combined.