Intrasellar xanthogranuloma mimicking macroadenoma

Intracranial xanthogranulomas (XGs) have been found at various sites, but xanthogranuloma of the sellar region is extremely rare. We report about a case of sellar XG in a 34-year-old female. Magnetic resonance imaging showed a solid-cystic mass located at the sella turcica. The cystic component was hyperintense on the T1-weighted image (WI) and T2WI. The solid component was hyperintense on T1WI and hypointense on T2WI. There was peripheral enhancement after gadolinium administration. The diagnosis of cystic macroadenoma was considered before surgery. Final diagnosis of XG was confirmed by histopathological examination after surgical resection. Gross total resection of the lesion was achieved using the microscope through endoscopic endonasal transsphenoidal approach. The patient had a good outcome and no symptom of diabetes insipidus, hormonal evaluation did not show any alterations compatible with hypopituitarism and prolactin levels were normal XG should receive diagnostic consideration for the sellar mass lesions with cystic components hyperintense on T1WI and T2WI, solid components hyperintense on T1WI and hypointense on T2WI, and CT without evidence of calcifications. It is important to consider the possibility of XG when pertinent, as it facilitates a proper surgical approach strategy.

Myxofibrosarcoma: Another mimicker of meningioma

Primary intracranial malignant fibrous histiocytoma (MFH), or myxofibrosarcoma, is an extremely rare condition, with only a few cases reported in the literature. We report a case of a dural-based myxofibrosarcoma in a previously healthy 42-year-old man that was initially presumed to be an atypical meningioma. The findings based on conventional and advanced magnetic resonance sequences, including diffusion-weighted imaging, perfusion weighted imaging and proton magnetic resonance spectroscopy, as well as histopathological aspects, are discussed.

Digital analysis of hormonal immunostaining in pituitary adenomas classified according to WHO 2017 criteria and correlation with preoperative laboratory findings

OBJECTIVE

The authors sought to evaluate clinical and laboratory data from pituitary adenoma (PA) patients with functioning PA (associated with acromegaly [n = 10] or Cushing disease [n = 10]) or nonfunctioning PA (NFPA; n = 10) that were classified according to 2017 WHO criteria (based on the expression of the transcription factors pituitary-specific positive transcription factor 1 [Pit-1], a transcription factor member of the T-box family [Tpit], and steroidogenic factor 1 [SF-1]) and to assess the immunostaining results for growth hormone (GH) and adrenocorticotropic hormone (ACTH) in the corresponding tumors.

METHODS

Clinical and laboratory data were collected retrospectively. The percentage of tumoral cells positive for Pit-1, Tpit, or SF-1 was assessed and ImageJ software was used to evaluate immunopositivity in PAs with 2 different antibodies against GH (primary antibody 1 [AbGH-1] and primary antibody 2 [AbGH-2]) and 2 different antibodies against ACTH (primary antibody 1 [AbACTH-1] and primary antibody 2 [AbACTH-2]).

RESULTS

Cells with positive Pit-1 staining were more frequently observed in lesions from patients with acromegaly (acromegaly group) than in lesions from patients with Cushing disease (Cushing group; p < 0.001) and those from patients with NFPA (NFPA group; p < 0.001). The percentage of Tpit-positive cells was higher in the Cushing group than in the acromegaly (p < 0.001) and NFPA (p < 0.001) groups. No difference was detected regarding SF-1 frequency among all groups (p = 0.855). In acromegalic individuals, GH immunostaining levels varied depending on the antibody employed, and only one of the antibodies (AbGH-2) yielded higher values in comparison with the values for NFPA patients (p < 0.001). For all of the antibodies employed, no significant correlations were detected between GH tissue expression and the laboratory data (serum GH vs AbGH-1, p = 0.933; serum GH vs AbGH-2, p = 0.853; serum insulin-like growth factor-1 [IGF-1] vs AbGH-1, p = 0.407; serum IGF-1 vs AbGH-2, p = 0.881). In the Cushing group data, both antibodies showed similar ACTH tissue expression, which was higher than that obtained in the NFPA group (p < 0.001). There were no significant associations between ACTH immunohistochemical findings and ACTH serum levels (serum ACTH vs AbACTH-1, p = 0.651; serum ACTH vs AbACTH-2, p = 0.987). However, ACTH immunostaining evaluated with AbACTH-1 showed a significant correlation with 24-hour urinary cortisol (24-hour cortisol vs AbACTH-1, p = 0.047; 24-hour cortisol vs AbACTH-2, p = 0.071).

CONCLUSIONS

Immunostaining for Pit-1 and Tpit accurately identified lesions associated with acromegaly and Cushing disease, respectively. Conversely, SF-1 did not differentiate NFPA from lesions of the other two groups. Regarding hormonal tissue detection, results of the current investigation indicate that different antibodies may lead not only to divergent immunohistochemical results but also to lack of correlation with laboratory findings. Finally, PA classification based on transcription factor expression (Pit-1, Tpit, and SF-1), as proposed by the 2017 WHO classification of pituitary tumors, may avoid the limitations of PA classification based solely on digital immunohistochemical detection of hormones.

Myxofibrosarcoma: Another mimicker of meningioma

Primary intracranial malignant fibrous histiocytoma (MFH), or myxofibrosarcoma, is an extremely rare condition, with only a few cases reported in the literature. We report a case of a dural-based myxofibrosarcoma in a previously healthy 42-year-old man that was initially presumed to be an atypical meningioma. The findings based on conventional and advanced magnetic resonance sequences, including diffusion-weighted imaging, perfusion weighted imaging and proton magnetic resonance spectroscopy, as well as histopathological aspects, are discussed.

Comparative analysis of rhinologic outcomes in Cushing disease and non-functioning pituitary adenoma in patients submitted to endoscopic endonasal transsphenoidal surgery

PURPOSE

Adrenocorticotropic hormone (ACTH) secreted by pituitary tumors lead to changes in nasal cavity anatomy and physiology. As a consequence of hormonal alteration, there is an abnormal soft tissue and an increased capillary fragility, inducting to a thinner mucosa that acts in the healing process. We compared post-operative nasal alterations in patients with Cushing's disease versus patients with non-functioning macroadenomas who underwent endoscopic endonasal transsphenoidal surgery.

METHODS

A retrospective study with 14 patients with Cushing's disease who underwent initial transsphenoidal endonasal surgery for an ACTH-secreting adenoma was conducted. Forty-two patients who underwent the same surgery for non-functioning adenomas were selected as controls. The following data were collected: operative technique, endoscopic alterations in late post-operative period and post-operative nasal complaints.

RESULTS

There were 13/14 (92.9%) females with Cushing disease versus 23/42 (54.8%) in the non-functioning adenoma group. Surgical approach was similar in both groups, with no differences in flap usage, turbinectomies or ethmoidectomies. No difference occurred concerning endoscopic alterations or nasal complaints in post-operative period.

CONCLUSIONS

Post-operative results are similar, and healing could be expected to be equal.

Pituitary carcinoma: A case report and discussion of potential value of combined use of Ga-68 DOTATATE and F-18 FDG PET/CT scan to better choose therapy

BACKGROUND

Pituitary carcinoma is extremely rare and carries a very poor prognosis. In most cases, apparently indolent tumors become malignant; however, there are no satisfactory biomarkers for predicting tumor behavior. Thus, scientific advances in the search for new biological markers, diagnostic methods, and therapies are needed to improve the prognosis of these patients.

CASE DESCRIPTION

We report the case of a woman with initial diagnosis of nonfunctioning pituitary adenoma which evolved to carcinoma after 4 years. Diagnosis was confirmed after biopsy of metastatic pulmonary nodules, in which neoplastic cells were immunohistochemically positive for chromogranin, synaptotophysin, prolactin, and growth hormone. Investigation with conventional somatostatin receptor scintigraphy, positron emission tomography-computed tomography (PET-CT) with Ga-68 DOTATATE and F-18 fluorodeoxyglucose (FDG) are showed. During temozolomide therapy, our patient had severe pancytopenia resulting in death from generalized infection despite 10 days of intensive care.

CONCLUSION

The present case of an aggressive pituitary carcinoma rising from a typical adenoma illustrates the importance of developing new prognostic biomarkers in these cases. In addition to demonstrating a serious side effect with the use of temozolomide, our case report suggests that the combined use of Ga-68 DOTATATE and F-18 FDG PET-CT scan may scale somatostatin receptors vs. tumor aggressiveness, therefore, helping to better choose the therapy for aggressive pituitary tumors.

Endoscopic skull base surgery: evaluation of current clinical outcomes

Endoscopic skull base surgery is one of the most recent fields of neurosurgery. Successive innovations were developed throughout history so that the current concepts that rule this surgical field could be reached. The current paper presents the evolution of endoscopic surgery and its current results on the treatment of skull base tumor, based on a review of meta-analysis and clinical series. A PubMed search for articles published between January 1990 and January 2014 about "endoscopic skull base surgery", "endoscopic transsphenoidal approach", "endoscopic treatment of parasellar tumors" and "suprasellar lesions" was performed. According to the current data, endoscopic surgery seems to be superior to open and transsphenoidal microscopic removal of giant pituitary adenomas. Endoscopy is at least as successful as transsphenoidal microsurgery for the removal of pituitary adenomas and craniopharyngiomas. Transcranial open approaches, in the context of anterior midline skull base meningiomas, present higher rates of gross total resection, fewer complications and better clinical results than endoscopy approaches. The rate of postoperative CSF leakage has been significantly reduced with the introduction of new techniques such as the Hadad-Bassagasteguy flap but still represent one of the most important complications of this technique. Currently, selected tumors located at the anterior, middle and posterior fossa can be adequately assessed using the endoscope with low rates of postoperative CSF leaks. Endoscopic surgery has substantially evolved in the last decades through the collaboration of different teams around the world. The endoscope is now an essential tool in the neurosurgery armamentarium with great potential for new applications in the nearby future.

Endoscopic endonasal transsphenoidal resection of pituitary adenomas: preliminary evaluation of consecutive cases✩✩Please cite this article as: Chone CT, Sampaio MH, Sakano E, Paschoal JR, Garnes HM, Queiroz L, et al. Endoscopic endonasal transsphenoidal resection of pituitary adenomas: preliminary evaluation of consecutive cases. Braz J Otorhinolaryngol. 2014;80:146–51.,✩✩✩✩Study conducted at Department of Otolaryngology Head and Neck, Department of Neurosurgery, Centro Medico de Campinas Hospital, Department of Endocrinology, Department of Surgical Pathology, Universidade Estadual de Campinas, Campinas, SP, Brazil

Introduçáo

A cirurgia endoscópica endonasal ganhou aceitação crescente por otorrinolaringologistas e neurocirurgiões. Em muitos centros, esta tecnica é agora rotineiramente utilizada para as mesmas indicações que a técnica microcirúrgica convencional.

Objetivo

Descrever resultados cirúrgicos relativos à remissão hormonal, ressecção do tumor e complicações de série consecutiva de pacientes com adenoma da hipófise submetidos à ressecção endoscópica.

Método

Estudo de série de pacientes consecutivos com adenomas da hipófise, submetidos à cirurgia endoscópica endonasal, avaliados quanto à taxa de tumor residual, remissão funcional, sintomas, complicações e o tamanho do tumor.

Resultados

De 47 pacientes consecutivos, 17 eram portadores de adenomas funcionantes, sete produtores de GH, cinco com doença de Cushing e cinco prolactinomas. Dos adenomas funcionantes, 12 foram macroadenomas, cinco microadenomas, e 30 macroadenomas não funcionantes. Dos adenomas funcionantes, 87% melhoraram. Em relação ao déficit visual, 85% melhoraram ao longo do tempo. A maioria dos pacientes que apresentou queixas de cefaléia melhorou (76%). Complicações cirúrgicas ocorreram em 10% dos pacientes, com duas lesões da carótida, duas fístulas liquóricas e uma fatalidade em um paciente com um histórico complicado.

Conclusão

A cirurgia hipofisária endoscópica endonasal é uma técnica viável, rendendo bons resultados cirúrgicos e funcionais e baixa morbidade.

© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Sylvian fissure arachnoid cysts: a survey on their diagnostic workout and practical management

BACKGROUND

The management of Sylvian arachnoid cysts in children is still a matter of debate. Diagnosis is often incidental, and symptoms are frequently aspecific in symptomatic cases. Suggested diagnostic investigation results have been often unclear. Surgical treatment is also controversial, pure, and assisted endoscopic cyst marsupialization having entered in the traditional debate between craniotomic and shunting approach

PURPOSE

The objective of the present study was to survey if (and, eventually, which) agreement points do actually exist between internationally recognized pediatric neurosurgery centers in the management of children with a controversial type of Sylvian arachnoid cyst (Type II cyst).

METHODS

Contributors were asked to answer to a six-separate-part multiple choice questionnaire related to the case of a 2.7-year-old boy with a Type II left Sylvian arachnoid cyst presented in different clinical situations. If surgery was indicated, it was asked which surgical procedure the authors would have suggested as first option.

RESULTS AND CONCLUSIONS

The option of the mere clinical observation was chosen by the majority of surgeons in case of asymptomatic clinical discovery. On the other hand, a constantly high percentage of participants suggested direct surgical treatment based on clinical manifestations or as a preventive measure justified by the risk of spontaneous or traumatic intracranial bleeding. The only diagnostic investigation result which significantly influenced the surgical indication was a localizing electroencephalography, if the child presented with seizures. The result is that in most cases the surgical indication was based on aspecific clinical manifestations and laboratory data. Craniotomy and arachnoid cyst marsupialization represented the preferred surgical option (66.6%), 28.8% of the participants suggesting pure or assisted endoscopic cyst marsupialization as primary surgical procedure. Cyst shunting was suggested by only three centers.

Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions

Object

The extended transsphenoidal approach to the suprasellar region has the advantages of minimal invasiveness and brain manipulation in the surgical treatment of small to medium lesions. At the same time, however, it carries a higher risk of postoperative cerebrospinal fluid (CSF) leakage and related complications than those for the standard transsphenoidal approach. Effective reconstruction of large skull base defects is a major concern in such extended approaches and remains challenging.

Methods

Between January 2004 and April 2006, 21 patients affected by different suprasellar lesions underwent the extended endoscopic endonasal transtuberculum-transplanum approach. Three different techniques were used for the skull base reconstructions. In all cases, dehydrated human pericardium (Tutoplast) for dural reconstruction and a copolymer of l-lactic acid and glycolic acid (LactoSorb) as a bone substitute were used. Collagen sponges, fibrin glue, and an inflated Foley balloon catheter were also used to fill the sphenoid sinus cavity.

Results

Two cases of postoperative CSF leaks (9.5%) and one case of mycotic sinusitis (4.8%) occurred following the intradural (inlay) and intraextradural (inlay-overlay) graft positioning. No cases of postoperative CSF leakage occurred in cases in which the extradural-only reconstruction procedure was applied. No meningitis or other complications related to the closure were noticed.

Conclusions

The rate of postoperative CSF leakage after an extended approach to the suprasellar area is higher compared with that following standard pituitary surgery. Reconstruction after craniopharyngioma surgery exposes patients to an increased risk of postoperative CSF leaks. The extradural (overlay) technique was found to be the most effective in assuring a watertight closure.

Endoscopic endonasal transsphenoidal surgery. Before scrubbing in: tips and tricks

BACKGROUND

The interest in endoscopic endonasal transsphenoidal surgery for the treatment of sellar and perisellar lesions is growing as a consequence of the results achieved in the past 10 years and of the interest by patients, endocrinologists, and neurosurgeons. Furthermore, the special ability of the endoscope to offer a wider and detailed view of anatomic structures is a major advantage that increases the attention of neurosurgeons who seek less invasive procedures and better results. Most neurosurgeons performing transsphenoidal surgery, however, are not used to endoscopy, and changing from microsurgical to endoscopic technique can be difficult and even discouraging, often because of difficulties in the initial phase of the procedure.

TECHNIQUE

With the purpose of helping minimize some of the difficulties, we describe herein useful tips and tricks that mainly concern familiarization with the endoscopic equipment, details of the transsphenoidal anatomy, and endoscopic skills. We stress the steps and details that we judge most important.

CONCLUSION

We believe that by following these recommendations neurosurgeons can overcome, or even avoid, the difficulties frequently encountered transsphenoidal surgery, allowing them to safely and efficiently perform endonasal transsphenoidal endoscopic procedures.