Giant-cell tumour involving the cranial vault: imaging and treatment

A giant-cell tumour involving the cranial vault was diagnosed in a 37-year-old man who presented with a large swelling at the vertex. The role of imaging in the diagnosis and treatment of this tumour is described. On CT and MRI the appearances were nonspecific and the diagnosis was established by histological examination after removal of the tumour. A preoperative angiogram showed a tumour blush and before surgery, embolisation was performed via the percutaneous and transarterial routes.

Postoperative aneurysm remnants: endovascular treatment as an alternative to further surgery

Because further surgery on postoperative aneurysm remnants can be difficult and lead to significant morbidity and mortality, endovascular treatment, using controlled detachable coils, was performed in three patients with such remnants. The endovascular approach was technically more difficult in these cases than in previously untreated patients. In one case, the "remodelling" technique was necessary. Given the successful outcome in these patients, endovascular treatment can be proposed as an alternative to another operation, when further surgery appears too risky or is refused by the patient.

Prevalence of lymphocytic infiltrate in 1400 pituitary adenomas

To evaluate the prevalence of lymphocytic infiltrate in a large series of pituitary adenomas, we retrospectively studied tumor tissues from 1400 patients. Based on immunocytochemical data, tumors were classified as PRL (n=411), multihormonal (n=310), immunonegative (n=275), ACTH (n=166), GH (n=137), alpha subunit (n=44), FSH and/or LH, (n=42), and TSH (n=15) adenomas. The lymphocytic infiltrate was diagnosed on histological examination and investigated by immunostaining with anti LCA (human leucocyte common antigen), anti CD45RO (human T cell) and anti CD20 (human B cell) antibodies. Lymphocytic infiltrate was present in 40 adenomas (2.9%), 26 females and 14 males, aged 18 to 77 years (mean+/-SD, 37+/-14 years). The tumors were 19 PRL, 8 multihormonal, 4 GH, 4 alpha subunit, 3 ACTH, and 2 immunonegative adenomas. In PRL adenomas, the sex ratio (female/male) and the age were similar in patients with and without lymphocytic infiltrate (2.8 vs. 4.6 and 29+/-6 years vs. 32+/-11 years, respectively). The frequency of lymphocytic infiltrate was similar in PRL, GH, ACTH and multihormonal adenomas, but lymphocytic infiltrate was significantly more frequent in PRL adenoma than in immunonegative adenoma, and in alpha subunit adenoma than in immunonegative, ACTH and multihormonal adenomas. The lymphocytic cells were almost exclusively T cells. We conclude that lymphocytic infiltrates are rare in pituitary adenomas. Their frequency is not statistically different in major categories of secreting adenomas (PRL, GH, ACTH, multihormonal). Their pathophysiological significance remains to be established.

[Surgery of pituitary adenoma]

The transsphenoidal approach is used in 99% of pituitary adenomas cases. In this kind of surgery, mechanical and endocrinological complications are rare. The visual disturbances of the huge macroadenomas are easily cured if the patient is operated on before optic atrophy. In secreting adenomas the cure of the hypersecretion depends mainly on the tumor size and is obtained in 90% or 95% of microadenomas. Recurrencies may occur in 10% or 15% of patients; if they are easily diagnosed in hypersecreting tumors they must be systematically searched for in ron secreting adenomas which require a regular follow-up.

McCune-Albright syndrome and acromegaly: clinical studies and responses to treatment in five cases

We report here five new patients with McCune-Albright syndrome and acromegaly. In the five patients studied (three males and two females aged 18-42 years), acromegaly began before the age of 20 years and was recognized after the diagnosis of fibrous dysplasia, which was polyostotic in three cases and monostotic in two. Bone fibrous dysplasia always involved the base of the skull and in four patients prevented surgical removal of the pituitary adenoma, which was visualized easily by magnetic resonance imaging. Serum growth hormone (GH) levels ranged between 20 and 48 micrograms/l and were not suppressed by an oral glucose load. Thyrotropin-releasing hormone administration produced a paradoxical increase in serum GH levels in all the patients. Four of the five patients had hyperprolactinemia (43-670 micrograms/l). In the sole patient who could be operated on, a typical adenoma with positive immunostaining for GH was incompletely removed and postoperative radiation therapy failed to cure the acromegaly. In two patients, medical therapy with bromocriptine and/or octreotide was partially or totally ineffective whatever the dose (up to 1.5 mg per day) and duration (2-4 years) of octreotide treatment.

Functioning ectopic supradiaphragmatic pituitary adenomas

Pituitary adenomas arising far from the pituitary gland occur rarely as a result of defects in embryological migration. Likewise, there have been reports of isolated suprasellar adenomas (clinically nonfunctioning), presumably derived from cells of the pars tuberalis. In this report, we present four cases of functional pituitary adenomas (three adrenocorticotrophic hormone, one prolactin) confined to the supradiaphragmatic region. In each case, the tumors were initially treated unsuccessfully by operations via the transsphenoidal route because of expected intrasellar processes with suprasellar extension.

Pituitary granuloma and pyoderma gangrenosum

Pyoderma gangrenosum is a rare chronic and recurrent skin disease characterized by progressing lesions from papulopustules to large necrotic sterile ulcers. Its definite etiology remains unknown. In a 40-year-old woman with typical pyoderma gangrenosum an intrasellar mass with suprasellar extension was diagnosed and removed by transsphenoidal surgery. Histopathological features of the lesion were those of a nonspecific granulomatous hypophysitis. Five months postoperatively the patient experienced visual defects and hypopituitarism demonstrated by endocrine evaluation. Computerized tomography showed the recurrence of the intrasellar expanding mass. Extensive and repeated evaluation failed to find any evidence of sarcoidosis, tuberculosis or histiocytosis. Corticosteroid therapy was preferred to surgery and 80 mg daily prednisone produced a dramatic shrinkage of the pituitary pseudotumor. Long-term follow-up studies did not disclose any recurrence of the pituitary granulomatous process nor objective evidence of underlying disease even after steroid dosage has been tapered. The hypothesis of a pituitary localization of pyoderma gangrenosum is suggested by the similarity between the histopathologic findings of the two conditions and the excellent response to steroid therapy.

[Upper cervical intradural lipoma. Apropos of a case]

Intradural lipoma is a rare and slow growing tumor which represents 1% of all intra-spinal tumors. This tumor is often associated with dysraphism. It can be isolated without any associated vertebral or cutaneous malformations. Its clinical evolution is extremely slow and progressive. The fatty composition of this type of tumor allows easy detection by CT as well as by MRI. MRI permits: Reliable and direct assessment (in 3 different plans) of the extension of the lesion. An excellent post operative control.

[Post-neurosurgical purulent meningitis. 31 cases]

Thirty-one cases of post neurosurgical bacterial meningitis from one center were reviewed to determine their promoting factors and responsible organisms. Most cases occurred after a protracted operation (6 hours on average). 26% cases were related to a primary cutaneous infection. 58% organisms were Gram negative bacilli. The course of meningitis was often complicated or prolonged due to a scalp decubitus ulcer or cerebrospinal fluid leakage. Vancomycin is often requested during staphylococcal meningitis. Third generation cephalosporins have low MIC against many Gram negative bacilli and should be used. Pefloxacin, a new quinolone, may be valuable. Treatment of scalp wound infection is often requested.

Surgical management of tumours invading the skull base

The author describes four different approaches to clival tumours, and reviews his experience with 33 chordomas of the clivus. He also reviews his large experience with tumours invading the floor of the anterior and middle cranial fossae, and describes various surgical approaches for the removal of these tumours, followed by reconstruction of the bony floor with bone grafts, and dural reconstruction.

Paradoxical response of thyrotropin to L-dopa and presence of dopaminergic receptors in a thyrotropin-secreting pituitary adenoma

We studied the dopaminergic control of TSH secretion in a patient with hyperthyroidism due to a TSH-secreting pituitary adenoma. A 34-yr-old previously thyroidectomized woman had mild clinical hyperthyroidism and a diffuse goiter without exophthalmos. She complained of headaches and had bitemporal hemianopsia. Serum T4 and T3 by RIA were elevated, and TSH was 112 microU/ml (normal range, 1.1-7.2). The alpha-subunit to TSH molar ratio was 1.7 (normal, less than 1), as reported in other patients with tumoral TSH hypersecretion. After TRH, a marked increase in TSH occurred. There was no evidence of pituitary deficiency. Skull x-rays and computerized axial tomography revealed an intrasellar tumor with suprasellar extension. Selective transsphenoidal adenomectomy was performed, and a pituitary tumor was removed. The tumor was almost entirely composed of cells reactive with antihuman beta TSH serum by indirect immunofluorescence. A unique feature of this patient was the marked increase in TSH levels after L-dopa administration. To our knowledge, this paradoxical response has never been reported previously in such patients. Using [3H]domperidone as ligand, dopaminergic receptors were demonstrated in the membranes of the adenomatous thyrotroph cells. The reason for the paradoxical response of TSH to dopaminergic agents is not known.

Hyperostosing meningiomas of the sphenoid ridge--clinical features, surgical therapy, and long-term observations: review of 49 cases

Thirty-three patients with en plaque, 9 with en masse (but with extensive bone involvement), and 7 with recurrent hyperostosing meningiomas of the sphenoid ridge were operated on. All patients underwent large extradural resection of the base of the skull as well as extirpation of the intradural tumors or adjacent plaques. The periorbita was involved in 13 patients (26.5%). Seventeen patients (34.7%) needed reconstruction of the base of the skull. This was achieved with autogenous bone grafts. In all but 3 patients, invasion of the bone by meningiomatous tissue was demonstrated histologically. Operative mortality was 4%. Total removal was possible in 91% of the patients with meningiomas located at the pterion or middle third of the sphenoid ridge. More difficult was the total removal of meningiomas of the inner third or of the entire sphenoid ridge (47%). However, long-term results have proved to be satisfying. Early surgical therapy should always be considered as the treatment of choice for such meningiomas.

[Pituitary and hypothalamic metastases : 5 cases (author's transl)]

Five cases of metastatic cancer in the pituitary gland are reported, four of which were revealed by chiasmatic syndrome and one by diabetes insipidus. Transphenoidal surgical treatment was possible in three cases. This site of metastasis is considered exceptional because of its customary inactivity. It is probable that the metastasis most often remain unrecognized and so, it requires careful study of the slightest sign because of treatment possibilities.

Endocrine outcome after transsphenoidal adenomectomy for prolactinoma: prolactin levels and tumor size as predicting factors

The level of prolactin in the serum was determined pre- and postoperatively in 90 patients who were operated upon transsphenoidally for prolactin-secreting pituitary adenomas. Twenty-three had microadenomas and 67 had macroadenomas. Those patients who were cured had a distinctly lower mean prolactin level (about 200 ng/ml or less) than those who were not cured. Of those patients whose adenomas were larger than 10 mm in diameter, only 39% were cured. The relationship between prolactin levels and tumor size and the return of menses and cure is discussed.

[Cerebrospinal fluid rhinorrhea (author's transl)]

A series of 140 surgical cases of CSF rhinorrhea have been reviewed, their diagnostic difficulties outlined and the possible etiologies and the modes of surgical approach explained. The localization of the leak is difficult in traumatic cases but if one searches diligently for the source with polytomography of the skull base as well as utilizing repetitive radioisotope studies, one can definitely find the source of the rhinorrhea. If the patient presents with purulent meningitis, a fistulous tract, acquired or congenital, should be sought and if present resected. Only precise surgical technique in and around the skull base in cases of rhinorrhea, allows total definitive recovery without recurrent leak and prevents post operative rhinorrhea in routine basal and trans-sphenoidal neurosurgical procedures.

[Prolactin secreting adenomas: surgical treatment and results. 120 female cases, 30 males cases (author's transl)]

Twenty one per cent of the female cases concerned microadenomas discovered because of amenorrhea with or without galactorrhea. Sixty two per cent of these cases were cured by surgery alone, against 40% of the other types of prolactin (Prl) -- secreting tumors with extra-sellar extensions which were not cured. With men, no microadenomas was discovered (although one case demonstrated their possible existence) and in the most frequent cases, tumors exhibited extra-sellar extensions sometimes very large (giant tumors). In these cases, tumoral symptoms were cured by surgery while only 5 out of 30 men recovered a normal plasma Prl. level (30 ng/ml). In all cases the prognosis was established taking into account the volume and invasive characters (at the surgical and histopathological level) of the tumors. The different therapeutical approaches of these tumors (i.e. medical treatment by CB 154, surgery of Rxtherapy) were evaluated. Anyway the necessity of an earlier diagnosis is pointed out allowing the possibility of a selective adenomectomy by a microsurgical approach.