Huge Sellar Plasmacytoma as Differential Diagnosis of Invasive Pituitary Adenoma: A Case Report

Sellar plasmacytomas are rare tumors arising from plasma cells. They are often misdiagnosed as adenomas.We report the case of a 63-year-old woman with headache, cranial nerve III palsy and decreased visual acuity. Imaging revealed an extensive lesion centered on the clivus, extending to the cavernous sinus bilaterally and into the sphenoid sinus. The hormonal tests were compatible with panhypopituitarism and mild hyperprolactinemia. The first hypothesis was invasive pituitary adenoma. Partial resection was achieved, and the immunohistochemical evaluation was compatible with plasmacytoma. After a few weeks, she developed lumbar and hip pain, and the imaging confirming osteolytic lesions. The final diagnosis was multiple myeloma.

Microsurgical and Endoscopic Anatomy of the Cavernous Sinus

Objective To describe the endoscopic and microsurgical anatomy of the cavernous sinus (CS) with focus on the surgical landmarks in microsurgical anatomy. Materials and methods Ten formalin-fixed central skull base specimens (20 CSs) with silicone-injected carotid arteries were examined through an extended endoscopic transsphenoidal approach. Fifteen formalin-fixed heads were dissected to simulate the surgical position in CS approaches. Results Endoscopic access enables identification of the anterior and posterior surgical corridors. Structures within the CS and on its lateral wall could be visualized and studied, but none of the triangular areas relevant to the transcranial microsurgical anatomy were fully visible through the endoscopic approach. Conclusion The endoscopic approach to the CS is an important surgical technique for the treatment of pathological conditions that affect this region. Correlating endoscopic findings with the conventional (transcranial)microsurgical anatomy is a useful way of applying the established knowledge into a more recent operative technique. Endoscope can provide access to the CS and to the structures it harbors.

Multiplanar MRI imaging of sellar and parasellar lesions with clinical and pathological correlation

Background: Sellar and parasellar/ juxtasellar regions are complex areas of the brain, hold delicate neurovascular structures. A number of diseases that affect the pituitary-hypothalamic axis can have profound clinical, endocrinological as well as neurological consequences. Aim of this retrospective study was to identify the MR imaging characteristics and epidemiology of sellar and suprasellar lesions, to correlate the MRI findings with histopathological findings and to highlight the diagnostic superiority of MR imaging.Methods: Author studied the records of 65 patients with sellar and suprasellar lesions for which preoperative MR imaging films or reports were available. Radiological appearances were correlated with intraoperative findings and post-operative histopathology.Results: Majority of patients in this study belonged to the age group 21-40 years. Most common mass lesion found was pituitary macroadenoma comprising 58% of the total cases. The accuracy of MRI in diagnosing macroadenomas are 96.80%. MR was 87.50%accurate, in diagnosing craniopharyngioma. MR was 100% in diagnosing meningioma in our study.Conclusions: MRI is the modality for characterizing sellar and suprasellar lesions, morphology of lesions, nature of contrast material enhancement and extent of lesions. Hence MRI is the modality of choice for diagnosing sellar and suprasellar masses with high accuracy

Anatomical variations of intra-sphenoid sinus septations in a sample of Kashmiri population: a non-contrast computed tomography study

Background: The sphenoid sinus shows multitude of variations in pneumatization, size and pattern of septations leading to differences in its segmentation. Pre-operative knowledge of their attachment especially to posterolateral bony walls covering vital structures is of utmost importance for a safe trans-sphenoidal approach for various surgical procedures involving skull base. Non-contrast computed tomography (NCCT) with its ability to provide multiplanar reformations (MPR) with sharp algorithms is now a reference standard for visualization of these intra-sphenoid sinus septations preoperatively. The objective of this study was to determine the number and attachment of intra-sphenoid sinus septations in a Kashmiri population sample.Methods: NCCT head images of 591 patients in the age range of 16 to 75 years were analyzed retrospectively. Individuals with age less than 16 years, previous surgery involving skull base/sphenoid sinus, trauma causing hem sinus/fractures around skull base or having space occupying lesions around skull base/sphenoid sinus were excluded from the study. On the CT workstation multi-planar coronal, sagittal and axial reconstructions were performed and subsequently examined.Results: The age range was 16 to 75 years with mean age of 43.56 years of which 453 (76.6%) were males and 138 (23.4%) were females. Single intra-sphenoid septation was the most common anatomic variant in present study (79.7%) being complete in 71.7% and partial or incomplete in 8% of the examined subjects. Double septa were found in 11% inpresent study and more than 2 septae in 3.4%. After sellar attachment (51%) the next most common site of attachment was to the carotid canal (29.5%) (23% to left ICA and 6.5% to the right ICA).Conclusions: Intricate knowledge about sphenoid sinus, its pneumatization and anatomical variations in intra-sphenoid sinus septations and its relationship with the surrounding vital structures is of utmost importance before performing any endoscopic/open surgery involving skull base via trans-sphenoidal approach. The present study shows that a significant percentage of septal attachment to the carotid canal makes main sphenoidal septum as not so reliable landmark for endoscopic procedures as used to be in the pre-imaging era. Thus, preoperative CT is mandatory to avoid injuries to para-sellar neurovascular and glandular structures.

Mri Characterization Of Sellar & Parasellar Lesions And Their Clinical Correlation

Aims & Objectives: This study aimed to describe the prevalence of the various lesions and to characterize imaging features of the sellar and parasellar lesions and to correlate between clinical and radiological diagnosis. Methodology: This study was done for the characterization of sellar & parasellar lesions with the help of MRI scan, which were done at the MRI centre, MB Hospital, Udaipur, Rajasthan from January 1, 2017, to December 2017. Medical case papers were reviewed for the primary clinical indication that led to a referral for pituitary MRI and serum prolactin levels were noted to follow up regarding surgical or conservative management was done. After analyzing the data results were expressed as frequency of occurrence and percentages of various lesions which were compared with clinical findings. Results: The study population consisted of 80 patients, of which majority were females. MRI revealed abnormality in 68% cases and it was found that combined sellar and suprasellar involvement was there in most of the patients, followed by pure intrasellar and parasellar involvement. Conclusion: The sellar and parasellar regions can be affected by a wide variety of lesions with almost similar presentation. When symptoms of mass effect, visual field deficits and endocrine abnormalities are not sufficient to distinguish these lesions, the use of MRI can helpful in reaching the proper diagnosis

Analysis of MRI Diagnosis and Misdiagnosis of Parasellar Cavernous Haemangioma / 现代生物医学进展

Objective:To analyze the magnetic resonance imaging (MRI) features of parasellar cavernous haemangioma and improve the diagnosis and differential diagnosis accuracy.Methods:13 patients with parasellar cavernous haemangioma were collected.All the patients were diagnosed by MRI and confirmed by pathology.Based on the pathologic findings,the MRI features were discussed.Results:9 cases presented horizontal dumbbell.The lesions located in the parasellar were larger than the sella turcica.The main body position of the lesions were centered lateral to the parasellar and encasesed the intracavernous internal carotid artery (ICICA).While,1 cases were similar in size and shape.1 case was located in the sella turcica.2 cases was centered lateral to the ICICA.pituitary were detected obscurity in 7 cases and displaced in 6 cases,6 cases appeared extremely high homogeneous intensity on T2-weighted images:as bright as cerebrospinal fluid signal.Only 5 cases underwent three-dimensional arterial spin labelling perfusion imaging (3D-ASL).The lesions revealed marked hypoperfusion.The cases of misdiagnosis were 9,including 4 cpituitary adenomas and 5 meningiomas.Conclusions:The characteristics of MR images ofparasellar cavernous haemangioma were horizontal bottle gourd form,the main body position of the lesions were centered lateral to the parasellar and encasesed the (ICICA),and their extremely high homogeneous intensity on T2-weighted images:as bright as cerebrospinal fluid signal.In cases that are equivocal,3D-ASL were useful in differentiating cavernous haemangiomas from parasellar meningiomas,which could decrease mistaken diagnosis.Graspping the imaging feature and differential diagnosis were helpful for the diagnosis of this disease.

Microsurgery for parasellar menningiomas and impact factors of recurrence / 中南大学学报(医学版)

Objective:To study the effect of microsurgery for parasellar menningiomas and to analyze the impact factors of recurrence. Methods:Clinical and follow-up data in a consecutive series of 134 patients with parasellar meningiomas were retrospectively analyzed. Results:A total of 109 patients (81.3%) had radical removal (Simpson grade I and II), and 116 patients were followed up for an average period of 81.6 months. The mean quality of life score (KPS) was 91.9, 90 patients regained full daily activity and 16 patients were able to take care of themselves. Oculomotor paralysis occurred in 7 patients, epilepsy in 8, and another 9 patients suffered hemispheral paralysis. Tumor recurred atfer the radical removal in 12 out of the 96 follow-up patients (12.5%). Tumor progressed atfer subtotal removal in 12 out of the 20 follow-up patients (60%). Tumor with cavernous sinus (CS) invasion had significantly higher risk of recurrence campared with non-CS invasion (P=0.043). The recurrence rate increased with the pathological grade (P<0.01). Conclusion:Patients with parasellar meningiomas undergoing microsurgical resection may have a good long-term function outcome. For most patients, total removal by microsurgery is the ifrst choice. Careful follow-up is needed if tumor invaded the CS and radiosurgery is proposed for WHO grade 1 and 2.

Supra-orbital keyhole removal of anterior fossa and parasellar meningiomas / Minicraniotomia supra-orbitária superciliar no tratamento de meningiomas na fossa craniana anterior e para-selares

The improvement of surgical techniques as well as the introduction of new surgical instruments promoted the use of keyhole craniotomies in neurosurgery. We evaluated the technical aspects of the supra-orbital keyhole approach considering the indications, limitations, and complications of this approach to treat anterior cranial fossa and parasellar meningiomas. Twenty-four patients (21 females; mean age, 53±8.6 years) operated on between 2002 and 2006 through a supra-orbital eyebrow approach were studied. Maximal tumor diameter ranged from 1.6 to 6 cm. Gross total resection was done in 20 (83.3 percent). All tumors were histologically benign. Two patients (8 percent) experienced CSF rinorhea and another two patients suffered transitory diabetes insipidus (8 percent). One patient experienced transitory hemiparesis. There was one case of meningitis and one mortality. Follow-up ranged between 6 to 66 months (mean 31.5±20.1 months), with no recurrence. The supra-orbital keyhole craniotomy is a useful minimally invasive approach to treat selected anterior fossa and parasellar meningiomas.

A evolução técnica e a introdução de instrumentais cirúrgicos mais delicados proporcionaram o uso de craniotomias menores no tratamento de patologias intracranianas. Avaliamos os aspectos técnicos da minicraniotomia supra-orbitária superciliar, considerando as indicações, limitações e complicações no tratamento de meningiomas na fossa craniana anterior e para-selares. Vinte e quarto pacientes (21 mulheres; idade média, 53±8,6 anos) operados entre 2002 e 2006 foram estudados. O diâmetro tumoral máximo variou de 1,6 a 6 cm. Ressecção total foi obtida em 20 (83,3 por cento). Todos os tumores eram histologicamente benignos. Dois pacientes (8 por cento) apresentaram fistula liquórica pós-operatória e outros dois diabetes insipido transitórioa (8 por cento). Um paciente evoluiu com hemiparesia transitória. Houve um caso de meningite e um de evolução fatal. O seguimento variou de 6 a 66 meses (média 31,5±20,1 meses), não houve recidiva. A minicraniotomia supra-orbitária superciliar é uma via de abordagem eficaz para o tratamento de meningiomas da fossa craniana anterior e para-selares selecionados.

Endoscopic Skull Base Surgery

Endoscopic skull base surgery has undergone rapid advancement in the past decade moving from pituitary surgery to suprasellar lesions and now to a myriad of lesions extending from the cribriform plate to C2 and laterally out to the infratemporal fossa and petrous apex. Evolution of several technological advances as well as advances in understanding of endoscopic anatomy and the development of surgical techniques both in resection and reconstruction have fostered this capability. Management of benign disease via endoscopic methods is largely accepted now but more data is needed before the controversy on the role of endoscopic management of malignant disease is decided. Continued advances in surgical technique, navigation systems, endoscopic imaging technology, and robotics assure continued brisk evolution in this expanding field.

Two Cases of Paraganglioma in the Parasellar Region and in the Urinary Bladder / 日本農村医学会雑誌

We report two cases of paraganglioma originating in the paraseller region (case 1) and in the urinary bladder (case 2). The subject in case 1 was a 59-year-old man who was admitted into the hospital with dizziness, muscular weakness of the left extremities and cold sweating. Magnetic resonance imaging (MRI) revealed a tumor in the parasellar region. The subject in case 2 was a 39-year-old man who was hospitalized because he had a sense of residual urine. Computed tomography and MRI showed a mass of tumor tissue in the posterior region of the left ureteric orifice of the bladder. Imprint cytology of both tumors showed isolated, loosely attached sheet-like cells with abundant cytoplasm and round or oval nuclei. Histologically, both tumors consisted of round or polygonal cells in small packets separated by vascular fibrous septa. Immunohistochemically, both tumor cells were positive for NSE, S-100 protein, chromogranin A, and synaptophysin. Electron microscopic examination revealed neurosectretory granules in the cytoplasm of tumor cells in either of these two cases.

Radiological Characteristics in Rathke's Cleft Cyst

OBJECTIVE: The study is conducted to define the preoperative radiological findings of Rathke's cleft cysts (RCCs) differentiating these lesions from other sellar/parasellar cystic tumors. METHODS: A retrospective study of 65 patients with RCC patients from two institutes (53 cases / 12 cases) was performed. All patients had preoperative magentic resonance imaging(MRI) studies, and computed tomography(CT) studies were available in 25 patients. RESULTS: Calcification detectable on CT scanning was present in only 8% of RCC patients. Of the patients who were available for precontrast CT images, 48% had cysts of low attenuation, 28% had cysts of the same attenuation, and 24% had cysts of increased attenuation relative to the brain. Of the patients who had postcontrast CT images, 84% showed no significant change following contrast agent administration, and 16% demonstrated rim enhancement. MR imaging revealed multiple patterns. In T1-weighted sequences, 55.4% showed hyperintense signals, 27.7% showed hypointense signals, 12.3% showed isointense signals, and we saw a mixed-intense signal in 4.6%. In T2-weighed images, we observed a hyperintense signal in 60%, a hypointense signal in 20%, a mixed-intense signal in 13.8%, and an isointense signal in the remaining 6.2%. In Gd-DTPA enhanced images, 72.3% of the 65 patients showed no enhancement either of the cyst contents or of the cyst wall, and 27.7% demonstrated rim enhancement. Forty-five of the 65 patients were preoperatively diagnosed as RCCs. CONCLUSION: RCCs show variable CT and MRI characteristics. There is no unique finding for this pathology. Thus, even with CT and MRI studies, differential diagnosis with other cystic lesions of the sellar/parasellar region remains difficult.

Symptomatic Graular Cell Tumor Involving Intra- and Suprasellar Area: A case report

Symptomatic parasellar granular cell tumor is a very rare tumor. To the best of our knowledge, 43 cases was be found in the English literatures. We recently experienced a case of a parasellar granular cell tumor in a 61-year-old female who had bilateral temporal hemianopsia and severe panhypopituitarism. The tumor was composed of diffuse sheets of polygonal cells with abundant eosinophilic PAS positive granular cytoplasm. In the immunohistochemical and ultrastructural examinations, the tumor failed to show any evidence of Schwann cell or glial differentiation. These findings suggest that granular cell tumor has heterogenous cell types of origin.

Surgical Tacties for Large Sellar and Parasellar Tumors

We analyzed 56 operations in 45 patients with sellar and parasellar tumors from March, 1990 to May, 1995, to evaluate the determining factors in selecting the surgical approaches for large and giant sellar and suprasellar tumors, based on clinical, endocrinological and radiological findings. The definition of "large" is when the longest diameter of the tumor is more than 20mm on radiographic studies and the term "small" is applied to tumor of diameter below 19mm. The results were as follows: 1) Number of the patients with small tumor was 14(31.1%) and all of them were treated with single stage transsphenoidal approach, and 42 operations were performed in 31(68.9%) patients with large tumors. 2) The approaches for large tumors were: transsphenoidal approach in 32 cases: pterional approach 5 cases: subfrontal interhemispheric approach 4 cases; and subfrontal paramedian approach 1 case. 3) The rate of complete removal for large and giant tumors in the first operation was 29.0%; in second operation, 72.7%; overall the rate was 54.8%. 4) Complications were; transient type diabetes insipidus in 24 cases; meningitis 2 cases; hypothalamic injury 3 cases; CSF rhinorrhea 1 case; and cerebral infarction 1 case; and death 1 case. 5) There was significant relationship between the size of the tumor and tumor types(p0.05) but not wih destruction of the sellar floor(p0.05). 7) In case of incomplete removal with first transsphenoidal approach, a second operation seems to be helpful. 8) In second stage transcranial approach following first transsphenoidal approach, it is easier to remove the tumor due to the decreased tumor size and thus, a reduced need for marked brain retraction. From our findings, we suggest guidelines in choosing the surgical approach for sellar and parasellar tumors as follows: 1) Many of the tumors in the sellae and suprasellar area can be removed successfully by transsphenoidal approach. 2) Taranssphenoidal approach can be repeated safely in stage O, A, B and C, if the diaphragm sella remains intact. 3) Tanscranial approach is recommended primarily in stage D & E, if intrasellar portion of the tumor is not significant or opening of the diaphragm sella is narrow. 4) Transsphenoidal approach followed by transcranial approach is adequate in stage D & E, if significant amount of the tumor remaining in the sella or sellar floor is severely destructed(Grage III, IV).

Postoperative Visual Results on Sellar and Parasellar Tumors

We reviewed the records of 28 patients who underwent transcranial(20 cases) or transsphenoidal(8 cases) surgery sellar and parasellar tumors. Both pre-and postoperative visual status(visual acuity and field) of each eye were analyzed under the rating system of Cohen, et al. The average duration of follow-up 3 months. The lesions encountered consisted of pituitary adenoma in 14 cases, craniopharyngioma in 5 cases, meningioma in 4 cases, chordoma in 3 cases, a dermoid cyst in 1 case, and an unspecified tumor in another case. All patients had objective signs of visual acuity or field defects preoperatively. Overall postoperative visual acuity and visual fields were normalized or improved in 73% and 71% of the eyes, respectively. The visual outcome of postoperative visual acuity was better in cases of craniopharyngioma(80%) than the other tumors. Visual evoked potentials(VEP) showed all postoperative improvement and was as helpful as visual fields in determining visual status. The visual outcome was better in patients with a shorter duration of symptoms and those with smaller tumors. Patients with lesser compromise of preoperative visual acuity had better outcome of postoperative visual acuity. However, the severity of preoperative visual field defects did not seem to influence postoperative field outcome. There also was no relationship between the presence of endocrine activity of the tumor and visual outcome. Patients who underwent transsphenoidal approach had either better visual acuity or field improvement than patients with transcranial approach.