Presentation
Visual disturbances and impotence.
Patient Data
AP and lateral views of the skull show left-sided sellar excavation.
Planum sphenoidale (yellow), L&R orbital roof (orange), sphenoid sinus (blue), L&R acoustic meati (green), mastoid air cells (pink) are all visible on this well centered lateral skull x-ray.
A lobulated peripherally-enhancing mixed solid/cystic/necrotic sellar/suprasellar 2-2.5 cm mass centered left of midline has remodeled/excavated the sellar floor, with inferior left parasellar extension. The mass compresses and elevates the optic chiasm and is intimately associated with the mildly displaced terminal left ICA and ACA A1 segment.
A mixed solid, cystic mass which fills and expands of the pituitary fossa and extends into the suprasellar cistern is demonstrated, measuring 25 x 26 x 23 mm. It is located predominately to the left of the midline, elevates and compresses the optic chiasm and the left optic track and optic nerve. Normal pituitary tissue cannot be identified. There is no evidence of extension into the cavernous sinus. No hydrocephalus.
The left A1 segment is dominant (the right A1 segment cannot be visualized) and is draped over the superior aspect of the tumor.
The diaphragma sella is slightly elevated (blue arrow) but the upward growth of the tumor (green arrow).
The optic chiasm (yellow dotted line) elevated and stretched over the right side of the tumor.
The patient went on to have transsphenoidal surgery.
Histology
Paraffin sections show a moderately cellular pituitary adenoma. It comprises sheets and nests, surrounded by vascularized stroma. The tumor cells have mildly enlarged round nuclei, finely granular chromatin and moderate amount of pale to amphophilic cytoplasm. No atypical features are identified. No normal anterior pituitary gland tissue is present. The tumor cells are prolactin positive and the pattern of staining corresponds to that of a sparsely granulated adenoma. The tumor cells are negative for all remaining pituitary hormone markers. The Ki67 proliferative index is 1%. The features are of a sparsely granulated prolactin secreting adenoma.
FINAL DIAGNOSIS: Pituitary adenoma: Sparsely granulated prolactin secreting adenoma.
Case Discussion
This case illustrates the appearances of a cystic / necrotic pituitary macroadenoma, which can have similar appearances to a papillary craniopharyngioma. Distinguishing between the two is not always possible (in fact it is difficult to be definitive prior to surgery).
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