Presentation
Visual failure, improved after surgery.
Patient Data
Evidence of sellar and suprasellar mass lesion, measuring 2.4 x 2.8 x 3.6 cm in AP, SS and CC dimensions. It is iso to hypointense on T1WI and hyperintense on T2WI and FLAIR. It shows restricted diffusion on DWI reflecting its high cellularity. It shows thin enhancing upper margin representing compressed pituitary gland parenchyma.
Extensions and mass effect:
- laterally, it is partially encasing both internal carotid arteries at the cavernous sinus bilaterally
- inferiorly, expanding the sellar cavity and its floor compressing both sphenoid sinuses with no intrasinus extensions
- superiorly, it is markedly compressing the optic chiasm and both optic tracts, more on the left
Residual suprasellar lesion attached to pituitary stalk averaging 1.2 x 1 x 1.4 cm in AP, SS and CC dimensions, suprachiasmatic in location with homogeneous texture and peripheral enhancement as the native lesion, representing residual tumor component.
Intrasellar high T1 and T2 signal soft tissue averaging 1 x 1.5 cm, representing sellar fat graft.
Decompressed optic chiasm with central infundibulum.
A small residual extension at the right cavernous sinus.
Pathology report
Speciment: Excision biopsy of sellar/suprasellar mass
Macroscopic examination: Multiple grayish white soft tissue fragments collectively 1.5 x 1 cm are submitted in formalin - processed on toto.
Microscopic examination: Sections through a tumorous growth disposed in sheets where cell aggregates are separated by arcades of slender sinusoidal vascular spaces. Individual cells are polygonal to ovoid with central round to ovoid nuclei that are mitotically inactive. Cells dusplay scant eosinophilic cytoplasm. No atypia is seen.
Diagnosis: Pituitary macroadenoma.
Case Discussion
A classic case of a pituitary macroadenoma, with snowman appearance made by its suprasellar extension seen in sagittal and coronal planes. It shows diffusion restriction due to high cellularity. It was managed by trans-sphenoidal resection to decompress the optic chiasm.
Note, there is a residual pituitary tumor component with peripheral enhancement as the native tumor. Macroadenomas with suprasellar extension can be difficult to be completely removed using transsphenoidal microsurgery.
The surgeon may have avoided further resection to prevent panhypopituitarism and to avoid chiasmatic injury. Also noted at difficult sites for resection like cavernous sinuses. The residual component could be managed surgically through the same route in non-improving patients with functioning adenomas. In non-functioning adenomas, radiotherapy can arrest tumor growth or even initiate its regression.
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