Presentation
Loss of peripheral vision.
Patient Data
The mildly hyperdense smoothly lobulated sellar/suprasellar mass measures 25 x 22 x 14 mm and demonstrates vivid contrast enhancement. Paranasal sinuses and ostiomeatal units are clear, with accessory anterior (Agger nasi) ethmoid air cells, left concha bullosa, relatively large septate sphenoid sinus and rightward nasal septal deviation noted.
Sagittal midline bone window image demonstrates smooth enlargement of the pituitary fossa.
Pituitary region mass (blue dotted line) is closely apposed to the left internal carotid artery (red arrow) and has similar density on post contrast images.
Sagittal reconstruction demonstrates the expanded pituitary fossa ( * ) and despite bone window the mass extending into the suprasellar cistern is faintly discernible (yellow dotted line).
The pituitary fossa is enlarged by a well circumscribed enhancing ovoid mass measuring 16 x 25 x 22 mm. The diaphragma sella is elevated and widely spread (diaphragmatic hiatus is approximately 2 cm wide). The optic chiasm is markedly elevated and thinned by the suprasellar component of the mass, and the A1/Acom/A2 complex is in close apposition to the superior surface of the mass, also elevated. There is no evidence of cavernous sinus involvement, and flow voids in the internal carotid arteries are unremarkable in appearance and location.
The patient went on to have a transsphenoidal hypophysectomy and resection.
Histology
MICROSCOPIC DESCRIPTION: The sections show a moderately cellular pituitary adenoma comprising nests, surrounded by vascularized stroma. The tumor cells have mildly enlarged round nuclei, finely granular chromatin and moderate amounts of eosinophilic cytoplasm. There are no atypical features. Very small amount of normal anterior pituitary gland tissue is present in specimen 3. The tumor cells are positive for FSH and SF-1. The Ki-67 index is about 2%. Immunostains for prolactin, TSH, LH, ACTH and GH are negative.
FINAL DIAGNOSIS: Silent gonadotroph adenoma.
Case Discussion
Typical appearances of a pituitary macroadenoma.