Presentation
Visual failure.
Patient Data
Large heterogenously enhancing sellar mass, measuring approximately 2 x 1.7 x 2.5cm in maximum perpendicular dimensions, with a large right laterally oriented component, widening the distal gap between the optic nerves, compressing the chiasm and displacing it posterosuperiorly.
Moderate mass effect was also noted exerted upon the narrow right A1 and ACOM, with normal looking flow voids distally.
There is a left lateral component extending into the cavernous sinus and completely encircling the atherosclerotic cavernous ICA. There is an impression for further extension of the cavernous component posteriorly surrounding the lacerum segment of the artery. There is also likely slight displacement of the paraclinoid artery to the left with no overt involvement.
The sella is widened and remodeled; however, the floor appears intact with no invasion into the sphenoid sinus.
There is a 1cm focus of enhancement anterior to the right transverse sinus which is not completely imaged and may represent a small meningioma. .
There is a suspicion for a 4mm right MCA bifurcation aneurysm.
Septum cavum pellucidum with no hydrocephalus.
Conclusion:
The findings are most consistent with a large pitutary macroadenoma with significant mass effect over the chiasm and cavernous extension as described. No evidence for hemorrhage/apoplexy.
Case Discussion
The patient went on to have a transphenoidal resection.
Histology
MICROSCOPIC DESCRIPTION:
Paraffin sections show small fragments of a moderately hypercellular adenoma which is partially surrounded by a mantle of normal anterior pituitary tissue. Tumor cells have uniform nuclear features anhd a moderate amount of pale cytoplasm. No mitotic figures or areas of necrosis are seen. Immunohistochemistry shows patchy strong staining of tumor cells for FSH. No staining for growth hormone, prolactin, ACTH, LH or TSH is seen in tumor cells. The features are of silent gonadotroph cell adenoma. The topoisomerase labeling index is approximately 2%.
FINAL DIAGNOSIS:
Pituitary tumor: Silent gonadotroph cell adenoma.
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