Pituitary macroadenoma (necrotic)

Case contributed by A.Prof Frank Gaillard

Presentation

Visual disturbances and impotence.

Patient Data

Age: 30 years
Gender: Male

Skull x-rays

Modality: X-ray

AP and lateral views of the skull show left-sided sellar excavation. 

Annotated image

Modality: Annotated image

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.

CT brain

Modality: CT

A lobulated peripherally-enhancing mixed solid/cystic/necrotic sellar/suprasellar 2-2.5 cm mass centred left of midline has remodelled/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. 

MRI brain

Modality: MRI

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 visualised) and is draped over the superior aspect of the tumour.

Modality: Annotated image

The diaphragma sella is slightly elevated (blue arrow) but the upward growth of the tumour (green arrow). 

The optic chiasm (yellow dotted line) elevated and stretched over the right side of the tumour.

The patient went on to have transsphenoidal surgery. 

Histology

Paraffin sections show a moderately cellular pituitary adenoma. It comprises sheets and nests, surrounded by vascularised stroma.  The tumour 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 tumour cells are prolactin positive and the pattern of staining corresponds to that of a sparsely granulated adenoma. The tumour 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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Case Information

rID: 17614
Case created: 30th Apr 2012
Last edited: 6th Nov 2015
Inclusion in quiz mode: Included

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