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CASE REPORT
Year : 2005  |  Volume : 53  |  Issue : 1  |  Page : 105-107

Giant pituitary adenoma invading the clivus


Department of Neurosurgery, Seth G. S. Medical College and King Edward Memorial Hospital, Parel, Mumbai, India

Date of Acceptance29-Jul-2004

Correspondence Address:
Atul Goel
Department of Neurosurgery, King Edward Memorial Hospital and Seth G. S. Medical College, Parel, Mumbai - 400 012
India
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DOI: 10.4103/0028-3886.15073

PMID: 15805667

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 » Abstract 

A 26-year-old man was admitted with complaints of worsening of vision for one month. Investigations revealed a large sellar and parasellar tumor mass invading into both the cavernous sinuses. The tumor invaded the clivus and both petrous apices. It was radically but partially resected through a transsphenoidal approach. Following surgery, the patient showed symptomatic improvement. The residual tumor was treated by radiation treatment. The case is discussed and the literature on the subject is briefly reviewed.


Keywords: Clivus, giant pituitary adenoma, invasion, petrous bone, sella


How to cite this article:
Goel A, Phalke U, Cacciola F, Muzumdar D P. Giant pituitary adenoma invading the clivus. Neurol India 2005;53:105-7

How to cite this URL:
Goel A, Phalke U, Cacciola F, Muzumdar D P. Giant pituitary adenoma invading the clivus. Neurol India [serial online] 2005 [cited 2014 Sep 23];53:105-7. Available from: http://www.neurologyindia.com/text.asp?2005/53/1/105/15073



 » Introduction Top


Despite the histological benign nature, pituitary tumors frequently achieve a large size, invade into the compartment of the cavernous sinus and transgress the dural confines of the sella and diaphragma sellae.[1] We encountered an unusual pituitary adenoma, which invaded the clivus and petrous bones. Although invasion of the bone by a pituitary tumor has been reported earlier,[2] we could not locate a report of a case wherein there was clear radiological and histological evidence of bone invasion.


 » Case Report Top


A 26-year-old man presented with complaints of generalized headaches and worsening vision in both eyes, left side being worse, for one month. In the last seven months, he had two episodes of relatively minor epistaxis. When admitted, he had severe bitemporal field defect. The vision was reduced to finger counting at one foot in the left eye and 6/18 in the right eye. Magnetic resonance (MR) imaging showed a massive sellar tumor with suprasellar extension [Figure - 1]a. The tumor invaded into both the cavernous sinuses and extended into the sphenoid and ethmoid air sinuses [Figure - 1]b. It also invaded the clivus and was present anterior to it and in the extradural space anterior to the brainstem [Figure - 1]c. It also involved both petrous apices. Endocrinological evaluation (baseline hormonal assay) showed serum growth hormone- 1.8 ng/ml; thyroxine- T3- 136 ng/dl, T4- 7.4 mcg/dl, TSH-1.9 mcU/ml, cortisol-11.3 mcg/dl, testesterone- 356 ng/dl, FSH- 4.6 mIU/ml, LH- 5.3 mIU/ml, prolactin-146 ng/ml. Chemiluminometric assay for serum prolactin was negative for prolactinoma. A transsphenoidal surgery was performed. The tumor within the confines of the sella and that underneath the markedly elevated diaphragma sellae was resected radically. The part extending into the cavernous sinuses was not removed. The tumor involved the clivus, which had become brittle and could be removed with the help of a scoop. The tumor extended in the retroclival extradural space. The part anterior to the dura was removed. The patient showed marked improvement in the vision following surgery. However, postoperative imaging showed a significant residual tumor in the sella, cavernous sinuses, subfrontal region and in the region of the clivus. Histological examination revealed a tumor composed of round cells with spherical nuclei arranged in sheets. The tumor cells showed infiltration into the bony trabeculae, which were seen amidst the sheet of cells [Figure - 2]. The tumor was immunonegative. The proliferative index using MIB-1 antibody was 4.5%. The lesion was then subjected to radiation treatment. At follow-up after 1 year, the patient was asymptomatic. The vision in the right eye was 6/9 and in the left eye was 6/12. The tumor had shown no radiological progression.


 » Discussion Top


Pituitary tumors frequently grow into a large size and invade into cavernous sinuses, extend into the intracranial compartment and in the paranasal air sinuses.[1] Findings on histological examination of invasive or giant pituitary tumors do not usually correlate well with the gross features and the tumor generally appears benign.[3],[4]

Various classifications of pituitary tumors have been proposed on the basis of size, radiographic appearance, cytogenesis, staining properties, and endocrine function. There is no consensus regarding the terminology to be used in describing large pituitary tumors.[5] They have been described as invasive adenoma, malignant adenoma and carcinoma. Hardy classified pituitary tumors on the basis of their biological behavior.[6] Some authors refer to pituitary tumors with size in excess of 40 mm, or to those extending less than 6 mm from the foramen of Monro as 'giant' irrespective of their invasiveness.[7] Jefferson observed an incidence of giant or invasive pituitary tumors in about 6% of all cases.[8]

Our patient reported two episodes of 'minor' epistaxis seven months prior to consultation. Epistaxis in a pituitary adenoma should raise the suspicion of a pituitary apoplexy in a giant pituitary adenoma with an infrasellar extension into the nasopharynx. Other reported causes of epistaxis related to pituitary tumors are an aggressive TSH-secreting adenoma and a rupture of an intratumoral aneurysm enclosed in a large prolactioma.[9],[10],[11]

There are no reports relating a poor outcome of a radically or partially resected invasive pituitary tumor. However, various reports mention about the need for and a positive outcome of a radical surgical resection.[12],[13],[14],[15],[16],[17] Intraoperative and postoperative tumor swelling and/or hematoma leading to an acute elevation of the intracranial pressure can be catastrophic.[14],[15] A variety of surgical options have been discussed for giant and invasive pituitary tumours.[17],[18],[19]

Multiple attempts have been made to identify prognostic markers of aggressive behavior among such tumors. Invasive adenomas have higher proliferation rates than non-invasive adenomas, as shown by immunohistochemical detection of proliferating cell nuclear antigen (PCNA), Ki-67, and MIB-1.[3],[20] The expression of p53, increased epidermal growth factor receptors, and protein kinase C activity correlate with invasion and aggressive behavior, which may be of prognostic significance.[20]

Invasion of pituitary tumors into the clivus has been described but there is no report in the literature showing radiographic and histological demonstration of bone invasion. During the operation it was observed that the tumor was not only present on either side of the clivus but had actually invaded and destroyed it. The benign histological features of the pituitary adenoma do not reflect such an aggressive pattern of extension.

 
 » References Top

1.Hamada J, Seto H, Miura M, Kuratsu J, Ushio Y. Suprasellar pituitary adenoma arising from the pars tuberalis: Case report. Neurosurgery 1990;27:647-9.  Back to cited text no. 1  [PUBMED]  
2.Wong K, Raisanen J, Taylor SL, McDermott MW, Wilson CB, Gutin PH. Pituitary adenoma as an unsuspected clival tumor. Am J Surg Pathol 1995;19:900-3.  Back to cited text no. 2  [PUBMED]  
3.Thapar K, Kovacs K. Neoplasms of the sellar region. In: Bigner DD, McLendon RE, Bruner JM, editors. In: Russell and Rubinstein's Pathology of tumors of the nervous system. 6th Ed. Vol. 2. London: Arnold; 1998. p. 561-677.  Back to cited text no. 3    
4.Symon L, Jakubowski J, Kendall B. Surgical treatment of giant pituitary adenomas. J Neurol Neurosurg Psychiatry 1979;42:973-82.  Back to cited text no. 4  [PUBMED]  
5.Garibi J, Pomposo I, Villar G, Gaztambide S. Giant pituitary adenomas: Clinical characteristics and surgical results. Br J Neurosurg 2002;16:133-9.  Back to cited text no. 5  [PUBMED]  
6.Hardy J. Transsphenoidal microsurgical treatment of pituitary tumors. In: Linfoot JA, editor. Recent advances in the diagnosis and treatment of pituitary tumors. New York: Raven; 1979. p. 375-88.  Back to cited text no. 6    
7.Fisher BJ, Gasper LE, Noone B. Giant pituitary adenomas: Role of radiotherapy. Int J Radiat Oncol Biol Phys 1993;15:677-81.  Back to cited text no. 7    
8.Jefferson G. Extrasellar extensions of pituitary adenomas. Proc R Soc Med 1940;33:433-58.  Back to cited text no. 8    
9.Godey B, Morandi X, Le Gall F, Feat S, Brassier G, Le Clech G. Pituitary adenomas with infra-sellar extension into the nasopharynx. J Laryngol Otol 1999;113:1109-11.  Back to cited text no. 9  [PUBMED]  
10.Ghannam NN, Hammami MM, Muttair Z, Bakheet SM. Primary hypothyroidism-associated TSH-secreting pituitary adenoma/hyperplasia presenting as a bleeding nasal mass and extremely elevated TSH level. J Endocrinol Invest 1999;22:419-23.  Back to cited text no. 10  [PUBMED]  
11.Imamura J, Okuzono T, Okuzono Y. Fatal epistaxis caused by rupture of an intratumoral aneurysm enclosed by a large prolactinoma - case report. Neurol Med Chir (Tokyo) 1998;38:654-6.  Back to cited text no. 11  [PUBMED]  
12.Hashimoto N, Handa H, Yamashita J, Yamagami T. Long term follow up of large or invasive pituitary adenomas. Surg Neurol 1986;25:49-54.  Back to cited text no. 12  [PUBMED]  
13.Mohr G, Hardy J, Comtois R, Beauregard H. Surgical management of giant pituitary adenomas. Can J Neurol Sci 1990;17:62-6.  Back to cited text no. 13  [PUBMED]  
14.Goel A, Deogaonkar M, Desai K. Fatal postoperative pituitary apoplexy: Its case and management. Br J Neurosurg 1995;9:37-40.  Back to cited text no. 14  [PUBMED]  
15.Goel A, Nadkarni T. Surgical management of Giant Pituitary Tumors - A Review of 30 cases. Acta Neurochir (Wien) 1996;138:1042-9.  Back to cited text no. 15  [PUBMED]  
16.Krisht AF. Giant invasive pituitary adenomas. In: Krisht AF, Tingdall GT, editors. Pituitary Disorders: Comprehensive Management. Baltimore: Lippincott; 1999. p. 287-94.  Back to cited text no. 16    
17.Goel A, Nadkarni T, Muzumdar D, Desai K, Phalke U, Sharma P. Giant pituitary tumors: A study based on surgical treatment of 118 cases. Surg Neurol 2004;61:436-45.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Bonicki W, Michalik R, Krajewski R, Kukwa A, Ozieblo A. [Skull base surgery techniques in the treatment of pituitary adenomas]. Neurol Neurochir Pol 2002;36:1121-30. [Article in Polish]  Back to cited text no. 18    
19.Alleyne CH Jr, Barrow DL, Oyesiku NM. Combined transsphenoidal and pterional craniotomy approach to giant pituitary tumors. Surg Neurol 2002;57:380-90.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Amar AP, Hinton DR, Krieger MD, Weiss MH. Invasive pituitary adenomas: Significance of proliferation parameters. Pituitary 1999;2:117-22.  Back to cited text no. 20    


Figures

[Figure - 1], [Figure - 2]

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