Sellar region lesion

Sellar masses are common. Incidental sellar masses are present in about 10-15% of the adult population; however, the vast majority of incidentally found lesions are relatively small (less than 10 mm in greatest diameter). Approximately 90% of sellar masses are pituitary adenomas.

If pituitary adenomas represent most of the sellar mass, it is important to recognize other pathologic conditions before any surgical procedure, because the optimal treatment may differ considerably from one lesion to another.

Thakkar et al. presented clinical, biochemical and radiologic characteristics and management outcomes of rare Suprasellar- Sellar region lesions (SSR) other than pituitary adenomas, craniopharyngioma, rathke's cleft cyst, hypophysitis, and meningioma.

The series consisted of ten patients, five with neoplastic and five with non-neoplastic lesions. Neoplastic masses included granular cell tumor (n=2), astrocytoma (n=1), malignant peripheral nerve sheath tumor (MPNST, n=1), and metastasis from occult papillary carcinoma of thyroid (n=1), while non-neoplastic masses were aspergillus abscess (n=1), sterile abscess (n=1), and tubercular abscess (n=1), aneurysm of left internal carotid artery (n=1) and ruptured dermoid cyst (n=1). All patients (except one) presented with headache and/or visual disturbance. Only one patient had acromegaly while most others had hypopituitarism. We describe detailed MRI characteristics of each of the lesions.

Most of the rare SSR masses present with symptoms of mass effects and hypopituitarism. Except for some non-neoplastic lesions like sellar abscesses, aneurysms and dermoid cysts which have some specific imaging characteristics that can provide clue to pre-operative diagnosis, most of the other neoplastic masses have overlapping radiological features and pre-operative suspicion remains difficult 1).

A careful clinical evaluation followed by neuroimaging studies and an endocrinologic and ophtalmologic workup will lead, in most cases, to a diagnosis with near certainty 2).

The cause of sellar region masses in large retrospective series is overwhelmingly pituitary adenomas (84.6%), followed by craniopharyngiomas (3.2%), cystic nonneoplastic lesions (2.8%), inflammatory lesions (1.1%), meningiomas (0.94%), metastases (0.6%), and chordomas (0.5%) (1). While other rare lesions were also identified (collectively 6.0%), single unusual entities in the above-cited series numbered <1-2 examples each out of the 4122 cases, underscoring their rarity. We searched our joint files for rare, often singular, sellar/suprasellar masses that we had encountered over the past several decades in our own specialty, tertiary care specialty pituitary center practices. Cases for this review were subjectively selected for their challenging clinical and/or histological features as well as teaching value based on the senior authors' (MBSL, BKD) collective experience with over 7000 examples. We excluded entities deemed to be already well-appreciated by neuropathologists such as mixed adenoma-gangliocytoma, posterior pituitary tumors, metastases, and hypophysitis. We identified examples that, in our judgment, were sufficiently unusual enough to warrant further reporting. Herein, we present 3 diffuse large cell B cell pituitary lymphomas confined to the sellar region with first presentation at that site, 2 sarcomas primary to sella in nonirradiated patients, and 1 case each of granulomatosis with polyangiitis and neurosarcoidosis with first presentations as a sellar/suprasellar mass. Other cases included 1 of chronic lymphocytic leukemia within a gonadotroph adenoma and 1 of ectopic nerve fascicles embedded within a somatotroph adenoma, neither of which impacted patient care. Our objective was to share these examples and review the relevant literature 3).

Inflammatory lesions of the hypophysis account for 0.5% of all symptomatic diseases of the pituitary, which include lymphocytic hypophysitis, granulomatous hypophysitis with or without specific etiology and pituitary abscess. Sellar tuberculoma is a rare type of granulomatous hypophysitis.

A postmenopausal lady who presented with galactorrhea, headache and blurring of vision. Based on preliminary investigations, a clinical diagnosis of pituitary adenoma was made and the pituitary gland was surgically excised. Histopathological examination showed caseating granulomas, along with normal areas of preserved pituitary gland and a final diagnosis of tuberculous hypophysitis was made. This case is being documented due to the extremely rare involvement of the pituitary gland by granulomatous lesions such as tuberculosis and to emphasize the role of intraoperative consultation to obviate the need for radical surgery in such lesions 4).

Thakkar K, Jadhav S, Kasaliwal R, Memon SS, Patil VA, Thadani P, Lomte NK, Sankhe SS, Goel A, Epari S, Goel N, Lila AR, Shah N, Bandgar TR. Sellar surprises: a single centre experience of unusual sellar masses. Endocr Connect. 2020 Jan 1. pii: EC-19-0497.R1. doi: 10.1530/EC-19-0497. [Epub ahead of print] PubMed PMID: 31910151.
Bresson D, Herman P, Polivka M, Froelich S. Sellar Lesions/Pathology. Otolaryngol Clin North Am. 2016 Feb;49(1):63-93. doi: 10.1016/j.otc.2015.09.004. Review. PubMed PMID: 26614829.
Abushamat LA, Kerr JM, Lopes MBS, Kleinschmidt-DeMasters BK. Very Unusual Sellar/Suprasellar Region Masses: A Review. J Neuropathol Exp Neurol. 2019 May 20. pii: nlz044. doi: 10.1093/jnen/nlz044. [Epub ahead of print] PubMed PMID: 31233145.
Rao S, Rajkumar A, Kuruvilla S. Sellar lesion: not always a pituitary adenoma. Indian J Pathol Microbiol. 2008 Apr-Jun;51(2):269-70. PubMed PMID: 18603706.
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  • Last modified: 2020/01/08 23:19
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