Cases reported "Pituitary Neoplasms"

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1/433. Interesting radiologic findings in suprasellar mass lesions. Report of three cases.

    The authors report three quite rare lesions of the sellar/parasellar region. They are namely; pituitary abscess, cystic macroadenoma and osteochondroma. In none of the cases, the preoperative diagnostic priority was not same as the final histopathologic diagnosis. The radiologic findings of these pathologies are discussed with emphasis on differential diagnosis.
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2/433. December 1998--16 year old female with headaches, lethargy and a sellar/suprasellar mass.

    A 16 year female with a history of developmental delay and shunted hydrocephalus presented with two months of progressive headaches, lethargy and visual disturbances. An MRI of the brain revealed a sellar and suprasellar cystic mass which was absent on a previous MRI six years earlier. The pre-operative clinical diagnosis was pituitary adenoma vs. craniopharyngioma. Histologically, the fibrous wall of the ciliated epithelial-lined cyst was thickened by non-caseating granulomatous inflammation, hemorrhage, hemosiderin, and cholesterol clefts, consistent with cyst rupture. Rathke's cleft cysts are uncommon symptomatic lesions in young people, and must be distinguished from craniopharyngioma.
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3/433. Dorsum sellae meningioma mimicking pituitary macroadenoma: case report.

    BACKGROUND: A dorsum sellae meningioma is a rare occurrence. It is difficult to evaluate dorsum sellae meningiomas preoperatively from the viewpoint of neuroimaging. We report a rare case of dorsum sellae meningioma mimicking pituitary macroadenoma in a 73-year-old woman. CASE PRESENTATION: The patient presented with bitemporal hemianopsia and panhypopituitarism. Magnetic resonance imaging demonstrated a bright, homogeneously enhancing intra- and suprasellar mass and a hypointense region in this mass, which was interpreted as a dorsum sellae. Transsphenoidal extirpation was used because of a suspicion of nonsecreting pituitary macroadenoma. Histopathologically, the tumor was diagnosed as a meningioma. Superselective external carotid angiography before the second surgery revealed that the mass was supplied by the left accessory middle meningeal artery and appeared to originate from dorsum sellae. After preoperative embolization, the patient developed hyponatremia. The tumor was subtotally removed via a transcranial route, and the attachment to the dorsum sellae was coagulated extensively. She did well after a second surgical procedure. CONCLUSION: These radiologic findings may be useful in differentiating dorsum sellae meningioma from pituitary macroadenoma.
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4/433. struma ovarii and hyperthyroidism.

    struma ovarii is a teratoma of the ovaries that contains a large amount of thyroid tissue. Like the cervical thyroid gland, this ectopic thyroid tissue can become autonomous. We present a case of hyperthyroidism caused by thyroid tissue in a large ovarian cystic teratoma and provide detailed endocrinological, radiological, and pathological preoperative and postoperative data. This is also the first documented case of struma ovarii in association with a secreting pituitary tumor. In addition, we provide a retrospective pathological analysis of 1390 surgically removed ovarian tumors at 2 major academic centers.
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5/433. Triple pituitary adenoma in Cushing's disease: case report.

    A case of a triple pituitary adenoma identified in a surgically removed pituitary gland from a 52-year-old woman operated on for Cushing's disease is presented. The histology revealed 3 distinctly separate microadenomas, 1 corticotroph and 2 immunoreactive for prolactin (PRL). The latter were apparently silent, since the serum PRL levels were within normal range. The problems associated with the inability to identify multiple adenomas pre-operatively and the possible failure of selective transsphenoidal adenomectomy in case of multiple adenomas are emphasised.
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6/433. Preoperative short-term administration of octreotide for facilitating transsphenoidal removal of invasive growth hormone-secreting macroadenomas.

    The somatostatin analog octreotide was administered prior to transsphenoidal surgery in three patients with tumors that extended to the suprasellar space and one side of the cavernous sinus. octreotide, 100 micrograms twice a day, was subcutaneously injected for 2 weeks. octreotide administration reduced the serum growth hormone (GH) levels in these patients from 82 to 22 ng/ml, from 148 to 12 ng/ml, and from 129 to 9 ng/ml. The tumor size shrank by about 50%, and the suprasellar extension disappeared in two patients. The main tumor was sharply dissected from the normal pituitary gland at surgery. Intracavernous portions were removed using a curette. Postoperatively, GH levels were less than 5 ng/ml in two patients, and 8.5 ng/ml in one patient. Follow-up magnetic resonance imaging revealed a small residual tumor in one side of the cavernous sinus in all patients. Follow-up GH levels were less than 5 ng/ml in one patient, and less than 2 ng/ml in two patients treated with bromocriptine. Preoperative administration of octreotide for 2 weeks reduced tumor volume and allowed near-total surgical resection of invasive macroadenomas without compromising the treatment course. Residual tumor due to intracavernous extension can be managed with bromocriptine or gamma knife radiosurgery.
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7/433. What can predict postoperative "endocrinological cure" in Cushing's disease?

    OBJECTIVE: The goal of surgical treatment for Cushing's disease is "endocrinological cure." The purpose of this study was to determine predictors for postoperative endocrinological cure in Cushing's disease. methods: Postoperative endocrinological studies were evaluated in 18 patients with Cushing's disease who underwent transsphenoidal surgery for selective adenomectomy. serum adrenocorticotropic hormone (ACTH) levels were measured by radioimmunoassay during the first week after surgery. One week after surgery, a test using corticotropin-releasing hormone (CRH) was performed on each patient to check the reserve function of normal ACTH-secreting cells. RESULTS: In eight patients, postoperative ACTH levels were below the measurable level for 1 week, and ACTH showed no response to the CRH test. In these patients, serum ACTH and cortisol levels were kept in the normal range with a normal diurnal variation during long-term follow-up. These patients can be defined as endocrinologically cured. In seven patients, the ACTH level returned to within normal range on the day after surgery, but ACTH was provoked by the CRH test. Five of these seven patients showed subsequent re-elevation of ACTH above the normal range. ACTH levels were never normalized in the remaining three patients, and medical treatments were unavoidable. CONCLUSION: The most reliable indicators for predicting endocrinological cure in Cushing's disease are no response of ACTH to the CRH test in the early postoperative stage and an unmeasurably low ACTH level in the week after surgery. Obtaining a normal range of ACTH level postoperatively is insufficient to define endocrinological cure.
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8/433. The bifrontal olfactory nerve-sparing approach to lesions of the suprasellar region in children.

    Suprasellar masses in children include lesions such as craniopharyngiomas and germ cell neoplasms. The difficult location of these lesions and their proximity to important neural and vascular structures pose challenges to resection. We operated on 14 patients using a bifrontal craniotomy with removal of both orbital rims to provide access to suprasellar masses, even those with significant extension into the third ventricle. A complete resection was possible in 8/14 patients and 8/10 craniopharyngiomas. In 13 patients, the optic nerves were identified and preserved, and vision was stable or improved postoperatively. Postoperatively, 1 patient with hydrocephalus developed a CSF leak which was successfully treated with a ventriculoperitoneal shunt. No patient had a cosmetic defect related to orbital rim removal. The bifrontal approach used here enhanced the exposure of the suprasellar region and minimized manipulation of the optic apparatus and the carotid arteries. It may be used alone, or in conjunction with other approaches, to resect lesions in the suprasellar region.
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9/433. Pituitary somatotroph adenoma producing growth hormone (GH)-releasing hormone (GHRH) with an elevated plasma GHRH concentration: a model case for autocrine and paracrine regulation of GH secretion by GHRH.

    An acromegalic patient with a pituitary somatotroph adenoma associated with an extremely elevated plasma GHRH concentration is presented. The preoperatively high concentration of plasma GHRH returned to the normal level after successful removal of the adenoma. GHRH production and GHRH gene expression were confirmed in the adenoma by studies including immunohistochemistry and in situ hybridization. Expression of GHRH receptor messenger ribonucleic acid was verified by in situ hybridization. Immunohistochemical double staining for GH and GHRH revealed their colocalization in single adenoma cells. These findings confirmed the autocrine or paracrine regulation of GH production by endogenous GHRH from the adenoma cells. GHRH synthesis in the pituitary gland has recently been demonstrated, however, there have been no previous reports of a GHRH-producing pituitary somatotroph adenoma associated with an elevated plasma GHRH concentration. The existence of this GHRH-producing adenoma suggests a possible role of locally generated GHRH in the progression of somatotroph adenomas, i.e. the monoclonally established somatotroph adenomas develop further under the influence of locally produced GHRH. The demonstration of GHRH production by this somatotroph adenoma is of importance in clarifying the autocrine or paracrine regulation of GH production and the progression of human somatotroph adenomas.
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10/433. High molecular weight corticotropin measured with immunoradiometric assay in a patient with asymptomatic pituitary corticotropinoma.

    A 57-yr-old female with corticotropinoma showing no Cushingoid stigmata is reported. Basal plasma levels of ACTH measured with immunoradiometric assay and beta-endorphin were high, 12.6-15.9 pmol/l and 3.5 pmol/l, respectively. plasma cortisol level and urinary free cortisol excretion were normal, 303-359 nmol/l and 171-226 nmol/day, respectively. plasma ACTH markedly increased to 70.5 pmol/l with intravenous administration of 100 microg CRH. Diurnal rhythm of plasma ACTH was seen, but its level in the night was still high. plasma ACTH suppression with dexamethasone was insufficient. CRH stimulation after dexamethasone suppression increased plasma ACTH level from 4.4 to 13.7 pmol/l. Intravenous administration of 4 microg desmopressin increased plasma ACTH from 15.6 to 19.6 pmol/l. Oral administration of 16 mg lepramide insufficiently decreased plasma ACTH from 7.3 to 5.3 pmol/l. However, plasma cortisol responses in these conditions were normal. Postoperative pathological study revealed subtype 1 corticotropinoma immunohistochemically and electron-microscopically. Postoperative basal plasma ACTH decreased to 3.9 pmol/l, although plasma cortisol did not change. Diurnal rhythm and dexamethasone suppressibility of plasma ACTH became normal. plasma sample was chromatographed on a Sephadex G-75 column. The elution profile showed two peaks of ACTH, one of which was compatible with 1-39 ACTH and another with higher molecular weight ACTH which was probably secreted from corticotropinoma. Anomaly in processing of proopiomelanocortin was suspected.
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