metastasis - uabmetastasis • 1% of sellar/parasellar masses • usually occurs with known primary...
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![Page 1: Metastasis - UABMetastasis • 1% of sellar/parasellar masses • Usually occurs with known primary • Can involve third ventricle, hypothalamus, infundibular stalk • May be both](https://reader033.vdocuments.site/reader033/viewer/2022053011/5f0f0cea7e708231d4423e2f/html5/thumbnails/1.jpg)
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Metastasis
• 1% of sellar/parasellar
masses
• Usually occurs with
known primary
• Can involve third
ventricle,
hypothalamus,
infundibular stalk
• May be both supra-,
intrasellar
57 year old with progressive Headache and Right Sided Visual Loss
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Metastasis: Pituitary Gland
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Metastasis: Pituitary Gland
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Pituitary Carcinoma
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Pituitary Carcinoma
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40 year old male with severe HA for 12 hours
Macroadenoma Mimic
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• Macroadenoma with necrosis
• Patient was referred for further evaluation
• Patient returned 6 days later with increasing headache, decreased vision and left 6th nerve palsy
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Pituitary Abscess
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• Rare
• Unusual to culture organism (Propionibacter)
• Sometimes associated with cav sinus thrombosis
• Occasionally related to sinus disease
Dx: Pituitary abscess with dehiscence into sphenoid sinus
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Suprasellar: Pathology
Meningioma
• 2nd most common
(adults)
• 15% of meningiomas
Tuberculum sellae
Clinoid processes
Cavernous sinus
• Look for pituitary
gland distinct from mass!
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Suprasellar: Meningioma
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Meningioma
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Suprasellar: Aneurysm
Aneurysm
• Third most common
(adults)
• Noncalcified central
suprasellar mass
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Suprasellar: Aneurysm
CT
• Noncalcified central
suprasellar mass
• Can be difficult to
distinguish from
adenoma, or
meningioma
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Parasellar: Aneurysm
MRI
• Flow void or
complex mass
separate from
pituitary
• Phase artifact
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Suprasellar: ThrombosedAneurysm
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Suprasellar Mass: Adult
Macroadenoma
• Pituitary is mass
• T2 intermediate
• Enhancement
Meningioma
• Pit separate
• Marked C+
• Dural tail
Aneurysm • Pit separate • Flow void • Complex
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Suprasellar Mass: Child
Astrocytoma
• Chiasm/Hypoth
• T2 hyperintense
• Variable C+
Craniopharyngioma
• Complex mass
• 90% cystic
• 90% calcified
Hamartoma
• Hypothalamus
• GM signal • No C+
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Suprasellar: Craniopharyngioma
Clinical • Most common
suprasellar
mass in children
• Peak incidence 5-15 yrs
• Second peak 50-60 yrs
• Visual changes
• Endocrine dysfunction
• Mass effect
• H/A, N, V, papilledema
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Suprasellar: Craniopharyngioma
Pathology
Adamantinomatous
• Classic
• “Crank-case oil” in cysts
Papillary (Adults)
• 70% suprasellar with
• small sellar component
• 5% purely intrasellar
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Craniopharyngioma: CT
NECT scan
Adamantinomatous
• 90% Ca++ (rim)
• 90% Cystic
• May enlarge sella
Papillary type
• 50% Ca++
• Majority solid
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Craniopharyngioma: MR
• Variable signal
• Often heterogeneous
• Ca++ difficult to detect
• Nodular & rim
enhancement
• Occasionally optic
tract hyperintensity on
T2WI – mass effect
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Craniopharyngioma: MR
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Craniopharyngioma: MR
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Craniopharyngioma: Papillary
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Chiasmatic-hypothalamic glioma
Clinical
• Second most common
suprasellar mass in
children
• Presentation-often large
• H/A, visual, endocrine
abnormalities common
• M = F
• 15-30% have NF-I
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Pathology
• 30% of all pilocytic
astrocytomas occur in
chiasm or hypothalamus
• 75% Pilocytic
astrocytoma
• 25% Low-grade fibrillary
• Long-term survival (90%
at 5 yrs, 75% at 10 yrs)
Chiasmatic-hypothalamic glioma
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MR
• Variable signal
• Iso-, hypointense on T1WI
• Hyperintense on T2WI
• Variable enhancement
• Spread along optic tracts common
Chiasmatic-hypothalamic glioma
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Chiasmatic-hypothalamic glioma
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Hypothalamic Hamartoma
Clinical
• Precocious puberty
• Usually < 2yrs
• Gelastic seizures
• M > F
• Pallister-Hall
• Facial anomalies
• Polydactyly
• Imperforate anus
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Hypothalamic Hamartoma
Pathology
• Hamartoma of tuber
cinereum
• Congenital
nonneoplastic
heterotopia
• Between infundibular
stalk, mamillary bodies
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Hypothalamic Hamartoma : MR
• Signal follows GM
• Isointense on T1WI
• May be slightly T2
hyperintense
• Pedunculated or sessile
• May project into 3rd
ventricle
• Do not enhance
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Hypothalamic Hamartoma
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Hypothalamic Hamartoma
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Suprasellar Mass: Child
Astrocytoma
• Chiasm/Hypoth
• T2 hyperintense
• Variable C+
Cranio
• Complex mass
• 90% cystic
• 90% calcified
Hamartoma
• Hypothalamus
• GM signal • No C+
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Infundibulum Differential Diagnosis
• Germinoma
• LCH
• Sarcoid
• Lymphoma,
Metastasis
• Hypophysitis
• Pituicytoma
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Germinoma
Pathology
• Pineal most common
• Pineal + suprasellar
10%
• Germinoma 2/3 of
GCT
• May be mixed GCT
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Germinoma
Clinical
• Suprasellar region is
second most common
site
• M = F suprasellar
• 90% present < 20 yrs
• Endocrine dysfunction
• Diabetes insipidus (most common)
• Panhypopituitarism (common)
• Radiosensitive
• Up to 90% 10 survival
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Germinoma: Imaging
CT & MR
• Combined lesion typical
but may affect only
infundibular stalk
• May be hyperdense (CT)
• Isointense T1WI
• Hyper- to isointense
T2WI
• Enhances
homogeneously
• CSF dissemination common
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Germinoma: MR
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Germinoma: MR
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Langerhans Cell Histiocytosis
Clinical
• First decade
• M > F
• Diabetes insipidus
• High signal of
neurohypophysis is
commonly absent
• Thickening of stalk
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Langerhans Cell Histiocytosis
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Infundibular Mass: Child
LCH
• Thickened
Stalk
• “Bright spot”
gone • Enhancement
Germinoma
• Stalk +/-
pineal
• T2
hyperintense • CSF spread
Meningitis
• Meningeal dz
• Diffuse • Enhanceme
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Sarcoid
Clinical
• Chronic, multisystem,
inflammatory disease
• Noncaseating
granulomas
• Neurologic findings 5%
• Diabetes insipidus or
hormone deficiency
• Steroid responsive
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Sarcoid
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Lymphoma
Clinical
• NHL (B-cell)
• 90% supratentorial
• Pituitary gland,
hypothalamus, stalk
• 6th-7th decade
• AIDS: 4th decade
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Imaging
• Pituitary gland,
hypothalamus, stalk
• Hyperdense on CT
• T1 Iso- to hypointense
• T2 hypointense
• Homogeneous
enhancement
Lymphoma
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Lymphocytic hypophysitis
Clinical/Imaging
• Occurs during late PG
or shortly after delivery
• F >>> M
• Pituitary insufficiency
• H/A & visual changes
• Amenorrhea or inability
to lactate
• Diffuse enlargement of
adenohypophysis
• May mimic hyperplasia
or adenoma
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Pathology • Diffuse infiltration of the
adenohypophysis by
lymphocytes and rare
plasma cells
• ? Autoimmune
• Infundibuloneurohypophysitis
• Affects infundibulum &
neurohypophysis
• Thickened pituitary stalk
• Diabetes insipidus
Lymphocytic hypophysitis
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Lymphocytic hypophysitis
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Metastasis:Infundibulum
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Infundibular Mass: Adult
Sarcoid
• Systemic dz
• Thickened stalk • Enhancement
Hypophysitis
• Clinical info
• Stalk or gland • Enhancement
Lymphoma
• +/- Systemic dz
• Stalk or gland • Enhancement
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Presentation Summary
Intrasellar Mass
• Microadenoma, Rathke cleft cyst
Suprasellar Mass
• Craniopharyngioma, Macroadenoma, Meningioma, Aneurysm
Infundibular Lesion
• Germinoma, LCH
• Granulomatous disease, LH
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