Senlin Yin

Three risk factors for WHO grade II and III meningiomas: A study of 1737 cases from a single center

BACKGROUND Meningiomas account for 35.5% of central nervous system (CNS) tumors, of which 21-37.8% are atypical or anaplastic/malignant. High-grade meningiomas have higher rates of recurrence and worse outcome than grade I/II meningiomas. Thus, it is of importance to assess the tumor biology before treatment initiation. MATERIALS AND METHODS This study reviewed 1737 patients with histologically confirmed meningioma at a single institution. Meningiomas were classified according to World Health Organization (WHO) 2007 grading and the location of the tumor was confirmed from the operation records and preoperative imaging. Univariate and multivariate logistic regression were used to analyze the potential risk factors for high-grade pathology. RESULTS Young men and pediatric patients were less likely to have meningioma, but they had high-grade meningioma. Tumors originated from non-skull base and lateral intracranial are more likely to be grade II/III meningioma. CONCLUSIONS Lateral and non-skull base location, male sex, and the younger patients increase the risk for grade II and III pathology. These factors should be considered while deciding treatment choice, surgical resection, and prognosis as well.

Combined gangliocytoma and non-functioning pituitary adenoma of the pituitary gland

311 Neurology India | May-Jun 2012 | Vol 60 | Issue 3 pituitary adenomas develop, are also derived from the cells of Rathke’s pouch. Although RCC and pituitary adenoma have a shared ancestry, they rarely occur together. Common symptoms of RCC are headache, visual disturbance, hypopituitarism, and hypothalamic dysfunction. Other rare symptoms include decreased libido, impotence, and diabetes insipidus.[3] When RCC and pituitary adenoma are found together, symptoms of mass effect may be accompanied by hormonal changes caused by the functioning tumor as in this patient. MRI is the modality of choice in detecting RCC. MRI also helps to diagnose the coexisting RCC and pituitary adenoma. RCCs almost always are homogeneous in signal intensity, whereas other lesions, such as cystic craniopharyngiomas and hemorrhagic adenomas, more frequently have heterogeneous signal intensity. Kunii et al.[4] concluded that singleshot fast spin-echo (SSFSE), diffusion-weighted MR imaging (DWI) with apparent diffusion coefficient (ADC) can be employed in the differentiation of RCCs from craniopharyngiomas and hemorrhagic pituitary adenomas. Some cases may be mistakenly diagnosed as arachnoid cyst, craniopharyngioma, and pituitary apoplexy. A combination of clinical, biochemical, and radiographic findings must be used to establish a diagnosis of RCC and the histologic examination seems to be much more important. Pituitary adenoma can be easily diagnosed by histologic examination of the resected mass. Most RCC have cuboidal or columnar epithelium and ciliated epithelium. But some researchers note that 12% of RCC displayed stratified squamous epithelium, a characteristic feature commonly associated with craniopharyngioma.[5] Decompression and biopsy may represent the optimal surgical management of RCC, with low morbidity rates; this patient underwent a transsphenoidal approach, where we excised not only the adenoma but also the Rathke’s cleft cyst at one go. The recurrence rate during postoperative follow-up can be up to 19%. [5]

Pituitary atypical adenoma or carcinoma sensitive to temozolomide combined with radiation therapy: a case report of early identification and management.

Pituitary carcinoma is extremely rare and difficult to diagnose early. Here we present a case of highly suspected pituitary malignant adenoma with early chemotherapy and radiation. A 30-year-old woman was admitted for headache and impaired vision, MRI found a sellar mass. Since there was no disturbance in serum hormone levels, she was diagnosed with non-functioning pituitary adenoma before surgery. Transsphenoidal removal of tumor was attempted but only partial resection of tumor was achieved. Pathology findings suggested a diagnosis of adenocarcinoma. PET-CT scan showed the tumor had elevated max standardized uptake value. No other abnormal sites were found, which excluded metastasis to pituitary. After surgery, the patient was treated with temozolomide assisted with radiation and tumor disappeared on MRI. No recurrence was observed on 1-year follow up. In conclusion, early temozolomide with radiation therapy for highly suspected pituitary carcinoma might be beneficial.

Presurgical treatment with somatostatin analogues in growth hormone-secreting pituitary adenomas: A long-term single-center experience

OBJECTIVE Acromegalic patients with macro- or giant adenomas often had poor prognosis after surgery. Somatostatin analogues (SSAs) show high effectiveness in both tumor shrinkage and serum GH reduction. But the role of SSAs in pre-surgical treatment and the management among macro- and giant adenomas remains controversial. PATIENTS AND METHODS A total of 100 acromegalic patients with macro- or giant adenomas that underwent surgery in our institution between January 2010 and December 2016 were enrolled in the current retrospective study. The relationships between several potential parameters and surgical outcomes were further analyzed. RESULTS The overall long-term remission rate was 45% accompanied by gross total resection (GTR) rate of 44%. GTR (adjusted OR = 16.346; p = .001) and nadir GH level on OGTT 7 days after surgery (GH-7, adjusted OR = 0.660, p = .039) showed predictive significance for remission after surgery. Tumor size and invasiveness as well as cavernous sinus invasion were risk factors for residual tumor. For invasive macro- or giant adenomas, 6 of 15 patients achieved long-term remission with SSA pre-treatment whereas none of the 18 patients without any preoperative treatment was endocrine controlled. CONCLUSIONS Acromegalic patients did not gain more benefits from SSAs pretreatment. But, pre-treatment with SSA could be recommended to patients with invasive macro- or giant adenomas for significant improvement in long-term remission. GTR and GH-7 could be significant predictors in postoperative management of macro- or giant adenomas.

Invasive pituitary adenomas with gross total resection: The wait-and-see policy during postoperative management

Although pituitary adenomas (PAs) are regarded as benign neoplasm, efficient postoperative management of PAs, especially invasive PAs, is still a major challenge for neurosurgeons. Thus, in order to verify the effect of postoperative surveillance alone for invasive PAs and identify helpful predictive factors of relapse after initial surgery, a series of 107 cases of surgically gross-totally resected invasive PAs were retrospectively investigated. With regarded to pituitary function, the preoperative incidence of hypothyroidism was higher than that of hypoadrenocorticism and hypogonadism (66.4% vs. 31.8% and 29.9%; p < 0.001). Tumors extended into sphenoid sinus or cavernous sinus may be less likely to develop hypoadrenocorticism or hypogonadism. Postoperative relapse was found in 35 cases (32.7%) during a median follow-up of 27 months. The overall relapse rates were 12.3, 28.9 and 38.4% at 1, 3 and 5 years, respectively. Tumor size was the exclusive independent risk factor for relapse. Higher relapse rates presented in large invasive PAs (more than 3.45 cm) were 24.5, 48.9 and 59.2% at 1, 3 and 5 years, respectively. In conclusion, preoperative larger tumors shared significantly higher risk of relapse after initial surgical total resection. Due to the relatively high relapse rate, close surveillance should be executed in strict rotation in postoperative management of gross-totally resected invasive PAs. Moreover, special attention should be payed to tumors with diameter of more than 3.45 cm for more than half of them relapsed in 5 years.

Giant Prolactinomas: Outcomes of Multimodal Treatments for 42 Cases with Long-Term Follow-Up

Giant prolactinomas represent a rare entity of pituitary tumors so that the management of these patients is still a prevalent challenge at present. Paying special attention to the treatment strategy and outcomes, we presented a large series of 42 cases looking forward to share our understanding and experience in management of these patients. Male patients accounted for 71.4% of this series and were relatively younger (35.70±2.42 vs. 52.00±3.55 years, p=0.0011) and harbored bigger tumors (14.57 vs. 7.74 cm3, p=0.0179) compared to females. Almost all of these tumors showed suprasellar extension (97.6%) and cavernous sinus invasion (92.9%). Dopamine agonist represented an efficient method to control PRL concentrations (98.8%) and reduce tumor burdens (81.2 %). PRL normalization was detected in 13 out of the 27 patients initially treated with bromocriptine (BRC) whereas none of the 14 patients with first-line operation gained a normalization of PRL concentration after surgery. Although there was no reliable predictor of tumor response, First PRL reduction was a predictive criterion for the nadir PRL level during the long-time period of follow-up for first-line bromocriptine treatment. In conclusion, patients with giant prolactinomas did not gain more benefits from initial surgery. Dopamine agonist (BRC) should be first-line treatment for giant prolactinomas whereas operation merely served as a remedy for acute compression symptoms and dopamine agonist resistance. Consecutive monitoring of serum PRL levels in the early stage of initial BRC treatment is useful for evaluation of therapeutic effect and further therapeutic decision.

Invasive Pituitary Adenoma-Derived Tumor-Associated Fibroblasts Promote Tumor Progression both In Vitro and In Vivo

Tumor-associated fibroblasts are the most abundant population in tumor stroma and impact on tumor initiation and progression. However, the biological function of tumor-associated fibroblasts in pituitary adenomas has not been fully elucidated to date. So, this study aims to clarify the function and significance of primary cultured pituitary adenoma-derived tumor-associated fibroblasts on rat pituitary adenoma cells. We identified primary cultured tumor-associated fibroblasts and normal fibroblasts based on the expression of α-smooth muscle actin as well as morphology. Furthermore, we investigated cell biological influences on rat pituitary adenoma cells through indirectly co-culturing tumor-associated fibroblasts with GH3 cells and subcutaneous xenograft model. All sorts of fibroblasts showed positive staining for α-smooth muscle actin. But α-smooth muscle actin and vascular endothelial growth factor highly expressed in invasive pituitary adenoma-derived tumor-associated fibroblasts compared to non-invasive pituitary adenoma-derived tumor-associated fibroblasts and normal fibroblasts. Besides, invasive pituitary adenoma-derived tumor-associated fibroblasts promoted the proliferation of GH3 cells in vitro as well as tumor growth in vivo. Finally, vascular endothelial growth factor was highly expressed in tumor specimens co-injected with invasive pituitary adenoma-derived tumor-associated fibroblasts. Our results suggested that invasive pituitary adenoma-derived tumor-associated fibroblasts displayed apparent growth promotion effects on rat pituitary cells both in vitro and in vivo accompanied by over-expression of vascular endothelial growth factor in invasive pituitary adenoma-derived tumor-associated fibroblasts and tumor specimens.

Ruptured Anterior Communicating Artery Aneurysm With Untreated Craniopharyngioma: A Case Report

Coexistence of intracranial aneurysm and craniopharyngioma has been reported in several patients who have undergone postoperative radiotherapy. However, we present an extremely rare case of ruptured aneurysm of anterior communicating artery (AComA) complicating with naive craniopharyngioma. The blood supply of A2 segment of left anterior cerebral artery was mainly from the right side through AComA in digital subtraction angiography. We suggest that by pressing the A1 segment of left anterior cerebral artery, the tumor imposed heavy burden to the AComA, which promoted the genesis and rupture of this aneurysm.

Multidisciplinary treatment of a giant craniofacial neurofibroma with intratumoral hemorrhage

A 19-year-old man presented with a rapidly growing right craniofacial lump and headache for 9 days, with vision loss in the right eye and no other manifestation of neurofibromatosis or neurologic disturbance. Imaging revealed a giant lesion with intratumoral hematoma and adjacent bone dysplasia (figure, A and B). The tumor and the involved right eye (figure, C) were removed following preoperative embolization. The wound was repaired using dorsal and lateral cervicothoracic flap grafting. Pathologic examination revealed a neurofibroma without malignant transformation.1 Solitary giant craniofacial neurofibromas with intratumoral hemorrhage are rare and require multidisciplinary care2 for optimal outcome (figure, D). Early intervention is preferable.