Shinya Jinguji

Early morphological recovery of the optic chiasm is associated with excellent visual outcome in patients with compressive chiasmal syndrome caused by pituitary tumors.

Abstract Objectives: The study objectives are (1) to identify factors predicting the excellent visual recovery after transsphenoidal removal of pituitary tumors and (2) to describe the association of excellent visual recovery and early restoration of symmetry of the decompressed optic chiasm. Methods: Thirty-five patients with visual symptoms due to pituitary tumors underwent endoscopic endonasal surgery. All patients received perioperative diagnostic magnetic resonance (MR) imaging and ophthalmological assessments within 2 weeks before surgery, within 2 weeks after surgery, and 3 months or later after surgery. Preoperative best-corrected visual acuity (BCVA ≧ 20/20), degree of visual field deficit (VFD, less than half of VF), thickness of retinal nerve fiber layer (RNFL) measured by optical coherence tomography (OCT), and thickness of ganglion cell complex (GCC) measured by OCT were considered for statistical analysis as predictive factors of VF outcome. Multivariate logistic regression models were used in statistical evaluation of data. Results: In the multivariate analysis, RNFL (odds ratio  =  62·137, P < 0·001) and preoperative VFD (odds ratio  =  8·244, P < 0·02) proved to be effective as factors predicting sufficient VF recovery. Postoperative restoration of symmetry of the optic chiasm was related to sufficient VF recovery (P < 0·0001, Fisher’s exact test) and RNFL (P < 0·0001, Fisher’s exact test). Discussion: Early decompression is crucial for sufficient VF recovery, in particular, while RNFL preserves normal or borderline thickness and while VFD keeps within hemianopia. Morphological reversibility is associated with functional reversibility in the optic chiasm compressed by a pituitary tumor. In particular, early morphological recovery suggests functional recovery, which indicates neurocyte reserve in the compressed optic pathway with functional recovery.

Synchronized multiple regression of diagnostic radiation-induced rather than spontaneous: disseminated primary intracranial germinoma in a woman: a case report.

IntroductionExamples of the spontaneous regression of primary intracranial germinomas can be found in the literature. We present the case of a patient with disseminated lesions of primary intracranial germinoma which synchronously shrunk following diagnostic irradiation. We will discuss whether this regression was spontaneous or radiation-induced.Case presentationA 43-year-old Japanese woman presented to our hospital complaining of memory problems over a period of one year and blurred vision over a period of three months. Following magnetic resonance imaging, she was found to have a massive lesion in the third ventricle and small lesions in the pineal region, fourth ventricle, and in the anterior horn of the left lateral ventricle. Prior to an open biopsy to confirm the pathology of the lesions, she underwent a single cranial computed tomography scan and a single cranial digital subtraction angiography for a transcranial biopsy. Fourteen days after the first magnetic resonance image - 12 and eight days after the computed tomography scan and digital subtraction angiography, respectively - a pre-operative magnetic resonance image was taken, which showed a notable synchronous shrinkage of the third ventricle tumor, as well as shrinkage of the lesions in the pineal region and in the fourth ventricle. She did not undergo steroid administration until after a biopsy that confirmed the pathological diagnosis of pure germinoma. She then underwent whole craniospinal irradiation and went into a complete remission.ConclusionsIn our case report, we state that diagnostic radiation can induce the regression of germinomas; this is the most reasonable explanation for the synchronous multiple regression observed in this case of germinoma. Clinicians should keep this non-spontaneous regression in mind and monitor germinoma lesions with minimal exposure to diagnostic radiation before diagnostic confirmation, and also before radiation treatment with or without chemotherapy begins.

A pineal region germ cell tumor with rapid enlargement after a long-term follow-up: case report.

BACKGROUND AND IMPORTANCE The natural history of pineal region germ cell tumors (GCTs) is not well known. We report a rare case of a pineal region GCT showing rapid enlargement within 2 months, after 7 years with no growth. CLINICAL PRESENTATION A boy presented with gonadotropin-independent precocious puberty at 6 years 10 months of age. Although a slight elevation of β-human chorionic gonadotropin suggested that a small pineal cystic lesion observed on magnetic resonance imaging might be an β-human chorionic gonadotropin--producing tumor, it was not clear whether the mass was truly a GCT. Accordingly, we followed up the pineal lesion and serum pituitary gonadotropin levels for approximately 7 years. After this period without essential tumor growth, the pineal tumor suddenly showed rapid enlargement, which prompted treatment. A histopathological investigation revealed a mixed GCT with a germinoma and an immature teratoma. Serum pituitary gonadotropin levels at 5 years after the first examination had increased to normal pubertal ranges. Although the pituitary gonadotropin levels had remained low during the period with no tumor growth, the gonadotropin levels were elevated and had continued to increase at least 2 years before the rapid enlargement of the tumor. CONCLUSION These phenomena suggest that levels of neuroendocrinological parameters such as pituitary gonadotropin at puberty might affect the enlargement of pineal region GCTs, which might account for the natural history of GCTs, ie, their frequent detection at puberty.

An organic light-emitting diode display for use in neuroendoscopic surgery in the ventricle

The organic light-emitting diode (OLED) display delivers a bright and high-contrast image compared to the liquid crystal display. The first experience of neuroendoscopic surgery using an OLED display was reported and its stereoscopic effect emphasized.

Has acromegaly been diagnosed earlier

PURPOSE We investigated whether acromegaly has been diagnosed earlier at the Niigata Medical and Dental University Hospital. METHODS Patients with acromegaly (n = 81) who underwent their first transsphenoidal surgery from 2006 to 2015 were reviewed. Two groups were compared: those who underwent surgery between 2006 and 2010 (n = 35) and those who underwent surgery between 2011 and 2015 (n = 46). We compared clinical features and serum levels of the growth hormone (GH) and insulin-like growth factor-1 (IGF-1), hypertension (HT) and diabetes mellitus (DM) prevalence between the two groups. RESULTS Compared with the early group, microadenomas (<10 mm) were more prevalent in the late group (0% vs. 15.2%, p < .05). Serum IGF-1 standard deviation score (SDS) was significantly lower in the late group (8.57 ± 2.50 vs. 6.44 ± 2.30, p < .001). In both groups, mean IGF-1 SDS was significantly lower in patients without DM than in those with DM (6.9 ± 2.6 vs. 8.3 ± 2.4, p = .02). Logistic regression analysis showed that serum GH and IGF-1 levels were significantly higher in patients with DM than in those without DM. CONCLUSION Regarding operated cases of GH-producing pituitary adenoma, acromegaly clinical manifestations tended to be milder at diagnosis in later years of the decade, and acromegaly was diagnosed at lower IGF-1 levels and in smaller lesions. Further study is mandatory for the generalization of this trend.

Nonfunctional intra‐ and suprasellar tumor in a patient with visual disturbance and panhypopituitarism

The patient, a 57-year-old woman, was admitted to a hospital because of a 2-year history of gradually deteriorating visual acuity and a 3-month history of easy fatigability. She had no family history of neurological disorders. An examination of her visual fields revealed bitemporal hemianopsia. Her corrected visual acuity with eye glasses was insufficient. An endocrine study revealed panhypopituitarism, with low fT3 and fT4 secretion, a very low range of cortisol, and an adrenocorticotrophic hormone level close to the lower limit. Replacement therapy with hydrocortisone and thyroid hormone was started. She showed no symptoms of diabetes insipidus. A brain MRI study demonstrated a mass lesion, measuring 17.5 × 17.5 × 30mm, occupying the slightly enlarged sella turcica and extending to the suprasellar region, which exhibited either hypoor iso-intensity on T2-weighted images (Fig. 1A). The hyper-intensity signal on T1-weighted image corresponding to the posterior lobe was not identified. The mass showed enhancement with gadolinium, but the contrast effect was weaker than that of the compressed pituitary gland (Fig. 1B,C). The optic chiasm was compressed markedly by the mass (Fig. 1B,C). The pituitary stalk was not identifiable. No invasion to the surrounding structures was evident. These clinical and radiological features appeared to be atypical for a nonfunctional pituitary macroadenoma, as the latter does not usually show low intensity on T2-weighted MRI. Moreover, patients with macroadenoma rarely show panhypopituitarism. Therefore, under a tentative diagnosis of macroadenoma, lymphocytic hypophysitis, or otherwise metastatic tumor of uncertain origin, gross total removal of the tumor by endoscopic endonasal transsphenoidal surgery was performed. Intraoperatively, we found that the gross appearance of the tumor was consistent with that of pituitary macroadenoma. The tumor was soft, whitish and welldemarcated from the pituitary gland identifiable to its ventral side. During the removal of the tumor, the amount of bleeding was moderate and controllable. The postoperative course was uneventful and the patient’s visual field defect improved dramatically. The patient was discharged on postoperative day 9, and 1 month later she required no adjuvant hydrocortisone. Follow-up MRI performed 3months after the operation confirmed total resection and no regrowth of the tumor, and revealed persistence of the pituitary stalk (Fig. 1D).