SELLA David M. Wilson UCSF Department of Neuroradiology UC SF - - PDF document

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SELLA David M. Wilson UCSF Department of Neuroradiology UC SF - - PDF document

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4/14/2018 SELLA David M. Wilson UCSF Department of Neuroradiology UC SF University of California, San Francisco Sella: The big 4: Macroadenoma Rathkes cleft cyst Craniopharyngioma Meningioma 1 4/14/2018 OUTLINE 1.

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4/14/2018 1 UCSF

University of California, San Francisco

SELLA

David M. Wilson UCSF Department of Neuroradiology

Sella: The big 4:

  • Macroadenoma
  • Rathke’s cleft cyst
  • Craniopharyngioma
  • Meningioma
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4/14/2018 2

OUTLINE

  • 1. Normal anatomy & imaging
  • 2. Adenoma and pitfalls
  • 3. Cystic lesions

OUTLINE

  • 1. Normal anatomy & imaging
  • 2. Adenoma and pitfalls
  • 3. Cystic lesions
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4/14/2018 3

www.autismpedia.org/wiki/images/e/e5/Pituitary.jpg

Pituitary gland- structure

  • Meningeal and periosteal layers
  • Continuous with dura along planum

sphenoidale & clivus

Capero A et al, Neurosurgery 2008; 62: 717-23

DURA

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Capero A et al, Neurosurgery 2008; 62: 717-23

  • Thin single layer along medial cavernous sinus
  • Double layer along lateral cavernous sinus

DURA

  • Sagittal & coronal pregad T1 - 12 minutes

TR=600ms, TE=min, NEX=3, 2.7 mm no skip

  • Coronal fatsat T2 FSE - 4 minutes

TR=3000ms,TE=102ms, ETL=16, NEX=3, 2.0 mm no skip

  • Dynamic gad T1- 45 second intervals

TR=600ms, TE=17 ms, ETL=8, NEX=2, 2 mm no skip (5 slices)

  • Sagittal & coronal gad T1 - 12 minutes

TR=800ms,TE=min,NEX=3, 2.7 mm no skip

  • Coronal GRE - 6 minutes

TR=787ms, TE=25ms,NEX=2, 3 mm no skip

microadenoma hemorrhage

UCSF Sella MRI protocol

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45 s 90s

  • Onset: ~36 sec
  • Peak signal: 1.2 - 2.2 min
  • Washout: 2.7 - 5 min

0 s

Adenoma: Dynamic Gad T1 45 sec 135 sec 90 sec

  • Higher time resolution but generally noisier
  • Estimated 10% increase* in sensitivity

*Bartynski W et al, AJNR 1997; 18: 965-72

Dynamic enhancement

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OUTLINE

  • 1. Normal anatomy & imaging
  • 2. Adenoma and pitfalls
  • 3. Cystic lesions
  • Endocrine dysfunction or incidental
  • Arise within the adenohypophysis
  • < 10 mm diameter
  • “Picoadenoma” (< 3 mm) diagnostic challenge
  • Rarely ectopic outside of pituitary fossa

Microadenoma

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  • Usually same or slightly lower signal than gland
  • High T1 signal if hemorrhagic (typical of prolactinoma)
  • Contour deformity +/-

Adenoma: T1 signal

??

  • Almost all lower signal than enhanced gland
  • May have higher signal after 30-45” delay

Adenoma: Enhancement

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Adenoma: T2 signal

  • Usually same or slightly higher than gland (“soft”)
  • Less commonly lower than gland (“firm”)
  • Higher T2 = higher secretion

80% PRL tumors have high T2 signal 40-60% GH tumors have low T2 signal

  • Vision changes, hypopituitarism
  • > 10 mm
  • “Giant” adenoma if > 4 cm
  • May grow in any of 6 directions

Superiorly (suprasellar) - 80% of cases Laterally (cavenous sinuses) Anteriorly & inferiorly (sphenoid) Posteriorly (clivus)

  • Important observations

Hemorrhage Optic chiasm T2 signal Cavernous sinus invasion

Macroadenoma

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  • Heterogeneous, typically ~ gray matter
  • High T1 signal implies hemorrhage or another lesion

T1 Signal

  • Highly variable - often heterogeneous, cysts and necrosis
  • Hemorrhage

Can have any T2 signal Fluid levels helpful feature for diagnosis If hemorrhage suspected, confirm with GRE or CT

T2 Signal

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  • Mild to avid enhancement typical
  • Rarely hypoenhancing (thyrotropin secreting)
  • Look for enhancing gland (preserved surgically)

Enhancement

  • Speculative role of diaphragmatic hiatus

Suprasellar extension

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  • 6-10% of adenomas
  • Biologically more aggressive tumors
  • Medial sinus has only 1 layer of dura
  • Clinical symptoms late
  • Suspect when prolactin > 1000 ng/mL

Macroadenoma: Cavernous invasion

Best signs of involvement

  • Involvement > 2/3 circumference (PPV 100%)
  • Carotid sulcus venous compartment (PPV 95%)
  • Lateral to lateral intercarotid line (PPV 85%)

Cottier J-P et al, Radiology 2000; 215: 463-69

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Best signs of NO involvement (all have NPV 100%)

  • Involvement of < 1/4 circumference
  • Gland between tumor, cavernous sinus
  • Medial venous compartment preserved
  • Medial to medial intercarotid line

Cottier J-P et al, Radiology 2000; 215: 463-69

  • 22 year-old woman, severely hypothyroid
  • Diagnosis: pituitary hyperplasia

Pitfalls…

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  • 58 year-old woman, hyperprolactinemia
  • Diagnosis: Tuberculum sellae meningioma

Pitfalls…

Optic/ hypothalamic glioma

Pitfalls…

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OUTLINE

  • 1. Normal anatomy & imaging
  • 2. Adenoma and pitfalls
  • 3. Cystic lesions
  • Incidental (13-22% of autopsy and MRI) or symptomatic
  • Non-neoplastic, single cell layered cyst arising from remnants of

embryonic Rathke’s cleft

  • Natural history also slow enlargment with time

RATHKE CLEFT CYST

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RATHKE CLEFT CYST

  • Well-defined round or ovoid, thin rim enhancement
  • Intrasellar (40%) and/or suprasellar (60%)
  • Between anterior and intermediate lobes (pars intermedia)
  • Stalk typically midline

T1 dark, T2 bright

  • Fluid like CSF

Two types

T1 bright, T2 variable

  • “Machine oil” cyst
  • More often symptomatic

2/3 1/3

RCC

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  • Arise out of pars intermedia
  • Midline or near midline
  • No displacement of stalk
  • Anterior to stalk if suprasellar
  • “Simple” single intensity

RCC: Useful Diagnostic Features

Case: 37F panhypopit, polydipsia, vision changes

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ABSCESS

  • Primary (in normal gland) or secondary (in pre-exisiting adenoma or

Rathke’s cyst)

  • Present like other cystic tumors, fever & meningismus rare
  • Source of infection hematogeous or via sphenoid sinus
  • Only 50% grow organisms, gram+ & gram- equally common
  • Histologic continuum with RCC
  • Childhood type

Adamantinomatous histology Poor prognosis (frequently recur)

  • Adult type

Papillary squamous epithelium Good prognosis (rarely recur)

  • Mixed type

Behave like adamantinomatous

The big third- Craniopharyngioma

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  • Locations:

75% suprasellar 21% supra- and intrasellar 4% intrasellar only

  • Intrinsic T1 & T2 signal varies with

contents of cysts (bright T1 cysts are typical)

  • “Complex” signal typical

Adamantinomatous Craniopharynioma

  • Rule of 9’s

90% mixed solid & cystic 90% enhance 90% calcify

Adamantinomatous Craniopharynioma

  • Rule of 9’s

90% mixed solid & cystic 90% enhance 90% calcify

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Case: 9 year-old with visual disturbances

Diagnosis: Craniopharyngioma

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  • Predominantly solid
  • Cysts (if present) hypointense
  • Spherical geometry typical

Papillary Craniopharynioma

  • Surrounded by pituitary gland
  • More frequently off midline (PRL)
  • Variable signal intensity
  • Evolve over time if hemorrhagic
  • May bloom on GRE

CYSTIC ADENOMA

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Question #1: Which of the following pineal tumors has the lowest rate of spinal metastases?

  • A. Endodermal sinus tumor
  • B. Germinoma
  • C. Pineocytoma
  • D. Pineoblastoma

Question #1: Which of the following pineal tumors has the lowest rate of spinal metastases?

  • A. Endodermal sinus tumor
  • B. Germinoma
  • C. Pineocytoma
  • D. Pineoblastoma

Ito et al. Pathol Int 1995 45(6): 463 Roberts et al. Am J Roentgenol 2006 186(3 supp): S224-6. Onesti et al. Clin Neurol Neurosurg 2012 114(7): 1081-5.

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Question #2: Which of the following has been reported in conjunction with NF1?

  • A. Tectal glioma
  • B. Craniopharyngioma
  • C. Hypothalamic hamartoma
  • D. Pineoblastoma

Question #2: Which of the following has been reported in conjunction with NF1?

  • A. Tectal glioma
  • B. Craniopharyngioma
  • C. Hypothalamic hamartoma
  • D. Pineoblastoma

Pollack et al. Neurology 1996 46(6): 1652-60 Chen et al. Oncogene 2013 (epub ahead of print) Crouse et al. Curr Top Dev Biol 2011 94: 283-308

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Question #3: Which of the following are common treatments for hypothalamic hamartoma?

  • A. Chemotherapy
  • B. Stereotactic radiosurgery
  • C. Endoscopic surgery
  • D. B and C
  • E. A and B

Question #3: Which of the following are common treatments for hypothalamic hamartoma?

  • A. Chemotherapy
  • B. Stereotactic radiosurgery
  • C. Endoscopic surgery
  • D. B and C
  • E. A and B

Wethe et al. Neurology 2013 81(12): 1044-50. Mittal et al. Neurosurg Focus 2013 34(6): E7. Choi et al. Adv Tech Stand Neurosurg 2012 39: 117-30.

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Question #4: Which of the following cell markers is 100% sensitive for choriocarcinoma?

  • A. AFP
  • B. hCG
  • C. LDH
  • D. CA-125
  • E. CEA

Question #4: Which of the following cell markers is 100% sensitive for choriocarcinoma?

  • A. AFP
  • B. hCG
  • C. LDH
  • D. CA-125
  • E. CEA

Jorsal et al. Acta Oncol 2012 51(1): 3-9. Kyritsis J Neurooncol 2010 96(2): 143-9. Chieffi et al. J Endocrinol Invest 35(11): 1015-20.

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Question #5: The following statement about papillary craniopharyngioma is correct:

  • A. Seen almost exclusively in adults
  • B. Calcification in 90%
  • C. Higher incidence in females
  • D. Commonly cystic
  • E. Consists of reticular endothelial cells

Question #5: The following statement about papillary craniopharyngioma is correct:

  • A. Seen almost exclusively in adults
  • B. Calcification in 90%
  • C. Higher incidence in females
  • D. Commonly cystic
  • E. Consists of reticular endothelial cells

Sartoretti-Schefer et al. AJNR 1997 18(1): 77-87 Eldevik et al. AJNR 1996 17(8): 1427-39

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THANK YOU!

David.m.wilson@ucsf.ed u