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

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

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

4/14/2018 Pituitary gland- structure www.autismpedia.org/wiki/images/e/e5/Pituitary.jpg DURA • Meningeal and periosteal layers • Continuous with dura along planum sphenoidale & clivus Capero A et al, Neurosurgery 2008; 62: 717-23 3

4/14/2018 DURA • Thin single layer along medial cavernous sinus • Double layer along lateral cavernous sinus Capero A et al, Neurosurgery 2008; 62: 717-23 UCSF Sella MRI protocol • 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 microadenoma • 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 hemorrhage TR=787ms, TE=25ms,NEX=2, 3 mm no skip 4

4/14/2018 Adenoma: Dynamic Gad T1 0 s 45 s • Onset: ~36 sec • Peak signal: 1.2 - 2.2 min 90s • Washout: 2.7 - 5 min 45 sec 90 sec 135 sec Dynamic enhancement • Higher time resolution but generally noisier • Estimated 10% increase* in sensitivity *Bartynski W et al, AJNR 1997; 18: 965-72 5

4/14/2018 OUTLINE 1. Normal anatomy & imaging 2. Adenoma and pitfalls 3. Cystic lesions Microadenoma • Endocrine dysfunction or incidental • Arise within the adenohypophysis • < 10 mm diameter • “ Picoadenoma ” (< 3 mm) diagnostic challenge • Rarely ectopic outside of pituitary fossa 6

4/14/2018 ?? Adenoma: T1 signal • Usually same or slightly lower signal than gland • High T1 signal if hemorrhagic (typical of prolactinoma) • Contour deformity +/- Adenoma: Enhancement • Almost all lower signal than enhanced gland • May have higher signal after 30-45 ” delay 7

4/14/2018 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 Macroadenoma • 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 8

4/14/2018 T1 Signal • Heterogeneous, typically ~ gray matter • High T1 signal implies hemorrhage or another lesion T2 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 9

4/14/2018 Enhancement • Mild to avid enhancement typical • Rarely hypoenhancing (thyrotropin secreting) • Look for enhancing gland (preserved surgically) Suprasellar extension • Speculative role of diaphragmatic hiatus 10

4/14/2018 Macroadenoma: Cavernous invasion • 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 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 11

4/14/2018 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 Pitfalls… • 22 year-old woman, severely hypothyroid • Diagnosis: pituitary hyperplasia 12

4/14/2018 Pitfalls… • 58 year-old woman, hyperprolactinemia • Diagnosis: Tuberculum sellae meningioma Pitfalls… Optic/ hypothalamic glioma 13

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

4/14/2018 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 RCC Two types 2/3 1/3 T1 bright, T2 variable T1 dark, T2 bright • “ Machine oil ” cyst • Fluid like CSF • More often symptomatic 15

4/14/2018 RCC: Useful Diagnostic Features • Arise out of pars intermedia • Midline or near midline • No displacement of stalk • Anterior to stalk if suprasellar • “ Simple ” single intensity Case: 37F panhypopit, polydipsia, vision changes 16

4/14/2018 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 The big third- Craniopharyngioma • 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 17

4/14/2018 Adamantinomatous Craniopharynioma • 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 • 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 18

4/14/2018 Case: 9 year-old with visual disturbances Diagnosis: Craniopharyngioma 19

4/14/2018 Papillary Craniopharynioma • Predominantly solid • Cysts (if present) hypointense • Spherical geometry typical CYSTIC ADENOMA • Surrounded by pituitary gland • More frequently off midline (PRL) • Variable signal intensity • Evolve over time if hemorrhagic • May bloom on GRE 20

4/14/2018 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. 21

4/14/2018 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 22

4/14/2018 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. 23

4/14/2018 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. 24

4/14/2018 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 25

4/14/2018 THANK YOU! David.m.wilson@ucsf.ed u 26