Pluridirectional
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ROBERT
Tomography
B. GEEHR,1
WILLIAM
in the Evaluation
E. ALLEN,
L. G.
111,1 STEPHEN
of Pituitary
ROTHMAN,1
AND
A series of 110 patients with suspected pituitary tumors was recently evaluated by endocrinologic and neuroradiologic studies. Of the 77 patients in this series who underwent surgery, 74 had confirmed pituitary adenomas, two had suprasellar tumors of the infundibulum, and one had an empty sella not previously diagnosed at pneumoencephalography. All 17 patients with normal plain skull films but abnormal thin
abnormalities
section pituitary
defined
on tomography
the
of interest
tomography who underwent surgery tumors. This includes six patients
raphy the
surgical
normal
had documented who presented
in
area
section. of
The
the
films
of the sella were
Received Presented
obtained
Section Section
for all patients.
reprint
© 1978 American
Department
requests
of Neurosurgery,
Am J Roentgenol
130:105-109,
Roentgen
and
of Diagnostic
to R. B. Geehr.
Department
January Ray Society
of Surgery,
1978
Yale
assays
was
better
which
places
to the
tomographic
early
tomognaphic
duna
or focal
asymmetric
half den
with
erosion
expansion
tomographic
evaluation,
(figs.
abnormalities
including
of prolactin,
of this are
currently
Three
growth
hormone,
the
hormone,
and
un-
following
being
dried
directional
skull
followed
tomography
patients
used
of a comparable
dysfunction
were
studied
Most
with tomography. exploration. The by thin-section
as
age
controls.
with
in a similar
also
About remain-
medically.
evaluated
were
cortisol,
steroids.
on treated
specimens
plasma
urinary
pneumoencephalography group underwent surgical
underwent
In
no evidence
pluniaddition.
of pituitary
manner.
Results The
basis
series
was
(table
Class Class
patients
endocrine Class abnormal
with
of the endocrine II. Those
thin
into
with
section Ill.
four
findings
major
classes
and alterations
on
the
in pituitary
1):
I. All
regardless mal
divided
of radiographic
function
abnormal
normal
plain
tomography
studies. Patients tomography,
plain
skull
films.
but
abnor-
findings. skull
of the
with but
normal normal
films
sella
and
plain skull baseline
abnormal films and endocrine
studies. Class IV. tomography, Within
Those with but abnormal
each
class,
normal plain skull endocrine studies.
patients
were
further
symptoms: (1) menstrual irregularities rhea, termed the amenorrhea-galactorrhea
(2) acromegaly;
and
ing
visual
headaches,
uted relatively orrhea-galactorrhea,
9, 1977. Society of Neuroradiology,
grant
Radiology,
Yale
University
School
105
Hamilton,
in neuroradiology
University
of Medicine,
Bermuda, (no.
School New
among 26%;
March
and
subdivided
by
galactonsyndrome;
symptoms
disturbances,
evenly
films
and/or
(3) miscellaneous
and Cushing’s syndrome. In class I (abnormal skull
sellar
training
lamina
without
endocrine
adrenocorticotropic
plain
When
of a U.S. Public Health Service
of Neuroradiology,
06510. Address 2
Initially
June 7, 1977; accepted after revision September in part at the annual meeting of the American
A. B. Geehr is the recipient ‘
gynecology.
or
projections
routine blood chemistry, thyroid function, glucose tolerinsulin tolerance, dehydration, gonadal function, metyraL-dopa, thorazine stimulation, dexamethasone suppres-
sion,
Methods
and
of the
subtle
at 1 mm
floor
projection,
diagnosing
and with
detect
lateral sella
perpendicular
for
tomog-
erosion Patients
to
anterior
in the Towne used
section
was performed and
The
of patients
careful
three
obstetrics
tomography
anteropostenior
with
thin
of bony sinus.
Tomography
thinning
floor
films,
sphenoid
on a plane
were
majority
tests: ance, pone,
gland.
and
plain
the extent
the
motion.
criteria
sellar
The
A group of 110 patients with suspected pituitary tumors was recently evaluated by endocninologic and neuronadiologic studies. Most of these patients were referred by the departments of neurosurgery,
the
D. SPENCER2
lB and 1C).
A significant group of patients presents with only minor endocrine and radiographic abnormalities [3, 4]. Most are women with menstrual irregularities and impaired fertility; some have clinical evidence of galactonrhea. The role of prolactin-secreting pituitary adenomas is becoming increasingly recognized in the pathogenesis of this amenorrhea-galactorrhea syndrome [3-7]. The radiology of these tumors is often subtle and not appreciated without the aid of thin section tomography [3]; the importance of correlating endocrine and radiographic changes has been stressed. With the advent of trans-sphenoidal surgery, the accurate diagnosis of these tumors is underscored, since surgical treatment with low morbidity can now be offered [8, 9]. This neport describes our recent experience with a series of patients with pituitary adenomas in whom endocrine data could be correlated with radiographic findings, particularly subtle tomographic changes. and
underwent
both
abnormalities
The obvious radiographic findings of pituitary adenomas are well known [1 , 2]. Recent advances in endocrine evaluation and radiographic technique have supplemented the plain skull film findings, enabling diagnosis and treatment of tumors of the pituitary at a much earlier stage. A growing body of literature concerns the diagnosis of small pituitary adenomas, or microadenomas. The early diagnosis and treatment of these tumors is important to avoid irreparable damage to the remaining
Subjects
films
hypocycloidal
derwent
pituitary
of
of the sella.
intervals using
on
to define
anatomy
plain
DENNIS
detected
performed
abnormalities
with amenorrhea and/or galactorrhea and normal baseline serum prolactin levels; the only abnormality was found on tomography of the sella. In the preoperative evaluation of these patients, pluridirectional tomography of the sella was the most sensitive indicator of intrasellar pathology.
normal
were
was
Tumors
includ-
panhypopituitanism.
films), the
patients three
acromegaly,
were
subgroups: 32%;
distnibamenmiscella-
1977.
5-T01-NSO5646).
of Medicine, Haven,
333 Cedar
Connecticut
Street,
New Haven, Connecticut
06510.
0361 -803X/78/01
00-01
05 $02.00
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106
GEEHR
ET AL.
I: Fig.
2.-Patient
with
. _
amenorrhea
and
view of sella turcica showing well normal. B, Corresponding lateral
and erosion
galactorrhea.
A,
Lateral
coned
defined floor of sella which appears tomogram showing early expansion
of floor of sella (arrows).
neous symptoms, 42%. The majority of patients in class II (71%) and all 15 patients in class Ill had the amenorrhea-galactorrhea syndrome. The latter group included one male with galactorrhea. Although the plain skull films
Fig. 1 -Normal and abnormal tomograms. A, Normal lateral tomographic section of sella showing intact lamina dura of uniform thickness. B , Lateral tomogram of sella in 23-year-old female with galactorrhea showing early thinning of lamina dura of anterior floor (arrows). C, Tomogram in 20-year-old female with history similar to patient in B showing more advanced changes with both erosion and expansion of anterior floor of sella (arrows).
in
classes
II
and
III
were
normal,
thin
section
tomography was abnormal (fig. 2). The abnormalities of the sella were primarily asymmetric and in some cases were demonstrated only on two on three adjacent 1 mm tomognaphic sections (fig. 3). in class II patients with the amenonrhea-galactorrhea syndrome, the major endocrine abnormality was an elevated baseline prolactin level (above 25 ng/mI); patients in this classification with clinical manifestations of acromegaly all had elevated serum growth hormone levels. All patients in class III had normal baseline serum prolactin levels. Six had elevated prolactin levels following insulin stimulation and two others had a blunted growth hormone response. One patient had a blunted cortisol
PLURIDIRECTIONAL
TOMOGRAPHY
OF
TABLE Distribution
PITUITARY
107
TUMORS
1 of Cases Class
Findings
--
I
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No.patients
Radiology: Skull films Tomograms Endocrinology Symptoms: Amenorrhea-galactorrhea Acromegaly Miscellaneous Note-Numbers
in parentheses
II
IV
Ill
73
17
15
5
Abnormal
Normal Abnormal Abnormal
Normal Abnormal Normal
Normal Normal Abnormal
19 (26) 23 (32) 31 (42)
12 (71) 5 (29) 0
15 (100)
2 (40)
0 0
0 3 (60)
are percentages.
TABLE
2
Amenorrhea-Galactorrhea
Syndrome Findings
Study
Skullfilm Tomogram Endocrine profile Pneumoencephalogram Surgery Note-Data .
Six with
on 48 patients. empty
Numbers
Normal
Abnormal
Not Done
29(60) 2 (4) 19 (40) 26 (54)
19(40) 46 (96) 26 (54) 19* (40)
0 0 3 (6) 3 (6) 22 (46)
C)
in parentheses
are percentages.
tumor.
response to insulin stimulation as the only endocrine abnormality, and one had been treated for hypothyroidism for many years. Class IV consisted of five patients: with
Cushing’s
syndrome,
(54)
sella.
t One with a suprasellar
two
26t
two
with
the
amenorrhea-
galactorrhea syndrome, and one male with panhypopituitanism and elevated prolactin levels. Of the 73 patients in classes I-Ill who underwent surgery, all but one had documented pituitary adenomas. One patient had an empty sella, not previously diagnosed by pneumoencephalography because air failed to enter the arachnoid diverticulum. In the 15 patients whose only abnormality was an abnormal sella tomogram (class III) two had the empty sella syndrome on pneumoencephalography. Of the remaining patients, six underwent transsphenoidal surgery, and each had a pituitary adenoma. Among class IV patients (normal tomography), two had suprasellar tumors involving the infundibulum, and the two with Cushing’s syndrome had small intrasellar microadenomas. The fifth patient in this group has not had surgery. In our series, 48 patients had menstrual irregularity and/or galactorrhea (table 2). Of these, 29 had normal plain skull films, two had normal thin section tomography, and 19 had normal baseline serum prolactin levels. Pneumoencephaiography was abnormal in 19, including six with an empty sella. Of the 26 patients with abnormal tomography who underwent surgery, all had docu-
mented pituitary adenomas. One patient with amenorrhea and galactorrhea had normal thin section tomography and a small suprasellar mass on pneumoencephalography which proved to be a hamartoma of the pituitary stalk. None of the patients in the control group had abnormalities on tomography of the sella. Discussion
Once pituitary tumors reach the stage where they cause gross sellar enlargement and erosion, striking endocrine changes, and suprasellar extension on pneumoencephalography, their diagnosis is seldom difficult. In our study, the patients in class I demonstrated these marked abnormalities. Excluding those with empty sellas, the majority had surgical confirmation of large pituitary adenomas. The remaining three classes represent those with more subtle radiologic and endocrine abnormalities. Class II included a group of patients with tumors which fit the criteria of prolactin-secreting microadenomas [3, 4]. Most were women with amenorrhea, some with galactonnhea, and all with baseline prolactin levels of oven 25 ng/mI. Despite normal plain films of the sella, all showed abnormalities on thin section tomography consisting of thinning or irregularity of the lamina dura or focal erosion of the sellar floor with on without
108
GEEHR
ET AL. literature
of the
prolactinemia surgical pituitary
coexistence
[10-12].
exploration adenoma.
had
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Class Ill consisted or galactorrhea and normal insulin only
baseline resulted six
others.
and
the
the
though
hyper-
underwent
Stress in serum
in growth
only
of
of
testing prolactin
have
with in in two
abnormality
in
change on the thin of elevated baseline a pituitary
adenoma
patient who underwent is not well recognized
there
a
and/ all had
hormone
significant
a subtle the lack
presence
was confirmed in every This group of patients literature,
with
confirmation
levels. rises
changes
Otherwise,
levels,
who
of 14 women with amenorrhea one male with galactorrhea;
this group of patients was section tomogram. Despite prolactin
sellas
patient
pathologic
prolactin in abnormal
patients
of empty
Each
been
some
surgery. in the
individual
ne-
ports [5, 13]. Thus women with menstrual irregularities may harbor pituitary tumors which are manifested only On meticulous thin section tomography. There were few patients in class IV. Of the three patients in this group with elevated serum prolactin, two underwent
surgery;
nonadenomatous
suprasellar
tumors
were found in each case. The hyperprolactinemia sumably resulted from interference of stalk ratherthan by the
from tumors
When
autonomous
are
findings
of prolactin
[3].
patients
drome
hypersecretion
prefunction
are
with
the amenorrhea-galactorrhea
considered
as
a
significant.
While
group 60%
syn-
(table
2),
of these
certain
patients
had
normal plain skull films and 40% had normal baseline serum prolactin levels, only 4% had normal thin section tomograms of the sella. In other series [7, 12, 13], a large percentage of such patients were found to have normal
sellas
on
both
plain
films
and
tomography.
This
difference may be related to our use of meticulous thin section plunidirectional tomography at 1 mm intervals. Exploratory surgery was performed in 54% of these patients. All but one had documented pituitary adenomas. Though volume determination was difficult because mens,
of the surgical
occupied
fragmented nature of the surgical reports indicate that most of these
at least
subtle
40%-50%
tomographic
of patients with pituitary adenomas
recognized,
but
their
tention to subtle tomographic Furthermore, our experience Fig. metric
posterior of right portion
3.-Pluridirectional expansion
of sellar
tomographic floor
sections
in woman
with
demonstrating amenorrhea.
asymA,
Antero-
projection showing sloping of sellar floor to night and erosion side of floor. B. Normal lateral tomographic section of left of sella. C, Lateral tomogram of right portion of sellar floor
demonstrating
expansion
and
erosion
(arrows).
tomography
expansion.
In some,
the
malities.
thin abnormality
fossa,
is the
However,
section
despite
most
menstrual irreguthan has been
diagnosis
requires
abnormalities suggests that sensitive
despite
tomognam
still
indicator
this
sensitivity,
reflects
at-
of the sella. thin section of the
ence of an intrasellan mass. It is particularly evaluating patients with minimal endocninologic
sellan asymmetric
pituitary
abnormalities.
A larger percentage lanities may harbor previously
of the
specitumors
the
late changes
pres-
useful in abnorabnormal
of intna-
pathology.
could
be demonstrated only in two adjacent tomographic sections, which emphasizes the importance of carrying out tomography of the sella in 1 mm intervals. None of these patients had an empty sella, despite reports in the
ACKNOWLEDGMENTS We thank Catherine Camputaro and Barbara Maione for their meticulous tomographic technique and Jacqualyn Parkinson for her assistance
in obtaining
clinical
data.
PLURIDIRECTIONAL
TOMOGRAPHY
REFERENCES
OF
PITUITARY
7. Franks
S, Murray
JDN, Jacobs 1 . Pnibram HW: Abnormal sella, in Radiology of the Skull and Brain, edited by Newton TH, Potts DG, St. Louis, Mosby,
Downloaded from www.ajronline.org by 206.214.10.52 on 10/07/15 from IP address 206.214.10.52. Copyright ARRS. For personal use only; all rights reserved
2.
3. 4.
5. 6.
1971 , pp 371-397 Stangandter F, Margolis MT: Sella turcica destruction with chromophobe adenomas. Am J Roentgenol 1 1 5 : 774-776, 1972 Vezina JL, Sutton TJ: Prolactin-secreting pituitary microadenomas.Am J Roentgenol 120:46-54, 1974 Pearson OH, Brodkey JS, Kaufman B: Endocrine evaluation and indications for surgery of functional pituitary adenomas. Clin Neurosurg 21 : 26-38, 1974 Malarkey WB, Johnson JC: Pituitary tumors and hyperproIactinemia.Arch Intern Med 136:40-44, 1976 Boyar AM, Kapen 5, Weitzman ED, Hellman L: Pituitary microademona and hyperprolactinemia: a cause of unexplained secondary amenorrhea. N Eng! J Med 294 : 263265, 1976
MAF,
HS: Incidence
tinemia in women with 607, 1975 8. Hardy J: Tnanssphenoidal
pathological 9. Guiot
G,
pituitary. Derome
transsphenoidale
interventions. 10.
Hsu
T,
Shapiro
109
TUMORS
JA,
AM,
amenorrhea.
Tyson
Interne JE,
SJ,
4 : 597-
of the normal and 16: 185-217, 1969 de Ia voie d’abord experience
(Paris) Leddy
Nabarro
of hyperprolac-
C!in Endocrinol
neuro-chirurgie:
Med
Steele
and significance
microsurgery Clin Neurosurg P: Les indications
en
Ann
Jequier
123 : 703-712. AL,
Paz-Guevara
de
521
1972 AT:
Hyperprolactinemia associated with empty sella syndrome. JAMA 235:2002-2004, 1976 1 1 Bar AS, Mazzaferni EL, Malarkey WB: Primary empty sella, galactorrhea, hyperprolactinemia and renal tubular acidosis.Am J Med 59:863-866, 1975 12. Kleinberg DL, Noel GL, Frantz AG: Galactorrhea: a study of 235 cases, including 48 with pituitary tumors. N Engi J .
Med 296:589-600, 1977 13. Jones JA, Kemmann E: Sella anovulatory population. Obstet
turcica Gyneco!
abnormalities 48 : 76-78,
in an 1976
Downloaded from www.ajronline.org by 206.214.10.52 on 10/07/15 from IP address 206.214.10.52. Copyright ARRS. For personal use only; all rights reserved
ROBERT
Tomography
B. GEEHR,1
WILLIAM
in the Evaluation
E. ALLEN,
L. G.
111,1 STEPHEN
of Pituitary
ROTHMAN,1
AND
A series of 110 patients with suspected pituitary tumors was recently evaluated by endocrinologic and neuroradiologic studies. Of the 77 patients in this series who underwent surgery, 74 had confirmed pituitary adenomas, two had suprasellar tumors of the infundibulum, and one had an empty sella not previously diagnosed at pneumoencephalography. All 17 patients with normal plain skull films but abnormal thin
abnormalities
section pituitary
defined
on tomography
the
of interest
tomography who underwent surgery tumors. This includes six patients
raphy the
surgical
normal
had documented who presented
in
area
section. of
The
the
films
of the sella were
Received Presented
obtained
Section Section
for all patients.
reprint
© 1978 American
Department
requests
of Neurosurgery,
Am J Roentgenol
130:105-109,
Roentgen
and
of Diagnostic
to R. B. Geehr.
Department
January Ray Society
of Surgery,
1978
Yale
assays
was
better
which
places
to the
tomographic
early
tomognaphic
duna
or focal
asymmetric
half den
with
erosion
expansion
tomographic
evaluation,
(figs.
abnormalities
including
of prolactin,
of this are
currently
Three
growth
hormone,
the
hormone,
and
un-
following
being
dried
directional
skull
followed
tomography
patients
used
of a comparable
dysfunction
were
studied
Most
with tomography. exploration. The by thin-section
as
age
controls.
with
in a similar
also
About remain-
medically.
evaluated
were
cortisol,
steroids.
on treated
specimens
plasma
urinary
pneumoencephalography group underwent surgical
underwent
In
no evidence
pluniaddition.
of pituitary
manner.
Results The
basis
series
was
(table
Class Class
patients
endocrine Class abnormal
with
of the endocrine II. Those
thin
into
with
section Ill.
four
findings
major
classes
and alterations
on
the
in pituitary
1):
I. All
regardless mal
divided
of radiographic
function
abnormal
normal
plain
tomography
studies. Patients tomography,
plain
skull
films.
but
abnor-
findings. skull
of the
with but
normal normal
films
sella
and
plain skull baseline
abnormal films and endocrine
studies. Class IV. tomography, Within
Those with but abnormal
each
class,
normal plain skull endocrine studies.
patients
were
further
symptoms: (1) menstrual irregularities rhea, termed the amenorrhea-galactorrhea
(2) acromegaly;
and
ing
visual
headaches,
uted relatively orrhea-galactorrhea,
9, 1977. Society of Neuroradiology,
grant
Radiology,
Yale
University
School
105
Hamilton,
in neuroradiology
University
of Medicine,
Bermuda, (no.
School New
among 26%;
March
and
subdivided
by
galactonsyndrome;
symptoms
disturbances,
evenly
films
and/or
(3) miscellaneous
and Cushing’s syndrome. In class I (abnormal skull
sellar
training
lamina
without
endocrine
adrenocorticotropic
plain
When
of a U.S. Public Health Service
of Neuroradiology,
06510. Address 2
Initially
June 7, 1977; accepted after revision September in part at the annual meeting of the American
A. B. Geehr is the recipient ‘
gynecology.
or
projections
routine blood chemistry, thyroid function, glucose tolerinsulin tolerance, dehydration, gonadal function, metyraL-dopa, thorazine stimulation, dexamethasone suppres-
sion,
Methods
and
of the
subtle
at 1 mm
floor
projection,
diagnosing
and with
detect
lateral sella
perpendicular
for
tomog-
erosion Patients
to
anterior
in the Towne used
section
was performed and
The
of patients
careful
three
obstetrics
tomography
anteropostenior
with
thin
of bony sinus.
Tomography
thinning
floor
films,
sphenoid
on a plane
were
majority
tests: ance, pone,
gland.
and
plain
the extent
the
motion.
criteria
sellar
The
A group of 110 patients with suspected pituitary tumors was recently evaluated by endocninologic and neuronadiologic studies. Most of these patients were referred by the departments of neurosurgery,
the
D. SPENCER2
lB and 1C).
A significant group of patients presents with only minor endocrine and radiographic abnormalities [3, 4]. Most are women with menstrual irregularities and impaired fertility; some have clinical evidence of galactonrhea. The role of prolactin-secreting pituitary adenomas is becoming increasingly recognized in the pathogenesis of this amenorrhea-galactorrhea syndrome [3-7]. The radiology of these tumors is often subtle and not appreciated without the aid of thin section tomography [3]; the importance of correlating endocrine and radiographic changes has been stressed. With the advent of trans-sphenoidal surgery, the accurate diagnosis of these tumors is underscored, since surgical treatment with low morbidity can now be offered [8, 9]. This neport describes our recent experience with a series of patients with pituitary adenomas in whom endocrine data could be correlated with radiographic findings, particularly subtle tomographic changes. and
underwent
both
abnormalities
The obvious radiographic findings of pituitary adenomas are well known [1 , 2]. Recent advances in endocrine evaluation and radiographic technique have supplemented the plain skull film findings, enabling diagnosis and treatment of tumors of the pituitary at a much earlier stage. A growing body of literature concerns the diagnosis of small pituitary adenomas, or microadenomas. The early diagnosis and treatment of these tumors is important to avoid irreparable damage to the remaining
Subjects
films
hypocycloidal
derwent
pituitary
of
of the sella.
intervals using
on
to define
anatomy
plain
DENNIS
detected
performed
abnormalities
with amenorrhea and/or galactorrhea and normal baseline serum prolactin levels; the only abnormality was found on tomography of the sella. In the preoperative evaluation of these patients, pluridirectional tomography of the sella was the most sensitive indicator of intrasellar pathology.
normal
were
was
Tumors
includ-
panhypopituitanism.
films), the
patients three
acromegaly,
were
subgroups: 32%;
distnibamenmiscella-
1977.
5-T01-NSO5646).
of Medicine, Haven,
333 Cedar
Connecticut
Street,
New Haven, Connecticut
06510.
0361 -803X/78/01
00-01
05 $02.00
Downloaded from www.ajronline.org by 206.214.10.52 on 10/07/15 from IP address 206.214.10.52. Copyright ARRS. For personal use only; all rights reserved
106
GEEHR
ET AL.
I: Fig.
2.-Patient
with
. _
amenorrhea
and
view of sella turcica showing well normal. B, Corresponding lateral
and erosion
galactorrhea.
A,
Lateral
coned
defined floor of sella which appears tomogram showing early expansion
of floor of sella (arrows).
neous symptoms, 42%. The majority of patients in class II (71%) and all 15 patients in class Ill had the amenorrhea-galactorrhea syndrome. The latter group included one male with galactorrhea. Although the plain skull films
Fig. 1 -Normal and abnormal tomograms. A, Normal lateral tomographic section of sella showing intact lamina dura of uniform thickness. B , Lateral tomogram of sella in 23-year-old female with galactorrhea showing early thinning of lamina dura of anterior floor (arrows). C, Tomogram in 20-year-old female with history similar to patient in B showing more advanced changes with both erosion and expansion of anterior floor of sella (arrows).
in
classes
II
and
III
were
normal,
thin
section
tomography was abnormal (fig. 2). The abnormalities of the sella were primarily asymmetric and in some cases were demonstrated only on two on three adjacent 1 mm tomognaphic sections (fig. 3). in class II patients with the amenonrhea-galactorrhea syndrome, the major endocrine abnormality was an elevated baseline prolactin level (above 25 ng/mI); patients in this classification with clinical manifestations of acromegaly all had elevated serum growth hormone levels. All patients in class III had normal baseline serum prolactin levels. Six had elevated prolactin levels following insulin stimulation and two others had a blunted growth hormone response. One patient had a blunted cortisol
PLURIDIRECTIONAL
TOMOGRAPHY
OF
TABLE Distribution
PITUITARY
107
TUMORS
1 of Cases Class
Findings
--
I
Downloaded from www.ajronline.org by 206.214.10.52 on 10/07/15 from IP address 206.214.10.52. Copyright ARRS. For personal use only; all rights reserved
No.patients
Radiology: Skull films Tomograms Endocrinology Symptoms: Amenorrhea-galactorrhea Acromegaly Miscellaneous Note-Numbers
in parentheses
II
IV
Ill
73
17
15
5
Abnormal
Normal Abnormal Abnormal
Normal Abnormal Normal
Normal Normal Abnormal
19 (26) 23 (32) 31 (42)
12 (71) 5 (29) 0
15 (100)
2 (40)
0 0
0 3 (60)
are percentages.
TABLE
2
Amenorrhea-Galactorrhea
Syndrome Findings
Study
Skullfilm Tomogram Endocrine profile Pneumoencephalogram Surgery Note-Data .
Six with
on 48 patients. empty
Numbers
Normal
Abnormal
Not Done
29(60) 2 (4) 19 (40) 26 (54)
19(40) 46 (96) 26 (54) 19* (40)
0 0 3 (6) 3 (6) 22 (46)
C)
in parentheses
are percentages.
tumor.
response to insulin stimulation as the only endocrine abnormality, and one had been treated for hypothyroidism for many years. Class IV consisted of five patients: with
Cushing’s
syndrome,
(54)
sella.
t One with a suprasellar
two
26t
two
with
the
amenorrhea-
galactorrhea syndrome, and one male with panhypopituitanism and elevated prolactin levels. Of the 73 patients in classes I-Ill who underwent surgery, all but one had documented pituitary adenomas. One patient had an empty sella, not previously diagnosed by pneumoencephalography because air failed to enter the arachnoid diverticulum. In the 15 patients whose only abnormality was an abnormal sella tomogram (class III) two had the empty sella syndrome on pneumoencephalography. Of the remaining patients, six underwent transsphenoidal surgery, and each had a pituitary adenoma. Among class IV patients (normal tomography), two had suprasellar tumors involving the infundibulum, and the two with Cushing’s syndrome had small intrasellar microadenomas. The fifth patient in this group has not had surgery. In our series, 48 patients had menstrual irregularity and/or galactorrhea (table 2). Of these, 29 had normal plain skull films, two had normal thin section tomography, and 19 had normal baseline serum prolactin levels. Pneumoencephaiography was abnormal in 19, including six with an empty sella. Of the 26 patients with abnormal tomography who underwent surgery, all had docu-
mented pituitary adenomas. One patient with amenorrhea and galactorrhea had normal thin section tomography and a small suprasellar mass on pneumoencephalography which proved to be a hamartoma of the pituitary stalk. None of the patients in the control group had abnormalities on tomography of the sella. Discussion
Once pituitary tumors reach the stage where they cause gross sellar enlargement and erosion, striking endocrine changes, and suprasellar extension on pneumoencephalography, their diagnosis is seldom difficult. In our study, the patients in class I demonstrated these marked abnormalities. Excluding those with empty sellas, the majority had surgical confirmation of large pituitary adenomas. The remaining three classes represent those with more subtle radiologic and endocrine abnormalities. Class II included a group of patients with tumors which fit the criteria of prolactin-secreting microadenomas [3, 4]. Most were women with amenorrhea, some with galactonnhea, and all with baseline prolactin levels of oven 25 ng/mI. Despite normal plain films of the sella, all showed abnormalities on thin section tomography consisting of thinning or irregularity of the lamina dura or focal erosion of the sellar floor with on without
108
GEEHR
ET AL. literature
of the
prolactinemia surgical pituitary
coexistence
[10-12].
exploration adenoma.
had
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Class Ill consisted or galactorrhea and normal insulin only
baseline resulted six
others.
and
the
the
though
hyper-
underwent
Stress in serum
in growth
only
of
of
testing prolactin
have
with in in two
abnormality
in
change on the thin of elevated baseline a pituitary
adenoma
patient who underwent is not well recognized
there
a
and/ all had
hormone
significant
a subtle the lack
presence
was confirmed in every This group of patients literature,
with
confirmation
levels. rises
changes
Otherwise,
levels,
who
of 14 women with amenorrhea one male with galactorrhea;
this group of patients was section tomogram. Despite prolactin
sellas
patient
pathologic
prolactin in abnormal
patients
of empty
Each
been
some
surgery. in the
individual
ne-
ports [5, 13]. Thus women with menstrual irregularities may harbor pituitary tumors which are manifested only On meticulous thin section tomography. There were few patients in class IV. Of the three patients in this group with elevated serum prolactin, two underwent
surgery;
nonadenomatous
suprasellar
tumors
were found in each case. The hyperprolactinemia sumably resulted from interference of stalk ratherthan by the
from tumors
When
autonomous
are
findings
of prolactin
[3].
patients
drome
hypersecretion
prefunction
are
with
the amenorrhea-galactorrhea
considered
as
a
significant.
While
group 60%
syn-
(table
2),
of these
certain
patients
had
normal plain skull films and 40% had normal baseline serum prolactin levels, only 4% had normal thin section tomograms of the sella. In other series [7, 12, 13], a large percentage of such patients were found to have normal
sellas
on
both
plain
films
and
tomography.
This
difference may be related to our use of meticulous thin section plunidirectional tomography at 1 mm intervals. Exploratory surgery was performed in 54% of these patients. All but one had documented pituitary adenomas. Though volume determination was difficult because mens,
of the surgical
occupied
fragmented nature of the surgical reports indicate that most of these
at least
subtle
40%-50%
tomographic
of patients with pituitary adenomas
recognized,
but
their
tention to subtle tomographic Furthermore, our experience Fig. metric
posterior of right portion
3.-Pluridirectional expansion
of sellar
tomographic floor
sections
in woman
with
demonstrating amenorrhea.
asymA,
Antero-
projection showing sloping of sellar floor to night and erosion side of floor. B. Normal lateral tomographic section of left of sella. C, Lateral tomogram of right portion of sellar floor
demonstrating
expansion
and
erosion
(arrows).
tomography
expansion.
In some,
the
malities.
thin abnormality
fossa,
is the
However,
section
despite
most
menstrual irreguthan has been
diagnosis
requires
abnormalities suggests that sensitive
despite
tomognam
still
indicator
this
sensitivity,
reflects
at-
of the sella. thin section of the
ence of an intrasellan mass. It is particularly evaluating patients with minimal endocninologic
sellan asymmetric
pituitary
abnormalities.
A larger percentage lanities may harbor previously
of the
specitumors
the
late changes
pres-
useful in abnorabnormal
of intna-
pathology.
could
be demonstrated only in two adjacent tomographic sections, which emphasizes the importance of carrying out tomography of the sella in 1 mm intervals. None of these patients had an empty sella, despite reports in the
ACKNOWLEDGMENTS We thank Catherine Camputaro and Barbara Maione for their meticulous tomographic technique and Jacqualyn Parkinson for her assistance
in obtaining
clinical
data.
PLURIDIRECTIONAL
TOMOGRAPHY
REFERENCES
OF
PITUITARY
7. Franks
S, Murray
JDN, Jacobs 1 . Pnibram HW: Abnormal sella, in Radiology of the Skull and Brain, edited by Newton TH, Potts DG, St. Louis, Mosby,
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2.
3. 4.
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