The coexistence of pituitary adenomas and meningiomas: three case reports and a review of the literature

A coexistence of pituitary adenomas and meningiomas is very rare. We have reported on three of our own cases and reviewed the 17 cases reported in the literature. One has to differenciate between the coexistence of a pituitary adenoma and a meningioma without previous irradiation, and the occurrence of a meningioma following the irradiation of a pituitary adenoma. In the cases without irradiation, the adenoma and the meningioma are diagnosed simultaneously. On the other hand meningiomas arising after irradiation of a pituitary tumour are usually diagnosed only after a long latent period. The coexistence of pituitary tumours and meningiomas resulting from hormone dependent growth as well as the induction of growth of meningiomas by irradiation are discussed.     

Coincidental pituitary adenoma and parasellar meningioma: case report

We report a patient who had pituitary adenoma and parasellar meningioma coincidentally, with neither irradiation nor a history of head injury. Preoperative computed tomographic (CT) scan had shown a large intrasellar mass with ring-like enhancement; in contact with this mass, another well-enhanced mass had been shown. Histopathologically, the intrasellar mass was diagnosed as chromophobic pituitary adenoma and the other mass as meningotheliomatous meningioma. We present clinical, radiological, and histopathological findings and discuss previously reported cases of coincidental pituitary adenoma and meningioma without irradiation. This is the first case report since the advent of CT that pituitary adenoma and parasellar meningioma in contact with each other could be clearly demonstrated by CT.     

A case report of adjacent tumor of sphenoid ridge meningioma and GH producing pituitary adenoma

A case of sphenoid ridge meningioma and pituitary adenoma adjacent in the brain is reported. A 70-year-old female was admitted to our hospital with headache. She had no neurological deficit but did have acromegalic change. Hormonal examination showed elevation of plasma levels of HGH (19.0 ng/ml), with normal levels of the other hormones. CT examination revealed a tumor with calcification in the inner third of the sphenoid ridge and another in the pituitary fossa with suprasellar expansion. MRI showed flow void of ICA between these tumors. Intensity of the T1-weighted image of the tumor in the sphenoid ridge was homogeneously iso intensity, and low intensity in the pituitary fossa. The diagnosis of adjacent tumors in the sphenoid ridge meningioma and pituitary adenoma had been made preoperatively. Left front-temporal craniotomy and removal of these tumors were performed. These tumors were close to each other, but were separated by the internal carotid artery and anterior cerebral artery. Pathological examination demonstrated meningotheliomatous meningioma in the sphenoid ridge and sparsely granulated somatotroph adenoma in the pituitary fossa. Fourteen cases showing association of meningioma and pituitary adenoma, which had no history of radiation and trauma, have been reported previously. Although GH producing pituitary adenoma may stimulate adjacent dura and arachnoid cells resulting in the formation of meningioma, the possibility of coincidental occurrence of the two tumors cannot be ignored.     

A case of intrasellar meningioma mimicking pituitary adenoma]

The authors report a patient with a rare intrasellar meningioma mimicking pituitary adenoma. A 60-year-old man was admitted to our hospital for evaluation of general fatigue. He had no neurological deficit including visual function. Endocrinological tests revealed panhypopituitarism. The craniogram showed slight enlargement of the sella turcica with thinning of the dorsum sellae. CT scan and MR imaging demonstrated a homogeneously enhanced intrasellar mass with slight suprasellar extension. Partial removal of the mass was performed via the transsphenoidal approach because it was extremely firm and hemorrhagic. Histological diagnosis was transitional meningioma. The patient has been well for two years after surgery without tumor progression on MR imaging. It is mandatory to distinguish intrasellar meningioma from pituitary adenoma preoperatively because of marked difference in their treatment strategies. Despite recent advances in neurodiagnostic imaging, it may still be difficult to differentiate pituitary adenoma from intrasellar meningioma. When we re-evaluated the MR imaging, we recognized that the tumor had demonstrated specific findings, ruling out pituitary adenoma, namely bright and homogeneous enhancement, dense enhancement in the early phase on the dynamic MR study, and flow void signal within the mass. The authors emphasize that careful evaluations of MR imaging will allow the correct preoperative diagnosis in patients with intrasellar meningioma mimicking pituitary macroadenoma.     

Meningioma of the pituitary stalk without dural attachment: case report and review of the literature

OBJECTIVE AND IMPORTANCE: Tumors in the suprasellar region such as adenomas of the pituitary gland, craniopharyngiomas, nonneoplastic cystic lesions (especially Rathke's cleft cysts), and meningiomas are frequently encountered in neurosurgical practice. Meningiomas originate from the arachnoid layer connected to the dura of the anterior or posterior clinoidal process, or the tuberculum, dorsum, or diaphragma sellae. Tumors originating from the pituitary stalk are rare. Such lesions may include germinomas, astrocytomas, histiocytosis X, hamartomas, and sarcoidosis. We report a patient with a suprasellar meningioma originating from the pituitary stalk with no connection to the adjacent dura. CLINICAL PRESENTATION: A 50-year-old man was assessed for impotence and loss of libido. Physical examination revealed no abnormalities. Endocrinological investigations disclosed nearly complete hypopituitarism, and magnetic resonance imaging revealed a suprasellar homogeneously enhancing tumor. INTERVENTION: Complete surgical resection was performed in an endoscope-assisted right-sided supraorbital craniotomy. The tumor originated from the pituitary stalk with no connection to the surrounding dura. The histopathological diagnosis was meningioma. CONCLUSION: Although meningiomas frequently occur in the suprasellar region, this patient with a suprasellar meningioma is unique because the tumor originated from the pituitary stalk with no connection to the surrounding dura. The absence of dural attachment has been described in 43 extracerebral meningiomas, but a suprasellar location has been reported only once previously. Recognition of this phenomenon is important, because meningiomas require a different therapeutic strategy than most other tumors of the pituitary stalk.     

Differentiation of pituitary adenoma and meningioma: visualization with positron emission tomography and [11C]-L-deprenyl.

Seven patients with clinically nonsecreting pituitary adenoma and 5 patients with meningioma were examined with positron emission tomography using [11C]-LL-deprenyl and [11C]-LL-methionine. The dynamics of the uptake of [11C]-L-deprenyl in the pituitary adenomas demonstrated a rapid and high uptake immediately after the injection, and, later, an almost constant level was observed that was equal to or higher than that observed in normal brain tissue. In the meningiomas, however, the initially high uptake was followed by a marked decrease with time, reaching a level that was approximately half that observed in brain tissue. The study demonstrated high binding of [11C]-L-deprenyl to monoamine oxidase B in pituitary adenomas, whereas the binding in meningiomas was very low. This fact can be used in the differential diagnosis of pituitary adenoma and parasellar meningioma. Operative samples from 10 patients with meningioma and from 5 patients with pituitary adenoma were analyzed biochemically for activity of monoamine oxidase B, using [14C]-phenyl-ethylamine as substrate. The nonsecreting pituitary adenomas demonstrated high enzyme activity, the secreting adenomas about one-tenth of that of the nonsecreting, and the meningiomas one-thirtieth of that of nonsecreting adenomas.     

Diaphragma sellae meningioma associated only with signs of hypopituitarism--case report.

A rare diaphragma sellae meningioma presenting only with signs of hypopituitarism occurred in a 54-year-old male. Preoperative magnetic resonance (MR) imaging clearly demonstrated a small lesion in the supradiaphragmatic area immediately beneath the optic chiasm, displacing the pituitary stalk laterally. Intraoperatively, the tumor was confirmed to be attached only to the posterior leaf of the diaphragma sellae. Histological examination revealed a transitional type meningioma. Such a small meningioma may be associated only with hypopituitarism, as compression is confined to the pituitary stalk, not affecting the optic pathways. MR imaging can demonstrate the clinicopathological features of this small but significant tumor.     

Non-functional recurrent pituitary adenoma with intracranial metastasis–Pituitary carcinoma: A case report and review of the literature

IntroductionPituitary carcinomas are rare, with only a few case reports to date. We present a null cell type non-functioning pituitary carcinoma (NFPC) with intracranial metastases and a review of the literature.Case reportA 56-year-old male with a history of an aggressive pituitary adenoma was admitted. Initial MRI highlighted a large intracranial mass with leptomeningeal involvement, simulating meningioma. Based on his previous pathology report of the sellar mass, a diagnosis of null cell type non-functioning pituitary carcinoma has been made.ConclusionsAn aggressive recurrent pituitary tumor with suprasellar and/or cavernous sinus invasion is the main characteristics of the NFPC. Single or multiple enhancing dural-based mass(es) mimicking meningioma is the most common MRI finding. The proof of malignancy is the same histopathological features of the recurrent aggressive pituitary tumor in the metastases. The histology alone is not distinctive in terms of malignancy. Most patients require a combined surgery, radiotherapy and chemotherapy.     

Diagnosis of the chiasmal meningioma (author's transl)

Not infrequently, it is difficult to differentiate the chiasmal meningioma from other suprasellar tumors, especially pituitary adenoma and craniopharyngioma. Authors examined 7 cases of chiasmal meningioma from neurological, endocrinological and neuroradiological points of view in comparison with the cases of pituitary adenoma and craniopharyngioma. As the results, the following features can be regarded as the differential characteristics of the chiasmal meningioma. 1) It was predominated in female of over 40 years of age. 2) Duration of the symptoms before admission was usually 2--3 years. 3) Disturbance of visual acuity and defect of visual field were initially unilateral in most of the cases, then extended to the other side when the disturbance of one eye had become severe. Visual field defect tended to be of irregular bitemporal hemianopsia with frequent involvement of peripheral nasal field. 4) Evidence of the endocrine disturbance were very scanty until the end stage. 5) Postero-superior elevation of A1 portion of the anterior cerebral artery in the tuberculum sellae meningioma was one of the pathognomonic features. 6) In the case of meningioma extending from tuberculum sellae to dorsum sellae or originated from dorsum sellae, PEG showed a finding of "capping on the dorsum sellae" and the tumor shadow over the posterior clinoid process took different feature from pituitary adenoma or craniopharyngioma.     

Tuberculum sellae meningioma symptomatic during pregnancy: pathophysiological considerations

A 31 year old woman in her second pregnancy presented in the 31st (+4) week of gestation with progressive visual impairment of the right eye. Magnetic resonance imaging (MRI) demonstrated a tuberculum sellae meningioma that was displaced upward by a markedly enlarged pituitary gland. Neuro-ophthalmological follow-up examinations showed a progressive decrease of visual acuity and right temporal field loss. Therefore, a caesarean section was performed in the 34th (+8) week. The meningioma was removed three days after childbirth via a right-sided pterional approach. Post-operatively, visual function was completely restored. Immunohistochemical examination showed positive staining for progesterone receptors (PR) in approximately 50% of tumour cells. Enlargement of the pituitary gland during late pregnancy in conjunction with a preexisting tuberculum sellae meningioma is the most likely pathophysiological factor responsible for visual loss. Enlargement of the PR-positive meningioma in the hormonal milieu of pregnancy might have contributed additionally to visual loss.     

Pituitary adenoma associated with intraventricular meningioma: case report.

Although rare, the association of intracranial meningiomas and pituitary adenomas has been reported. Intraventricular meningiomas are unusual, and meningiomas located in the fourth ventricle are even more so. We report a patient who harbored a prolactin-secreting pituitary adenoma and a fourth ventricle meningioma who was treated with surgical resection of the latter and medical treatment for the former. To our knowledge, this is the first report of such an unusual association.     

Radiation-induced meningioma after treatment for pituitary adenoma: case report and literature review

Radiation-induced meningiomas are becoming increasingly well-recognized. We report a case of a 35-year-old man who developed a suprasellar meningioma 9 years after receiving a radiation dose of 4480 cGy for a pituitary adenoma. The literature is also reviewed.     

Intracranial ectopic pituitary tumour

Pituitary tumours originating primarily from sites other than the sella turcica are rare. A case of an ectopic pituitary tumour in the region of the lesser wing of the sphenoid is reported. The patient presented with signs and symptoms of a progressive increase in intracranial pressure. CT scan appearances resembled those of a sphenoid wing meningioma. The vascular lesion was partially excised. Histology showed it to be a pituitary tumour.     

Intrasellar meningioma

Two purely subdiaphragmatic intrasellar meningiomias are described. The rarity of this unusual intrasellar tumor is stressed, and the differential diagnosis of intrasellar meningioma versus pituitary adenoma is discussed. The good results of the rhinoseptal route for surgery are emphasized.     

Possibilities and limitations of microsurgery in patients with meningiomas of the sellar region

Problems associated with the operative technique and operative results in 40 patients who underwent surgical removal of a meningioma in the sellar region are analysed. Attention must be paid not only to the possibilities and limitations of microsurgery but also to general aspects such as hypothalamic and pituitary function.     

Intracranial meningioma subsequent to radiation for a pituitary tumor: case report

The authors report a case of an intracranial meningioma that developed 33 years after radiation therapy for a pituitary tumor. Radiation-induced tumors form a distinct biological group with aggressive growth characteristics and a malignant potential.     

Magnetic resonance imaging of tuberculum sellae meningiomas: preventing preoperative misdiagnosis as pituitary macroadenoma.

Despite recent advances in neurodiagnostic imaging, it may be difficult to differentiate tuberculum sellae meningiomas from pituitary macroadenomas preoperatively. Magnetic resonance (MR) imaging has supplanted computed tomography as the imaging modality of choice for sellar and parasellar lesions, but unenhanced MR imaging does not reliably distinguish between all tuberculum sellae meningiomas and pituitary macroadenomas. Accurate differentiation between these alternative diagnoses of a suprasellar mass is important because a tuberculum sellae meningioma always requires a craniotomy, whereas a transsphenoidal route is preferred for removing most pituitary macroadenomas. The gadolinium-enhanced MR images of seven patients with tuberculum sellae meningioma and seven with pituitary macroadenoma were reviewed retrospectively. Although no specific radiological feature was pathognomonic, a combination of several features allowed the correct diagnosis in all cases. Three characteristics of tuberculum sellae meningiomas distinguish them from pituitary macroadenomas: 1) bright homogeneous enhancement with gadolinium, as opposed to heterogeneous, relatively poor enhancement; 2) a suprasellar rather than a sellar epicenter of tumor; and 3) tapered extension of an intracranial dural base. Each of these findings can be subtle, but careful examination of gadolinium-enhanced, high-quality, thin section coronal and sagittal MR images of the parasellar region for this constellation of findings will allow the correct preoperative diagnosis in patients with either of these tumors.     

Reformatted sagittal images in the differential diagnosis of meningiomas and pituitary adenomas with suprasellar extension

Approximately 3 to 4 times a year, a tumor with suprasellar extension escapes classification on high resolution coronal and transaxial computed tomography. When arteriography failed to determine the diagnosis, the differential choices were usually meningioma or pituitary adenoma. The authors report the use of sagittal reformatted images in this differential diagnosis and conclude that these images may aid in the distinction between pituitary tumors with suprasellar extension and meningiomas located in this area.     

Production of collagenase and inhibitor (TIMP) by intracranial tumors and dura in vitro

The production of collagenase and collagenase inhibitor (TIMP) by various intracranial tumors (25 meningiomas, eight gliomas, seven metastases, four pituitary adenomas, and five others) was studied in short-term organ culture. While meningiomas produced negligible amounts of collagenase, two metastatic carcinomas of bronchial and breast origin produced significant amounts of the enzyme. Cultures of dura from an invasive meningioma and of bone invaded by a meningioma also produced collagenase. In varying amounts, TIMP was detected in culture media from most of the tumors studied; invasive tumors tended to produce less TIMP than noninvasive tumors. The results are discussed in relation to current views on tissue degradation and mechanisms of tumor invasion.