Evaluation of modern pathologic nomenclature,tumor imaging and treatment of pituitary adenomas in a recent surgical series

This study reviews retrospectively 49 patients with pituitary adenomas, using a modern, immunohistochemically and ultrastructurally-based nomenclature. It also compares tumor imaging by CT and MRI scans, and analyzes the results of recent neurosurgical and radiotherapeutic treatments. Based on the findings of the study, several recommendations on clinical management of pituitary macroadenoma are made.     

TUMORS INVADING PARAPHARYNGEAL SPACE : REFINED IMAGING DIAGNOSIS

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肾上腺神经鞘瘤的诊断及临床特点并文献复习（附8例报告）

背景与目的：肾上腺神经鞘瘤非常少见,多为良性,缺乏特异性的临床及影像学表现。该研究通过对肾上腺神经鞘瘤的CT和MRI表现与病理对照分析,提高对肾上腺神经鞘瘤的诊断水平。方法：回顾性分析经病理证实的8例肾上腺神经鞘瘤患者的CT和MRI影像特征,其中4例患者仅行CT扫描,3例患者仅行MR扫描,1例患者行CT和MR扫描。并将影像学诊断结果与病理诊断结果进行对比分析。结果：5例肿瘤位于左侧肾上腺,3例位于右侧肾上腺;所有患者均未出现内分泌症状。所有8例肿瘤表现为边界清楚的类圆形、分叶状肿块,2例肿瘤见钙化,5例肿瘤伴囊变,2例肿瘤伴出血;7例肿瘤CT或MRI的强化表现为中度不均匀、延迟强化,并可见强化的包膜,4例肿瘤增强可见兔尾征。结论：肾上腺神经鞘瘤的影像及病理有一定的特征性,完整包膜、囊变、兔尾征、钙化及渐进强化等影像征象有助于提高肾上腺神经鞘瘤的诊断准确率。     

肝脏原发性平滑肌瘤影像学表现

Objective: To investigate the imaging features of primary hepatic leiomyoma. Methods: 3 patients of primary hepatic leiomyoma confirmed by pathology without immunodeficiency were retrospectively analyzed about CT and MRI findings, clinical and pathological correlation. 2 cases had routine CT scan, 2 cases had routine MRI. Results: 2 case CT scans showed low-density lesions, 2 cases MRI showed lesions with long T1 and long T2 signal. One case of uniform density and signal showed homogeneous enhancement; two cases showed uneven density and signal, of which one case was inhomogeneous enhancement. 3 cases presented pseudocapsule without hepatic cirrhosis and venous tumor thrombus. Pathology showed spindle tumor cell proliferation and capillary hyperplasia; one case showed central hyalinization and one case central liquefaction necrosis. Conclusion: Primary hepatic leiomyoma is a hypervascular tumor, and CT and MRI help in the diagnosis.     

鼻内窥镜和术中磁共振在经蝶垂体瘤手术中的应用

神经外科医生一直在努力追求垂体瘤手术微创且有效的途径。近年来鼻内镜和术中磁共振技术发展迅速，两者均促进了垂体瘤手术的发展，它们的结合在垂体瘤手术中是可行的。本文对鼻内窥镜和术中磁共振在经蝶垂体瘤手术中的应用作一介绍。     

Recurrence and Metastasis of Lung Cancer Demonstrate Decreased Diffusion on Diffusion-Weighted Magnetic Resonance Imaging

Background: Diffusion-weighted magnetic resonance imaging (DWI) is reported to be useful for detecting malignant lesions. The purpose of this study is to clarify characteristics of imaging, detection rate and sensitivity of DWI for recurrence or metastasis of lung cancer. Methods: A total of 36 lung cancer patients with recurrence or metastasis were enrolled in this study. While 16 patients underwent magnetic resonance imaging (MRI), computed tomography (CT) and positron emission tomography-computed tomography (PET-CT), 17 underwent MRI and CT, and 3 underwent MRI and PET-CT. Results: Each recurrence or metastasis showed decreased diffusion, which was easily recognized in DWI. The detection rate for recurrence or metastasis was 100% (36/36) in DWI, 89% (17/19) in PET-CT and 82% (27/33) in CT. Detection rate of DWI was significantly higher thanthat of CT (p=0.0244) but not significantly higher than that of PET-CT (p=0.22). When the optimal cutoff value of the apparent diffusion coefficient value was set as 1.70×10-3 mm2/sec, the sensitivity of DWI for diagnosing recurrence or metastasis of lung cancer was 95.6%. Conclusions: DWI is useful for detection of recurrence and metastasis of lung cancer.     

Efficacy of DR,CT and MRI in bone tumors

Objective:The aim of the study was to investigate the ef icacy of digital radiography (DR), computed tomography (CT) and magnetic resonance imaging (MRI) in bone tumors. Methods:Fifty-five patients with histological y confirmed bone tumors underwent imaging examinations. Fifty-five patients were performed DR, 21 CT and 20 MRI. Results:DR of 51 pa-tients clearly revealed bone changes. DR of 40 patients wel showed marginal. Twenty tumors appeared periosteal reaction on DR and 19 calcification on DR. CT scan of 21 patients clearly depicted bone changes, marginal and calcification and CT scan of 8 revealed periosteal reaction. MRI scan of 20 patients al showed marginal and soft-tissue mass and bone marrow edema was prominent in 8 patients. Conclusion:DR is the first imaging approach for born tumors. CT wel reveal the extent and minute structure of the bone tumors, the extent, soft-tissue mass and bone marrow edema are more dramatical y demon-strated on MRI imaging. DR integrates with CT and MRI, is helpful in diagnosis of bone tumors.     

内镜经鼻蝶入路手术治疗大型垂体腺瘤

背景与目的：对于大型垂体腺瘤,传统的开颅和经蝶入路手术均难以全切,本文探讨内镜经鼻蝶入路切除大型垂体腺瘤的手术技术。方法：回顾性分析2000年9月-2005年12月间治疗的大型垂体腺瘤患者39例,术前均行头CT、MRI及内分泌学检查,手术采用内镜经鼻蝶入路肿瘤切除术。结果：本组患者无手术死亡,肿瘤全切除23例（60．0％）,近全切除14例（35．9％）,部分切除2例（5．1％）。术后随访6—24个月,症状和内分泌学指标均有所改善,肿瘤复发2例。结论：内镜经鼻蝶手术是治疗大型垂体腺瘤微创、安全的方法。     

Symptom resolution, tumor control, and side effects following postoperative radiotherapy for pituitary macroadenomas

This study reports the outcome of 70 patients who were treated by a consistent treatment plan of surgery and postoperative radiotherapy (RT) for pituitary macroadenomas in the modern era [computed tomographic scan or magnetic resonance imaging (MRI), dopamine agonist therapy (DA) added as indicated, and immunohistochemical staining]. Sixty-two patients underwent transsphenoidal surgery (vs. transcranial surgery) and 61 received 45-Gy/25 fractions postoperatively (vs. other dose fractionation schemes). Twenty-four patients received DA for prolactin-secreting tumors. With a median follow-up of 8 years (range 2–15), 68 patients have experienced continuous control of their tumors. Most symptoms related to mass effect abated, while physiologic symptoms such as amenorrhea from markedly elevated prolactin levels tended to persist. Treatment-induced hypopituitarism occurred in 42% of the patients at risk. No patients in this series have died as a result of their pituitary tumor. No gross neuropsychologic dysfunction after treatment has been noted. While it is possible at this time with serial MRI to withhold postoperative RT and observe some patients who have had a “gross total” resection of a macroadenoma, the therapeutic ratio for surgery and adjuvant radiotherapy for patients with nonfunctional tumors as well as select patients with secretory macroadenomas is favorable.     

Analysis of positron emission tomography/computed tomography in patients to differentiate between malignant transformation of endometrioma and endometrioma

Purpose

Of those patients who undergo open surgery for a suspicion of malignant transformation of endometrioma (MTOE) due to solid nodule enhancement identified by contrast-enhanced magnetic resonance imaging (MRI), some benign endometrioma cases are included. The aim of this retrospective study was to determine the value and diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) using 18-fluoro-2-deoxy-d-glucose (FDG) to differentiate between MTOE and endometrioma.

Patients and methods

We retrospectively analyzed 1599 consecutive patients who underwent laparoscopic surgery for the diagnosis of endometrioma preoperatively and 31 patients who underwent open surgery for a suspicion of MTOE preoperatively from January 2003 to December 2011. We analyzed the age, serum CA125 levels, and MRI findings of the patients and calculated the optimal cut-off value for PET/CT using receiver operating characteristic curve analysis.

Results

Of the 1,599 patients who underwent laparoscopic surgery for a suspicion of endometrioma preoperatively, malignancy was identified in one (0.062 %) patient. Of the 31 patients who underwent open surgery for a suspicion of MTOE preoperatively, 11 were diagnosed with endometrioma (false positive group) and 20 with MTOE stage I (positive group). Age, tumor size, presence of shading on MRI and maximum standardized uptake values (SUV_max) on PET/CT were significantly different between the two groups. A SUV_max cut-off >4.0 is capable of excluding endometrioma cases, with 75 % sensitivity and 100 % specificity (area under the curve 90 %).

Conclusion

PET/CT is a good diagnostic tool for MTOE using the optimal SUV_max cut-off of 4.0 (75 % sensitivity and 100 % specificity).

     

头颈部炎性肌纤维母细胞瘤的影像表现及临床特点

  目的  探讨头颈部炎性肌纤维母细胞瘤的影像学表现及临床特征,提高该病的术前诊断水平。  方法  回顾性分析收治11例病理确诊头颈部炎性肌纤维母细胞瘤患者的临床特征以及CT、MRI表现。  结果  11例患者中8例临床上表现为进行性增大的无痛性头颈部肿块,2例表现为面部肿胀,1例表现为进行性眼球突出,72.7%（8/11）在术前临床诊断为恶性肿瘤。11例患者均在术前行CT或MRI检查,其中6例行MRI检查,3例行CT检查,2例同时行CT和MRI检查。头颈部炎性肌纤维母瘤在CT和MRI上表现与恶性肿瘤相近。11例患者共发现15个病灶,其中86.7%病灶（13/15）边界不清楚,侵犯临近肌肉,46.7%（7/15）病灶有骨质侵犯。3例患者出现神经孔道侵犯,其中2例为发生于咀嚼肌间隙病灶沿圆孔和卵圆孔向颅内侵犯,1例为发生于眼眶视神经管侵犯。头颈部炎性肌纤维母瘤在CT平扫时呈稍低密度,增强扫描呈明显强化。在MRI上表现为:T1W上呈稍低于肌肉信号,在T2WI上信号强度低于或等于信号肌肉,信号明显不均匀,增强扫描呈明显不均匀强化。  结论  头颈部炎性肌纤维母细胞瘤在临床表现及影像学特征上与恶性肿瘤相近。但是MRI可以在一定程度上反映病灶的组织构成,对诊断和鉴别诊断具有重要作用。      

Aggressive Giant Pituitary Adenoma Presenting as a Nasopharyngeal Mass: Magnetic Resonance Imaging and Pathologic Findings

We report a giant pituitary adenoma with aggressive histologic features that prominently invaded the nasopharynx. Magnetic resonance imaging (MRI) demonstrated a large heterogeneous nodular mass that was hypointense to isointense on T1-weighted images and mixed hypointense, isointense, and hyperintense on T2-weighted images. The mass measured 7.5×5×7cm, extending from the nasopharynx posteriorly through the clivus, and superiorly through the paranasal sinuses, and sellar-suprasellar region. After contrast administration, heterogeneous nodular enhancement was noted. A nasopharyngeal neoplasm extending into the sella was suspected because voice change and nasal speech long preceded the patient's visual symptoms. A biopsy disclosed an aggressive, infiltrating, hemorrhagic tumor, which was diagnosed as a non-secreting pituitary macroadenoma. This report indicates that pituitary adenomas may grow invasively to tremendously large sizes resulting in their initial presentation as nasopharyngeal masses.     

Bladder Paraganglioma: CT and MR Imaging Characteristics in 16 Patients

BackgroundBladder paraganglioma (BPG) is a rare extra-adrenal pheochromocytoma with variable symptoms and easy to be misdiagnosed and mishandled. The aim of the study was to document the imaging features of BPG using computed tomography (CT) and magnetic resonance imaging (MRI).Patients and methodsWe retrospectively enrolled consecutive patients with pathology-proven BPG, who underwent CT or MRI examinations before surgery between October 2009 and October 2017. The clinical characteristics, CT, and MRI features of the patients were described and analysed.ResultsA total of 16 patients with 16 bladder tumours (median age 51 years, 9 females) were included. Among them, 13 patients underwent CT examinations and eight patients underwent MRI examinations preoperatively. Tumour diameters ranged from 1.6−5.4 cm. Most of the tumours grew into the bladder cavity (n = 11) with oval shapes (n = 10) and well-defined margins (n = 14). Intratumour cystic degeneration or necrosis (n = 2) was observed. Two lesions showed peripheral tissue invasion, suggesting malignant BPGs. All 13 lesions imaged with CT exhibited slight hypoattenuation and moderate to marked enhancement. Compared to the gluteus maximus, all lesions showed slight h yperintensity in T2-weighted images, hyperintensity on diffusion-weighted images (DWI), hypointensity on apparent diffusion coefficient maps, hyperintensity on T1-weighted images and a “fast in and slow out” enhanced pattern on contrast-enhanced MRI images.ConclusionsBPGs are mostly oval-shaped, broadly-based and hypervascular bladder tumours with hypoattenuation on non-contrast CT, T2 hyperintensity, slight T1 hyperintensity compared to the muscle, marked restricted diffusion on DWI. Peripheral tissue invasion can suggest malignancy of the BPGs. All of these features contribute to preoperative decision-making.Key words: paraganglioma, urinary bladder, computed tomography, magnetic resonance imaging     

Incidental uptake of 18F-fluorocholine (FCH) in the head or in the neck of patients with prostate cancer

Background

Positron emission tomography-computed tomography (PET/CT) with ¹⁸F-fluorocholine (FCH) is routinely performed in patients with prostate cancer. In this clinical context, foci of FCH uptake in the head or in the neck were considered as incidentalomas, except for those suggestive of multiple bone metastases.

Results

In 8 patients the incidental focus corresponded to a benign tumour. The standard of truth was histology in two cases, correlative imaging with MRI in four cases, ^99mTc-SestaMIBI scintigraphy, ultrasonography and biochemistry in one case and biochemistry including PTH assay in one case. The final diagnosis of benign tumours consisted in 3 pituitary adenomas, 2 meningiomas, 2 hyperfunctioning parathyroid glands and 1 thyroid adenoma.Malignancy was proven histologically in 2 other patients: 1 papillary carcinoma of the thyroid and 1 cerebellar metastasis.

Conclusions

To the best of our knowledge, FCH uptake by pituitary adenomas or hyperfunctioning parathyroid glands has never been described previously. We thus discuss whether there might be a future indication for FCH PET/CT when one such tumour is already known or suspected: to detect a residual or recurrent pituitary adenoma after surgery, to guide surgery or radiotherapy of a meningioma or to localise a hyperfunctioning parathyroid gland. In these potential indications, comparative studies with reference PET tracers or with ^99mTc-sestaMIBI in case of hyperparathyroidism could be undertaken.     

Assessment of future remnant liver regeneration after portal vein embolization using three‐dimensional CT and MR volumetric analyses

The purpose of this study is to portray right portal vein embolization (PVE) as a valuable technique that helps in expanding the volume of the left liver lobe and discuss the relevant published work. We describe our experience with four patients who underwent PVE and analyse the value of CT and MRI in the preoperative evaluation of these patients. Four patients with hepatic malignancy (hepatocellular carcinoma) (n = 2) and metastatic liver disease (n = 2) underwent portal vein occlusion. PVE was carried out in three patients using polyvinyl alcohol and stainless steel coils. Portal vein ligation was carried out in the fourth patient. In patients who were candidates for right hepatectomy, CT volumetric analysis was carried out before the surgery to assess the total liver volume and the future remnant liver, which is the residual left hepatic volume (in cases of right hepatectomy) or left lateral segment volume (in cases of right tri‐segmentectomy). Because the left lobe volumes were insufficient, patients were selected to undergo right PVE. Computed tomography volumetry was carried out 2–4 weeks after embolization to assess left hepatic lobe regeneration. Magnetic resonance volumetric analysis was carried out in two patients before and after embolization. All four patients had significant regeneration of the left lobe and tolerated the surgery with uneventful postoperative recovery.     

SPECT骨显像联合CT和MRI在恶性肿瘤骨转移诊断中的临床价值

目的探讨单光子发射计算机断层成像术(SPECT)骨显像联合CT和MRI在恶性肿瘤骨转移诊断中的应用价值。方法选取2016年3月至2019年3月间北京市房山区第一医院收治的80例恶性肿瘤并发骨转移患者,均采用SPECT骨显像、CT和MRI检查,分析原发肿瘤骨转移灶区域分布及三种检测方式诊断骨转移瘤的效能。结果无明显骨痛症状者46例,有明显骨痛症状者34例。骨转移瘤发生部位依次为脊柱、肋骨、骨盆、胸部、四肢和颅骨。脊柱转移瘤中,好发部位依次为胸椎、腰椎、骶椎和颈椎。SPECT与CT相同扫描野内诊断出464处病灶,SPECT检出429处(92.5%),CT检出率361处(77.8%),两者比较,差异有统计学意义(P<0.05),在相同扫描野之外SPECT另检出143处病灶。SPECT与MRI相同扫描野内诊断出321处病灶,SPECT检出307处(95.6%),MRI检出265处(82.6%),两者比较,差异有统计学意义(P<0.05),在相同扫描野之外SPECT另检出286处病灶。CT与MRI相同扫描野内诊断出259处病灶,CT检出185处(71.4%),MRI检出248处(95.8%),两者比较,差异有统计学意义(P<0.05)。SPECT骨显像联合CT和MRI检查的灵敏度、特异性和准确度均高于单独使用SPECT骨显像、CT或MRI,差异均有统计学意义(均P<0.05)。结论SPECT可作为可疑骨转移瘤的首选筛查手段,联合CT和MRI能明确恶性肿瘤骨转移的区域分布情况,提高诊断的灵敏度、特异性及准确度,有较高的临床价值。     

CT and MR imaging of the adrenal glands in cortisol-secreting tumors

Cushing's syndrome (CS), first described by the neurosurgeon Harvey Cushing in the 1930s, is the result of chronic glucocorticoid excess. In patients with adreno-corticotropic hormone (ACTH)-dependent CS, bilateral hyperplasia of the adrenal cortex occurs, while in those with ACTH-independent primary CS, either adrenocortical tumors or primary adrenal hyperplasia can be observed. Cortisol-secreting adrenocortical tumors are more frequently adenomas, while adrenal carcinoma accounts for only 5% of cases. Unfortunately, no reliable endocrinological tests are available and no specific tumor markers exist to differentiate between benign and malignant adrenal tumors, so both computed tomography (CT) and magnetic resonance (MR) imaging studies are currently required to localize and define adrenal lesions. Additional information to conventional imaging can be obtained using 1?F-fluoro-2-deoxyglucose (FDG)-positron emission tomography (PET)/CT, while percutaneous image-guided fine-needle aspiration cytology (FNAC) in some cases has shown a high accuracy in detecting malignancy and in confirming adrenal metastases. New PET tracers with selective affinity for the adrenal tissue are still under evaluation. Multidetector CT scan, with the combination of unenhanced and dynamic scans, represents the single most accurate modality for the detection and the characterization of adrenal adenomas. In these lesions, chemical-shift MR imaging produces a typical loss of signal intensity on out-of-phase breath-hold gradient-echo images in lipid-rich adenomas. For these lesions there is no difference between CT and MR imaging, while MR chemical shift imaging is very helpful in identifying the additional small group of adenomas where intracellular lipid content is minimal.     

SSE 垂体无功能巨腺瘤术后残余肿瘤的转归与处理

目的:探讨鞍上扩展（the suprasellar extension ,SSE）的垂体无功能巨腺瘤手术治疗后残余肿瘤的转归与处理措施。方法:回顾性分析我科首次手术治疗为经蝶入路的资料齐全的68例巨大型SSE 垂体无功能腺瘤患者的临床资料,重点分析肿瘤的术中处理,术后肿瘤的残余情况、随访过程中残余肿瘤的转归及其相应的处理措施。结果:一期手术SSE 肿瘤全切者20例（20.6%）,术后第1 天MRI 复查存在鞍上残余肿瘤者48例（79.4%）;术后3 个月复查,残余肿瘤21例下降至鞍窝底,8 例下降至鞍窝内,3 例下降至垂体柄水平和鞍窝入口处（下降率为66.7%）,均采用再次经蝶手术切除（下降后残余肿瘤的全切除率96.9%）;2 例患者肿瘤虽然下降,但仍为明显的伴有SSE 的残余肿瘤,采用开颅切除;其余的12例有残余肿瘤的患者由于术后MRI 显示残余肿瘤小采取持续临床观察,其中2 例视力改善不明显者辅以伽马刀治疗。本组无死亡病例;没有患者发生术后脑脊液漏,脑膜炎或视力恶化;有2 例术后常规的CT检查中观察到鞍隔上少量出血但不需特殊处理。结论:巨大型SSE 垂体无功能腺瘤宜采用分期经蝶手术切除治疗,疗效确切,并发症少;有关垂体腺瘤的生长方式问题尚需进一步研究。      

Cranial cystic epidermoid: Report of two cases and review of the literature

Intercranial epidermoid tumours are benign lesions of congenital origin that are potentially curable. Although computerized axial tomography (CT) and magnetic resonance imaging (MRI) are usually diagnostic, a few atypical features sometimes make pre-operative diagnosis difficult. Two cases of cystic epidermoids with peripheral ring enhancement are reported. Relevant literature has been reviewed.     

Early MRI findings in High Grade Glioma

Magnetic resonance imaging (MRI) is more sensitive than computerized tomography in the detection of many intracerebral lesions; however, the significance of some MRI findings may be unclear. Over four years, nine patients, aged 40–79 years, have been encountered whose initial MRI scans were negative or had minimal abnormalities and soon thereafter had high grade glioma. Initial MRI was performed in eight patients for new-onset seizures and one patient for a focal deficit. MRI was negative in four of the patients and mildly abnormal in five of the patients (small areas of increased T2 and/or minimal enhancement). The initial diagnoses usually included inconclusive differentials of stroke and infection with neoplasm less frequently considered. Radiographic progression leading to the diagnosis of high grade glioma became evident on repeat MRI in 1–8 months with six patients showing progression within three months. All patients underwent surgery and had histologic diagnosis of glioma. Although MRI is quite sensitive, four of the initial scans were negative with reasonable quality studies. Conversely, in five of the initial scans, the tumors were detected when so small that the radiographic findings were not typically diagnostic. Glioma must be considered as a possible cause of initial seizures or new neurologic deficits in adults with normal or minimally abnormal MRI. In this group, seizures were the overwhelming hallmark of presentation. In such a clinical situation, close follow-up with short interval repeat MRI should be performed.