|
| Article Access Statistics | | | Viewed | 7873 | | | Printed | 306 | | | Emailed | 5 | | | PDF Downloaded | 147 | | | Comments | [Add] | | | Cited by others | 5 | | |
|
Click on image for details.
|
|
|
|
|
|
| Year : 2000 | Volume
: 48
| Issue : 1 | Page : 72-4 |
Pituitary adenoma and parasagittal meningioma : an unusual association.
Mathuriya SN, Vasishta RK, Dash RJ, Kak VK
Department of Neurosurgery, Postgraduate Institute of Medical Educationand Research, Chandigarh-160012, India.
Correspondence Address:
Department of Neurosurgery, Postgraduate Institute of Medical Educationand Research, Chandigarh-160012, India.
Simultaneous detection of an intracranial meningioma with a pituitary tumour prior to radiotherapy is an extremely uncommon occurrence. Authors have managed an elderly acromegalic lady with an acidophilic pituitary adenoma, who also harboured an asymptomatic anterior third parasagittal meningioma. There were no features of neurofibromatosis. Both tumours were concurrently excised.
How to cite this article:
Mathuriya S N, Vasishta R K, Dash R J, Kak V K. Pituitary adenoma and parasagittal meningioma : an unusual association. Neurol India 2000;48:72 |
It is not unusual to encounter meningiomas along with other intracranial tumours or two meningiomas together.[1] The commonly reported tumour along with meningioma is a neurofibroma in Von-Reckling Hausen's disease, followed by a glioma.[2] Meningiomas accompanying pituitary tumours are infrequent and are located in close proximity to the sella, viz suprasellar and sphenoid ridge.[3],[4] An elderly acromegalic female with an acidophilic pituitary adenoma and parasagittal meningioma is discussed. Meningioma was an incidental observation on CT scan.
A 58 years female, known diabetic for seven years, was admitted with five years history of acral enlargement, coarsening of facial features, and intermittent left hemicranial headaches. She was lethargic and inattentive at work. She had no features of thyroid dysfunction, however, she had been prescribed eltroxin by a private practitioner. She was on irregular therapy for diabetes mellitus. She had coarse skin, thick lips, fingers and heel pads. Cardiovascular, respiratory and neurological examinations were normal. Her blood sugar was 130 mg dl-1 with normal glucose tolerance test (GTT). Hormonal profile depicted marked elevation of growth hormone (GH) (over 200 ng ml-1 with a paradoxical elevation on GTT. Cortisol, T3,T4,LH and FSH were within normal range. Skull X-rays demonstrated a ballooned sella with undercutting of the anterior clinoids. A hyperdense enhancing sellar mass with suprasellar extension was visualized on CT scan, which also revealed a uniformly enhancing hyperattenuated globular mass in the right frontal parasagittal location. There was no peritumoural oedema, ventricular compression or midline shift [Figure. 1]. A diagnosis of pituitary adenoma with suprasellar extension and an incidental right frontal parasagittal meningioma was made.
Pituitary adenomectomy and excision of meningioma was performed through a right frontal trephine craniotomy. She became drowsy 18 hours following surgery. CT scan showed a right frontal haemorrhagic infarct with marked mass effect. The infarcted portion was excised at emergency re-exploration. The patient developed left hemiparesis which improved to grade IV in 3 weeks time.
Histopathological examination revealed the typical structure of a pituitary adenoma disposed in a sinusoidal and capillary fashion. The cytoplasm showed acidophilia on PAS-orange G staining. The meningioma was of meningothelial type and did not show atypical features or brain invasion. She was subjected to radiotherapy and had improved at follow up after 6 months.
Numerous extraneous factors have been implicated for induction of meningiomas e.g. trauma, oncogenic infections and irradiations.[5] Meningioma can be consequent to pituitary irradiation but these have also been identified along with pituitary adenomas even before radiation therapy.[6] An asymptomatic meningioma along with an overt pituitary tumour has been reported in twenty five patients, whereas the contrary was recognized only in a single case.[6] The acidophil adenoma was responsible for acromegaly in our patient but meningioma was an incidental observation on imaging. Incidence of discovering occult intracranial lesions in association with the overt pathologies have enhanced after introduction of excellent neurodiagnostic techniques. There is still a possibility of missing these lesions in the studies limited to specific areas. It is unlikely for the sizeable sellar lesions to drop out as it is customary to commence an imaging in relation to orbitomeatal line.[3] The patient under discussion had very high levels of growth hormone. There is a possibility that hormones may incite genesis of meningiomas.[7],[8] The observations supporting this statement are (i) 80% of spinal and 66% of intracranial meningiomas are found in females,[8] (ii) The symptomatology in meningiomas worsen during menstruation and pregnancy due to increased vascularity and cellularity.[8],[11] (iii) Association of meningioma is established with breast, ovarian and endometrial carcinomas which are proven hormone dependent neoplasms[11] (iv) Studies exist depicting the presence of more progesterone than oestrogen receptors in meningiomas,[12],[13] (v) Female steroidal hormone receptors are in paucity in fibroblastic and transitional meningiomas than the syncytial ones.[6],[8],[13] (vi) Six of the [eight] meningiomas encountered after pituitary irradiation were in acromegalics, suggesting that somatostatin alone or in combination with other factors, could play a part in the development and growth of meningiomas.[6],[7]
The present case was acromegalic with elevated GH and had an asymptomatic meningioma along with a pituitary tumour. Psammomatous meningiomas are unusually associated with pituitary tumours and are uncommon amongst the hormone induced ones. A trial of bromocriptine, antiandrogens or medroxyprogesterone acetate can be given in a patient with a small meningioma associated with a pituitary tumour as these lesions have a slow growth rate.[14] A close follow up is mandatory for deciding surgery at an appropriate juncture.
| 1. | Love JG, Blackburn CM: Association of intracranial meningioma with pituitary adenoma. Report of successfully treated case. Minn Med 1955; 37: 335-336.  |
| 2. | Rubinstein AB, Shalit MN, Cohen ML et al: Radiation induced cerebral meningioma: a recognizable entity. J Neurosurg 1984; 61: 966-971. |
| 3. | Yamada K, Hatayama T, Ohta M et al: Coincidental pituitary adenoma and parasellar meningioma. Case report. Neurosurgery 1986; 19: 267-270. |
| 4. | Parizel PM, Willams PJ, Van-de Kelft E et al: The association of meningioma and pituitary adenoma: Report of seven cases and review of literature. Eur Neurol 1993; 33: 416-422. |
| 5. | Waga S, Handa H: Radiation induced meningioma with review of literature. Surg Neurol 1976; 5: 215-219. |
| 6. | Honegger J, Buchfelder M, Schrell U eL al: The coexistence of pituitary adenomas and meningiomas: Three case reports and review of literature. Br J Neurosurg 1989; 3: 59-69. |
| 7. | Bunick EM, Millis LC, Rose LI: Association of acromegaly and meningiomas. JAMA 1978; 240: 1267-1268. |
| 8. | Donnel MS, Meyer GA, Donegan WL: Estrogen receptor protein in intracranial meningiomas. J Neurosurg 1979; 50: 499-502. |
| 9. | Bickerstaff ER, Small JM, Guest IA: The relapsing course of certain meningiomas in relation to pregnancy and menstruation. J Neurol Neurosurg Psychiatry 1958; 21: 89-91. |
| 10. | Brennan TG Jr, Rao CVGK, Robinson W et al: Tandom lesions. Chromophobe adenoma and meningioma Case report. J Comput Tomogr 1977; 1: 517-520. |
| 11. | Piquer J, Cerda M, Liuch A et al: Correlation of female steroid hormone receptors with histologic features in meningiomas. Acta Neurochir (Wien) 1991; 110: 38-43. |
| 12. | Schrell UMN, Adams EF, Fahibusch R et al: Hormone dependency of cerebral meningiomas. Part 1. Female sex steroid receptors and their significance as specific markers for adjuvant medical therapy. J Neurosurg 1990; 73:743-749. |
| 13. | Adams EF, Schrell UMH, Fahibusch R et al: Hormone dependency of cerebral meningiomas. Part 2. In vitro role of steroids, bromocriptine and epidermal growth factor on growth of meningiomas. J Neurosurg 1990; 73: 750-755. |
| 14. | Firsching RP, Fisher A, Peters R et al: Growth rate of incidental meningiomas. J Neurosurg 1990; 73: 545-547. |
 |
 |
|
|
|
|
