0:00

Dr. Shupack, this is a 52-year-old woman.

0:03

I'm presenting you with a coronal T1,

0:07

non-contrast on the far left,

0:09

a coronal contrast-enhanced image, non-dynamic.

0:13

So this one's pretty early,

0:15

about one and a half to 2 minutes out,

0:18

but not 20 seconds out.

0:20

And then I've also given you an equilibrium phase

0:23

or dynamic, sorry, non-dynamic, earlier phase.

0:26

Sagittal T1 with contrast.

0:28

So contrast-enhanced sagittal, contrast-enhanced coronal,

0:32

non-contrast coronal T1-weighted MRI.

0:36

We've got an obvious abnormality in the left portion of

0:38

the pituitary gland. What shall we name the baby?

0:42

Okay, so this is the lesion in question.

0:46

I assume we can agree on that.

0:50

So it's in the pituitary and there's mass effect.

0:52

Okay, so the stalk, we talked about some stalk deviation.

0:57

It could be normal, but in this case,

0:58

you got a mass and deviation.

1:01

So these two are related.

1:02

Okay, so this is actually a mass,

1:04

it's just not a signal abnormality.

1:06

And the stalk's kind of bowed, too.

1:07

If you go back to the stalk,

1:08

it's got this kind of funny curve shape to it.

1:12

And while that's obvious because there's a mass,

1:14

if there wasn't a mass,

1:16

you could have a curved shape or

1:18

even a displacement or a slope,

1:20

and that would be okay if everything else was all right.

1:22

But in this case, it's not okay.

1:24

Right. So we got a mass with mass effect.

1:27

And also when we're talking about the sellar, remember,

1:31

one of the things we're going to emphasize is

1:33

what's around it in terms of structures,

1:35

because that's going to have a lot to

1:36

do with what ends up being done.

1:38

And so here's your optic apparatus right here,

1:41

and it's pretty close,

1:43

although I don't think that there is mass effect on the

1:45

optic apparatus. So we got an intrasellar lesion.

1:48

Now, if we measure this,

1:50

I think we can measure it at about 9 mm.

1:55

Okay,

1:55

so a nine-millimeter mass hypointense on post-contrast.

1:59

And you said earlier that an adenoma may do that.

2:04

That is, it'll be cold.

2:06

Sure. But if you wait too long,

2:08

it can be iso intense and it can even be hot.

2:10

Right. So you don't want to wait too long.

2:12

You don't want to wait six, seven,

2:13

eight or 9 minutes or you'll miss the lesion or confuse

2:16

it with something else. But I wanted to ask you,

2:19

it's 9 cutoff for a macroadenoma is 10 mm.

2:24

What do we name this baby?

2:25

Yeah, a big micro, I guess.

2:28

A big micro. Big micro.

2:29

Or a small macro. Or a small macro,

2:32

but it's right on that border.

2:34

But that's what you're looking for.

2:35

That 1 cm, which is sort of an arbitrary thing,

2:39

but nevertheless,

2:40

that's sort of what you're looking for.

2:41

So that 1 cm measurement.

2:44

So anything smaller, theoretically at least, is a micro,

2:46

bigger macro. This one's kind of right on the border.

2:49

So you can kind of take whichever direction you want.

2:52

Now, another thing is,

2:54

what's going to happen, happen now.

2:55

Okay, so we've identified this lesion.

2:57

I think our differential is definitely

2:59

going to be an adenoma.

3:00

Okay, micro, macro,

3:01

whatever direction we decide to take.

3:03

So what's going to happen?

3:05

Well, the goal of surgery is it going to

3:09

be treated surgically? Well,

3:10

there's not a goal in decompression because there's

3:13

no pressure on the optic apparatus.

3:15

So the other goal of surgery is endocrine.

3:17

So if there is Cushing's let's say acromegaly,

3:21

those are two life-threatening conditions that

3:23

you would operate for endocrine reasons.

3:26

Prolactin elevations of prolactin

3:29

can be treated medically.

3:30

So there's a pretty good chance that this

3:32

is going to be not operated, followed,

3:35

depending on the endocrine status.

3:37

But from what we can see here, a substantial,

3:40

but maybe not operative lesion.

3:41

Let me ask you a clinical question.

3:44

It's touching the optic apparatus,

3:46

but not really compressing it.

3:47

What if the patient still had a visual field cut?

3:50

Right. This is something that you would follow,

3:53

visual fields,

3:54

meaning I had a bunch of patients with something like

3:56

this. So we get visual fields as a baseline,

3:59

and then a lot of times we'll just do it once or twice a

4:01

year. And then if you see the fields are deteriorating,

4:03

you reimage at that point,

4:05

because then you would have an indication if

4:07

there was a reproducible visual field cut,

4:10

particularly a progressive one,

4:12

and you can see that there's an extrinsic

4:14

compression causing that,

4:16

then you're kind of maybe getting

4:17

into the surgical realm. Sure.

4:19

And unlike Rathke's cyst that we showed you earlier,

4:22

where we didn't show you the coronal,

4:24

but you had a kind of a big cystic lesion going up this

4:27

way, and everything was draped over the top of it.

4:30

So you had a cold area in the middle,

4:32

and you had that so-called bear claw sign

4:35

here in the sagittal projection,

4:36

you've got circumferential tissue

4:39

all the way around the lesion.

4:40

It's not just the pars distalis and the stalk going up,

4:43

making the bear claw.

4:44

It's circumferential signal all the way,

4:48

almost 360 degrees around the lesion,

4:50

telling you it's intrasellar. It's in the pars distalis.

4:54

And these are common lesions.

4:55

They're 10% of all primary intracranial tumors.

4:59

And in fact,

5:00

these lesions are seen in about 15% of every autopsy.

5:05

Now,

5:05

we know microadenomas are inordinately more common

5:08

than macroadenomas. In past studies,

5:11

microadenomas are 400 times more

5:13

common than macroadenomas,

5:15

which tells you they're almost in everybody.

5:18

I mean, not really, but they're super common.

5:20

And when you do imaging,

5:22

macroadenomas are two times more common

5:24

than microadenomas. So, again,

5:26

that tells you that these are very frequent

5:29

as very small structures.

5:30

And that's why a lot of times you may have a true

5:33

prolactin elevation. And the MRI may be normal.

5:35

It may just simply be a microscopic microadenoma.

5:39

Right. Now, another thing about it, though,

5:41

is that you talk about micro and macro and you think,

5:43

well, okay, all the macros have to start off as micros,

5:48

and they're going to get there, but not necessarily.

5:50

There are really two different ways of behavior.

5:52

A lot of the micros stay micros and then the macros

5:56

really grow. Get to that size rapidly.

6:00

So it's kind of a different entity.

6:01

So you can have a micro that just sits there for years

6:03

on end and follow them, but when it's a macro,

6:07

it's a little bit different.

6:08

This one may be more likely to grow

6:09

than a tiny little one.

6:10

I think that's both a scientific description of

6:13

it and that's been both of our experience.

6:15

The micros behave very tight,

6:17

they don't grow very quickly.

6:19

And the macros,

6:21

it's a free for all, so to speak,

6:23

in terms of the secretory behavior of the lesion.

6:28

You really can't tell that from imaging.

6:30

But I will say that the signal intensity of a

6:33

macroadenoma helps you understand a

6:35

little bit about its histology.

6:37

Most of the macroadenomas are iso intense with

6:39

gray matter. But if they're bright on T2,

6:42

they don't have to be really cystic,

6:43

just brighter than gray matter.

6:45

That implies that they're softer.

6:47

And sometimes the softer ones can be a

6:49

little bit more difficult to remove.

6:52

And especially if you treat them with medical therapy,

6:56

then they can get very gooey and hard to extract.

6:59

Is that a fair statement?

7:00

Yeah, I think that's correct.

7:02

Now the other thing that you would

7:04

want to look at a little bit,

7:05

let's say you decided you did need to do surgery

7:08

for some reason. Can you resect it?

7:10

And I think we talked earlier about the cavernous sinus.

7:13

And you can see that this one looks pretty clean

7:16

over here. Maybe it's sticking in a little bit,

7:19

but it's short of that mid carotid line.

7:22

So this would be kind of that in that category one,

7:25

grade one.

7:30

So if you were going to resect it, that's a possibility.

7:33

You're not going to necessarily have frank

7:36

cavernous sinus invasion at this point.

7:38

So let's explain that to him.

7:39

It's in another vignette,

7:40

but we should explain it real quickly.

7:42

So the medial line along the medial

7:45

border of the carotid right here.

7:47

Then you bisect the carotids right here and

7:50

then a line along the lateral border.

7:53

So if this tissue extends beyond that lateral border,

7:57

then it completely is unresectable.

8:00

And how do you stage these?

8:02

So over here,

8:04

if you're short of this line medial to this line,

8:06

that's a zero. Crossing these one, two and then three.

8:10

Okay. And when you get to grade three,

8:13

that is crossing that lateral line,

8:14

crossing this last line, last line,

8:17

those are the ones that you're going to have

8:18

a hard time getting out surgically.

8:20

And that may not be a reasonable goal

8:21

of surgery up to grade two.

8:24

You may have a decent chance of trying

8:26

to get that out surgically.

8:27

This is on correlation with endoscopy and pathology

8:30

and it was published recently in

8:32

the Journal of Neurosurgery.

8:33

So just to be really clear for our viewing audience,

8:37

a grade three would be here, my red dot.

8:41

A grade two would be here.

8:43

And there might even be a little component of grade two.

8:45

In the upper compartment, there,

8:47

a grade one would be here,

8:49

and a grade zero would be here.

8:51

And as you've mentioned many times,

8:53

circumferential 67% or more surrounding the

8:57

carotid artery. Carotid is also an.

9:00

But another statistical way of saying

9:02

that you're not getting it out.

9:05

Your curate is not getting there.

9:06

If it's less than 25% of the carotid circumference,

9:11

you probably have a good chance of getting it out.

9:13

Because, you see,

9:13

there's an arachnoidal plane that may be preserved at

9:16

that point that you can kind of get medial to get

9:18

your curate and kind of scoop that stuff out.

9:22

When you're getting that far beyond it, probably not.

9:25

And then a couple of other easy points besides the near

9:29

circumferential involvement around the carotid.

9:31

But if you start to color in and opacify

9:34

with intermediate signal intensity,

9:35

the cavernous sinus you lose the cranial nerves,

9:39

you lose the clarity of the carotid and

9:41

then you have a nice dark interface,

9:44

a black interface at the dural edge right here.

9:48

Instead of just a line with signal on either side of it.

9:52

That's an obvious sign of involvement

9:54

of the cavernous sinus.

9:55

A clinical sign would be if your prolactin level is

10:00

1000 or 1500 or 2000 nanograms per ml, then you're

10:04

probably just spilling cavernous sinus invasion

10:07

right into the cavernous sinus.

10:09

Now,

10:09

just another little thing.

10:10

The Framino Valley is a very important thing to

10:13

assess when you're looking at the cella, okay?

10:16

Because there are other lesions in the sella, tumors,

10:19

things like that that can go right along there.

10:21

And that's a very important thing to notice.

10:24

And this one happens to show that yeah,

10:26

I think I might have even accidentally earlier

10:28

drawn right over the foramen ovale.

10:30

I think it's right here.

10:32

Right? So there is the sella.

10:34

If you got stuff in there,

10:35

you got kind of a problem because it's out of the barn.

10:37

Then nice and clean. And then just for giggles,

10:41

we have Meckel's cave here on the left.

10:43

So with that,

10:44

we'll conclude our discussion of this pituitary

10:47

macroadenoma which is resectable if you needed to if

10:51

it was hormonally secreting in any adverse way.

10:53

It's not doing a lot of damage to the optic

10:55

apparatus yet. Let's move on, shall we?

10:58

Sure.