|Year : 2019 | Volume
| Issue : 1 | Page : 3-9
Accuracy of magnetic resonance imaging in evaluation of sellar and juxtasellar tumors
Pratisruti Hui, Sasmita Parida, Jayashree Mohanty, Mamata Singh, Pradosh Kumar Sarangi
Department of Radiodiagnosis, SCB Medical College, Cuttack, Odisha, India
|Date of Web Publication||3-May-2019|
Dr. Pradosh Kumar Sarangi
Department of Radiodiagnosis, SCB Medical College, Cuttack - 753 007, Odisha
Source of Support: None, Conflict of Interest: None
Background: Sellar and parasellar/juxtasellar regions are complex areas of the brain, and different varieties of tumors can occur in this area. Preoperative noninvasive diagnosis with magnetic resonance imaging (MRI) is essential for treatment planning. Aim of the Study: The aim of this study is to characterize MRI features of the sellar and juxtasellar tumors and to correlate MRI diagnosis with histopathological diagnosis in order to evaluate the efficiency of MRI. Materials and Methods: Patients with sellar and juxtasellar lesions who were operated during September 2015–August 2017 and the pathological reports were compared with the MRI findings retrospectively. Results: A total of 50 patients were enrolled in the study, and the mean age of presentation was 34.6 years. MRI-based radiological diagnosis showed 21 cases of pituitary macroadenoma, 15 cases of craniopharyngioma, 9 cases of meningioma, 2 cases of germinoma, 1 case of glioma, and 2 cases of epidermoid cysts. Histopathological correlation revealed MRI accuracy of 94.12%, 94%, 100%, 98%, 100%, and 100% for the diagnosis of pituitary macroadenoma, craniopharyngioma, meningioma, germinoma, glioma, and epidermoid cyst, respectively. One case each of pituitary macroadenoma and germinoma diagnosed on MRI comes out to be as craniopharyngioma after final histopathological correlation, whereas one case of craniopharyngioma turned out to be macroadenoma after final histopathological examination. Conclusions: The present study revealed a strong correlation between MRI and histopathological diagnosis for sellar and juxtasellar tumors. MRI is the modality of choice for characterizing sellar and suprasellar lesions.
Keywords: Correlation, histopathology, magnetic resonance imaging, sellar and juxtasellar tumors
|How to cite this article:|
Hui P, Parida S, Mohanty J, Singh M, Sarangi PK. Accuracy of magnetic resonance imaging in evaluation of sellar and juxtasellar tumors. Oncol J India 2019;3:3-9
|How to cite this URL:|
Hui P, Parida S, Mohanty J, Singh M, Sarangi PK. Accuracy of magnetic resonance imaging in evaluation of sellar and juxtasellar tumors. Oncol J India [serial online] 2019 [cited 2019 May 19];3:3-9. Available from: http://www.ojionline.org/text.asp?2019/3/1/3/257614
| Introduction|| |
The sellar and juxtasellar regions are anatomically complex areas in the skull base with a variety of neoplastic and nonneoplastic lesions occurring in this confined space and require a combination of endocrinologic, ophthalmologic, and neurologic examinations along with advanced neuroimaging modalities. Neoplasia, granulomatous and inflammatory lesions, infections including bacterial abscesses, and developmental and vascular diseases are the different types of possible lesions. Neoplastic lesions can be benign or malignant such as pituitary adenomas, cystic lesions, germ cell tumors, gliomas, lymphomas, meningiomas, and metastatic tumors. Symptoms of presentation for these masses vary and depend on the involvement of specific anatomical landmarks. Manifestations due to endocrine dysfunction or mass effect with compressive symptoms such as headache or visual symptoms are the different types of clinical presentation.
Extensive knowledge on sellar and parasellar anatomies along with the use and interpretation of various imaging modalities are necessary to reach the correct diagnosis of sellar and parasellar lesions and to offer the appropriate therapeutic approach including surgery, radiotherapy, and primary or adjuvant medical treatment including replacement of endocrine deficits. Certain imaging findings for these lesions may provide important information to determine the use of surgical versus nonsurgical techniques and the extent of resection. Magnetic resonance imaging (MRI) is the gold standard imaging modality to characterize such lesions due to superior soft-tissue contrast differentiation, availability of advanced sequences offering high spatial resolution, and nonexistence of ionizing radiation, thus allowing accurate visualization of mass effects on neighboring soft tissues.,, However, there is a lack of large population-based study regarding the use of MRI as a diagnostic tool for sellar masses.
With this above background, the present study was conducted to evaluate the MRI imaging findings in sellar and juxtasellar tumors which were correlated with histopathology to find out the diagnostic accuracy of MRI.
| Materials and Methods|| |
This study was retrospective in nature and was conducted over a period of 2 years from September 2015 to August 2017 in SCB Medical College and Hospital, a tertiary care institute of eastern zone of India. We included patients with sellar and juxtasellar lesions who were operated during the study period. The patients with previously treated sellar and juxtasellar tumors and with second primary were excluded from the study.
The patients' demographic data, preoperative MRI reports, and final histopathological reports were retrieved from the hospital record. MRI was performed in GE Signa HDxt 1.5T scanner with standard MRI protocol for pituitary imaging. Different MRI features in terms of T1 and T2 signal characteristics (iso/hypo/hyperintensity), consistency, enhancement, and involvement of adjacent structures were noted in the structured format. The consistency of different lesions was categorized into solid, cystic, and mixed. The enhancement of lesions was categorized into homogenous, heterogeneous, and rim. Preoperative radiological diagnoses were performed on the basis of the above MRI findings. Histopathological reports were compared with these MRI diagnoses retrospectively, and conclusions were drawn with regard to the accuracy of MRI in evaluating sellar, suprasellar, and parasellar tumors. Sensitivity, specificity, and diagnostic accuracy of MRI were calculated.
Statistical analysis was performed using IBM SPSS software version 20 (Chicago, IL, USA).
| Results|| |
The findings of the fifty patients were compiled and analyzed. Majority of the patients (58%) belonged to the age group of 20–49 years with a mean age of presentation of 34.6 years. There was a female predominance with a male-to-female ratio of 1:1.17. Most of the patients involved both sellar and suprasellar regions consisting of 74%, whereas 22% of patients involved only parasellar area and 4% of patients involved only sellar area. Pituitary macroadenomas, craniopharyngioma, and meningioma were the major constituents for the study consisting of 42%, 32%, and 18% of the cases, respectively, followed by epidermoid (4%), germinoma (2%), and chiasmatic-hypothalamic glioma (2%).
Headache and visual defects were the common presentations constituting 78% and 76% of cases, respectively, followed by amenorrhea (14%), galactorrhea (2%), acromegaly (2%), and others which include seizures, vomiting, and hemiparesis [Table 1].
Majority of the macroadenoma cases (71.43%) and all the meningioma cases were homogeneous in enhancement, whereas 62.5% of craniopharyngioma cases were heterogeneous in enhancement. Majority of the macroadenoma cases were isointense (85.71%) on T1 signal and all the cases were hyperintense on T2 signal, whereas for meningioma, all the cases were isointense on T1W and 88.89% were isointense on T2 signals. For craniopharyngioma, 62.5% of cases were hypointense on T1W signal and 87.5% of cases were hyperintense on T2W signal. Most of the macroadenoma cases (85.71%) and all the meningioma cases were solid in consistency, whereas 68.75% of craniopharyngioma cases were mixed solid-cystic in consistency [Table 2].
The involvement of adjacent structures is highlighted in [Table 3]. Optic chiasma was stretched in 57.14% and 68.75% of macroadenoma and craniopharyngioma cases, respectively. Infundibulum involvement was commonly seen in 85.71% of macroadenoma cases. The third ventricle compression was seen in all the epidermoid cysts, germinomas and glioma, and most of the craniopharyngioma cases (68.75%). Sellar widening and bony erosion were exclusively seen in macroadenoma cases consisting of 85.71% and 14.29% of cases, respectively, whereas calcification was seen in most of the craniopharyngioma cases (43.75%).
In our study, MRI correctly diagnosed 47 cases (94%) correlating well with histopathology [Table 4]. Results of MRI-based diagnosis as true or false positive and true or false negative are mentioned in [Table 5].
|Table 5: Results of magnetic resonance imaging-based diagnosis as true or false positive and true or false negative|
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Pituitary macroadenoma was the most common finding and 21 cases (42%) were MRI-based diagnosis. However, after histopathological analysis, one case of 30-year-old male with MRI feature of a solid lesion at sellar/suprasellar location with sellar widening taking up inhomogeneous contrast enhancement having isointense on T1 signal and hyperintense on T2 signal and no calcification turned out to be craniopharyngioma.
The second most common tumor was craniopharyngioma, and 15 cases (30%) were MRI-based diagnosis. However, one case of 32-year-old male with MRI feature of a heterogeneously enhanced solid-cystic sellar and suprasellar mass having a major solid part and few areas of calcifications without any sellar widening or erosion, isointense on T1 signal, and hyperintense on T2 signal turned out to be macroadenoma on histopathological analysis.
Out of two suspected germinoma cases on MRI basis, one case showed germinoma on histopathological examination. Another one case of 29-year-old female with MRI features of a predominantly solid lesion with a small cystic component in a suprasellar location and with central calcifications taking up inhomogeneous enhancement, hypointense on T1 signal, and hyperintense on T2 signal turned out to be craniopharyngioma.
After histopathological correlation, MRI imaging for pituitary adenoma, craniopharyngioma, and germinoma showed 94.12%, 94%, and 98% of diagnostic accuracy, respectively. All the meningioma cases (9 out of 9 cases), epidermoid cysts (2 out of 2 cases), and glioma (1 out of 1 case) had 100% accuracy for the MRI diagnosis when finally correlated with histopathological examination [Table 6].
|Table 6: Sensitivity, specificity, and accuracy of magnetic resonance imaging-based diagnosis|
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| Discussion|| |
Computed tomography maintains a role in delineating osseous erosion and characterizes calcified tumor matrices. However, MRI is the mainstay in the neuroimaging assessment of most pathology occurring at the skull base because of high soft-tissue contrast, multiplanar capability, tissue characterization (lipids, paramagnetic and diamagnetic elements, and tissue cellularity) ability to detect hemorrhage, necrosis, solid or cystic components within the tumor, absence of bone artifacts, and not having the hazards of radiation. Thus, this study was undertaken to determine the distribution, morphology, and tissue character of pathologies of the sellar and juxtasellar regions and correlation of the MRI findings with histopathological examination to know the efficacy of MRI.
In our study, majority of the cases (58%) were encountered in the age group of 20–49 years, and the mean age of presentation was 34.6 years. There was a female predominance with a male-to-female ratio of 1:1.17. Our data were supported by Ogbole et al. and Batra et al., Ogbole et al. found the modal age group of 40–49 years with a mean age of 39.94 years (±16.65 years) and male-to-female ratio of 1:1.30. Batra et al. encountered a maximum number of cases in the age group of 21–40 years and a female predominance (60%).
Sellar and suprasellar lesions are basically divided into pituitary lesions and nonpituitary/nonadenomatous lesions with the pituitary adenomas being the most common accounting for 90% of the cases., Pituitary tumors/adenomas represent 10%–15% of all intracranial masses. Nowadays, the incidence of nonadenomatous lesions is increasing possibly due to the screening of masses based on imaging parameters, rather than a pathological diagnosis or due to the reporting of miscellaneous masses including empty sella syndrome and ectopic pituitary tissue, which are diagnosed only by imaging and would not have been identified in a surgical or pathological series. We found pituitary adenoma as the most common lesion consisting 42% of cases, followed by craniopharyngioma (32%), meningioma (18%), epidermoid cysts (4%), germinoma (2%), and chiasmatic-hypothalamic glioma (2%). Furthermore, Tosaka et al. reported 44.90%, 22.45%, 16.33%, 8.16%, and 8.16% of patients with pituitary adenomas, craniopharyngiomas, chordoma, meningioma, and Rathke's cleft cyst, respectively. Ogbole et al. reported 58.06% of the sellar and parasellar lesions as pituitary adenomas and rest were parasellar meningiomas, craniopharyngiomas, and giant aneurysms.
Dedicated pituitary MRI is the gold standard imaging modality for diagnostic evaluation of sellar and parasellar tumors. Both Rathke's cleft cysts and craniopharyngiomas are derived from Rathke's cleft remnants. However, MRI usually shows homogenous hyperintense T1 signal intensity and midline anterior infundibular displacement in Rathke's cleft cysts and the presence of prominent cystic components and heterogeneous hyperintense T1 signal intensity in craniopharyngiomas.,
Lesions confined to the pituitary gland particularly small size may be asymptomatic. Functioning adenomas may present with signs and symptoms of endocrine dysfunction due to excess or reduced production of one or several anterior pituitary hormones, particularly in younger patients. Large lesions may result in signs and symptoms of mass effects, particularly raised intracranial pressure, and headache is the most common manifestation. Headache (78%), followed by visual disturbances (76%), is the most common symptom in our study, and other complaints are hormonal imbalance leading to amenorrhea, galactorrhea, and acromegaly and mass effect causing seizures, hemiparesis, and vomiting. These findings are similar to the study done by Famini et al. which reported headache and visual deficits to be the most common presentations. They found a higher rate of headache occurrence for nonadenomatous lesions than both nonfunctioning and functioning adenomas (P < 0.001). Hyperprolactinemia, increased growth hormone production, and diabetes insipidus were noted less frequently. However, we found headache occurrence little more in pituitary adenoma cases than nonadenomatous lesions possibly due to majority of the pituitary adenoma cases involving both the sellar and juxtasellar areas. We found one case with diabetes insipidus.
Distortion and compression of the pituitary stalk and/or hypothalamus result in an increase in serum prolactin which is the only endocrine abnormality in patients with large nonfunctioning adenoma. Features of pituitary apoplexy may occur, i.e., involvement of pituitary stalk, optic chiasma, having infarction and presentation of sudden visual loss, and acute severe headache. MRI is useful in detecting hemorrhagic infarction in such cases. Sellar lesions with large temporal lobe extensions may be associated with partial complex seizures, and we found seizures in two cases with extensive lesions involving the temporal lobe. Cranial nerve palsies may occasionally occur due to large expanding sellar mass.
Among all the macroadenoma cases, two cases were purely sellar and rest 19 cases showed a combination of suprasellar and parasellar extensions. Macroadenomas are usually isointense relative to gray matter on T1-weighted image and may be hypointense relative to the normal pituitary gland but with variable T2-weighted appearance. High signal intensity on T1-weighted images may be seen due to the presence of hemorrhage or necrosis accompanying pituitary adenoma. We found that majority of the pituitary adenomas were isointense to gray matter (85.71%), followed by hypointense (14.29% of cases) on T1-weighted images, and all the 21 cases were T2 hyperintense. Nearly 71.43% of cases showed homogeneous enhancement [Figure 1] and 85.71% of cases were solid in consistency. We did not find any cases with high signal intensity on T1-weighted images. The presence of cystic or necrotic areas could result in inhomogeneous or rim enhancement. We found that one case turned out to be craniopharyngioma after histopathological examination showing 94.12% accuracy, 95.24% sensitivity, and 93.33% specificity of MRI in diagnosing. Batra et al. found that 60 out of 68 MRI-based pituitary adenomas turned out as similar diagnosis and rest 8 cases with wrong MRI diagnosis showing 86% accuracy, 88% sensitivity, and 83% specificity in diagnosing macroadenoma.
|Figure 1: T1C + sagittal image showing homogeneous enhancement and sellar widening of pituitary macroadenoma with snowman appearance|
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It is important to determine whether the invasion of cavernous sinus has occurred because this makes complete surgical removal of the tumor impossible and these cases are aimed for radiation therapy. On MRI, the most reliable sign of cavernous sinus invasion is tumor encasing the unilateral carotid artery. In our study in about 42.86% of the cases, internal carotid artery (ICA) encasement is noted which is supported by Johnsen et al. where it was 43%.
Majority of the craniopharyngioma cases have peak age of occurrence at 5–14 years, followed by 50–74 years' age group, and have equal sex distribution supporting our findings. Craniopharyngiomas are predominantly suprasellar in location with sellar and parasellar extensions, and a pure interstellar lesion is rare as in our study. We did not find any pure sellar craniopharyngioma. Craniopharyngiomas are usually hypointense on T1-weighted images and exhibit inhomogeneous high intensity on T2-weighted images., On MRI, most of the cases (68.75%) showed solid-cystic in consistency. Majority were hypointense (62.5%), followed by isointense on T1-weighted images, and 87.5% of cases were hyperintense and 2 cases were hypointense on T2-weighted images. Our data were correlated with the study by Johnsen et al. where 60% of cases were mixed solid-cystic lesions. Most of the craniopharyngiomas showed heterogeneous enhancement (62.5%) with rim enhancement of the cystic components on postcontrast study and were supported by the study of Batra et al. where cystic component showed peripheral enhancement and solid portion showed heterogeneous enhancement.
In our study, 1 out of 15 MRI cases of craniopharyngiomas finally turned out as pituitary adenoma on histopathological examination of the operated specimen showing 94% accuracy, 87.50% sensitivity, and 97.06% specificity of MRI in diagnosing craniopharyngioma. Our data were supported by Batra et al., where 24 out of 28 MRI-based craniopharyngiomas turned out as similar diagnosis and rest 4 cases with wrong MRI diagnosis showing 93% accuracy, 85% sensitivity, and 95% specificity in diagnosing craniopharyngioma.
Most of the meningiomas (88.89%) belonged to the age group of 40–49 years with a female preponderance (male-to-female ratio: 1:8). Johanson et al. found that 71.43% of meningiomas occurred in women with an average age of 64 years. Majority of the cases showed a combination of suprasellar and parasellar extensions with few extending into sella. Meningiomas typically show isointensity on T1- and T2-weighted sequences with characteristic homogeneous enhancement., In sellar meningiomas, majority of the cases are isointense on T1- and T2-weighted images, whereas macroadenoma though typically isointense on T1-weighted images are less often isointense on T2-weighted images. We found, 88.89% of cases of meningioma showing isointensity on T2-weighted images and all showing isointensity on T1-weighted images supporting the literature. Furthermore, a study by Batra et al. found that 85% of the cases showed isointensity on both T1- and T2-weighted images. We found all the cases of meningiomas having solid consistency and showed marked, uniform enhancement [Figure 2]. One of our cases showed calcifications which were responsible for the hypointensity noted in T2-weighted images supported by Johnsen et al. Meningiomas were seen to encase ICA in about 33% of the cases. However, they caused luminal narrowing of the ICA when cavernous sinus invasion was present, unlike macroadenomas where luminal narrowing of the vessels was not noticed. This is similar to the study done by Young et al. All the cases diagnosed to be meningiomas by MRI were confirmed by a histopathological study showing 100% accuracy of MRI diagnosis for meningioma. According to Batra et al., out of 20 radiologically diagnosed meningiomas, 16 cases on histopathologically turned out to be the same showing 93% accuracy, 80% sensitivity, and 95% specificity of MRI in diagnosing meningioma.
|Figure 2: T1 C + sagittal section showing homogeneous enhancement of meningioma|
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Cerebellopontine angle is the most common site of occurrence for epidermoid cysts, followed by parasellar region. MRI of epidermoid cysts shows isointense to slightly hyperintense relative to cerebrospinal fluid on T1- and T2-weighted MRI sequences without postcontrast enhancement, whereas macroadenoma shows postcontrast enhancement. Radiologically, our both the lesions showed low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. The presence of restricted diffusion on diffusion-weighted images is the hallmark feature of epidermoids distinguishing from other cystic tumors, which does not show any restriction such as arachnoid cyst., Both the cases showed diffusion restriction on diffusion-weighted images, which is consistent with the study of Chen et al. The MR images in both the cases correlated well with the histopathological results showing 100% accuracy for the MRI diagnosis.
Germinomas are most commonly found in the pineal and suprasellar regions. MRI shows nonspecific hypointense T1 signal and isointense to hyperintense T2 signal with cystic changes and homogeneous or heterogeneous enhancement. Suprasellar germinomas may mimic a pituitary macroadenoma because of their common MRI signal characteristics, but a more posteriorly positioned mass with a separate and/or anteriorly displaced pituitary gland suggests the possibility of a nonadenomatous lesion. Preoperative imaging is important to diagnose germinoma as radiation therapy effectively treats 90% of these lesions., Two of our cases radiologically suspected as germinoma and belonged to the age group of 10–19 years. One case showed isointensity on both T1- and T2-weighted images with solid consistency which took up homogeneous contrast enhancement. The other case showed mixed consistency with hypointensity on T1 and heterogeneous hyperintensity on T2-weighted images with inhomogeneous contrast enhancement. Central calcification was also noted. Our finding was supported by Abele et al. The first one case turned out to be same diagnosis and the second one case turned out to be as craniopharyngioma after histopathological examination of the operated sample showing MR diagnosis with 98% accuracy, 100% sensitivity, and 97.96% specificity.
Chiasmatic-hypothalamic gliomas are usually low-grade gliomas and may contain cystic areas. On MRI, lesions are hypointense to isointense on T1- and hyperintense on T2-weighted images. We found one case of chiasmatic-hypothalamic glioma with suprasellar location. The lesion was isointense on T1- and hyperintense on T2-weighted images with solid in consistency taking up predominantly homogeneous contrast enhancement which was supported by Johnsen et al. MRI findings correlated well with the final histological result.
Cases misdiagnosed by magnetic resonance imaging
In our study, 3 out of 50 cases were diagnosed wrongly by MRI and confirmed as different tumors after histopathological examination. Out of 21 MRI-based macroadenomas, one case with MRI showing a solid mass lesion and sellar widening taking up inhomogeneous contrast enhancement turned out to be craniopharyngioma. However, it should be kept in mind that sellar widening is observed in about 65% of craniopharyngioma as in this case. Out of 15 MRI-based craniopharyngiomas, one case turned out to be macroadenoma in which MRI revealed a sellar suprasellar mass with a solid-cystic consistency with a major solid part and few areas of calcifications without any sellar widening or erosion. Hence, it is important to keep in mind that not all cases of macroadenoma show sellar widening/erosions. Although rare, calcifications can be seen in macroadenomas. Out of two MRI-based germinomas, one case turned out to be craniopharyngioma having a predominantly solid lesion with small cystic component in a suprasellar location with central calcifications. It took up inhomogeneous enhancement and lacked a predominant cystic part or curvilinear/eggshell type of calcifications commonly seen in craniopharyngioma.
The overlapping clinical and imaging features of these lesions can cause confusion in arriving at a diagnosis. However, advanced MRI tools such as three-dimensional volumetric analysis of pituitary volume, high-resolution MRI at 3 Tesla, perfusion-weighted imaging, MR spectroscopy, magnetization transfer ratio, and intraoperative MRI can be of help to overcome this issue., Intraoperative MRI during pituitary surgery has better visualization of intra- and parasellar anatomy facilitating complete resection of the tumor.
| Conclusions|| |
Precise preoperative MRI and the knowledge of key differentiating characteristics in common and uncommon diseases of the sellar and juxtasellar regions, in conjunction with the clinical findings, help in deciding the appropriate path of management. Hence, MRI can be considered as the modality of choice for diagnosing sellar, suprasellar, and parasellar lesions with high accuracy, sensitivity, and specificity.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]