Sphenoethmoidal bone hyperostosis due to invasive pituitary adenoma

Ravindra B Kamble; Ravi Mohan Rao; N Diwakar; M Sanjeev

doi:10.4103/1115-1474.146152

CASE REPORT

Year : 2015 | Volume : 22 | Issue : 1 | Page : 45-47

Sphenoethmoidal bone hyperostosis due to invasive pituitary adenoma

Ravindra B Kamble¹, Ravi Mohan Rao², N Diwakar¹, M Sanjeev¹
¹ Department of Radiology, Vikram Hospital, Millers Road, Bangalore, Karnataka, India
² Department of Neurosurgery, Vikram Hospital, Millers Road, Bangalore, Karnataka, India

Date of Web Publication

3-Dec-2014

Correspondence Address:
Dr. Ravindra B Kamble
Department of Radiology, Vikram Hospital, Millers Road, Bangalore - 560 052, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1115-1474.146152

Abstract

Hyperostosis of skull base can be observed in tumorous lesions like meningioma or primary bone tumors. Rarely few non-meningiomatous lesions can also cause skull base hyperostosis. We present an interesting case of skull base hyperostosis due to invasive pituitary adenoma with invasion into surrounding structures.

Keywords: Computed tomography; magnetic resonance imaging; pituitary adenoma; skull base hyperostosis

How to cite this article:
Kamble RB, Rao RM, Diwakar N, Sanjeev M. Sphenoethmoidal bone hyperostosis due to invasive pituitary adenoma. West Afr J Radiol 2015;22:45-7

How to cite this URL:
Kamble RB, Rao RM, Diwakar N, Sanjeev M. Sphenoethmoidal bone hyperostosis due to invasive pituitary adenoma. West Afr J Radiol [serial online] 2015 [cited 2023 Jun 3];22:45-7. Available from: https://www.wajradiology.org/text.asp?2015/22/1/45/146152

Introduction

Pituitary adenomas are slow-growing benign tumors and usually confined within the capsule. However, when these tumors invade the capsule and spread into contiguous surrounding structures like cavernous sinus, dura matter, skull base bones and sphenoid sinus then it is termed as invasive pituitary adenoma. ^[1] Approximately 35% of all pituitary neoplasms are invasive pituitary adenoma. ^[2] Juxtasellar hyperostosis of bone is commonly associated with meningioma, however non-meningiomatous tumors like invasive pituitary adenoma, primary bone tumors like chondroblastoma and craniopharyngioma can also cause hyperostosis. ^[3] Of these tumors, invasive pituitary adenoma is a rare cause of skull base hyperostosis and very few case reports are described in the literature. ^[3],[4],[5] We present similar case of invasive pituitary adenoma with large sellar, suprasellar and parasellar extension with invasion into orbit and sphenoid sinus associated with hyperostosis of the sphenoid and ethmoid bones bilaterally.

Case History

A 39-year-old male patient who presented with history of decreased sensation of smell with proptosis of the right eye, associated with blurring of vision for three months. On examination complete loss of smell sensation was noted in the right nostril and decreased in the left. There was proptosis of the right eye with minimal congestion. Visual acuity was normal in both eyes. Routine blood investigations were normal. Routine MRI (1.5T MAGNETOM AVANTO SIEMENS GERMANY MUENCHEN) was done with multiplanar T1W (TR-675, TE-9 and matrix 512X408) and T2W (TR-5170, TE-116 and matrix-384X312) of brain involving pituitary fossa and orbits. Both pre and post contrast (Gadobenate dimeglumine, Multihance Bracco) images were acquired. MRI of brain revealed large mass lesion in sella which was T1 isointense and T2 slightly hypointense and extending into suprasellar, bilateral parasellar, retrosellar region, bilateral sphenoid and ethmoid sinuses and into the right orbit through superior orbital fissure. Post contrast the lesion showed moderate contrast enhancement. The sphenoid and ethmoid bones were hypointense on T1 and T2 with minimal contrast enhancement suggesting hyperostosis with invasion [Figure 1]. CT scan (SOMATOM SENSATION 64 SLICE SIEMENS GERMANY MUENCHEN) of brain revealed mass lesion in sella with extensions into parasellar, suprasellar region involving right orbit and ethmoid and sphenoid sinuses. In addition hyperostosis of both ethmoid and sphenoid bones including clivus was noted [Figure 2]. The patient was subsequently operated and histopathological diagnosis was "non-functioning invasive pituitary adenoma" [Figure 3]. His endocrinological workup was not done except for serum prolactin levels (18.16 ng/ml).

Figure 1: T2W coronal images in (a) and post contrast T1W images in (b) showing tumor extensions in bilateral cavernous sinus, along cribriform plate and right orbit. T1W post contrast sagittal image in (c) shows inferior extension of tumor into sinuses

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Figure 2: CT scan axial (a) and coronal (b) bone window images showing hyperostosis of bilateral ethmoid and sphenoid bones

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Figure 3: H and E stain showing pituitary adenoma infiltrating orbital muscle

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Discussion

Approximately 35% of all pituitary tumors can be invasive pituitary adenoma which by definition invades its capsule and surrounding structures. ^[1],[2] However, invasive pituitary adenomas are not synonymous to pituitary carcinomas. Local invasion is seen in invasive adenomas and distant metastasis is the hallmark of pituitary carcinomas. Pituitary carcinomas however contribute to only 0.1% to 0.2% of pituitary tumors. Nevertheless, both cannot be differentiated by histopathology alone. ^[6],[7]

There are few case reports of invasive pituitary adenomas invading sphenoid sinus and nasal cavity, ^[8] orbit ^[9] and nasopharyx. ^[10] However, the present case showed extensive local spread of the tumor. The pituitary tumor was seen extending anteriorly along the planum sphenoidale, cribriform plate and right orbit. Laterally it was invading cavernous sinus and posteriorly extending into prepontine cistern. Optic chiasm was compressed due to suprasellar extension of the tumor. Bilateral sphenoid and ethmoid sinuses were seen invaded by the tumor with extension into nasal cavity. There was associated hyperostosis of clivus and bilateral ethmoid and sphenoid bones.

Association of skull base hyperostosis with invasive pituitary adenoma is extremely rare and to our knowledge very few case reports have described it. ^[3],[4],[5] Meningioma is the most common sellar and parasellar tumor associated with skull base hyperostosis that causes expansion and blistering of the involved bone. Other tumors that cause similar bony changes are chondroblastoma, craniopharyngioma, epidermoidoma of the orbit without blistering and expansion of the involved bone. ^[3] Fibrous dysplasia is another important differential for skull base hyperostosis which is also known to frequently involve the ethmoid and the sphenoid bones. Cystic aneurysmal bony changes in fibrous dysplasia can sometimes mimic malignant transformation with associated soft tissue component and surrounding invasion; although malignant transformation of fibrous dysplasia is rare. ^[11] The hyperostosis of the bones is possibly due to tumor infiltration which on contrast study shows enhancement supporting the theory of bony infiltration and is well documented in earlier reports of meningiomatous bony infiltration. ^[12] Thus, similar pathology can be a possible explanation for the cause of hyperostosis in invasive pituitary adenomas.

In conclusion, invasive pituitary adenoma should be considered in differential diagnosis of sellar and parasellar mass lesions with associated skull base hyperostosis.

Acknowledgment

We acknowledge staff of Ophthalmology department and department of pathologyVikram hospital, Bangalore

References

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