Functioning Pituitary Adenoma with Xanthogranulomatous Features: Review of Literature and Case Report

Abstract

Objectives We present a patient with a prolactin-secreting adenoma with extensive secondary, noninfectious, xanthogranulomatous changes due to remote intratumoral bleeding and provide a literature review of xanthogranulomas (XGs) of the sellar region with emphasis on prolactinomas with xanthogranulomatous features. Design Case report, with PubMed search of cases of sellar XG, focusing on neuroimaging and surgical approach. Results A 35-year-old male was found to have a large sellar/suprasellar calcified/cystic mass. Endoscopic transsphenoidal approach for extradural resection was performed and diagnosis made. Review generated 31 patients with the diagnosis of sellar XG. In a minority (6 patients), the underlying lesion for the XG was a pituitary adenoma. Headache was the most common presenting symptom and panhypopituitarism the most common endocrinological abnormality. Examples of hyperprolactinemia associated with sellar XG are also uncommon and due to stalk effect. Neuroimaging of XG on T1-weighted magnetic resonance imaging (MRIs) showed 18 cases (56.3%) were hyperintense, 1 case (3.13%) was isointense, 4 (12.5%) had mixed-signal intensity, and 2 (6.25%) were hypointense. On T2-weighted MRIs, five lesions (15.6%) were hyperintense, three (9.38%) were isointense, nine (28.1%) were heterogeneous, and nine (28.1%) were hypointense. Only one case (3.1%) had calcifications on computed tomography scan similar to ours. In 14 cases (43.7%), the lesions enhanced with contrast administration on MRI. Conclusion Prolactinomas with secondary xanthogranulomatous change represent a rare cause of XG of the sella. With no radiological or clinical signs specific for XG of the sellar region, preoperative diagnosis can be challenging, if not impossible.

Keywords: craniopharyngioma; endoscopic transphenoidal; pituitary adenoma; prolactinoma; xanthogranuloma.

Fig. 1

Preoperative T1 contrasted magnetic resonance imagings showing mixed signal intensity with expansion of the sella and caudal displacement of the optic chiasm. ( A ) Coronal view. ( B ) Sagittal view. Preoperative computed tomography scan of the head showing calcifications of the cyst wall. ( C ) Coronal view. ( D ) Sagittal view.

Fig. 2

Intraoperative endoscopic view of the sellar lesion. ( A ) Incision of the capsule. ( B ) Inside view. ( C ) Bimanual dissection of the anterior capsule. ( D ) Dissection of the lateral capsule.

Fig. 3

Postoperative T1 contrasted magnetic resonance imagings showing tumor resection with empty tumor cavity and decompression of mass effect to the parasellar structures. ( A ) Coronal view. ( B ) Sagittal view.

Fig. 4

Pathological slides showing ( A ) cholesterol clefts, multinucleated giant cells fibrosis organizing hemorrhage; ( B ) metaplastic bone (arrowhead), and very scant residual monomorphic adenoma at the periphery of the mass (arrow). The latter was estimated to compose <15% of the overall volume of resected materials; ( C ) extensive golden-brown hemosiderin pigment and cholesterol clefts attested to hemorrhage, likely repeated, as the cause of the xanthogranuloma component; ( D ) the residual adenoma was strongly and diffusely immunoreactive for prolactin in the typical Golgi pattern of the common sparsely granulated lactotroph adenoma (lower right).