Calcification in a chromophobe adenoma Case report
A. ALAN CHAMBERS, M.D., ROBERT LUKIN, M.D., AND NAKOTO TSUNEKAWA, M.D. Departments of Radiology and Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio v, A patient with a densely calcified chromophobe adenoma is reported. Considerable hemorrhage and fibrosis were present in the tumor and may have been responsible for the extensive calcification. KEY WORDS 9 pituitary neoplasm chromophobe adenoma calcification
HE incidence of chromophobe adenoma calcification varies among series in the literature. Camp 1 reported a 4% incidence of calcified chromophobe adenomas, whereas M~iller and Hoffmann6 found only one radiologically-confirmed calcified chromophobe adenoma in a series of 408 cases. They noted 30 histologically-proven calcified adenomas, but calcification in all but one was too sparse to be seen on x-ray film. Tumor calcification about the pituitary fossa usually suggests a craniopharyngioma. Extensive calcification can be seen with chordomas, chondromas, and meningiomas? Aneurysms usually have a characteristic curvilinear calcification, yet craniopharyngiomas and rarely chromophobe adenomas may also exhibit curvilinear capsular calcifications? ,5 The following report describes an extensively calcified chromophobe adenoma associated with hemorrhage into the tumor.
T
J. Neurosurg. / Volume 44 / May, 1976
9 sella turcica
9
Case Report This 59-year-old man was admitted to the Psychiatric Service of the Cincinnati Veterans Administration Hospital on April 21, 1974. A diagnosis of schizophrenia had been made 12 years earlier at another psychiatric institution and for the ensuing period, the patient had been totally secluded with virtually no outside contact. For 1 week prior to admission, he fell frequently and manifested more bizarre behavior than usual. A review of his past history was difficult to obtain, but he did admit to having periodic vague headaches, unassociated with nausea, vomiting, convulsions, or visual difficulties. Early in his marriage of 26 years, his wife had had a miscarriage, and shortly thereafter the patient had totally lost interest in sexual intercourse. He shaved only once a week during the course of his entire adult life. A further review of the endocrine and neurological 623
A. A. Chambers, R. Lukin and N. Tsunekawa
F~. l. Left: Anteroposterior skull film shows extensive suprasellar calcification. Right: Lateral view shows extensive sellar and suprasellar calcification.
TABLE 1 Endocrinological studies* Serum
Our Patient
8:00 AM plasma cortisol 10, 11.2 (ug/100 ml) thyroid-stimulatinghormone 1.55 (/~U/ml) thyroxine(vg/100 ml) 8.1 androgens (ng/100 ml) 0.14 androgen binding(~) 58 folliclestimulatinghormone 2 (mlU/ml) luteinizinghormone (mlU/ml) 4.2 prolactin (ng/ml) 100
Normal Range 17-25 2-8 3.8-10.6 0.53-1.35 34-69 12-35 22-52 7-12
* Provocative testing with L-dopa 0.5 gm orally after pretreatment by stilbestrol for 2 days showed a paradoxicalrise in prolactin levels. systems was unobtainable due to the patient's mental confusion. Examination. The patient was a normally developed and well-nourished man. Although he was somewhat uncooperative, he was alert and oriented to time, place, and person. He responded poorly to questions with only a few words. His voice was somewhat low and speech was slow. He drooled constantly. Vital signs were normal. The skin had the "fawn" appearance suggestive of pituitary myxedema or androgen deficiency. The face and hands were puffy with fine wrinkling of the skin. Eye examination revealed normal ocular movement with constriction of the right pupil, 624
which dilated paradoxically when the light was focused on the left eye. Visual fields were unobtainable because of lack of cooperation, but right visual acuity was obviously markedly decreased on gross confrontation. On funduscopic examination, there appeared to be cupping of discs bilaterally with probable temporal pallor on the right. Axillary hair was absent and pubic hair was very scant. The testes were very small and soft. The remainder of the neurological examination was not remarkable. The patient's white blood cell count was 8000 with a normal differential; red blood cell count, 4,670,000/cu mm; hemoglobin, 12 gm/100 ml; hematocrit, 36.7%. Chemistry tests were normal. Serum tests were as follows: sodium, 141 mEq/l; potassium, 3.8 mEq/l; chloride, 102 mEq/l; CO2, 28 mM/1. Endocrine studies are outlined in Table 1. Skull films showed extensive sellar and suprasellar calcification (Fig. 1). Tomograms demonstrated destruction of the sella and clivus, and angiograms showed stretching and elevation of the anterior and middle cerebral arteries. Operation. Through a right frontotemporal craniotomy a mass that looked like a hematoma was exposed in the suprasellar region; 5 cc of dark brown material was aspirated from a presellar cystic component of the tumor. The remainder of the tumor was friable and hemorrhagic. Because it was wrapped around the optic chiasm, the tumor J. Neurosurg. / Volume 44 / May, 1976
C a l c i f i c a t i o n in a c h r o m o p h o b e
adenoma calcifications (calcospherites) replaced almost the entire chromophobe adenoma in cases reported by Russell and Rubinstein, 7 and by Hastrup; 4 these could be seen on the x-ray films. Other types of calcification occur in colloid material or mucopolysaccharides, but are usually not visible on x-ray films? A fourth suggested mechanism involves calcification within a hematoma. Although we are unable to find a similar case in the literature, we believe the extensive calcification in this case was secondary to the hemorrhage and fibrosis.
References
FIG. 2. Histological section shows typical chromophobe adenoma with hemorrhage. Two large dark areas of dystrophic calcification were characteristic of calcifications seen throughout the histological sections. H & E, • 400.
was biopsied; complete excision was not attempted. Histological Study. Abundant chromophobe adenoma cells were identified in the biopsy specimen. Hemorrhage with fibrosis and calcification was intermixed with these typical chromophobe cells (Fig. 2). Postoperative Course. The patient recovered uneventfully from the operation and replacement therapy was reinstituted. A total of 4000 rads of external irradiation was given after his condition became stable. The patient did not show significant changes after this treatment. He was placed in a nursing home and died for unclear reasons several months later. No autopsy was permitted. Discussion
Four types of calcification in the pituitary have been reported. Concentrically laminated
J. Neurosurg. / Volume 44 / May, 1976
1. Camp JD: Significance of intracranial calcification in the roentgenologic diagnosis of intracranial neoplasms. Radiology 55:659-667, 1950 2. du Boulay GH, Trickey SE: Calcification in chromophobe adenoma. Case report. Br J Radiol 35:793-795, 1962 3. Falconer MA, Bailey K, Duchen LW: Surgical treatment of chordoma and chondroma of the skull base. J Neurosurg 29:261-275, 1968 4. Hastrup J: Chromophobe adenoma of the pituitary with extensive calcifications. Acta Neuropathol 6:98-100, 1966 5. Lindgren E, DiChiro G: Suprasellar tumours with calcification. Acta Radiol 36:173-195, 1951 6. Mfiller W, Hoffmann H: LJber Verkalkungen in Hypophysenadenomen. Zbl Neuroehir 28: 287-290, 1967 7. Russell DS, Rubinstein LJ: Pathology of "rumors of the Nervous System, ed 3. Baltimore: Williams & Wilkins, 1971
Address reprint requests to: A. Alan Chambers, M.D., Radiology Department, Cincinnati General Hospital, 234 Goodman Street, Cincinnati, Ohio 45267.
625
A. ALAN CHAMBERS, M.D., ROBERT LUKIN, M.D., AND NAKOTO TSUNEKAWA, M.D. Departments of Radiology and Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio v, A patient with a densely calcified chromophobe adenoma is reported. Considerable hemorrhage and fibrosis were present in the tumor and may have been responsible for the extensive calcification. KEY WORDS 9 pituitary neoplasm chromophobe adenoma calcification
HE incidence of chromophobe adenoma calcification varies among series in the literature. Camp 1 reported a 4% incidence of calcified chromophobe adenomas, whereas M~iller and Hoffmann6 found only one radiologically-confirmed calcified chromophobe adenoma in a series of 408 cases. They noted 30 histologically-proven calcified adenomas, but calcification in all but one was too sparse to be seen on x-ray film. Tumor calcification about the pituitary fossa usually suggests a craniopharyngioma. Extensive calcification can be seen with chordomas, chondromas, and meningiomas? Aneurysms usually have a characteristic curvilinear calcification, yet craniopharyngiomas and rarely chromophobe adenomas may also exhibit curvilinear capsular calcifications? ,5 The following report describes an extensively calcified chromophobe adenoma associated with hemorrhage into the tumor.
T
J. Neurosurg. / Volume 44 / May, 1976
9 sella turcica
9
Case Report This 59-year-old man was admitted to the Psychiatric Service of the Cincinnati Veterans Administration Hospital on April 21, 1974. A diagnosis of schizophrenia had been made 12 years earlier at another psychiatric institution and for the ensuing period, the patient had been totally secluded with virtually no outside contact. For 1 week prior to admission, he fell frequently and manifested more bizarre behavior than usual. A review of his past history was difficult to obtain, but he did admit to having periodic vague headaches, unassociated with nausea, vomiting, convulsions, or visual difficulties. Early in his marriage of 26 years, his wife had had a miscarriage, and shortly thereafter the patient had totally lost interest in sexual intercourse. He shaved only once a week during the course of his entire adult life. A further review of the endocrine and neurological 623
A. A. Chambers, R. Lukin and N. Tsunekawa
F~. l. Left: Anteroposterior skull film shows extensive suprasellar calcification. Right: Lateral view shows extensive sellar and suprasellar calcification.
TABLE 1 Endocrinological studies* Serum
Our Patient
8:00 AM plasma cortisol 10, 11.2 (ug/100 ml) thyroid-stimulatinghormone 1.55 (/~U/ml) thyroxine(vg/100 ml) 8.1 androgens (ng/100 ml) 0.14 androgen binding(~) 58 folliclestimulatinghormone 2 (mlU/ml) luteinizinghormone (mlU/ml) 4.2 prolactin (ng/ml) 100
Normal Range 17-25 2-8 3.8-10.6 0.53-1.35 34-69 12-35 22-52 7-12
* Provocative testing with L-dopa 0.5 gm orally after pretreatment by stilbestrol for 2 days showed a paradoxicalrise in prolactin levels. systems was unobtainable due to the patient's mental confusion. Examination. The patient was a normally developed and well-nourished man. Although he was somewhat uncooperative, he was alert and oriented to time, place, and person. He responded poorly to questions with only a few words. His voice was somewhat low and speech was slow. He drooled constantly. Vital signs were normal. The skin had the "fawn" appearance suggestive of pituitary myxedema or androgen deficiency. The face and hands were puffy with fine wrinkling of the skin. Eye examination revealed normal ocular movement with constriction of the right pupil, 624
which dilated paradoxically when the light was focused on the left eye. Visual fields were unobtainable because of lack of cooperation, but right visual acuity was obviously markedly decreased on gross confrontation. On funduscopic examination, there appeared to be cupping of discs bilaterally with probable temporal pallor on the right. Axillary hair was absent and pubic hair was very scant. The testes were very small and soft. The remainder of the neurological examination was not remarkable. The patient's white blood cell count was 8000 with a normal differential; red blood cell count, 4,670,000/cu mm; hemoglobin, 12 gm/100 ml; hematocrit, 36.7%. Chemistry tests were normal. Serum tests were as follows: sodium, 141 mEq/l; potassium, 3.8 mEq/l; chloride, 102 mEq/l; CO2, 28 mM/1. Endocrine studies are outlined in Table 1. Skull films showed extensive sellar and suprasellar calcification (Fig. 1). Tomograms demonstrated destruction of the sella and clivus, and angiograms showed stretching and elevation of the anterior and middle cerebral arteries. Operation. Through a right frontotemporal craniotomy a mass that looked like a hematoma was exposed in the suprasellar region; 5 cc of dark brown material was aspirated from a presellar cystic component of the tumor. The remainder of the tumor was friable and hemorrhagic. Because it was wrapped around the optic chiasm, the tumor J. Neurosurg. / Volume 44 / May, 1976
C a l c i f i c a t i o n in a c h r o m o p h o b e
adenoma calcifications (calcospherites) replaced almost the entire chromophobe adenoma in cases reported by Russell and Rubinstein, 7 and by Hastrup; 4 these could be seen on the x-ray films. Other types of calcification occur in colloid material or mucopolysaccharides, but are usually not visible on x-ray films? A fourth suggested mechanism involves calcification within a hematoma. Although we are unable to find a similar case in the literature, we believe the extensive calcification in this case was secondary to the hemorrhage and fibrosis.
References
FIG. 2. Histological section shows typical chromophobe adenoma with hemorrhage. Two large dark areas of dystrophic calcification were characteristic of calcifications seen throughout the histological sections. H & E, • 400.
was biopsied; complete excision was not attempted. Histological Study. Abundant chromophobe adenoma cells were identified in the biopsy specimen. Hemorrhage with fibrosis and calcification was intermixed with these typical chromophobe cells (Fig. 2). Postoperative Course. The patient recovered uneventfully from the operation and replacement therapy was reinstituted. A total of 4000 rads of external irradiation was given after his condition became stable. The patient did not show significant changes after this treatment. He was placed in a nursing home and died for unclear reasons several months later. No autopsy was permitted. Discussion
Four types of calcification in the pituitary have been reported. Concentrically laminated
J. Neurosurg. / Volume 44 / May, 1976
1. Camp JD: Significance of intracranial calcification in the roentgenologic diagnosis of intracranial neoplasms. Radiology 55:659-667, 1950 2. du Boulay GH, Trickey SE: Calcification in chromophobe adenoma. Case report. Br J Radiol 35:793-795, 1962 3. Falconer MA, Bailey K, Duchen LW: Surgical treatment of chordoma and chondroma of the skull base. J Neurosurg 29:261-275, 1968 4. Hastrup J: Chromophobe adenoma of the pituitary with extensive calcifications. Acta Neuropathol 6:98-100, 1966 5. Lindgren E, DiChiro G: Suprasellar tumours with calcification. Acta Radiol 36:173-195, 1951 6. Mfiller W, Hoffmann H: LJber Verkalkungen in Hypophysenadenomen. Zbl Neuroehir 28: 287-290, 1967 7. Russell DS, Rubinstein LJ: Pathology of "rumors of the Nervous System, ed 3. Baltimore: Williams & Wilkins, 1971
Address reprint requests to: A. Alan Chambers, M.D., Radiology Department, Cincinnati General Hospital, 234 Goodman Street, Cincinnati, Ohio 45267.
625
