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References 1. 2. 3. 4.
5.
Deane S, Selmi C, Naguwa SM, Teuber SS, Gershwin ME. Common variable immunodeficiency: Etiological and treatment issues. Int Arch Allergy Immunol 2009;150:311-24. Dalakas MC, Illa I. Common variable immunodeficiency and inclusion body myositis: Adistinct myopathy mediated by natural killer cells. Ann Neurol 1995;37:806-10. Gause A, Inderrieden DC, Laas R, Arlt AC, Gross WL. Common variable immunodeficiency (CVID) and inclusion body myositis (IBM). Immunobiology 2000;202:199-203. Váncsa A, Szodoray P, Kovács I, Kapitány A, Gergely L, Dankó K. The association of common variable immune deficiency with idiopathic inflammatory myopathies. Joint Bone Spine 2010;77:620-2. Prasad K, Behari M, Maheshwari MC. Muscle hypertrophy in chronic polymyositis. J Neurol Neurosurg Psychiatry 1985;48:1309.
formation and also diffusely infiltrating single tumor cells in the fibrous tissue [Figure 2a]. Immunostaining for pan-cytokeratin was strongly positive [Figure 2b]. Hormone receptors were found to be negative for both estrogen and progesterone. Positron emission tomography-computed tomography for whole body and scintigraphy for skeletal system were negative. At 1 week after the index surgery, radiosurgery treatment was given with Leksell Gamma Knife, Model B (Elekta Instruments AB, Stockholm, Sweden). 11 Gy for 50% isodose area [22 Gy maximal dose, Figure 3]. She was referred to her regular oncologist for multidisciplinary follow-up.
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Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128315
Received: 04-11-2013 Review completed: 01-12-2013 Accepted: 29-01-2014
a
c
b
Figure 1: Pre-operative magnetic resonance imaging shows the sellar mass extending to the suprasellar region. It is isointense to brain on both coronal T1-weighted (a) and T2-weighted (b) sections. (c) Coronal contrast enhanced T1-weighted image shows homogenous enhancement of the mass without non-enhancing necrotic portion (white arrows)
Isolated metastasis of breast cancer to the pituitary gland Sir, A 56-year-old female patient presented with paracetamol-resistant headache of 3 months duration and gait disturbance of 1 week. She had been on levothyroxin medication for Hashimato’s thyroiditis since 10 years. She had a left radical mastectomy operation for invasive ductal carcinoma 7 years earlier and post-operative radiotherapy and chemotherapy. During these 7 years, no local or distant recurrence of tumor had been observed. On neurological examination visual field was intact and visual acuity was 20/40 for right eye and 20/20 for left eye. On tandem-walk, gait was improper. Brain magnetic resonance imaging (MRI) showed a sellar mass lesion extending to the suprasellar area. It was isointense to brain on both T1-and T2-weighted scans [Figure 1a and b-white arrows]. Contrast administration, showed homogenous enhancement of the lesion [Figure 1c-white arrows]. Hormone profile was normal. Due to tumor extension out of sellar region, we chose transcranial approach for surgery. Frozen result was metastatic lesion. The lesion was debulked. Post-operative period was uneventful. Histopathology revealed small fragments consisted of medium sized tumor cells doing incomplete acinar 70
a
b
Figure 2: (a) Small fragments consisting of medium sized tumor cells with small nucleoli (H and E, ×400). (b) Tumor cells stain positive with pan-cytokeratin, immunohistochemically (pan-cytokeratin, ×200)
Figure 3: On post-operative 7th day, radiosurgery treatment was given to the residual tumor bed
Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
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Other than pituitary adenomas, tumors present in sellar and suprasellar regions include craniopharyngiomas, germ cell tumors, optic pathway gliomas, hamartomas, dermoids, epidermoids, lipomas, choristomas and metastases. [1] Metastasis to pituitary gland is very rare (1% of all pituitary neoplasms) and presents with similar clinical presentation as pituitary adenoma.[1-3] Mainly lung in men and breast in women are the primary sites for metastasis.[3,4] Radiology is usually not sufficient to differentiate metastatic lesions from pituitary adenomas. [1,2,4,5] In our case, brain MRI depicted a sellar lesion extending to the suprasellar region, enhanced uniformly after intravenous contrast material. There was no necrotic area, ring enhancement or bony erosion. Furthermore, the clinical progress was insidious. She had been operated for breast carcinoma 7 years before this presentation. Histopathology and immunohistochemical studies helped to make the correct diagnosis. MIB-1 value was very high and compatible with metastatic lesion.[2] Immunostaining was strongly positive for pan-cytokeratin and negative for synaptophysin. Pan-cytokeratin suggested the relationship of the current pathology with the previous breast neoplasm. Our case is unique that there was neither a local recurrence nor distant metastasis. Due to suprasellar invasion of the tumor and frozen diagnosis of metastasis, we preferred debulking surgery with post-operative adjuvant stereotactic radiosurgery.
Acknowledgments We thank to Gülcan Davulcu and Ardınç Arpınar for their technical support in preparing the manuscript in this study.
Murat Şakir Ekşi, Teyyub Hasanov1, Baran Yılmaz2, Akın Akakın2, Yaşar Bayri1, Suheyla Uyar Bozkurt3, Türker Kılıç2
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Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128322
Received: 23-01-2014 Review completed: 23-01-2014 Accepted: 25-01-2014
Giant calcified intraventricular pilocytic astrocytoma: A rare entity Sir, Pilocytic astrocytomas (PA) account for about 5-6% of all gliomas. In PA calcifi cation is an infrequent finding. It is extremely rare for an intraventricular PA to present as a calcified mass. [1] We present two cases of giant intraventricular calcified PA. The clinical characteristics, image findings and pathological features of both patients are given in Table 1 [Figures 1-3]. Tumors of the lateral ventricles account for
References 1. 2. 3. 4.
5.
Deane S, Selmi C, Naguwa SM, Teuber SS, Gershwin ME. Common variable immunodeficiency: Etiological and treatment issues. Int Arch Allergy Immunol 2009;150:311-24. Dalakas MC, Illa I. Common variable immunodeficiency and inclusion body myositis: Adistinct myopathy mediated by natural killer cells. Ann Neurol 1995;37:806-10. Gause A, Inderrieden DC, Laas R, Arlt AC, Gross WL. Common variable immunodeficiency (CVID) and inclusion body myositis (IBM). Immunobiology 2000;202:199-203. Váncsa A, Szodoray P, Kovács I, Kapitány A, Gergely L, Dankó K. The association of common variable immune deficiency with idiopathic inflammatory myopathies. Joint Bone Spine 2010;77:620-2. Prasad K, Behari M, Maheshwari MC. Muscle hypertrophy in chronic polymyositis. J Neurol Neurosurg Psychiatry 1985;48:1309.
formation and also diffusely infiltrating single tumor cells in the fibrous tissue [Figure 2a]. Immunostaining for pan-cytokeratin was strongly positive [Figure 2b]. Hormone receptors were found to be negative for both estrogen and progesterone. Positron emission tomography-computed tomography for whole body and scintigraphy for skeletal system were negative. At 1 week after the index surgery, radiosurgery treatment was given with Leksell Gamma Knife, Model B (Elekta Instruments AB, Stockholm, Sweden). 11 Gy for 50% isodose area [22 Gy maximal dose, Figure 3]. She was referred to her regular oncologist for multidisciplinary follow-up.
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128315
Received: 04-11-2013 Review completed: 01-12-2013 Accepted: 29-01-2014
a
c
b
Figure 1: Pre-operative magnetic resonance imaging shows the sellar mass extending to the suprasellar region. It is isointense to brain on both coronal T1-weighted (a) and T2-weighted (b) sections. (c) Coronal contrast enhanced T1-weighted image shows homogenous enhancement of the mass without non-enhancing necrotic portion (white arrows)
Isolated metastasis of breast cancer to the pituitary gland Sir, A 56-year-old female patient presented with paracetamol-resistant headache of 3 months duration and gait disturbance of 1 week. She had been on levothyroxin medication for Hashimato’s thyroiditis since 10 years. She had a left radical mastectomy operation for invasive ductal carcinoma 7 years earlier and post-operative radiotherapy and chemotherapy. During these 7 years, no local or distant recurrence of tumor had been observed. On neurological examination visual field was intact and visual acuity was 20/40 for right eye and 20/20 for left eye. On tandem-walk, gait was improper. Brain magnetic resonance imaging (MRI) showed a sellar mass lesion extending to the suprasellar area. It was isointense to brain on both T1-and T2-weighted scans [Figure 1a and b-white arrows]. Contrast administration, showed homogenous enhancement of the lesion [Figure 1c-white arrows]. Hormone profile was normal. Due to tumor extension out of sellar region, we chose transcranial approach for surgery. Frozen result was metastatic lesion. The lesion was debulked. Post-operative period was uneventful. Histopathology revealed small fragments consisted of medium sized tumor cells doing incomplete acinar 70
a
b
Figure 2: (a) Small fragments consisting of medium sized tumor cells with small nucleoli (H and E, ×400). (b) Tumor cells stain positive with pan-cytokeratin, immunohistochemically (pan-cytokeratin, ×200)
Figure 3: On post-operative 7th day, radiosurgery treatment was given to the residual tumor bed
Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
[Downloaded free from http://www.neurologyindia.com on Thursday, March 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
Other than pituitary adenomas, tumors present in sellar and suprasellar regions include craniopharyngiomas, germ cell tumors, optic pathway gliomas, hamartomas, dermoids, epidermoids, lipomas, choristomas and metastases. [1] Metastasis to pituitary gland is very rare (1% of all pituitary neoplasms) and presents with similar clinical presentation as pituitary adenoma.[1-3] Mainly lung in men and breast in women are the primary sites for metastasis.[3,4] Radiology is usually not sufficient to differentiate metastatic lesions from pituitary adenomas. [1,2,4,5] In our case, brain MRI depicted a sellar lesion extending to the suprasellar region, enhanced uniformly after intravenous contrast material. There was no necrotic area, ring enhancement or bony erosion. Furthermore, the clinical progress was insidious. She had been operated for breast carcinoma 7 years before this presentation. Histopathology and immunohistochemical studies helped to make the correct diagnosis. MIB-1 value was very high and compatible with metastatic lesion.[2] Immunostaining was strongly positive for pan-cytokeratin and negative for synaptophysin. Pan-cytokeratin suggested the relationship of the current pathology with the previous breast neoplasm. Our case is unique that there was neither a local recurrence nor distant metastasis. Due to suprasellar invasion of the tumor and frozen diagnosis of metastasis, we preferred debulking surgery with post-operative adjuvant stereotactic radiosurgery.
Acknowledgments We thank to Gülcan Davulcu and Ardınç Arpınar for their technical support in preparing the manuscript in this study.
Murat Şakir Ekşi, Teyyub Hasanov1, Baran Yılmaz2, Akın Akakın2, Yaşar Bayri1, Suheyla Uyar Bozkurt3, Türker Kılıç2
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128322
Received: 23-01-2014 Review completed: 23-01-2014 Accepted: 25-01-2014
Giant calcified intraventricular pilocytic astrocytoma: A rare entity Sir, Pilocytic astrocytomas (PA) account for about 5-6% of all gliomas. In PA calcifi cation is an infrequent finding. It is extremely rare for an intraventricular PA to present as a calcified mass. [1] We present two cases of giant intraventricular calcified PA. The clinical characteristics, image findings and pathological features of both patients are given in Table 1 [Figures 1-3]. Tumors of the lateral ventricles account for
