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Unusual causes of sellar/parasellar masses in a large transsphenoidal surgical series.

Differentiating among the etiologies of a mass in the sella may not always be straightforward. Most often these masses are either hormone-secreting or nonsecreting pituitary adenomas. However, as shown here in this large transsphenoida1 surgical series, in 9% of cases other etiologies are responsible for these mass lesions. In some cases there are no features that clearly distinguish the unusual etiologies from the clinically nonfunctioning pituitary adenoma, but in our experience certain endocrine and neurological abnormalities are more characteristic of patients with a nonpituitary sellar mass. We present here the transsphenoidal surgical experience of K.D.P. and describe the incidence and presentations of the nonpituitary intrasellar and parasellar masses. Two cases in which the diagnoses were unexpected are presented in detail, one from this operative series and one who did not require surgery, to illustrate certain critical features that may aid in the evaluation of the sellar/parasellar mass. On physical examination, the patient was mildly obese, but otherwise normal in appearance. Her examination was notable for a visual acuity of 20/40, a bitemporal superior visual field deficit, and patchy loss of central vision in the left eye without other cranial neuropathy. She had expressible galactorrhea of the right breast with no masses. Admission laboratories showed normal routine chemistries and hematocrit. Urinalysis showed a specific gravity of 1.020 and a pH of 5.0. Endocrine studies showed a morning cortisol of 3.4 Fg/dL, T, of 2.3 pg/dL (normal range, 4.5-12.0), T, radioiodine uptake of 0.90 (normal range, 0.84-1.31), TSH of 2.8 mU/L (normal range, 0.23-5.9), LH of 0.8 mIU/L, FSH of 1.2 mIU/L, PRL of 42 ng/mL, and GH of 2.3 ng/mL. She was given glucocorticoid and thyroid hormone replacement and underwent transsphenoidal exploration. At surgery, an extremely vascular extensive mass was found in the sella and sphenoid sinus, with erosion of the sella. The mass was partially resected and proved on pathology to be metastatic breast carcinoma. She did well postoperatively, with mild diabetes insipidus that did not require vasopressin, and was discharged under ongoing treatment with levothyroxine (100 Fg/ day) and dexamethasone (0.5 mg/day). There was no evidence of metastatic disease elsewhere. She received 4500 cGy of radiation to the pituitary fossa.