Haruko Yoshimoto

Male lactotroph pituitary neuroendocrine tumors (PitNETs) are often considered more aggressive than those in women, but surgically treated cohorts are highly selected and may reflect differences in presentation and indication for surgery. We examined whether advanced clinical presentation in surgically treated lactotroph PitNETs is accompanied by distinct pathologic features. We reviewed 43 patients who underwent surgery for lactotroph PitNETs between 2018 and 2023 at a high-volume referral center. Cases were classified by surgical indication as preference for surgery/intolerance to dopamine agonists (P/I, n=26), resistance with hormonal symptoms (R/H, n=10), and resistance with mass effect (R/M, n=7). Clinical, radiologic, and pathologic parameters, including Ki-67, cytokeratin (CAM5.2), estrogen receptor, somatostatin receptor 2/5, and O6-methylguanine-DNA methyltransferase, were compared. Postoperative endocrinological remission was assessed at the last follow-up (median: 34 mo). All tumors were prolactin-immunoreactive, confirming lactotroph differentiation. Patients in the R/M group were older (median: 56 y), predominantly male (71.4%), and had larger tumors (median: 26 mm) with more frequent cavernous sinus invasion (Knosp grade 4, 85.7%) than those in the other groups. Long-term endocrinological remission differed significantly by indication (P/I, 88.5%; R/H, 80.0%; and R/M, 0%). In contrast, Ki-67 labeling index did not differ significantly across groups (P/I, 1.3%; R/H, 1.5%; and R/M, 2.6%; P =0.598), and no clear between-group differences were identified in CAM5.2 pattern, estrogen receptor, somatostatin receptor 2/5, or O6-methylguanine-DNA methyltransferase status. These findings suggest that the clinically most advanced surgical cases are not matched by distinct pathologic differences in the markers assessed and that the apparent aggressiveness of male-predominant mass-effect cases should not be interpreted solely as reflecting intrinsically aggressive tumor biology.

The carotid web was first reported by Momose et al. in 1977. Most case reports involve patients under 60 years old; thus, the carotid web is recognized as

Background: Nodular fasciitis (NF) is a self-limiting mesenchymal neoplasm. Although it can occur in various parts of the body, its presence within the sphenoid sinus is extremely rare in adults. To the best of our knowledge, only one other case has been reported in the English literature. Because of its rapid growth and potential to mimic malignant tumors, accurate diagnosis and timely treatment are essential. Case Description: We report a case of a 58-year-old man who presented with visual disturbance in the right eye. Computed tomography and magnetic resonance imaging revealed a mass lesion in the sphenoid sinus, with erosion of the bony wall of the right optic nerve canal. The mass was completely removed through an endoscopic transnasal transsphenoidal approach, both for histopathological diagnosis and optic nerve decompression. Pathological examination confirmed the diagnosis of NF. Postoperatively, the patient’s visual field improved significantly. Conclusion: This case highlights NF as a rare but important differential diagnosis in patients presenting with visual impairment due to a mass in the paranasal sinus. In symptomatic cases, early surgical intervention should be considered to prevent symptom progression and ensure an accurate diagnosis.

Objective: Many patients with pituitary neuroendocrine tumours (PitNETs) containing beta (β) thyroid‐stimulating hormone (TSH)‐immunopositive cells, without syndrome of inappropriate secretion of TSH (SITSH), show a significant reduction in TSH levels following surgical removal of the tumour‐like functioning thyrotroph PitNET. We evaluated the pathophysiological and clinical characteristics of TSH‐positive cells in PIT1‐lineage PitNETs in patients without the syndrome of inappropriate secretion of TSH.Design: Retrospective cohort study.Patients and Mesurements: Overall, 165 patients diagnosed with PIT1‐lineage PitNETs without SITSH between April 2018 and July 2023 at Moriyama Memorial Hospital were reviewed. They were categorised into three groups based on the rate of βTSH‐immuno‐positive cells in their PitNETs: strongly positive group with 10% or more βTSH‐immuno‐positive cells, weakly positive group with less than 10%, and negative group. Clinical data from these groups were compared.Results: Patient age, sex, and tumour size did not differ significantly among the groups. Most of the weakly positive cases had acromegaly, whereas many of the strongly positive cases had clinically nonfunctioning tumours. Preoperative TSH levels were slightly higher in strongly positive cases than in the other groups but fell within the normal range postoperatively, whereas postoperative TSH levels were significantly lower across all groups. The degree of TSH reduction postoperatively was significantly higher in the strongly positive group.Conclusions: In the strongly positive group, TSH levels decreased significantly after surgery, whereas no such decrease was observed in the other two groups, suggesting that thyrotrophs in strongly positive PitNETs are TSH‐producing, similar to clinically functioning thyrotroph PitNETs.

Purpose: Rathke’s cleft cyst can lead to visual and pituitary dysfunction. Surgical decompression may alleviate these issues, but the decision to operate remains controversial because of the risk of worsening function. Methods: A retrospective analysis was conducted on 80 patients who underwent endoscopic transnasal transsphenoidal surgery for Rathke’s cleft cyst from April 2018 to April 2024. Clinical outcomes were assessed using magnetic resonance imaging, intraoperative findings, and histopathology to evaluate factors associated with recovery. Results: After a median follow-up of 13.5 months (interquartile range: 6-30.8 months), anterior pituitary function significantly improved in patients with cysts that did not compress the optic nerve and had minimal thinning of the ganglion cell layer-inner plexiform layer (P < .05). Arginine vasopressin deficiency occurred significantly more often in patients with preoperative adult GH deficiency, a history of surgery, and evidence of inflammation in specimens on pathology (P < .05). Retinal nerve fiber layer thickness correlated with visual field impairment both before and after surgery, suggesting it may predict visual recovery. Conclusion: Decompression of Rathke’s cleft cysts can improve anterior pituitary function in patients with smaller cysts and minimal optic nerve pressure. Visual function will likely improve in those with minimal optic nerve fiber layer thinning. Therefore, preoperative optical coherence tomography and visual field testing are mandatory to set expectations regarding potential improvement in vision and anterior pituitary function following surgery. Patients with preoperative adult GH deficiency and a history of surgery are at higher risk of developing postoperative arginine vasopressin deficiency.

Background: Pituitary metastasis from papillary thyroid cancer (PTC) is rare and only a few cases have been reported. Case Description: We report the case of a patient who presented with visual dysfunction and panhypopituitarism. Magnetic resonance imaging revealed a pituitary tumor and hydrocephalus. Transsphenoidal surgery had been indicated, but his surgery had been postponed due to COVID-19 pandemic. During that waiting period, he showed pituitary apoplexy with consciousness disturbance, resulting in acute adrenal insufficiency and diabetes insipidus. He was urgently hospitalized and underwent transsphenoidal surgery. Rapid and permanent pathological examinations have confirmed metastasis of PTC to the pituitary. The patient also underwent serial thyroidectomy. He was also suspected to have secondary hydrocephalus and underwent lumboperitoneal shunting after excluding cerebrospinal fluid metastasis. Thereafter, his cognitive dysfunction and performance status improved dramatically. Conclusion: To the best of our knowledge, this is the first patient with PTC who developed pituitary apoplexy secondary to metastasis.

Injury of the internal carotid artery (ICA) during transsphenoidal surgery (TSS) is a rare but critical complication. There are several reports on endovascular treatment of ICA injury during TSS. With the recent flourishing of extended TSS, injuries to the distal arteries such as the anterior cerebral artery (ACA) are more likely to occur. In the present case, we report a pseudoaneurysm of the right ACA due to injury during extended TSS for aggressive prolactinoma. Due to the absence of collateral vessels, the pseudoaneurysm had to be obliterated while preserving the parent artery. Hence, we decided to treat the pseudoaneurysm using stent-assisted coiling (SAC). The pseudoaneurysm was completely obliterated and he was discharged without any complications. To the best of our knowledge, this is the first case in which an ACA pseudoaneurysm caused by injury during the TSS was treated with SAC and the parent artery was preserved.

This report describes a 49-year-old male patient who presented with a pituitary adenoma extending to the suprasellar region. Subarachnoid hemorrhage (SAH) occurred after conventional transnasal transsphenoidal surgery for a non-functioning pituitary adenoma despite no suprasellar arachnoid membrane breakdown. Through extended transsphenoidal route, the suprasellar hematoma was removed and bleeding from a small vessel thought to be the branch of left superior hypophyseal artery was successfully controlled. Indeed, several case reports regarding this rare complication have been published, but the mechanism of SAH has never been identified and the prognosis was poor in most cases. This report illustrates the origin and mechanism of the bleeding clearly using the intraoperative video. This case suggests that immediate therapeutic intervention is necessary and extended transnasal transsphenoidal repeat surgery is useful for an appropriate hemostasis and removal of hematoma located in the suprasellar region.

Cushing’s disease (CD), which manifests as excess cortisol secretion, is caused by adrenocorticotrophic hormone (ACTH)-secreting pituitary adenomas. Such adenomas are occasionally difficult to identify on magnetic resonance imaging (MRI), and thorough endocrinological examination may be required to detect them. Inferior petrosal sinus (IPS) sampling (IPSS) has been the gold standard test for distinguishing CD from ectopic ACTH syndrome (EAS). However, IPSS is an invasive procedure, and proper catheterization is occasionally challenging due to anatomical variations. Thus, there have been ongoing debates regarding the necessity of this procedure. Here, we present our recent IPSS data derived from the analysis of 65 patients who were referred to us for possible CD between April 2018 and December 2020 after undergoing meticulous endocrinological testing. Even with detailed MRI, no obvious lesions were identified in 19 patients. IPSS performed on these 19 individuals identified an IPS-to-peripheral ACTH gradient in 15 of them. The four patients who lacked this gradient were subjected to a classical algorithm using concurrently measured prolactin levels, the results of which were consistent with their ultimately confirmed diagnoses: two true-positive and two true-negative diagnoses. These findings support the validity of the algorithm and demonstrate that the prolactin-adjusted IPS-to-peripheral ACTH ratio can improve the differentiation between CD and EAS. We had no false-negative results, but three patients were false-positive. Consequently, those three patients in which no apparent tumor was clarified during surgery could not have any endocrinological improvement postoperatively.

Applying more than one clip for a complicated-shaped aneurysm is an established strategy, particularly for middle cerebral arteries (MCA). However, obliterating the cleft of the internal elastic lamina with a single clip is theoretically possible because the line is usually on a single plane. Crankshaft clips were reformed for that purpose decades ago, but are not widely used and have been described in almost no report ever since.To reconsider and describe the utility of crankshaft clips for complicated MCA aneurysms and to articulate the advantages and limitations of the clips, we meticulously analyzed a series of more than 150 cases in which the crankshaft clips were used, predominantly for treatment of MCA aneurysms, at Moriyama Memorial Hospital between August 2010 and December 2015.Readjustment of the clip was not necessary in almost all cases, and the first application was the final one. None of the patients had morbidity or mortality related to the surgical technique. To date, we have not experienced any trouble or recurrence.Crankshaft clips are useful and safe for clipping of complicated MCA aneurysms.