Diagnostic Accuracy of Hyperacute MRI in Prediction of Residual Tumor and Progression in Pituitary Macroadenomas

1
Diagnostic Accuracy of Hyperacute MRI in
Prediction of Residual Tumor and Progression in
Pituitary Macroadenomas
Abstract Id IRIA 1249
- A Retrospective Study
2
Aims and Objectives

• Detection of residual tumor for follow up in
  patients with a pituitary macroadenoma who
  undergo surgery
• Distinguish post operative bed contents on post
  op imaging
• Imaging for early detection of recurrence

3
Selection Criteria

• Any patient with pituitary macroadenoma (size
  gt1cm) who presented to our institution between a
  period of 1 year (July 2013 and June 2014) for
  whom pre operative and post operative hyperacute
  (within 6 hours post op) MRI brain were done and
  follow up (6 months and later) MRI brain was done
  / planned for

4
Materials and Methods

• Total number of patients 46
• MRI sequences used
• Preoperative MRI - T2W, FLAIR, T1W and post
  contrast T1W sequences
• Hyperacute MRI - T2W, FLAIR and T1W sequences
• Follow up MRI - T2W, FLAIR, T1W and post contrast
  T1W sequences

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Materials and Methods

• Availability of pre operative MRI all patients
• Availability of hyperacute MRI all patients
• Availability of follow up MRI 26 patients
• Tumor volumes were calculated using the tool
  provided in Centricity PACS

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Results - Demographics

• Gender
• Age between 20 and 62 years (mean 41 years)

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Tumor Functional Characteristics

• 91.67 of non functioning macroadenomas were
  Hardy grade C and higher

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Hardy Grade A
Case144 year male with coarsening of facial
features
Fig. 1B
Fig. 1A
Post gadolinium T1W coronal sagittal sections
showing a heterogeneously enhancing intrasellar
pituitary macroadenoma
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Hardy Grade B
Case 240 year old female with headache
Fig. 2B
Fig. 2A
Post gadolinium T1W coronal sagittal sections
showing a homogeneously enhancing sellar
-suprasellar lesion, with extension into the
right cavernous sinus
10
Hardy Grade C
Case 3 22 year old male with acromegaly, visual
loss
Fig. 3A
Fig. 3B
Post gadolinium T1W coronal sagittal sections
showing a homogeneously enhancing
sellar-suprasellar mass with a small superiorly
placed cystic component reaching upto the floor
of the third ventricle
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Hardy Grade D
Case 440 year old male with headache, visual loss
Fig. 4B
Fig. 4A
Post gadolinium T1W coronal sagittal sections
showing a homogeneously enhancing
sellar-suprasellar lesion extending superiorly
into the basifrontal region and into the left
cavernous sinus
12
Giant Macroadenoma
Fig. 5D
Fig. 5A
Fig. 5B
Fig. 5C
Post gadolinium T1W coronal sections showing a
large homogeneously enhancing sellar-suprasellar
mass measuring 5.5 cm in the anteriposterior
dimension
9 of 46 pituitary tumors were giant macroadenomas
measuring gt 5 cm, few of which were found to be
eroding and extensively invading the skull base
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Extension into Cavernous Sinus
Preop MRI, T1W coronal sections showing dumb bell
shaped sellar -suprasellar mass extending into
bilateral cavernous sinuses
6 month follow up MRI T1W coronal sections
showing residual tumor in the right cavernous
sinus
Fig. 6A
Fig. 6B

• Extension into cavernous sinus, though commonly
  seen with Hardy grade C and D tumors was not
  exclusive to them
• Surgical approach being difficult, this was the
  most common site where residual tumor was found
  in the hyperacute MRI and also the most common
  site for tumor recurrence seen on the subsequent
  follow up MRI

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Hyperacute MRIPostop Bed Appearance
Fig. 7B
Fig. 7A
Hyperacute MRI of a 61 year old male who had a
Hardy grade C pituitary macroadenoma.
Intraoperatively surgicel was used to achieve
hemostasis.

• Heterogeneity in the post op bed was found to be
  contributed by
• Hemorrhage
• Edema
• Hemostatic material (Surgicel in all cases both
  surgicel and gelfoam in 5 cases)
• Graft material (fat/fascia) used to repair CSF
  leaks (8 cases) or large dural defects

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Hyperacute MRIPostop Bed Appearance
Fig. 8A
Fig. 8B
Fig. 8C
A. Preop, B. Hyperacute, C. 6 month follow up MRI
of a 62 year old male with Hardy grade C
macroadenoma that was surgically excised While
the hyperacute MRI appeared to show a large,
heterogeneous residual sellar suprasellar tumor
with areas of haemorrhage within, the follow up
MRI did not show any evidence of residual tumor.
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Hyperacute MRIDirective in Reoperation




Fig. 9D
Fig. 9B
Fig. 9A
Fig. 9C
Residual Tumor

• 5 of 46 cases in which significant residual tumor
  (gt50) was found in the hyperacute MRI, in the
  sella and suprasellar regions underwent
  re-exploration and tumor excision / stereotactic
  radiotherapy.
• None of these patients have presented with tumor
  recurrence so far

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In conclusion

• Hyperacute MRI is useful to predict re-surgery if
  required
• Residual tumor was most commonly seen in the
  cavernous sinus region
• Only on comparison with the preoperative MRI the
  amount or nature of the residual tissue being
  imaged can be truly ascertained

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Clinical Relevance

• Hyperacute MRI is a very good diagnostic tool in
  the post op evaluation of residual tumor and to
  predict recurrence in pituitary macroadenomas

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