PMC7391092_01
Radiographic imaging, on initial workup of the heterogeneously enhancing eccentric. T1-weighted sequence magnetic resonance imaging with contrast presented in axial, coronal, and sagittal planes, respectively. The mass invades the left cavernous sinus and orbit with envelopment of the left internal carotid artery (a). In the suprasellar region, the mass extends into the right hypothalamus (b) with mass effect on the third ventricle (c). The mass measures 4.3 x 3.3 x 3.7 cm with a calculated volume of 17.11 mL using 3D modelling. Boxes highlight the tumor of interest.
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An MRI of the brain performed one month previously at an outside hospital displayed a sellar mass with suprasellar extension (4.6 x 3.4 cm) into the orbital apex and cavernous sinus on the left side (Figure 1).
Radiographic imaging of tumor progression preoperatively. T1-weighted sequence magnetic resonance imaging with contrast presented in axial, coronal, sagittal, and axial planes, respectively. Imaging demonstrates growth of the previously described mass with further encasement of the left cavernous internal carotid artery (a) with superior extension (b) with further effacement of the third ventricle (c). A subcentimeter-enhancing, spherical, paraventricular, left occipital lesion is apparent (d). The sellar mass now measures 5.7 x 3.8 x 4.4 cm with a total estimated volume of 22.7 mL. Yellow boxes highlight the tumor of interest. Green box highlights an occipital lesion.
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A preoperative MRI with and without contrast demonstrated growth to a 5.7 x 3.1 x 3.0 cm peripherally enhancing, centrally necrotic mass with sellar expansion (Figure 2). During postoperative imaging, a new intracranial lesion was noticed in the left occipital lobe (Figure 2(d)).
Radiographic imaging of tumor progression postoperative. T1-weighted sequence magnetic resonance imaging with double contrast presented in axial, coronal, and sagittal planes, respectively. The mass has undergone subtotal resection (a-c). The left occipital lesion is stable (a). The suprasellar lesion measures 2.7 x 1.4 x 2.0 cm with total volume calculated at 4.6 mL. Yellow boxes highlight the tumor of interest. Green box highlights occipital lesion.
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Tumor volume decreased from 22.70 mL preoperatively to 4.59 mL postoperatively (Figure 3).
Histopathologic stains of the pituitary mass. (a) H and E stain of the pituitary lesion. (b) Magnified image of red box in a showing evidence of pituitary adenoma which is surrounded by clear cells that resemble RCC but without the nuclear changes. (c) Magnified image of blue box in (a) showing clear cytoplasm arranged in nests with severe nuclear atypia consistent with WHO/ISUP grade 3 RCC.
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The microscopic findings and immunophenotype indicated a metastatic clear cell renal cell carcinoma to a pituitary adenoma (Figures 4 and 5).
(a) Admixed pituitary adenoma (star) and the surrounding metastatic carcinoma (arrows) in one of the fragments. (b) Juxtaposition of pituitary adenoma (lower left) and metastatic renal cell carcinoma (upper right). (c) Pituitary adenoma shows sheets of cytologically bland, monotonous cells. (d) Renal cell carcinoma shows large atypical cells with prominent nucleoli and clear cytoplasms. (e) Synaptophysin is positive in the pituitary adenoma and negative in the renal cell carcinoma. PAX-8 shows nuclear positivity in the renal cell carcinoma, while the pituitary adenoma is negative. (a-e) Hematoxylin-eosin. (d, e) Immunohistochemistry. Original magnifications: (a) 20x; (b, e, f) 200x; and (c, d) 400x.
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The microscopic findings and immunophenotype indicated a metastatic clear cell renal cell carcinoma to a pituitary adenoma (Figures 4 and 5).