statdx/docs_md/articles/sellar-parasellar-mass-with-skull-base-invasion_9465656a-fba7-46d3-8538-2307f2441151.md

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Sellar/Parasellar Mass With Skull Base Invasion	9465656a-fba7-46d3-8538-2307f2441151	key value e0282a62-994d-4550-a127-1eb773b1e920 Blair A. Winegar, MD key value 5cff4116-3654-4b3a-bb75-5ebe0b8c9850 Anne G. Osborn, MD, FACR	name slug treeNodeId Brain brain 6d8829f1-14d7-45af-8675-255189aa526a name slug treeNodeId Differential Diagnosis differential-diagnosis a7fdd139-664e-4bb8-8d18-400e4733ff60 name slug treeNodeId Sella/Juxtasellar, Pineal Region sellajuxtasellar-pineal-region 5e38b9c1-3137-47e3-aa83-1fc82cb4099a name slug treeNodeId Anatomically Based Differentials anatomically-based-differentials 7a51b2ca-8fee-4c16-aff3-b7189f68ea60 name slug treeNodeId Sellar/Parasellar Mass With Skull Base Invasion sellarparasellar-mass-with-skull-b- null	Brain	144664c4-89e2-415f-836d-1f31c40a378f	29	01/26/23	Sellar/Parasellar Mass With Skull Base Invasion	Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Sellar/Parasellar Mass With Skull Base Invasion	Sellar/Parasellar Mass With Skull Base Invasion | STATdx	Sellar/Parasellar Mass With Skull Base Invasion	DDX	true	Brain Differential Diagnosis Sella/Juxtasellar, Pineal Region Anatomically Based Differentials Sellar/Parasellar Mass With Skull Base Invasion

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title: "Sellar/Parasellar Mass With Skull Base Invasion" docid: "9465656a-fba7-46d3-8538-2307f2441151" authors:

• key: "e0282a62-994d-4550-a127-1eb773b1e920" value: "Blair A. Winegar, MD"
• key: "5cff4116-3654-4b3a-bb75-5ebe0b8c9850" value: "Anne G. Osborn, MD, FACR" breadcrumbs:
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• name: "Sella/Juxtasellar, Pineal Region" slug: "sellajuxtasellar-pineal-region" treeNodeId: "5e38b9c1-3137-47e3-aa83-1fc82cb4099a"
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• name: "Sellar/Parasellar Mass With Skull Base Invasion" slug: "sellarparasellar-mass-with-skull-b-" treeNodeId: null category: "Brain" documentVersionId: "144664c4-89e2-415f-836d-1f31c40a378f" imageCount: 29 lastUpdated: "01/26/23" pageDescription: "Sellar/Parasellar Mass With Skull Base Invasion" pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Sellar/Parasellar Mass With Skull Base Invasion" pageTitle: "Sellar/Parasellar Mass With Skull Base Invasion | STATdx" enhancedTitle: "Sellar/Parasellar Mass With Skull Base Invasion" type: "DDX" references: true breadcrumbs:
• "Brain"
• "Differential Diagnosis"
• "Sella/Juxtasellar, Pineal Region"
• "Anatomically Based Differentials"
• "Sellar/Parasellar Mass With Skull Base Invasion"

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ESSENTIAL INFORMATION

• Key Differential Diagnosis Issues

  • Pattern of skull base involvement - Included: Lesion(s) with permeative, infiltrative, destructive features - Invasive macroadenoma, metastases, lymphoma - Excluded: Lesion(s) with expansile, erosive pattern (e.g., trigeminal schwannoma, aneurysm)
  • Anatomic origin - Included: Involvement from lesions mostly above or lateral to central base of skull (BOS) - Excluded: Involvement due to cephalad extension from structures below central BOS - Sphenoid sinus (e.g., aggressive polyposis, invasive fungal sinusitis) - Nasopharynx (carcinomas with direct or perineural extension)
  • Specific origin of mass helpful - Pituitary gland - Macroadenoma - Less common lymphoma, metastasis - Cavernous sinus (CS)/dura - Metastasis, lymphoma, meningioma, myeloma - Less common hemangiomas, histiocytoses - Clivus - Metastasis, lymphoma, myeloma, chordoma - Petrooccipital fissure - Chondrosarcoma
  • Key imaging findings help - Look for pituitary gland separate from mass - If cannot find, mass probably of pituitary origin - Adult: Macroadenoma > metastasis, lymphoma, pseudotumor - Child: Histiocytosis > macroadenoma, leukemia - Intracranial dural involvement - Adult: Metastasis, meningioma, lymphoma, pseudotumor - Child: Histiocytosis, leukemia - Associated multiple enhancing cranial nerves - Adult: Metastases, lymphoma - Child: Leukemia

• Helpful Clues for Common Diagnoses

  • Pituitary Macroadenoma - Pituitary gland = mass - Most commonly invades upward through diaphragma sellae - Less common = inferior extension - Rare but important = invasion, destruction of central BOS - If adult man with invasive, destructive central BOS mass, check prolactin prior to surgery, biopsy - Infrasellar pituitary adenoma - Extremely rare tumors, completely within sphenoid body - Develop from ectopic pituitary tissue in remnants of Rathke pouch
  • Metastases - May arise from many sellar/parasellar tissues (e.g., pituitary gland, dura, osseous BOS) - Can involve, infiltrate pituitary gland/stalk - Extend into central BOS, CSs - Look for other lesions (e.g. calvarium, brain)

• Helpful Clues for Less Common Diagnoses

  • Meningioma**, Skull Base** - Most common = suprasellar mass extending into CS - Frequent associated osseous changes: Hyperostosis, sclerosis - Look for pituitary gland separate from mass - Pituitary usually displaced inferiorly, laterally - Occasionally can be elevated - Beware: Meningiomas occasionally appear aggressive, invade adjacent skull (mimic metastasis, lymphoma, etc.)
  • Lymphoma, Metastatic, Intracranial - Metastatic > primary lymphoma in/around central BOS, sella/CSs - Uni- > bilateral CS involvement - May infiltrate pituitary gland, stalk, cranial nerves, dura - Isointense, avidly enhancing, reduced diffusion
  • Myeloma - Multifocal or solitary (plasmacytoma) - Central BOS > > pituitary, CS - Bilateral > unilateral CS - Usually elevates, displaces pituitary gland but occasionally invades gland, stalk

• Helpful Clues for Rare Diagnoses

  • Pseudotumor, Intracranial - 90% of intracranial pseudotumors occur without orbital disease - Originates in CS, dura - Smooth > "lumpy-bumpy" dural thickening, enhancement - Typically ↓ following steroids - May be part of IgG4-related disease - Less common: Posterior extension from orbit - Tolosa-Hunt syndrome (painful ophthalmoplegia) = CS involved - Uni- > bilateral disease - Look for associated meningeal thickening (can be extensive) - Rare variant = idiopathic invasive pseudotumor - Can invade, destroy bone, mimic neoplasm or aggressive infection - Child > > adult
  • Langerhans Cell Histiocytosis - Osteolysis ± soft tissue mass - Varies from small, punched-out lesion to widespread, diffuse involvement - Variable brain lesions (pituitary stalk/gland, meninges > parenchyma, choroid plexus)
  • Thrombophlebitis, Cavernous Sinus - Mimic: Osteolysis central BOS rare - Usually secondary to paranasal sinus infection - Look for dural thickening, filling defects in CS
  • Chordoma, Extraosseous - Typical chordoma originates in clivus - Destructive midline mass - May indent ("thumb") pons - Rare: Extraosseous origin - Laterally located mass in CS, Meckel cave - Osseous invasion secondary - Typically hyperintense on T2WI, strong uniform enhancement
  • Chondrosarcoma - Typically centered on petrooccipital fissure - Rare sellar/parasellar location - Possible chondroid tumor matrix calcification - High T2 signal with scattered hypointense foci (calcifications), heterogeneous enhancement - High ADC map value (≥ 2.0 x 10⁻³ mm²/sec)
  • Leukemia - Paranasal sinus/orbit involvement typical - May extend into 1 or both CSs, pituitary gland/stalk
  • Hemangioma - True vasoformative neoplasm of CS, dura - May mimic meningioma - If child without neurofibromatosis type 2 lesion that looks like meningioma, consider hemangioma - If large, may involve adjacent bone
  • Erdheim-Chester Disease - Rare non-Langerhans cell histiocytosis - Disseminated xanthogranulomatous infiltrative disease - Adults > children - Long bones > brain, CS, orbits (rare)

References

Selected References

1. Goulam-Houssein S et al: IgG4-related intracranial disease. Neuroradiol J. 32(1):29-35, 2019
2. Kunimatsu A et al: Skull base tumors and tumor-like lesions: a pictorial review. Pol J Radiol. 82:398-409, 2017
3. Sharma M et al: Pituitary chondrosarcoma presenting as a sellar and suprasellar mass with parasellar extension: an unusual presentation. Iran J Pathol. 11(2):161-6, 2016
4. Koiso T et al: Malignant lymphoma in the parasellar region. Case Rep Med. 2014:747280, 2014
5. Yeom KW et al: Diffusion-weighted MRI: distinction of skull base chordoma from chondrosarcoma. AJNR Am J Neuroradiol. 34(5):1056-61, S1, 2013
6. Chen X et al: Clival invasion on multi-detector CT in 390 pituitary macroadenomas: correlation with sex, subtype and rates of operative complication and recurrence. AJNR Am J Neuroradiol. 32(4):785-9, 2011

Images

Selected Images

Pituitary Macroadenoma Sagittal T2 MR shows a heterogeneous mass indistinguishable from the pituitary gland, which expands the sella with suprasellar extension and skull base invasion .

Pituitary Macroadenoma Sagittal T2 MR shows a heterogeneous mass indistinguishable from the pituitary gland, which expands the sella with suprasellar extension and skull base invasion .

Pituitary Macroadenoma Coronal T1 C+ FS MR in the same patient shows a heterogeneous, hypoenhancing mass that invades the skull base and encases the bilateral internal carotid artery (ICA) without luminal narrowing in this case of invasive pituitary macroadenoma.

Metastases Coronal CECT in a patient with metastatic breast carcinoma shows a large sellar/parasellar mass with extension to the cavernous sinus and destruction of the adjacent central skull base.

Metastases Sagittal T1 MR shows an infiltrative T1-hypointense lesion in the pituitary gland and clivus with adjacent dural thickening . An additional cervical spine osseous lesion is present in this case of metastatic prostate cancer.

Meningioma, Skull Base Axial T2 FS MR demonstrates a large central and posterior skull base mass with extension to the sella (cavernous sinus) along the petroclival ligament and petrous bone . Note the decrease in the caliber of the encased cavernous carotid artery .

Meningioma, Skull Base Coronal T1 C+ MR in the same patient shows homogeneous enhancement of the mass. Note the normal pituitary gland is compressed and displaced to the right. Surgical pathology was consistent with a meningioma.

Lymphoma, Metastatic, Intracranial Sagittal T1 C+ MR demonstrates an enhancing mass invading the pituitary gland, stalk , central skull base, and nasopharynx . Note the dural involvement with thickening and enhancement of the dura.

Myeloma Coronal T1 C+ FS MR shows a destructive, enhancing mass within the skull base with intracranial and extracranial extension. Additional enhancing osseous lesions in the mandible and skull are present in this case of myeloma.

Pseudotumor, Intracranial Coronal T1 C+ MR demonstrates an infiltrating lesion in the right parasellar region involving the cavernous sinus and Meckel cave. The adjacent skull base shows abnormal marrow enhancement . Endoscopic biopsy revealed an inflammatory pseudotumor.

Pseudotumor, Intracranial Axial T1 C+ FS MR shows an infiltrative, enhancing lesion in the central skull base with adjacent dural thickening and involving the petrous ICA canals in this biopsy-proven inflammatory pseudotumor.

Langerhans Cell Histiocytosis Sagittal T1 C+ MR demonstrates an extensive, enhancing mass involving the pituitary gland and stalk , central skull base, and nasopharynx. This patient was a 6-year-old with a history of sinus treatment and new-onset right vision loss.

Chordoma, Extraosseous Coronal T2 MR shows a lobulated, hyperintense chordoma in the right sellar/parasellar region. Note the displacement of the pituitary gland .

Chondrosarcoma Axial T2 FS MR shows a hyperintense mass with internal hypointense chondroid matrix centered in the right central skull base with mild mass effect upon the pituitary gland in this case of chondrosarcoma.

Leukemia Axial T1 C+ MR in a patient with acute lymphoblastic leukemia and multiple cranial neuropathies shows enhancing soft tissue in the cavernous sinuses and along the trigeminal nerves. Note the involvement of the adjacent sphenoid .

Hemangioma Axial T1 C+ MR in a 13-year-old shows an enormous left cavernous invasive, enhancing mass . An initial trigeminal schwannoma or meningioma differential diagnosis gave way to the surgical pathologic diagnosis of a hemangioma.

Erdheim-Chester Disease Axial T1 C+ MR in a patient with Erdheim-Chester disease reveals large bilateral cavernous sinuses and a mass that invades the skull base with multifocal enhancing cerebellar lesions . (Courtesy M. Warmuth-Metz, MD.)

Additional Images

Meningioma, Skull Base Axial CECT shows an "en plaque" meningioma that involves the left cavernous sinus , orbit , and sphenoid sinus .

Chordoma, Extraosseous Coronal T1 C+ MR demonstrates a mildly enhancing lesion in the left cavernous sinus and Meckel cave from chordoma with central skull base destruction .

Pituitary Macroadenoma Sagittal T2 MR shows a hyperintense extensively invasive mass . The pituitary gland cannot be identified separately from the lesion in this male patient with elevated prolactin and an invasive macroadenoma.

Meningioma, Skull Base Coronal T1 C+ MR shows a large, enhancing mass that elevates and displaces the pituitary gland . Note the bone erosion . A transsphenoidal biopsy specimen disclosed a typical meningioma.

Pseudotumor, Intracranial Coronal T1 C+ MR in a patient with multiple left-sided cranial neuropathies shows an enhancing left cavernous sinus mass extending into the skull base and nasopharynx . Note dural involvement . Symptoms resolved completely with steroids.

Langerhans Cell Histiocytosis Coronal T1 C+ FS MR in a patient with Langerhans cell histiocytosis shows an extensive destructive central mass that erodes the skull base and infiltrates the pituitary gland and cavernous sinuses.

Hemangioma Coronal T1 C+ MR in a 13-year-old patient demonstrates a large hemangioma involving the sella , cavernous sinus , and floor of the middle cranial fossa .

Chordoma, Extraosseous Axial T2 MR reveals a very hyperintense mass that originates in the left cavernous sinus with bone destruction . Note the displacement of the pituitary gland .

Myeloma Sagittal T1 MR in a patient with myeloma reveals an infiltrative, destructive lesion with involvement of the cavernous sinus, sphenoid sinus, clivus, and dura. The pituitary gland is seen separate from the mass .

Pituitary Macroadenoma Axial T2 MR demonstrates a large, lobulated sellar/parasellar mass with extension to the left cavernous sinus. Note encasement of the left cavernous carotid artery .

Pituitary Macroadenoma Coronal T1 C+ MR in the same patient shows homogeneous enhancement of the mass. There is involvement of the adjacent skull base , and the pituitary gland was not seen separate from the mass. These findings are typical of a giant pituitary macroadenoma.

Metastases Coronal T1 C+ MR shows a mass in the right cavernous sinus extending into the foramen rotundum in a patient with ovarian cancer and right facial numbness. Compare to the normal left side .

Chondrosarcoma Coronal T1 C+ MR demonstrates a skull base chondrosarcoma with extension to the right cavernous sinus and Meckel cave. Note the normal enhancing pituitary gland . CT (not shown) demonstrated chondroid-type calcifications in the mass.