Ross
312 lines
28 KiB
Markdown
312 lines
28 KiB
Markdown
---
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title: "Sellar/Parasellar Mass With Skull Base Invasion"
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docid: "9465656a-fba7-46d3-8538-2307f2441151"
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authors:
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- key: "e0282a62-994d-4550-a127-1eb773b1e920"
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value: "Blair A. Winegar, MD"
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- key: "5cff4116-3654-4b3a-bb75-5ebe0b8c9850"
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value: "Anne G. Osborn, MD, FACR"
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breadcrumbs:
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-
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name: "Brain"
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slug: "brain"
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treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
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-
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name: "Sella/Juxtasellar, Pineal Region"
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slug: "sellajuxtasellar-pineal-region"
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treeNodeId: "5e38b9c1-3137-47e3-aa83-1fc82cb4099a"
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-
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name: "Anatomically Based Differentials"
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slug: "anatomically-based-differentials"
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treeNodeId: "7a51b2ca-8fee-4c16-aff3-b7189f68ea60"
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-
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name: "Sellar/Parasellar Mass With Skull Base Invasion"
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slug: "sellarparasellar-mass-with-skull-b-"
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treeNodeId: null
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category: "Brain"
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documentVersionId: "144664c4-89e2-415f-836d-1f31c40a378f"
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imageCount: 29
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lastUpdated: "01/26/23"
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pageDescription: "Sellar/Parasellar Mass With Skull Base Invasion"
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pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Sellar/Parasellar Mass With Skull Base Invasion"
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pageTitle: "Sellar/Parasellar Mass With Skull Base Invasion | STATdx"
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enhancedTitle: "Sellar/Parasellar Mass With Skull Base Invasion"
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type: "DDX"
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references: true
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breadcrumbs:
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- "Brain"
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- "Differential Diagnosis"
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- "Sella/Juxtasellar, Pineal Region"
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- "Anatomically Based Differentials"
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- "Sellar/Parasellar Mass With Skull Base Invasion"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Pattern of skull base involvement
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- Included: Lesion(s) with permeative, infiltrative, destructive features
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- Invasive macroadenoma, metastases, lymphoma
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- Excluded: Lesion(s) with expansile, erosive pattern (e.g., trigeminal schwannoma, aneurysm)
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- Anatomic origin
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- Included: Involvement from lesions mostly above or lateral to central base of skull (BOS)
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- Excluded: Involvement due to cephalad extension from structures below central BOS
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- Sphenoid sinus (e.g., aggressive polyposis, invasive fungal sinusitis)
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- Nasopharynx (carcinomas with direct or perineural extension)
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- Specific origin of mass helpful
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- Pituitary gland
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- Macroadenoma
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- Less common lymphoma, metastasis
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- Cavernous sinus (CS)/dura
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- Metastasis, lymphoma, meningioma, myeloma
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- Less common hemangiomas, histiocytoses
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- Clivus
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- Metastasis, lymphoma, myeloma, chordoma
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- Petrooccipital fissure
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- Chondrosarcoma
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- Key imaging findings help
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- Look for pituitary gland separate from mass
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- If cannot find, mass probably of pituitary origin
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- Adult: Macroadenoma > metastasis, lymphoma, pseudotumor
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- Child: Histiocytosis > macroadenoma, leukemia
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- Intracranial dural involvement
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- Adult: Metastasis, meningioma, lymphoma, pseudotumor
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- Child: Histiocytosis, leukemia
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- Associated multiple enhancing cranial nerves
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- Adult: Metastases, lymphoma
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- Child: Leukemia
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- ## Helpful Clues for Common Diagnoses
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- **Pituitary Macroadenoma**
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- Pituitary gland = mass
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- Most commonly invades upward through diaphragma sellae
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- Less common = inferior extension
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- Rare but important = invasion, destruction of central BOS
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- If adult man with invasive, destructive central BOS mass, check prolactin prior to surgery, biopsy
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- Infrasellar pituitary adenoma
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- Extremely rare tumors, completely within sphenoid body
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- Develop from ectopic pituitary tissue in remnants of Rathke pouch
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- **Metastases**
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- May arise from many sellar/parasellar tissues (e.g., pituitary gland, dura, osseous BOS)
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- Can involve, infiltrate pituitary gland/stalk
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- Extend into central BOS, CSs
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- Look for other lesions (e.g. calvarium, brain)
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- ## Helpful Clues for Less Common Diagnoses
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- **Meningioma****, Skull Base**
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- Most common = suprasellar mass extending into CS
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- Frequent associated osseous changes: Hyperostosis, sclerosis
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- Look for pituitary gland separate from mass
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- Pituitary usually displaced inferiorly, laterally
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- Occasionally can be elevated
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- Beware: Meningiomas occasionally appear aggressive, invade adjacent skull (mimic metastasis, lymphoma, etc.)
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- **Lymphoma, Metastatic, Intracranial**
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- Metastatic > primary lymphoma in/around central BOS, sella/CSs
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- Uni- > bilateral CS involvement
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- May infiltrate pituitary gland, stalk, cranial nerves, dura
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- Isointense, avidly enhancing, reduced diffusion
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- **Myeloma**
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- Multifocal or solitary (plasmacytoma)
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- Central BOS > > pituitary, CS
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- Bilateral > unilateral CS
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- Usually elevates, displaces pituitary gland but occasionally invades gland, stalk
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- ## Helpful Clues for Rare Diagnoses
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- **Pseudotumor, Intracranial**
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- 90% of intracranial pseudotumors occur without orbital disease
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- Originates in CS, dura
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- Smooth > "lumpy-bumpy" dural thickening, enhancement
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- Typically ↓ following steroids
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- May be part of IgG4-related disease
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- Less common: Posterior extension from orbit
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- Tolosa-Hunt syndrome (painful ophthalmoplegia) = CS involved
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- Uni- > bilateral disease
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- Look for associated meningeal thickening (can be extensive)
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- Rare variant = idiopathic invasive pseudotumor
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- Can invade, destroy bone, mimic neoplasm or aggressive infection
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- Child > > adult
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- **Langerhans Cell Histiocytosis**
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- Osteolysis ± soft tissue mass
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- Varies from small, punched-out lesion to widespread, diffuse involvement
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- Variable brain lesions (pituitary stalk/gland, meninges > parenchyma, choroid plexus)
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- **Thrombophlebitis, Cavernous Sinus**
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- Mimic: Osteolysis central BOS rare
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- Usually secondary to paranasal sinus infection
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- Look for dural thickening, filling defects in CS
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- **Chordoma, Extraosseous**
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- Typical chordoma originates in clivus
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- Destructive midline mass
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- May indent ("thumb") pons
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- Rare: Extraosseous origin
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- Laterally located mass in CS, Meckel cave
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- Osseous invasion secondary
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- Typically hyperintense on T2WI, strong uniform enhancement
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- **Chondrosarcoma**
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- Typically centered on petrooccipital fissure
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- Rare sellar/parasellar location
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- Possible chondroid tumor matrix calcification
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- High T2 signal with scattered hypointense foci (calcifications), heterogeneous enhancement
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- High ADC map value (≥ 2.0 x 10⁻³ mm²/sec)
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- **Leukemia**
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- Paranasal sinus/orbit involvement typical
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- May extend into 1 or both CSs, pituitary gland/stalk
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- **Hemangioma**
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- True vasoformative neoplasm of CS, dura
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- May mimic meningioma
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- If child without neurofibromatosis type 2 lesion that looks like meningioma, consider hemangioma
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- If large, may involve adjacent bone
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- **Erdheim-Chester Disease**
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- Rare non-Langerhans cell histiocytosis
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- Disseminated xanthogranulomatous infiltrative disease
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- Adults > children
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- Long bones > brain, CS, orbits (rare)
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## References
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# Selected References
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1. [Goulam-Houssein S et al: IgG4-related intracranial disease. Neuroradiol J. 32(1):29-35, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30320530%5Bpmid%5D)
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1. [Kunimatsu A et al: Skull base tumors and tumor-like lesions: a pictorial review. Pol J Radiol. 82:398-409, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28811848%5Bpmid%5D)
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1. [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](http://www.ncbi.nlm.nih.gov/pubmed/?term=27499779%5Bpmid%5D)
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1. [Koiso T et al: Malignant lymphoma in the parasellar region. Case Rep Med. 2014:747280, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24660002%5Bpmid%5D)
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1. [Yeom KW et al: Diffusion-weighted MRI: distinction of skull base chordoma from chondrosarcoma. AJNR Am J Neuroradiol. 34(5):1056-61, S1, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23124635%5Bpmid%5D)
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1. [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](http://www.ncbi.nlm.nih.gov/pubmed/?term=21436342%5Bpmid%5D)
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## Images
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### Selected Images
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**Pituitary Macroadenoma**
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*Sagittal T2 MR shows a heterogeneous mass indistinguishable from the pituitary gland, which expands the sella <img src='img/arrows/CS.png'/> with suprasellar extension <img src='img/arrows/CO.png'/> and skull base invasion <img src='img/arrows/CC.png'/>.*
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**Pituitary Macroadenoma**
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*Sagittal T2 MR shows a heterogeneous mass indistinguishable from the pituitary gland, which expands the sella <img src='img/arrows/CS.png'/> with suprasellar extension <img src='img/arrows/CO.png'/> and skull base invasion <img src='img/arrows/CC.png'/>.*
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**Pituitary Macroadenoma**
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*Coronal T1 C+ FS MR in the same patient shows a heterogeneous, hypoenhancing mass that invades the skull base <img src='img/arrows/CO.png'/> and encases the bilateral internal carotid artery (ICA) without luminal narrowing <img src='img/arrows/CS.png'/> in this case of invasive pituitary macroadenoma.*
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**Metastases**
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*Coronal CECT in a patient with metastatic breast carcinoma shows a large sellar/parasellar mass <img src='img/arrows/CC.png'/> with extension to the cavernous sinus and destruction of the adjacent central skull base.*
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**Metastases**
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*Sagittal T1 MR shows an infiltrative T1-hypointense lesion in the pituitary gland and clivus <img src='img/arrows/CS.png'/> with adjacent dural thickening <img src='img/arrows/CO.png'/>. An additional cervical spine osseous lesion <img src='img/arrows/CC.png'/> is present in this case of metastatic prostate cancer.*
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**Meningioma, Skull Base**
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*Axial T2 FS MR demonstrates a large central and posterior skull base mass with extension to the sella <img src='img/arrows/CS.png'/> (cavernous sinus) along the petroclival ligament and petrous bone <img src='img/arrows/CO.png'/>. Note the decrease in the caliber of the encased cavernous carotid artery <img src='img/arrows/CC.png'/>.*
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**Meningioma, Skull Base**
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*Coronal T1 C+ MR in the same patient shows homogeneous enhancement <img src='img/arrows/CC.png'/> of the mass. Note the normal pituitary gland <img src='img/arrows/CO.png'/> is compressed and displaced to the right. Surgical pathology was consistent with a meningioma.*
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**Lymphoma, Metastatic, Intracranial**
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*Sagittal T1 C+ MR demonstrates an enhancing mass invading the pituitary gland, stalk <img src='img/arrows/CO.png'/>, central skull base, and nasopharynx <img src='img/arrows/CC.png'/>. Note the dural involvement <img src='img/arrows/CS.png'/> with thickening and enhancement of the dura.*
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**Myeloma**
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*Coronal T1 C+ FS MR shows a destructive, enhancing mass within the skull base with intracranial <img src='img/arrows/CC.png'/> and extracranial <img src='img/arrows/CO.png'/> extension. Additional enhancing osseous lesions in the mandible and skull <img src='img/arrows/CS.png'/> are present in this case of myeloma.*
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**Pseudotumor, Intracranial**
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*Coronal T1 C+ MR demonstrates an infiltrating lesion in the right parasellar region <img src='img/arrows/CC.png'/> involving the cavernous sinus and Meckel cave. The adjacent skull base shows abnormal marrow enhancement <img src='img/arrows/CS.png'/>. Endoscopic biopsy revealed an inflammatory pseudotumor.*
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**Pseudotumor, Intracranial**
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*Axial T1 C+ FS MR shows an infiltrative, enhancing lesion in the central skull base with adjacent dural thickening <img src='img/arrows/CO.png'/> and involving the petrous ICA canals <img src='img/arrows/CS.png'/> in this biopsy-proven inflammatory pseudotumor.*
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**Langerhans Cell Histiocytosis**
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*Sagittal T1 C+ MR demonstrates an extensive, enhancing mass <img src='img/arrows/CS.png'/> involving the pituitary gland and stalk <img src='img/arrows/CO.png'/>, central skull base, and nasopharynx. This patient was a 6-year-old with a history of sinus treatment and new-onset right vision loss.*
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**Chordoma, Extraosseous**
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*Coronal T2 MR shows a lobulated, hyperintense chordoma <img src='img/arrows/CC.png'/> in the right sellar/parasellar region. Note the displacement of the pituitary gland <img src='img/arrows/CS.png'/>.*
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**Chondrosarcoma**
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*Axial T2 FS MR shows a hyperintense mass <img src='img/arrows/CS.png'/> with internal hypointense chondroid matrix <img src='img/arrows/CC.png'/> centered in the right central skull base with mild mass effect upon the pituitary gland <img src='img/arrows/CO.png'/> in this case of chondrosarcoma.*
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**Leukemia**
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*Axial T1 C+ MR in a patient with acute lymphoblastic leukemia and multiple cranial neuropathies shows enhancing soft tissue in the cavernous sinuses <img src='img/arrows/CC.png'/> and along the trigeminal nerves. Note the involvement of the adjacent sphenoid <img src='img/arrows/CS.png'/>.*
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**Hemangioma**
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*Axial T1 C+ MR in a 13-year-old shows an enormous left cavernous invasive, enhancing mass <img src='img/arrows/CO.png'/>. An initial trigeminal schwannoma or meningioma differential diagnosis gave way to the surgical pathologic diagnosis of a hemangioma.*
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**Erdheim-Chester Disease**
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*Axial T1 C+ MR in a patient with Erdheim-Chester disease reveals large bilateral cavernous sinuses and a mass that invades the skull base <img src='img/arrows/CO.png'/> with multifocal enhancing cerebellar lesions <img src='img/arrows/CS.png'/>. (Courtesy M. Warmuth-Metz, MD.)*
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### Additional Images
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**Meningioma, Skull Base**
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*Axial CECT shows an "en plaque" meningioma that involves the left cavernous sinus <img src='img/arrows/WO.png'/>, orbit <img src='img/arrows/WC.png'/>, and sphenoid sinus <img src='img/arrows/WS.png'/>.*
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**Chordoma, Extraosseous**
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*Coronal T1 C+ MR demonstrates a mildly enhancing lesion in the left cavernous sinus and Meckel cave <img src='img/arrows/WS.png'/> from chordoma with central skull base destruction <img src='img/arrows/WO.png'/>.*
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**Pituitary Macroadenoma**
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*Sagittal T2 MR shows a hyperintense extensively invasive mass <img src='img/arrows/WS.png'/>. The pituitary gland <img src='img/arrows/WO.png'/> cannot be identified separately from the lesion in this male patient with elevated prolactin and an invasive macroadenoma.*
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**Meningioma, Skull Base**
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*Coronal T1 C+ MR shows a large, enhancing mass that elevates and displaces the pituitary gland <img src='img/arrows/WS.png'/>. Note the bone erosion <img src='img/arrows/WO.png'/>. A transsphenoidal biopsy specimen disclosed a typical meningioma.*
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**Pseudotumor, Intracranial**
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*Coronal T1 C+ MR in a patient with multiple left-sided cranial neuropathies shows an enhancing left cavernous sinus mass <img src='img/arrows/WC.png'/> extending into the skull base and nasopharynx <img src='img/arrows/WS.png'/>. Note dural involvement <img src='img/arrows/WO.png'/>. Symptoms resolved completely with steroids.*
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**Langerhans Cell Histiocytosis**
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*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.*
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**Hemangioma**
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*Coronal T1 C+ MR in a 13-year-old patient demonstrates a large hemangioma involving the sella <img src='img/arrows/WS.png'/>, cavernous sinus <img src='img/arrows/WO.png'/>, and floor of the middle cranial fossa <img src='img/arrows/WC.png'/>.*
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**Chordoma, Extraosseous**
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*Axial T2 MR reveals a very hyperintense mass that originates in the left cavernous sinus <img src='img/arrows/WS.png'/> with bone destruction <img src='img/arrows/BO.png'/>. Note the displacement of the pituitary gland <img src='img/arrows/WC.png'/>.*
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**Myeloma**
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*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 <img src='img/arrows/CS.png'/> is seen separate from the mass <img src='img/arrows/CO.png'/>.*
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**Pituitary Macroadenoma**
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*Axial T2 MR demonstrates a large, lobulated sellar/parasellar mass <img src='img/arrows/CC.png'/> with extension to the left cavernous sinus. Note encasement of the left cavernous carotid artery <img src='img/arrows/CS.png'/>.*
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**Pituitary Macroadenoma**
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*Coronal T1 C+ MR in the same patient shows homogeneous enhancement of the mass. There is involvement of the adjacent skull base <img src='img/arrows/CO.png'/>, and the pituitary gland was not seen separate from the mass. These findings are typical of a giant pituitary macroadenoma.*
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**Metastases**
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*Coronal T1 C+ MR shows a mass in the right cavernous sinus <img src='img/arrows/CC.png'/> extending into the foramen rotundum <img src='img/arrows/CS.png'/> in a patient with ovarian cancer and right facial numbness. Compare to the normal left side <img src='img/arrows/CO.png'/>.*
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**Chondrosarcoma**
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*Coronal T1 C+ MR demonstrates a skull base chondrosarcoma <img src='img/arrows/CO.png'/> with extension to the right cavernous sinus and Meckel cave. Note the normal enhancing pituitary gland <img src='img/arrows/CC.png'/>. CT (not shown) demonstrated chondroid-type calcifications in the mass.*
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