Supplementary Materials and Methods; Supplementary Tables S1-S5.

This article reviewed the classification, morphologic features, and pathogenesis of human hypophyseal adenomas and differences between hyperplasia and adenoma. Histologic, immunohistochemical, and electron microscopic investigation obtained a deeper insight into several aspects of pituitary cytopathology. Based on these studies, a meaningful classification has been developed that separates hypophyseal adenomas into distinct entities. It hinges on histology, hormone content, ultrastructural characteristics, cellular composition, and cytogenesis and correlates the morphologic features of adenoma cells with endocrine activity. Although progress has been spectacular during the last two decades in the better understanding of structural characteristics and hormonal function of pituitary adenomas, much more work is necessary to shed light on structure-function correlations and pathogenesis. Collaborative investigations between clinical investigators and basic scientists can further advance knowledge in this intriguing and important field.

Perineuriomas are rare tumors arising in either a soft tissue or an intraneural form. We report the first case of intracranial dural-based perineurioma. Following histological confirmation of diagnosis, a rigorous literature review was undertaken for intracranial dural-based perineuriomas. Finding no previous such reports a case review and literature review of perineuriomas as a whole, and specifically intracranial perineuriomas, was undertaken. Mimicking a meningioma, a large left frontal duralbased tumor occurred in a 63-year-old woman experiencing personality change. The diagnosis on this gross totally resected tumor was based on its histologic features (spindle cells with long narrow processes), the finding of EMA, GLUT-1, and claudin-1 immunoreactivity, and the ultrastructural presence of surface micropinocytotic vesicles, partial basal lamina, and of simple intercellular junctions. Soft tissue perineurioma is rarely encountered in the intracranial space. Radiographically, the present tumor mimicked a meningioma with its well defined extra-axial location. The gross totally resected tumor was examined histologically, as well as by immunocytochemistry and electron microscopy.

Rosette-forming glioneuronal tumor (RGNT) of the IV ventricle is a rare and recently recognized brain tumor entity. It is histologically composed by two distinct features: a glial component, resembling pilocytic astrocytoma, and a component forming neurocytic rosettes and/or perivascular rosettes. Herein, we describe a 33-year-old man with RGNT arising in the spinal cord. Following an immunohistochemistry validation, we further performed an extensive genomic analysis, using array-CGH (aCGH), whole exome and cancer-related hotspot sequencing, in order to better understand its underlying biology. We observed the loss of 1p and gain of 1q, as well as gain of the whole chromosomes 7, 9 and 16. Local amplifications in 9q34.2 and 19p13.3 (encompassing the gene SBNO2) were identified. Moreover, we observed focal gains/losses in several chromosomes. Additionally, on chromosome 7, we identified the presence of the KIAA1549:BRAF gene fusion, which was further validated by RT-PCR and FISH. Across all mutational analyses, we detected and validated the somatic mutations of the genes MLL2, CNNM3, PCDHGC4 and SCN1A. Our comprehensive molecular profiling of this RGNT suggests that MAPK pathway and methylome changes, driven by KIAA1549:BRAF fusion and MLL2 mutation, respectively, could be associated with the development of this rare tumor entity.

Pituicytoma is a rare low-grade (WHO grade I) sellar region glioma. Among sellar tumors, pituitary adenomas, mainly prolactinomas, may show amyloid deposits. Gelsolin is a ubiquitous calcium-dependent protein that regulates actin filament dynamics. Two known gene point mutations result in gelsolin amyloid deposition, a characteristic feature of a rare type of familial amyloid polyneuropathy (FAP), the Finnish-type FAP, or hereditary gelsolin amyloidosis (HGA). HGA is an autosomal-dominant systemic amyloidosis, characterized by slowly progressive neurological deterioration with corneal lattice dystrophy, cranial neuropathy, and cutis laxa. A unique case of pituicytoma with marked gelsolin amyloid deposition in a 67-year-old Chinese woman is described. MRI revealed a 2.6-cm well-circumscribed, uniformly contrast-enhancing solid sellar mass with suprasellar extension. Histologically, the lesion was characterized by solid sheets and fascicles of spindle cells with slightly fibrillary cytoplasm and oval nuclei with pinpoint nucleoli. Surrounding brain parenchyma showed marked reactive piloid gliosis. Remarkably, conspicuous amyloid deposits were identified as pink homogeneous spherules on light microscopy that showed apple-green birefringence on Congo red with polarization. Mass spectrometric-based proteomic analysis identified the amyloid as gelsolin type. Immunohistochemically, diffuse reactivity to S100 protein and TTF1, focal reactivity for GFAP, and no reactivity to EMA, synaptophysin, and chromogranin were observed. HGA-related mutations were not identified in the tumor. No recurrence was noted 14 months after surgery. To the knowledge of the authors, amyloid deposition in pituicytoma or tumor-associated gelsolin amyloidosis has not been previously described. This novel finding expands the spectrum of sellar tumors that may be associated with amyloid deposition.

We report here the case of an 82‐year‐old woman who presented with visual disturbance. MRI demonstrated a sellar mass. The diagnosis of pituitary adenoma was made. She underwent transnasal surgery. Histologic, immunohistochemical and ultrastructural studies indicated that the tumor was a melanoma. Despite an exhaustive search for a primary lesion elsewhere, none was found. The sellar tumor was considered a primary lesion, although extrasellar primary tumor imaging cannot be excluded with 100% certainty. Reported examples of melanoma affecting the sellar region are few. They exhibit morphologic features identical to those of melanomas arising elsewhere. Although very rare, primary melanomas enter into the differential diagnosis of sellar lesions.

Meningioma is a meningothelial （ arachnoidal ） cell neoplasm, typically attached to the inner surface of the dura mater. Most meningiomas are benign and correspond to WHO grade Ⅰ . Certain histological subtypes or meningiomas with specific combinations of morphologic parameters are associated with less favourable clinical out-comes and correspond to WHO grade Ⅱ , including chordoid, clear cell, and atypical meningiomas, and grade Ⅲ , including papillary, rhabdoid, and anaplastic meningiomas. The treatment strategy for meningiomas is total removal. While benign meningiomas have recurrence rates of about 7 − 25 ％ , WHO grade Ⅱ meningiomas recur in 29 − 52 ％ of cases and grade Ⅲ meningiomas at rates of 50 − 94 ％ . Thus, radiotherapy for grade Ⅱ and Ⅲ meningiomas after tumor removal may be needed.

AIMS:Hemangioblastomas may arise sporadically or in the setting of Von Hippel-Lindau (VHL) disease. In either instance, it rarely occurs outside the central nervous system. By analysis of a large case series, we sought to further characterize the clinical, radiologic and pathologic features of hemangioblastomas involving nerve root.MATERIALS AND METHODS:The clinical resentations of 6 proximal nerve root hemangioblastomas (1 an aggressive tumor) were analyzed with emphasis on the neuroimaging, operative, and pathologic findings. The literature is fully reviewed and updated.RESULTS:Nerve hemangioblastoma usually affects proximal spinal roots. Peripheral nerve is rarely involved. Both clinically and radiologically, the diagnosis is usually not suspected before surgery. Profuse bleeding at resection may be the first indication of the nature of the lesion. These tumors may arise both sporadically and in association with VHL disease.CONCLUSION:Given their rarity, nerve root hemangioblastomas are not generally considered in the preoperative differential diagnosis of proximal nerve root lesions. Given their propensity to bleed profusely at surgery and the potential association with VHL disease, knowledge of this entity is important.

BACKGROUND:Thymomas are typically benign tumors of thymic epithelium. Metastases to distal sites, particularly intracranial locations, are extremely rare. Herein, we present the third case of thymoma and the second invasive thymoma to metastasize to the cavernous sinus, adjacent to the pituitary.CASE DESCRIPTION:A 41-year-old female patient presented with headaches, stuffy nose, and drooping of the right face. A magnetic resonance imaging scan revealed a complex, multilobulated mass centered upon the right cavernous sinus. The mass was removed via transsphenoidal surgery, and histopathological investigation confirmed the diagnosis of metastatic thymoma. A positron emission tomography-computed tomography scan demonstrated a large anterior mediastinal mass. A biopsy confirmed the diagnosis of invasive thymoma morphologically identical to the World Health Organization type B2 sellar region metastasis.CONCLUSION:Although rare, thymomas can metastasize to the central nervous system. Our case is the second invasive thymoma to metastasize to the cavernous sinus, adjacent to the pituitary.

CONTEXT:Pituitary stalk lesions have various etiologies, often not clinically apparent. Pathological samples from these lesions are rarely obtained, because of the critical location and function of the hypophyseal stalk.OBJECTIVES:The purpose of this study was to characterize the etiological spectrum of pituitary stalk lesions seen at Mayo Clinic Rochester over 20 years and to determine whether specific magnetic resonance imaging (MRI) characteristics could provide clinician guidance with regard to the etiology of infundibular lesions.DESIGN:A retrospective review of patients with pituitary stalk lesions seen at Mayo Clinic Rochester between 1987 and 2006 was conducted. Demographic, clinical presentation, imaging, laboratory, operative, and pathology data were reviewed and are reported using descriptive statistics.RESULTS:Of the 152 pituitary stalk lesions included, 49 (32%) were neoplastic, 30 (20%) were inflammatory, 13 (9%) were congenital anomalies, and 60 (39%) were of unclear etiology. Diabetes insipidus was diagnosed in 43 (28%) of the 152 patients, and 49 (32%) patients had at least one anterior pituitary hormone deficit. Secondary hypogonadism was the most common endocrine deficiency. Eleven of 13 congenital lesions were round in appearance and 5 of 7 patients with neurosarcoidosis confirmed by pathology had a uniformly thickened pituitary stalk on MRI. There were no statistically significant correlations between hypopituitarism and the pattern of enhancement or size of the lesion.CONCLUSIONS:Findings on MRI remain key in guiding the diagnosis of pituitary stalk lesions, particularly when used in conjunction with other clinical clues. There are no good imaging predictors for hypopituitarism, making clinical evaluation of all patients with pituitary stalk lesions crucial.

Perineurial cells (PCs) participate in reactive and neoplastic processes, of the latter pure perineurial being intraneural (IP) and soft tissue perineuriomas with oral examples being reported in both. In our review of over 500 peripheral nerve sheath tumors including granular cell tumor, we identified a single ostensible case of IP occurring on the tongue of a 45-year-old African-American male that was characterized by classic perineurial pseudo-onion bulbs (PsOb), proliferating PCs among these PsOb, sclerosis apparently due to long term duration and a plexiform pattern. We have also encountered 37 examples of apparently reactive, hyperplastic or traumatic, PsOb intraneural pseudoperineuriomatous proliferation (IPP) simulating microscopically some of the properties of IP. The majority of the lesions occurred in women and close to 80 % affected the tongue. Three microscopic patterns were appreciated. Type I lesions were those where IPP was seen only focally, type II where it was seen in roughly half of the lesion, and type III where the majority of the lesional tissue or the lesion itself was characterized by IPP. Immunohistochemically, IPP featured PsOb with generally a single layer of PCs decorated by epithelial membrane antigen, glut-1 or claudin-1, and decreased numbers of S-100 positive Schwann cells. The number of axons was not apparently altered. A prominent collagenous intraneural component was occasionally evident among PsOb and the affected nerve featured discontinuous or absent perineurial envelop. While type I and II IPP can be distinguished from IP, the distinction from type III lesions can be problematic. However, the discontinuity of the perineurium of the affected nerve, the spacing and collagenization among PsOb, the limited perineurial cell layer defining the pseudo-onion bulbs, the absence of proliferating PCs between PsObs and the decreasing number of Schwann cells may be of help in the distinction from IP.

OBJECTIVE:In pregnant women, the pituitary is enlarged and the prolactin (PRL) secreting cells increase in size and number. This PRL cell hyperplasia is associated with hyperprolactinemia. The aim of the present work was to investigate adenohypophysial vascularization and immunoexpression of vascular endothelial growth factor (VEGF) in pituitaries of pregnant and post-partum women and compare the results with age-matched adenohypophyses of nonpregnant women who had no endocrine diseases.DESIGN:Pituitaries (n=18) obtained by autopsy from female patients of reproductive age who had died during pregnancy, after abortion or during post-partum were immunostained for CD-34 and VEGF using the streptavidinbiotin- peroxidase complex method.RESULTS:The results showed that microvessel densities and VEGF immunoexpression in the adenohypophyses of pregnant and post-partum women were similar to those found in the control pituitaries.CONCLUSION:It can be concluded that pituitary enlargement and PRL cell hyperplasia in pregnant women may occur without neovascularization and increased VEGF immunoexpression.

Pituitary tumor transforming gene (PTTG) plays a role in many cellular processes. PTTG overexpression is seen in several tumor types and correlates with survival time/recurrence. We evaluated PTTG expression in various types of brain tumors (n=94). Immunohistochemistry was performed using a monoclonal PTTG antibody (DCS‐280, Abcam;Cambridge, MA) and the streptavidin‐biotin‐peroxidase complex method. The intensity of PTTG immunoreactivity was evaluated semi‐quantitatively on a 0‐4 scale. PTTG expression was evident in most tumor cells and was predominantly nuclear. In glial tumors, PTTG immunoreactivity was higher in glioblastomas (IV), anaplastic oligoastrocytomas (III), anaplastic oligodendrogliomas (III), oligoastrocytomas (II), oligodendrogliomas (II), and pilocytic astrocytomas (I) (range: 3.1–3.5), whereas notably lower PTTG was seen in myxopapillary ependymomas (I) and ependymomas (II) (1.5 & 1.6). In non‐glial tumors, hemangiopericytomas and schwannomas had higher PTTG score (3.4), than meningiomas (2.3). Thus, it appears that PTTG expression is not associated with tumor grade, but rather with tumor type, the most striking difference being between ependymomas and other glial tumors. PTTG may be a valuable therapy target in some brain tumors. Acknowledgments Authors thank the Jarislowsky Foundation and the Lloyd‐Carr‐Harris Foundation for their generous support.

Primary hypothyroidism causes adenohypophysial hyperplasia via stimulation by hypothalamic thyrotropin-releasing hormone (TRH). The effect was long thought to simply result in thyroid-stimulating hormone (TSH) and prolactin (PRL) cell hyperplasia, an increase in TSH and PRL blood levels with resultant pituitary enlargement, often mimicking adenoma. Recently, it was shown that transformation of growth hormone (GH) cells into TSH cells takes place in both clinical and experimental primary hypothyroidism. Such shifts from one cell to another with a concomitant change in hormone production are termed “transdifferentiation” and involve the gradual acquisition of morphologic features of thyrotrophs (“somatothyrotrophs”). We recently encountered a unique case of pituitary hyperplasia in a 40-year-old female with primary hypothyroidism wherein increased TSH production was by way of PRL cell recruitment. The resultant “lactothyrotrophs” maintained TSH cell morphology (cellular elongation and prominence of PAS-positive lysosomes) but expressed immunoreactivity for both hormones. No co-expression of GH was noted nor was thyroidectomy cells seen. This form of transdifferentiation has not previously been described.

Purpose While pituitary adenomas are common, pituitary carcinomas are rare. It is unclear whether pituitary carcinomas arise de novo or evolve from adenomas.Methods We studied the clinical characteristics and tissue samples from eight pituitary surgeries and the autopsy from a patient with pituitary carcinoma. A 16-year-old female patient was diagnosed with an aggressive Crooke cell macroadenoma. Following transsphenoidal surgery, clinical signs of Cushing disease quickly reappeared. During the 14-year course of the illness, eight pituitary surgeries, three courses of extracranial irradiation and two (90)Yttrium-DOTATOC treatments were undertaken. A bilateral adrenalectomy was performed. The patient died of metastatic disease and uncontrolled hypercortisolism due to an adrenal remnant. A systematic morphologic study (histologic staining, electron microscopy) of all available surgical and autopsy specimens was undertaken.Results Brisk mitotic activity, high Ki-67 and p53 immunolabelling were present in the pituitary samples from the onset. High proportion of tumour cells showed irregular nuclei and large nucleoli, and gradual increase in MGMT staining was observed. The tumour remained of Crooke cell type throughout the course. Autopsy disclosed a postirradiation sarcoma in the pituitary area.Conclusions The question whether pituitary carcinomas arise de novo or transform from an adenoma cannot be answered at present with certainty.

Previous studies showed that in pregnancy the pituitary enlarges and increases in weight due to lactotroph hyperplasia. We demonstrated that in pituitaries of pregnant women, microvessel density is significantly increased compared to those of age– matched non pregnant women. Vascular endothelial growth factor (VEGF) stimulates new vessel formation in several tissues and neoplasms. The aim of the present study was to reveal whether VEGF is involved in the causation of increased vascularity in the pituitaries of pregnant women. We assessed VEGF immunoexpression in 20 autopsy obtained pituitaries of pregnant women and compared the results with 20 controls. Slides were immunostained for VEGF and pituitary hormones using the streptavidin‐biotin‐peroxidase complex method. VEGF immunoexpression was evaluated in 10 random high‐power fields using an image analyzer and the results compared by chi‐square or Fisher exact tests. Immunoexpression of VEGF was not increased in the adenohypophyses of pregnant women compared with the controls indicating that VEGF plays no major role in the causation of increased vascularity. The cause remains to be investigated.

We briefly review the characteristics of pituitary tumors associated with multiple endocrine neoplasia type 1. Multiple endocrine neoplasia type 1 is an autosomal-dominant disorder most commonly characterized by tumors of the pituitary, parathyroid, endocrine-gastrointestinal tract, and pancreas. A MEDLINE search for all available publications regarding multiple endocrine neoplasia type 1 and pituitary adenomas was undertaken. The prevalence of pituitary tumors in multiple endocrine neoplasia type 1 may vary from 10% to 60% depending on the studied series, and such tumors may occur as the first clinical manifestation of multiple endocrine neoplasia type 1 in 25% of sporadic and 10% of familial cases. Patients were younger and the time between initial and subsequent multiple endocrine neoplasia type 1 endocrine lesions was significantly longer when pituitary disease was the initial manifestation of multiple endocrine neoplasia type 1. Tumors were larger and more invasive and clinical manifestations related to the size of the pituitary adenoma were significantly more frequent in patients with multiple endocrine neoplasia type 1 than in subjects with non-multiple endocrine neoplasia type 1. Normalization of pituitary hypersecretion was much less frequent in patients with multiple endocrine neoplasia type 1 than in subjects with non-multiple endocrine neoplasia type 1. Pituitary tumors in patients with multiple endocrine neoplasia type 1 syndrome tend to be larger, invasive and more symptomatic, and they tend to occur in younger patients when they are the initial presentation of multiple endocrine neoplasia type 1.