Primary hypophysitis: a single-center experience in 16 cases

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Object. The authors review their experience in the treatment of 16 patients with primary hypophysitis.

Methods. A retrospective study was undertaken to review cases of primary hypophysitis. The mean age of the patients was 47 years and there was an equal distribution of sexes. Recent pregnancy and underlying autoimmunity were noted in 50% of the patients. Two patients had undergone previous transsphenoidal operations at other centers, one for prolactinoma and another for hypophysitis. Headache, anterior pituitary deficiency, and suprasellar mass lesions were the most common presenting features. The initial presumptive diagnosis was pituitary adenoma in six patients (37.5%) and inflammatory hypophysitis in 10 (62.5%). Five patients received initial medical therapy for hypophysitis; although three (60%) responded satisfactorily, two (40%) did not and later underwent surgery.

Altogether 13 patients (81.2%) underwent transsphenoidal surgery. The histological diagnoses were lymphocytic hypophysitis in 10 (76.9%) and granulomatous hypophysitis in three (23.1%) of the surgically treated patients. A coexistent Rathke cleft cyst was noted in one patient. There was no death in this series. One patient experienced postoperative cerebrospinal fluid leakage and meningitis. One patient had bilateral internal carotid artery occlusion secondary to inflammatory involvement of the cavernous sinuses and arteritis. This patient recovered and is capable of independent functional activities.

Conclusions. All surgical patients experienced improvement in their headache and/or visual field defects and none had visual deterioration. None of the patients experienced any improvement in endocrine function and all required long-term hormone replacement. Transsphenoidal surgery was a safe and effective treatment especially for visual and pressure symptoms. A postoperative recurrence developed in two patients (15.4%) and the treatment modalities included steroid therapy, repeated surgery, and radiosurgery.

Article Information

Address reprint requests to: Edward R. Laws Jr., M.D., Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, Virginia 22908. email: bjb4k@hscmail.mcc.virginia.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 7. Coronal (left) and sagittal (right) Gd-enhanced MR images demonstrating features of inflammatory hypophysitis. Note the contrast-enhanced triangular sellar mass, the cavernous sinus extension, and the thickened and enhanced, pituitary stalk.

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    Photomicrographs showing lymphocytic hypophysitis. The pituitary gland is diffusely infiltrated by lymphocytes and plasma cells (left), resulting in the destruction of the adenohypophysial parenchyma and clusters of residual pituitary acini (right). H & E, original magnifications × 100 (left) and × 200 (right).

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    Photomicrographs showing granulomatous hypophysitis. The adenohypophysis contains granulomas characterized by aggregates of lymphocytes and epithelioid histiocytes with the formation of giant cells (left). There is destruction of the pituitary tissue with dense stromal fibrosis (right). Residual epithelial cells may be seen in the center of the right panel. H & E, original magnifications × 100 (left) and × 200 (right).

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    Case 16. Coronal Gd-enhanced MR images obtained in a patient with postoperative recurrent hypophysitis: on presentation (a), 6 months after surgery when the patient experienced a recurrence of symptoms (b), during steroid therapy for this recurrence (c), 19 months after GKS (d), and 33 months after GKS (e).

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    Algorithm for the treatment of presumed lymphocytic hypophysitis. DI = diabetes insipidis.

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