Polish Medical Society of Radiology and Polish Society of Rheumatology Recommendations for Magnetic Resonance Imaging of Musculoskeletal Disorders in Rheumatology.

This document presents the recommendations of the Polish Medical Society of Radiology (PLTR) and the Polish Society of Polish Society of Rheumatology (PTR) regarding the standards of collaboration between radiologists and rheumatologists so as to optimize the diagnostics and treatment of patients with rheumatic diseases of the musculoskeletal system, including rheumatoid arthritis and spondyloarthropathies.

Endosonography and magnetic resonance imaging in the diagnosis of high anal fistulae - a comparison.

Anal fistula is a benign inflammatory disease with unclear etiology which develops in approximately 10 in 100 000 adult patients. Surgical treatment of fistulae is associated with a risk of damaging anal sphincters. This usually happens in treating high fistulae, branched fistulae, and anterior ones in females. In preoperative diagnosis of anal fistulae, endosonography and magnetic resonance imaging play a significant role in planning the surgical technique. The majority of fistulae are diagnosed in endosonography, but magnetic resonance is performed when the presence of high fistulae, particularly branched ones, and recurrent is suspected. THE AIM OF THIS PAPER: The aim of this paper was to compare the roles of the two examinations in preoperative assessment of high anal fistulae. MATERIAL AND METHODS: The results of endosonographic and magnetic resonance examinations performed in 2011-2012 in 14 patients (4 women and 10 men) with high anal fistulae diagnosed intraoperatively were subject to a retrospective analysis. The patients were aged from 23 to 66 (mean 47). The endosonographic examinations were performed with the use of a BK Medical Pro Focus system with endorectal 3D transducers with the frequency of 16 MHz. The magnetic resonance scans were performed using a Siemens Avanto 1.5 T scanner with a surface coil in T1, T1FS, FLAIR, T2 sequences and in T1 following contrast medium administration. The sensitivity and specificity of endosonography and magnetic resonance imaging were analyzed. A surgical treatment served as a method for verification. The agreement of each method with the surgery and the agreement of endosonography and magnetic resonance imaging were compared in terms of the assessment of the fistula type, localization of its internal opening and branches. The agreement level was determined based on the percentage of consistent assessments and Cohen's coefficient of agreement, κ. The integrity of the anal sphincters was assessed in each case. RESULTS: In determining the fistula type, magnetic resonance imaging agreed with intraoperative assessment in 79% of cases, and endosonography in 64% of cases. Endosonography agreed with magnetic resonance in 57% of cases. In the assessment of internal opening, the agreement between endosonography and intraoperative assessment was 65%, between magnetic resonance and intraoperative assessment - 41% and between endosonography and magnetic resonance - 53%. In the assessment of fistula branches, endosonography agreed with intraoperative assessment in 67% of cases, magnetic resonance in 87% of cases, and the agreement between the two methods tested was 67%. CONCLUSIONS: Magnetic resonance is a more accurate method than endosonography in determining the type of high fistulae and the presence of branches. In assessing the internal opening, endosonography proved more accurate. The agreement between the two methods ranges from 53-67%; the highest level of agreement was noted for the assessment of branching.

Significance of bone marrow edema in pathogenesis of rheumatoid arthritis.

Assessing the pathology of the synovium, its thickening and increased vascularity through ultrasound and magnetic resonance examinations (more often an ultrasound study alone) is still considered a sensitive parameter in the diagnosis of rheumatoid arthritis and in monitoring of treatment efficacy. Magnetic resonance studies showed that, aside from the joint pannus, the subchondral bone tissue constitutes an essential element in the development of rheumatoid arthritis. Bone marrow edema correlates with inflammation severity, joint destruction, clinical signs and symptoms of rheumatoid arthritis, and thus is considered a predictor of rapid radiological progression of the disease. The newest studies reveal that bone marrow edema may be a more sensitive indicator of the response to therapy than appearance of the synovium. Bone marrow edema presents with increased signal in T2-weighted images, being most visible in fat saturation or IR sequences (STIR, TIRM). On the other hand, it is hypointense and less evident in T1-weighted images. It becomes enhanced (hyperintense) after contrast administration. Histopathological studies confirmed that it is a result of bone inflammation (osteitis/osteomyelitis), i.e. replacememt of bone marrow fat by inflammatory infiltrates containing macrophages, T lymphocytes, B lymphocytes, plasma cells and osteoclasts. Bone marrow edema appears after a few weeks from occurrence of symptoms and therefore is considered an early marker of inflammation. It correlates with clinical assessment of disease activity and elevated markers of acute inflammatory phase, i.e. ESR and CRP. It is a reversible phenomenon and may become attenuated due to biological treatment. It is considered a "herald" of erosions, as the risk of their formation is 6-fold higher in sites where BME was previously noted.

The pathogenesis of rheumatoid arthritis in radiological studies. Part II: Imaging studies in rheumatoid arthritis.

Early diagnosis of rheumatoid arthritis followed by early initiation of treatment, prevent the destruction of joints and progression to disability in the majority of patients. A traditional X-ray fails to capture early inflammatory changes, while late changes (e.g. erosions) appear after a significant delay, once 20-30% of bone mass has been lost. Sonography and magnetic resonance imaging studies have shown that erosions are seen in the first 3 months from the appearance of symptoms in 10-26% of patients, while in 75% they are seen in the first 2 years of the disease. Power Doppler ultrasound and dynamic magnetic resonance studies allow for qualitative, semiquantitative and quantitative monitoring of the vascularization of the synovium. In addition, magnetic resonance enables assessment of the bone marrow. The ultrasonographic examination using a state-of-the-art apparatus with a high-frequency probe allows for images with great spatial resolution and for the visualization of soft tissues and bone surfaces. However, the changes seen in ultrasonography (synovial pathologies, the presence of exudate, tendons changes, cartilage and bone lesions, pathologies of tendon attachments and ligaments - enthesopathies) are not only specific for rheumatoid arthritis and occur in other rheumatic diseases. Qualitative methods are sufficient for diagnosing the disease through ultrasound or magnetic resonance imaging. Whereas semiquantitative and quantitative scales serve to monitor the disease course - efficacy of conservative treatment and qualification for radioisotope synovectomy or surgical synovectomy - and to assess treatment efficacy.

The pathogenesis of rheumatoid arthritis in radiological studies. Part I: Formation of inflammatory infiltrates within the synovial membrane.

Rheumatoid arthritis is a chronic inflammatory disease with a multifactorial etiology and varied course, which in the majority of patients leads to partial disability or to permanent handicap. Its characteristic trait is a persistent inflammation of the synovial membrane and the formation of an invasive synovial tissue, called the pannus, which in time leads to destruction of the cartilage, subchondral bone tissue, and the soft tissue of the affected joint(s). The pathogenesis of rheumatoid arthritis is complex and involves cells of both innate and adaptive immunity, a network of various cytokines and an immunoregulatory dysfunction. An important role in the discovery of rheumatoid arthritis pathogenesis was played by magnetic resonance imaging, which showed the disease process to extend beyond the synovium into the bone marrow. Many studies have shown a strict correlation between the vascularity of the synovium (assessed through the power Doppler ultrasound and magnetic resonance examinations), bone marrow edema and the clinical, laboratory and histopathological parameters of rheumatoid arthritis. From the current understanding of rheumatoid arthritis, bone erosions could occur from two directions: from the joint cavity and from the bone marrow. With power Doppler ultrasound, as well as in magnetic resonance imaging, it is possible to visualize the well-vascularized pannus and its destructive effects on joint structures and ligaments. In addition, the magnetic resonance study shows inflammatory and destructive changes within the bone marrow (bone marrow edema, inflammatory cysts, and erosions). Bone marrow edema occurs in 68-75% of patients with early rheumatoid arthritis and is considered to be a predictor of rapid disease progression.

Familial narcolepsy.

BACKGROUND AND PURPOSE: Narcolepsy is a disease characterized by chronic excessive daytime sleepiness with episodic sleep attacks. There are several associated symptoms of narcolepsy: cataplexy (bilateral muscle weakness without loss of consciousness, provoked by an emotional trigger, e.g. laughter), sleep paralysis (isolated loss of muscle tone associated with rapid eye movement [REM] in normal sleep) and hypnagogic-hypnopompic hallucinations (vivid dreaming occurring at the time of sleep onset and awakening that can be difficult to distinguish from reality). MATERIAL AND METHODS: The authors present eleven patients with suspected narcolepsy, who were members of a five-generation family with many cases of episodic excessive daytime sleepiness. Some of them experienced sleep attacks which were occasionally associated with a sudden loss of muscle tone (cataplexy), as well as with sleep paralysis and hypnagogic hallucinations. All probands had magnetic resonance (MR) of the brain performed, along with routine blood tests, EEG, polysomnography, examination of the level of hypocretin in the cerebrospinal fluid and evaluation by means of Epworth and Stanford Sleepiness Scales. RESULTS: Narcolepsy was diagnosed in nine patients. Improvement in their clinical state was observed during the treatment with modafinil.

[Compression neuropathy of cranial nerves in the course of Takayasu arteritis]. / Neuropatia z ucisku nerwów czaszkowych w przebiegu choroby Takayasu.

Takayasu arteritis is a rare vasculitis of the aorta and its branches. Neurological manifestation usually results from central nervous system ischaemia. We report a case presenting with unilateral paresis of the cranial nerves (V, IX and XII nerve) caused by a vascular conflict due to Takayasu arteritis. A 38-year-old male was admitted to the hospital complaining of dysarthria, dysphagia, numbness of the right side of the tongue and a headache localized behind the right eye. The symptoms had sudden onset. Neurological examination revealed isolated trigeminal, glossopharyngeal and hypoglossal nerve dysfunction on the right side without other neurological symptoms. Magnetic resonance angiography showed internal carotid artery dissection and prominent thickening of walls of both vertebral arteries as well as the left renal artery with narrowing of lumen. Compression of glossopharyngeal and hypoglossal nerves and the trigeminal ganglion was a result of a markedly dilated intracranial segment of the right carotid artery. The clinical and radiological findings were consistent with the diagnosis of Takayasu arteritis.

[Diagnostic value of multislices computed tomography and magnetic resonance in deeply seated tumors of pharynx, neck and larynx]. / Wartosc diagnostyczna wielorzedowej tomografii komputerowej i rezonansu magnetycznego w diagnostyce gleboko polozonych guzów gardla, szyi i schorzen krtani.

Ultrasound, CT, MR examinations are complementary in preoperative and post-treatment follow up diagnosis in neck region pathology as well as conventional angiography in vascular tumors. The paper presents retrospectively analized CT and MR examinations of 100 patients treated in ORE Department of Military Medical Institute. The limitations and value of CT and MR methods were taken into the consideration. The high value of spiral multislice CT method should be pointed in pathology of larynx due to possibility of precise evaluation of soft tissues with nodular changes and cervical vascular system, expansion into the cartilage structures and functional examination performed during fonation. MR method is more sensitive than CT in localization of neoplastic infiltration among soft tissues structures, so the method is highly essential in estimation of post-surgical cases as well as fusion of nuclear medicine and CT or MR finding or PET.

[Diagnostic difficulties of advanced forms of exudative AMD]. / Trudnosci diagnostyczne zaawansowanych postaci wysiekowego AMD.

UNLABELLED: Advanced forms of exudative AMD often form diagnostic difficulties and need to be differentiated with other proliferative diseases of the posterior pole. The necessary diagnostic examinations in theses cases are fluorescein and indocyanine green angiography, and nuclear magnetic resonance (MR) of the eye balls. Angiogenesis in the degenerative changes of the retina results in similar degree of enhancement in MR as in melanomas and metastases. The aim of this presentation is to discuss and compare the images of advanced forms of exudative AMD in images from fluorescein angiography, ultrasound, and especially MR based on clinical cases. CONCLUSIONS: Despite being a very sensitive method due to its high tissues differentiation MR does not allow to define degenerative and proliferative changes in small foci.

Co-registration of cardiac MRI and rest gated SPECT in the assessment of myocardial perfusion, function and viability.

PURPOSE: Myocardial perfusion is routinely measured by SPECT--this technique has a rather low spatial resolution but covers the whole myocardium and is equipped with efficient image analysis software. Cardiac MRI has higher spatial resolution than SPECT and excellent sequences for myocardial function and viability detection but the lack of easy-to-use methods of acquisition and post-processing of perfusion images prevents this method from being used for perfusion evaluation in clinical practice. The aim of the study was to explore whether the 3-D co-registration of "cine" MRI (cine MRI), delayed enhancement MRI (DE MRI) and gated SPECT (GSPECT) images might be used for differentiating all reversible and irreversible effects of ischemia in anatomically matched myocardial regions. METHODS: We analyzed 685 segments of the heart (6 segments in each short axis slice)-obtained as a result of MRI and GSPECT studies performed in 18 patients. In each segment, myocardial function, perfusion and viability were analyzed. Myocardial wall function was evaluated using the matched images of diastolic and systolic phases of cine MRI. Perfusion as MIBI uptake per volume (MIV) (counts/mm3) in each myocardial segment was evaluated by co-registration of diastolic phases of cine MRI and GSPECT. Transmural extent of infarction was determined by co-registration of DE MRI and diastolic phase of cine MRI. RESULTS: We have found a close correlation between regional perfusion and function at rest in matched MRI and SPECT images: dysfunctional segments had significantly less MIV (MIV = 4.63 SD 1.58) than normal segments (MIV = 8.86 SD 2.77) (p < .05). There was no significant difference in MIV between viable and non-viable dysfunctional segments defined by DE MR due to a small number of nonviable segments in our study (18/685). CONCLUSION: Matching rest perfusion and function in anatomically co-registered myocardial segments in our study confirms that 3-D image co-registration of cine MRI, DE MRI and gated SPECT could be a precise method of integrated visualization of perfusion, function and viability helping in differentiating all forms of reversible and irreversible effects of myocardial ischemia.

[Diagnostic problems of unilateral exophthalmos--case report]. / Trudnosci rozpoznawcze jednostronnego wytrzeszczu--opis przypadku.

This paper presents a case of a 54-year-old patient with unilateral exophthalmos. During the hospitalization basic laboratory investigations, USG, skull X-ray film, NMR of orbits were carried out. The patient was treated with systemic corticosteroids with good response. Inflammatory infiltration and venous stasis are considered to be the cause of exophthalmos. Granulomatous orbital inflammation was detected. The etiology of nonspecific orbital inflammation remains still unknown.

[Transsphenoidal surgery of secretory and invasive pituitary adenomas (somatotropinoma or corticotropinoma)--own experiences]. / Zastosowanie dostepu przezklinowego w leczeniu operacyjnym czynnych hormonalnie (wydzielajacych GH lub ACTH) inwazyjnych guzów przysadki mózgowej--doswiadczenia wlasne.

UNLABELLED: Invasive pituitary adenomas with extension to the cavernous sinus are rare and comprise 6-10% of all pituitary tumors. Their effective surgical treatment is very difficult. Cavernous sinus invasion increases the morbidity and mortality associated with surgical procedures. Prolonged medical treatment and radiotherapy are an alternative to the surgery. PURPOSE: Efficiency of the extended transnasal transsphenoidal approach in the treatment of the invasive pituitary adenomas with extension to the cavernous sinus. MATERIAL AND METHOD: During the past two years (from January 2000 to December 2001) authors carried out 24 surgical operation in the medial compartment of the cavernous sinus (extended transnasal transsphenoidal approach). Our experience is based on the analysis of 24 patients (19 patients with GH-secreting tumors and 5 patients with ACTH-secreting adenomas--2 with Cushing disease and 3 with Nelson's syndrome) with invasive macroadenomas expanding to the cavernous sinus. Mean age was 46.21 years (range 28-68, SD +/-9.54 years) in our group. Mean serum GH level was 43.95 microg/l (range 9-170 microg/l, SD +/-39.68 microg/l) and mean serum ACTH level in the group of Nelson's syndrome was 1180 pg/ml (range 790-1780 pg/ml, SD +/-527.35 pg/ml). Parasellar extension of the tumor was measured according to Knosp's scale. There were 16 patients in stage III and 9 patients in stage IV. RESULTS: Total surgical removal of invasive GH-secreting adenoma (according cure criteria: basal serum GH level below 2.5 microg/l, OGTT<1 microg/l, normal sex and age-related IGF-I level) we achieved in 6 patients. Basal serum GH level was below 5 microg/l (postoperative mean serum IGF-I level was significantly lower but abnormal) in the next five patients. Remission (normalization of 24-hour urine-free cortisol (UFC) and its metabolites) was achieved in one patient with Cushing disease. Out of 3 patients with Nelson's syndrome two were cured. Their postoperative serum ACTH level was below 80 pg/ml. There were no mortality and no deterioration of cranial and optic nerves. CSF leakage occurred in one patient and was treated surgically. Deterioration of pituitary function and diabetes insipidus occurred in one patient. CONCLUSION: Extended transnasal transsphenoidal approach is the safe surgical procedure in the treatment of invasive GH or ACTH-secreting pituitary adenomas. The overall morbidity rate of this surgical intervention is rare. We suppose the extended transnasal transsphenoidal approach is an alternative for prolonged medical treatment and radiotherapy.

[Own experience in surgical treatment of the pineal region and midbrain tumors via the infratentorial approach]. / Wlasne doswiadczenia w leczeniu chirurgicznym guzów okolicy szyszynki i sródmózgowia z zastosowaniem dostepu podnamiotowego.

Nine cases of tumours located in the pineal and midbrain region in adults operated on between November 1998 and July 2002 in Dept. of Neurosurgery, Central Military Hospital in Warsaw are reported. The patients (2 men and 7 women) were aged from 27 and 69 years (mean age 43.6 years). Their main initial symptoms were caused by hydrocephalus. The histopathological examination revealed anaplastic pinealoma in 2 cases, and pineocytoma, pineal cyst, mesencephalic glial cyst, protoplasmatic astrocytoma, epidermoid cyst, unclear glial scar, and papillary ependymoma in single cases. Five patients had been treated, usually elsewhere, with shunt implantation prior to the surgery. Occipito-suboccipital osteoplastic craniotomy was performed in each case and tumours were totally removed microsurgically via the infratentorial epicerebellar approach. In one case a part of the glial periaqueductal tumour was resected additionally via the fourth ventricle and aqueduct in one stage. Postoperative haematomas in the third and fourth ventricle were found in 2 cases. Main complaints after the surgery included transient diplopia. All the patients improved significantly and resumed their previous life activities. Follow-up ranged from 3 to 44 months. Three patients with pineal tumours and one with a small postoperative ependymoma recurrence were irradiated after the surgery. One patient had been irradiated prior to surgery. Very good results of the surgical treatment of tumours in this area suggest that such patients should be referred earlier to one stage surgical management, as the procedure is easier to perform and shunt implantation may be avoided.

[Surgical treatment of invasive pituitary adenomas (somatotropinoma or corticotropinoma)]. / Leczenie operacyjne czynnych hormonalnie (wydzielajacych GH lub ACTH) inwazyjnych gruczolaków przysadki mózgowej.

AIM OF THE STUDY: To evaluate efficiency of the transcranial epidural approach in the treatment of invasive GH- or ACTH-secreting pituitary adenomas with extension to the cavernous sinus. MATERIAL AND METHODS: During the past two years (from January 2000 to December 2001) 14 patients with invasive GH- or ACTH-secreting pituitary adenomas extending to the cavernous sinus were operated on using the transcranial epidural approach. Our experience is based on an analysis of 12 patients with GH-secreting tumors and 2 patients with ACTH-secreting adenomas. The patients' mean age was 45.36 years (range 28-66, SD +/- 10.26 years). Parasellar extension of the tumor was measured using the Knosp scale--in all the cases there was an extension to the cavernous sinus, in stage III (4 patients) or stage IV (10 patients). RESULTS: In none of the cases a total surgical removal of the invasive GH-secreting adenoma was attained (according the following cure criteria: basal serum GH level below 2.5 micrograms/l, OGTT < 1 microgram/l, normal sex- and age-related IGF-I level). In four patients the surgery resulted in a reduction of the basal serum GH level to below 5 micrograms/l (their postoperative mean serum IGF-I level was 530 micrograms/l--significantly lower, but still abnormal, p < 0.05). In a single case of a female patient the basal serum GH level was below 10 micrograms/l, while in other 7 patients the GH level remained above 10 micrograms/l. Remission (normalization of 24-hour urine-free cortisol (UFC) and its metabolites) was achieved in one patient with the Cushing disease. There were no complications involving case fatality. A transient deterioration of the third cranial nerve function observed in one patient disappeared within 3 months from the surgery. There was no deterioration of pituitary function and no cases of diabetes insipidus in our group. CONCLUSION: Transcranial epidural approach is an alternative to radiotherapy and/or prolonged medication in the treatment of invasive GH- or ACTH-secreting pituitary adenomas.

[Surgical treatment of trigeminal neurinoma]. / Leczenie operacyjne nerwiaków nerwu trójdzielnego.

The article presents the group of five patients with clinical and radiological symptoms of trigeminal neurinoma that were operated on in the Neurosurgical Clinic of Central Clinical Hospital of Military Medical Academy in the five-years period (1995-2000). Three of them were operated in a single step procedure from subtemporal and suboccipital approach. Two other were operated in two steps, also from subtemporal and suboccipital approaches. Four neurinomas were removed radically, as confirmed by CT, and MRI scans. All the patients are independent and professionally active. Complications observed after the operation were: persistent anaesthesia in the trigeminal area, atrophy of the masseter muscle, transient paresis of the facial nerve with ulceration and opacification of the cornea, and transient paresis of the abducens nerve.

[Colloid cysts of the pituitary gland]. / Wystepowanie torbieli koloidowych przysadki mózgowej.

Colloid cysts of the pituitary gland are very rare pathological lesions occurring in sellar region. Their pathogenesis is not clear. They are located between the anterior and posterior lobe of the pituitary. Colloid cysts of the pituitary gland are space occupying lesions and induce hypopituitarism, diabetes insipidus, visual disturbances, etc. They cause pituitary apoplexy too. Magnetic resonance imaging is the preferred neurodiagnostic method in evaluating these lesions. 503 transsphenoidal procedures were performed from January 1996 to February 2001. Hypothalamo-hypophyseal dysfunction was caused by colloid cyst in seven cases. The most frequent presenting symptoms were headaches, oligomenorrhea and loss of libido. Diabetes insipidus was found in two cases before surgery. Colloid cyst induced pituitary apoplexy in one patient. Two patients presented visual disturbances. All our patients were operated on. We performed six transsphenoidal procedures and one transcranial operation. Postoperatively, the endocrine function of the pituitary gland was evaluated. We concluded that transsphenoidal operation is a safe method for treating colloid cyst located in the sellar region.

[Ectopic pituitary adenoma. Case report and review of literature]. / Ektopowy gruczolak przysadki. Opis przypadku i przeglad pismiennictwa.

Ectopic pituitary adenomas are very rare neoplasms. They are usually located in the sphenoid sinus or nasopharynx. Ectopic tumors derive from a residual pituitary fragment in the craniopharyngeal duct. They are similar in morphology, immunohistochemistry and hormonal activity to the typical pituitary adenoma. One third ectopic pituitary tumors reported in the literature are endocrine inactive, while the remaining ones indicate a hormonal activity and usually secrete ACTH, causing the Cushing disease. About 50% of pituitary adenomas are located at the skull base and present as aggressive neoplasms. The computed axial tomography (CAT) and magnetic resonance imaging (MRI) are very useful in revealing the presence of these tumors. Preoperative diagnosis of ectopic pituitary adenomas located at the skull base is difficult. Diagnostic procedures usually suggest another type of neoplasm, e.g. chordoma, nasopharyngeal carcinoma, or a metastatic tumor. Pathological examination including immunohistochemical studies of neuroendocrine markers is important in establishing the diagnosis. A unique case of ectopic, nonfunctioning pituitary adenoma involving the sphenoid sinus and nasopharynx and causing palsy of cranial nerves is presented. MRI examination revealed the presence of a large invasive tumor. The neoplasm was partially resected by transnasal approach. The diagnosis was confirmed by a pathological examination including immunohistochemical smears.

[Thyrotropin--TSH secreting pituitary tumor]. / Tyreotropinoma--gruczolak przysadki wydzielajacy TSH.

Thyrotropin-releasing pituitary tumors represent 0.9 to 2.8% of all pituitary adenomas. They cause secondary or central hyperthyroidism. The diagnosis of these tumors has been increasing in the past 20 years. It was produced by introduction of the sensitive immunoradio-metric assay of TSH and better radiological imaging (magnetic resonance imaging). TSH--secreting pituitary adenomas are aggressive and invasive neoplasms. Most reports describe a poor outcome after pharmacological therapy, surgery and radiation therapy. Presently the diagnosis of thyrotropin-secreting pituitary tumor is based on the lack of: a. inhibition of TSH levels in the presence of increased free thyroid hormones; b. response of TSH to stimulation with TRH; c. and presence of a abnormal, neoplastic(adenomatous) intrasellar or parasellar mass. Surgical excision (selective adenomectomy) by the transsphenoidal route is the first treatment. Craniotomy should be reserved for parasellar tumors with significant lateral extension. Pharmacological pretreatment with long acting somatostatin analogues is recently a standard before surgery. This medical treatment of the TSH-omas is effective in reducing TSH and free thyroid hormone plasma levels. Administration of the somatostatin analogues causing tumor mass shrinkage and changes consistency. This pretreatment is effective therapy and improves surgical outcome especially in patients harbouring macroadenomas. Radiotherapy is noncurative and produces long term complications (hypopituitarism). Authors present and discuss current cure criteria of TSH-omas with reference to their clinical experience.