Development and validation of a prediction model for consistency of pituitary adenoma: the PiTCon score.

PURPOSE: Pituitary adenomas (PAs) usually have a soft consistency, facilitating gross total resection. However, 5-13% of PAs with fibrous consistency are challenging to remove entirely and are accompanied by greater morbimortality. This study aims to identify the clinical and radiological characteristics that correlate with PA fibrous consistency preoperatively. A simple scoring system has been proposed to predict incidence of fibrous PAs. MATERIALS AND METHODS: Consecutive interventions (226) were analyzed, all performed through an endoscopic endonasal transsphenoidal approach. Univariable and multivariable logistic regression analysis was performed. Hosmer-Lemeshow test and receiver operating characteristic (ROC) curves were assessed to evaluate the model. A point scoring system (PiTCon) was derived based on the multivariable regression model. Our study aimed to identify the clinical and radiological characteristics that correlate with fibrous tumor consistency preoperatively. RESULTS: The best diagnostic accuracy for predicting PA consistency consisted of five predictive factors: age, compressive symptoms, panhypopituitarism, craniocaudal extension of the PA in mm, and prior surgery. The multivariable model achieved good discrimination with an area under the curve (AUC) of the ROC curve being 0.82 and the 95% CI 0.76 to 0.88. Internal validation yielded an optimism-adjusted C-statistic of 0.80 (95% CI 0.74 to 0.86). A point scoring system (PiTCon score) was designed using the best predictive model. CONCLUSIONS: PA consistency can be estimated preoperatively regarding clinical and radiological characteristics. We propose a point-based scoring system (PiTCon score) that can better guide neurosurgeons in clinical decision-making and surgical risk assessment and help establish and describe patient prognosis.

Giant fronto-spheno-orbitary juvenile psammomatoid ossifying fibroma: Case report and literature review.

Juvenile psammomatoid ossifying fibroma (JPOF) is an osteofibrous neoplasm that originates in the craniofacial skeleton typically during the first three decades of life. JPOFs usually involve the orbit, paranasal sinuses or the jaws. Extensive involvement of the anterior cranial base with compromised visual function is a rare phenomenon. In such clinical context, a definite diagnosis can only be made on the basis of histopathological findings, given the absence of pathognomonic radiological features. Despite being considered a benign entity, JPOFs present a locally aggressive behavior. Therefore, these neoplasms must be included in the differential diagnosis in every patient harboring a skull base osteofibrous lesion, and, once diagnosed, gross total surgical removal should be attempted. In this study, we present our experience in the diagnosis and treatment of a patient diagnosed with a giant JPOF involving the cranial base.

Neuropathological findings in fatal COVID-19 and their associated neurological clinical manifestations.

Severe cases of Coronavirus Disease 2019 (COVID-19) can present with multiple neurological symptoms. The available neuropathological studies have described different lesions; the most frequent was the presence of neuroinflammation and vascular-related lesions. The objective of this study was to report the neuropathological studies performed in a medical institution, with abundant long intensive care unit stays, and their associated clinical manifestations. This is a retrospective monocentric case series study based on the neuropathological reports of 13 autopsies with a wide range of illness duration (13-108 days). A neuroinflammatory score was calculated based on the quantification of CD8- and CD68-positive cells in representative areas of the central nervous system. This score was correlated afterwards with illness duration and parameters related to systemic inflammation. Widespread microglial and cytotoxic T-cell activation was found in all patients. There was no correlation between the neuroinflammatory score and the duration of the illness; nor with parameters of systemic inflammation such as the peak of IL-6 or the HScore (a parameter of systemic macrophage activation syndrome). Two patients had global hypoxic ischaemic damage and five patients had subacute infarcts. One patient had many more brain vascular microthrombi compared to the others and multiple subacute pituitary infarcts. SARS-CoV-2 RNA was not detected with qRT-PCR. The proportion of brain lesions in severe COVID-19 patients could be related to illness duration. In our series, with abundant long hospitalisation stays, neuroinflammation was present in all patients and was more prominent between day 34 and day 45 after onset of symptoms. Clinical correlation showed that two patients with the highest neuroinflammatory scores had severe encephalopathies that were not attributable to any other cause. The second most frequent lesions were related to vascular pathology.

Late Cardiac Pathology in Severe Covid-19. A Postmortem Series of 30 Patients.

The role of SARS-CoV-2 as a direct cause in the cardiac lesions in patients with severe COVID-19 remains to be established. Our objective is to report the pathological findings in cardiac samples of 30 patients who died after a prolonged hospital stay due to Sars-Cov-2 infection. We performed macroscopic, histological and immunohistochemical analysis of the hearts of 30 patients; and detected Sars-Cov-2 RNA by RT-PCR in the cardiac tissue samples. The median age of our cohort was 69.5 years and 76.6% were male. The median time between symptoms onset and death was 36.5 days. The main comorbidities were arterial hypertension (13 patients, 43.3%), dyslipidemia (11 patients, 36.7%), cardiovascular conditions (8 patients, 26.7%), and obesity (8 patients, 26.7%). Cardiovascular conditions included ischemic cardiopathy in 4 patients (13.3%), hypertrophic cardiomyopathy in 2 patients (6.7%) and valve replacement and chronic heart failure in one patient each (3.3%). At autopsy, the most frequent histopathological findings were coronary artery atherosclerosis (8 patients, 26.7%), left ventricular hypertrophy (4 patients, 13.3%), chronic epicardial inflammation (3 patients, 10%) and adipose metaplasia (2 patients, 6.7%). Two patients showed focal myocarditis, one due to invasive aspergillosis. One additional patient showed senile amyloidosis. Sars-Cov-2 RNA was detected in the heart of only one out of 30 patients, who had the shortest disease evolution of the series (9 days). However, no relevant cardiac histological alterations were identified. In present series, cardiac pathology was only modest in most patients with severe COVID-19. At present, the contribution of a direct effect of SARS-CoV-2 on cardiac lesions remains to be established.

Development of Thyroid Carcinoma During Treatment With Pembrolizumab in a Lung Cancer Patient.

Pembrolizumab, a programmed death 1 inhibitor, has been shown to have clinically significant efficacy in different types of cancer, providing long-term survival benefit for patients with lung cancer. Herein, we report the development of a primary thyroid cancer in a lung cancer patient that was being treated with pembrolizumab. Primary thyroid malignancy (and not only metastatic disease or immunotherapy-induced thyroiditis) should be considered in patients with lung cancer being treated with immune checkpoint inhibitors who develop new incidental thyroid lesions on imaging studies.

Meningiomas quísticos: correlación radiológica y patológica con implicaciones quirúrgicas / Cystic meningiomas: Radiological and pathological correlation with surgical implications

Introducción: Los meningiomas que asocian cambios quísticos prominentes (MQ) han representado un reto diagnóstico y terapéutico desde los orígenes de la neurocirugía moderna. Presentamos la experiencia en el manejo clínico y quirúrgico de esta entidad en nuestro Servicio. Material y métodos: En este estudio descriptivo se incluyen los MQ intervenidos en nuestro Servicio en los últimos 15 años, evaluando las variables clínicas, diagnósticas y terapéuticas de este subgrupo de meningiomas, con especial énfasis en la correlación de los hallazgos radiológicos y patológicos. Los tumores se clasificaron siguiendo el esquema propuesto por Nauta y sus colaboradores. Resultados: Se identificaron 11 casos, lo que supone un 1,8% de los meningiomas intervenidos en ese periodo. Todos los pacientes eran adultos y 8 de ellos, mujeres. Entre los síntomas, destacó la alta frecuencia de crisis epilépticas, mientras que solo un caso desarrolló hipertensión intracraneal aguda. La morfología predominante fue el tipo 2, seguida de los tipos 1, 3 y 4. En 5 casos pudo establecerse un diagnóstico radiológico inequívoco de meningioma. Todos los pacientes fueron tratados mediante cirugía, sin evidenciarse casos de recurrencia durante un seguimiento medio de 52,8 meses. Aunque la mayoría de las neoplasias correspondieron al grado i de la OMS, incluyendo subtipos variados, 4 de ellas fueron diagnosticadas como meningiomas atípicos. Conclusiones: De forma excepcional, los meningiomas pueden desarrollar cambios quísticos, intra- o extratumorales, en número y tamaño variable. Estos constituyen hallazgos poco típicos que pueden dificultar seriamente su diagnóstico diferencial radiológico. Los meningiomas con quistes periféricos de cápsula fina (tipos 2 y 3) suponen el escenario quirúrgico más complejo, pues el realce capsular en las pruebas de imagen no traduce necesariamente infiltración tumoral, mientras que el quiste puede contener células neoplásicas. Por lo tanto, recomendamos realizar al menos biopsia de la cápsula o seudocápsula, y lavado minucioso de la cavidad quirúrgica especialmente en estos subtipos

Introduction: Meningiomas associating prominent cystic changes (CM) have challenged neurosurgeons since the beginning of this surgical discipline. We present the experience in the diagnostic and therapeutic management of this entity in our institution. Material and methods: A review of our patient database was carried out, searching for those CM that were operated on in the last 15 years. Relevant clinical data were recorded and analyzed for each case, with special emphasis in the correlation of radiological and pathological findings. Cystic changes were classified according to the scheme proposed by Nauta et al. Results: A total of 11 patients were gathered, which represents 1.8% of the meningiomas operated on in our department during the period studied. All were adults, predominantly female patients (8 cases). Among the clinical symptoms a high rate of epileptic seizures was observed while only one patient developed acute intracranial hypertension. Morphologically, most tumors corresponded to type 2 CMs, followed by types 1, 3 and 4. In only five patients an unequivocal radiological diagnosis of meningioma could be made. All neoplasms were surgically removed and there were no records of recurrence (mean follow-up: 52.8 months). Microscopic findings were consistent with the pathological diagnosis of atypical meningioma in 4 cases, while the remaining tumors corresponded to OMS grade I neoplasms with variable microscopic patterns. Conclusions: Meningiomas can exceptionally associate cystic changes, both intra and/or extratumoral, in variable number and size. When cystic changes become too prominent (a large number or big-sized cysts), a serious preoperative diagnostic dilemma may arise. The surgical management of those CMs displaying a peripheral, thin-walled cyst (types 2 and 3) is especially complex, as contrast enhancement of the tumor wall did not correlate strictly with neoplastic invasion; even in the absence of this feature free floating islands of meningothelial cells intermixed with cyst fluid can be found. Consequently both surgical biopsy of every suspicious tissue and copious irrigation of the surgical cavity are strongly recommended for these CM types

Cystic meningiomas: Radiological and pathological correlation with surgical implications. / Meningiomas quísticos: correlación radiológica y patológica con implicaciones quirúrgicas.

INTRODUCTION: Meningiomas associating prominent cystic changes (CM) have challenged neurosurgeons since the beginning of this surgical discipline. We present the experience in the diagnostic and therapeutic management of this entity in our institution. MATERIAL AND METHODS: A review of our patient database was carried out, searching for those CM that were operated on in the last 15 years. Relevant clinical data were recorded and analyzed for each case, with special emphasis in the correlation of radiological and pathological findings. Cystic changes were classified according to the scheme proposed by Nauta et al. RESULTS: A total of 11 patients were gathered, which represents 1.8% of the meningiomas operated on in our department during the period studied. All were adults, predominantly female patients (8 cases). Among the clinical symptoms a high rate of epileptic seizures was observed while only one patient developed acute intracranial hypertension. Morphologically, most tumors corresponded to type 2 CMs, followed by types 1, 3 and 4. In only five patients an unequivocal radiological diagnosis of meningioma could be made. All neoplasms were surgically removed and there were no records of recurrence (mean follow-up: 52.8 months). Microscopic findings were consistent with the pathological diagnosis of atypical meningioma in 4 cases, while the remaining tumors corresponded to OMS grade I neoplasms with variable microscopic patterns. CONCLUSIONS: Meningiomas can exceptionally associate cystic changes, both intra and/or extratumoral, in variable number and size. When cystic changes become too prominent (a large number or big-sized cysts), a serious preoperative diagnostic dilemma may arise. The surgical management of those CMs displaying a peripheral, thin-walled cyst (types 2 and 3) is especially complex, as contrast enhancement of the tumor wall did not correlate strictly with neoplastic invasion; even in the absence of this feature free floating islands of meningothelial cells intermixed with cyst fluid can be found. Consequently both surgical biopsy of every suspicious tissue and copious irrigation of the surgical cavity are strongly recommended for these CM types.

Incidental finding of a primary thyroid tuberculosis.

Thyroid tuberculosis (TT) is a very rare condition, even in countries where tuberculosis is endemic. However, the prevalence of tuberculosis has increased worldwide and thyroid involvement can be a primary manifestation of the disease. We present the case of a 43-year-old patient with this diagnosis and perform a review of the related literature. After searching for similar case reports in Western Europe since 2010 we identified six cases in four countries. TT should be considered in the differential diagnosis of a thyroid nodule. Fine-needle aspiration cytology and polymerase chain reaction are useful tools as preoperative diagnosis. Typical caseous necrotic granulomas are the hallmark in biopsy.

Metástasis cerebelosa de carcinoma folicular de tiroides / A cerebellar metastasis from follicular thyroid carcinoma

Presentamos el primer caso clínico de metástasis cerebelosa de carcinoma folicular de tiroides. Se trata de una mujer de 78 años de edad, que fue sometida a tiroidectomía total, hace 23 años cuyo estudio histológico fue de adenoma de tiroides atípico en el lóbulo tiroideo izquierdo. Los niveles séricos de tiroglobulina (Tg) aumentaron en las revisiones posteriores. Los niveles de anticuerpos anti-tiroglobulina fueron siempre negativos. Recibió tratamiento con radioyodo en varias ocasiones. En el estudio de seguimiento una nueva TC reveló una lesión a nivel de hemisferio cerebeloso izquierdo. La paciente fue sometida a resección quirúrgica de esta lesión. Los hallazgos inmunohistoquímicos mostraron un origen tiroideo de la metástasis, con células tumorales con positividad difusa e intensa para citoqueratina-7 (CK7), factor de transcripción tiroideo-1 (TTF-1) y positiva focal para Tg, y débil para CK19, y negatividad para PGAF, galectina-3 y CK20. El análisis de las mutaciones V600E y V600K del gen BRAF fue negativa (AU)

We present here, for the first time, a case of cerebellar metastasis from a follicular thyroid carcinoma. A 78 year-old woman had undergone total thyroidectomy 23 years previously for an atypical thyroid adenoma in the left thyroid lobe. Serum thyroglobulin (tg) levels subsequently increased but thyroglobulin antibody levels were always negative. She received radioiodine therapy on several occasions. In the follow-up localizing study a whole body CT scan revealed an image at the left cerebellar hemisphere level. The patient underwent surgery for the cerebellar lesion and immunohistochemistry revealed it to be a metastasis of thyroid origin; the tumour cells had diffuse and intense positivity for cytokeratin-7 (CK7), thyroid transcription factor-1 (TTF-1) and tg, focal and weak positivity for CK19 and negativity for PGAF, galectin-3 and CK20. The analysis of V600K V600E BRAF gene mutations was negative (AU)

Rare association of secondary superficial siderosis caused by a fourth ventricle hemorrhagic ependymoma mimicking a cavernoma: Case report and literature review.

BACKGROUND: The association of a hemorrhagic tumor with secondary superficial siderosis (SS) is a relatively rare although well described phenomenon. CASE DESCRIPTION: We present the case report of a 35-year-old male with a history of drowsiness, hypoacusia, drop attacks, and multidirectional nystagmus during the last 2 months, who presented with acute obstructive hydrocephalus caused by a fourth ventricle mass displaying radiological signs of repeated intra and extratumoral hemorrhage with SS. He underwent gross surgical removal of the solid component of the tumor. Microscopic examination revealed an ependymoma with atypical features, including prominent angiomatous formations and internal chronic hemorrhages with hemosiderin deposits, resembling a cavernoma. The scarce tumoral component, which extended around these cavernous vessels, lacked the gross typical features of fibrillary stroma or perivascular pseudorosettes. CONCLUSION: To our knowledge, including the present case, there are 45 published reports of tumors associating secondary SS. Besides ependymoma, no other hemorrhagic lesion, tumoral or vascular, has been previously published associating a fourth ventricle location with secondary SS. The present case represents the fifth with this finding, and we strongly suggest ependymoma as a presumptive diagnosis when this rare association is encountered. In addition, this appears to be the first case reported in the scientific literature of a hemorrhagic fourth ventricle ependymoma mimicking both, radiologically and histologically, a cavernous malformation.