Newly Diagnosed Sellar Tumors in Patients with Cancer. Advantages of Surgical Intervention Over Empiric Radiotherapy

Introduction: The use of imaging modalities like PET/CT and MRI for staging in cancer patients has led to increased incidence of incidental detection of sellar masses. Imaging findings can be suggestive of a benign pituitary tumor but metastasis can never be completely ruled out. Appropriate diagnosis of these sellar lesions is critical as the treatment paradigm might change in the presence of pituitary metastasis. Moreover definitive diagnosis might avoid radiotherapy to the skull base or even the need for systemic treatment when benign pituitary disease is confirmed.

The objective of this study is to discuss the management of patients who were diagnosed with a sellar mass during radiological work up while staging a primary cancer.

Patients and Methods: A retrospective chart review of all patients with recently diagnosed cancer and undergoing surgery for sellar and suprasellar mass was done.

Results: Seven patients (3 women and 4 men) were included in the study. Lung cancer was the primary condition in 5 patients while breast cancer and renal cell carcinoma was the diagnosis for the other two patients. Two patients had known metastases while in the remaining 5 patients the sellar mass was the only other lesion besides the primary tumor. Three patients presented with visual deterioration while one patient had worsening headaches.

All patients underwent endonasal endoscopic resection of the sellar mass. In two patients the diagnosis of the sellar lesion was critical, as the presence of a metastatic sellar lesion would have precluded surgical resection of the isolated lung lesion. In 5 patients the sellar mass was a benign pituitary adenoma while in two patients the sellar mass proved to be metastatic lung cancer on final histopathology. The two patients with isolated lung lesion and sellar mass where the sellar mass turned out to be benign were referred for the resection of the lung mass. One patient with known metastatic disease where the sellar mass turned out to be benign, died a year later due to progression of his systemic disease. Only two patients were referred for radiotherapy in view of the metastatic cancer to the sella.

Conclusions: Pituitary metastases are rare lesions, but must be considered when one is confronted with sellar lesions with or without FDG uptake in the setting of cancer and possible systemic involvement. Endonasal endoscopic resection of the tumor not just helps in the decompression of the optic apparatus but also provides tissue for definitive diagnosis. The rarity of the pituitary metastasis warrants caution in the empirical use of radiotherapy for the treatment of such lesions. Moreover the indiscriminate use of radiotherapy might result in the loss of a powerful tool for the management of true metastatic brain disease.