Departments of Neurosurgery (DBA, SES, JDT), Ophthalmology and Visual Sciences (CAA, JDT), Radiology, Division of Neuroradiology (HAP), Otolaryngology, Head and Neck Surgery (SES), and Neurology University of Michigan (SES, JDT), Ann Arbor, Michigan.
J Neuroophthalmol. 2021 Dec 1;41(4):512-518. doi: 10.1097/WNO.0000000000001164.
Pituitary adenomas and nonadenomatous lesions in the sellar region may be difficult to distinguish by imaging yet that distinction is critical in guiding management. The nature of the diagnostic errors in this setting has not been well documented.
Two neurosurgeons and 2 neuroradiologists of differing experience levels viewed deidentified MRIs of 18 nonadenomatous sellar lesions and 21 adenomas. They recorded their diagnoses, the imaging features they used to make those diagnoses, and their confidence in making those diagnoses.
Among the 18 nonadenoma cases, 11 (61%) were incorrectly diagnosed as adenoma by at least 1 reader, including Rathke cleft cyst, plasmacytoma, aneurysm, craniopharyngioma, chordoma, Langerhans cell histiocytosis, metastasis, and undifferentiated sinonasal carcinoma. Among the 21 adenoma cases, 8 (38%) were incorrectly diagnosed by at least 1 reader as craniopharyngioma, Rathke cleft cyst, sinonasal carcinoma, hemangioblastoma, and pituitary hyperplasia. Incorrect imaging diagnoses were made with high confidence in 13% of readings. Avoidable errors among the nonadenomatous cases occurred when readers failed to appreciate that the lesion was separate from the pituitary gland. Unavoidable errors in those cases occurred when the lesions were so large that the pituitary gland had been obliterated or the imaging features of a nonadenomatous lesion resembled those of a cystic pituitary adenoma. Avoidable errors in misdiagnosis of adenomas as nonadenomas occurred when readers failed to appreciate features highly characteristic of adenomas. An unavoidable error occurred because a cystic adenoma had features correctly associated with craniopharyngioma.
Errors in imaging differentiation of pituitary adenoma from nonadenomatous lesions occurred often and sometimes with high confidence among a small sample of neurosurgeons and neuroradiologists. In the misdiagnosis of nonadenomatous lesions as adenomas, errors occurred largely from failure to appreciate a separate pituitary gland, but unavoidable errors occurred when large lesions had obliterated this distinguishing feature. In the misdiagnosis of adenomas as nonadenomatous lesions, avoidable errors occurred because readers failed to recognize imaging features more characteristic of adenomas and because cystic adenomas share features with craniopharyngiomas and Rathke cleft cysts. Awareness of these errors should lead to improved management of sellar lesions.
鞍区的垂体腺瘤和非腺瘤性病变可能难以通过影像学来区分，但这种区分对于指导治疗至关重要。然而，这种情况下的诊断错误的性质尚未得到很好的记录。
两名神经外科医生和两名不同经验水平的神经放射科医生查看了 18 例非腺瘤性鞍区病变和 21 例腺瘤的 MRI 图像。他们记录了自己的诊断、用于做出这些诊断的影像学特征以及对这些诊断的信心。
在 18 例非腺瘤病例中，至少有 1 位读者错误地将 11 例（61%）诊断为腺瘤，包括 Rathke 裂囊肿、浆细胞瘤、动脉瘤、颅咽管瘤、脊索瘤、朗格汉斯细胞组织细胞增生症、转移瘤和未分化的鼻旁窦癌。在 21 例腺瘤病例中，至少有 1 位读者错误地将 8 例（38%）诊断为颅咽管瘤、Rathke 裂囊肿、鼻旁窦癌、血管母细胞瘤和垂体增生。在 13%的阅读中，错误的影像学诊断是在高度确信的情况下做出的。在非腺瘤病例中，当读者未能意识到病变与垂体腺分离时，就会发生可避免的错误。在这些病例中，当病变非常大以至于垂体腺被破坏或非腺瘤性病变的影像学特征类似于囊性垂体腺瘤时，就会发生不可避免的错误。当读者未能意识到高度典型的腺瘤特征时，就会发生将腺瘤误诊为非腺瘤的可避免错误。由于囊性腺瘤具有与颅咽管瘤正确相关的特征，因此发生了不可避免的错误。
在一小部分神经外科医生和神经放射科医生中，对垂体腺瘤与非腺瘤性病变的影像学鉴别常发生错误，有时错误程度很高。在将非腺瘤性病变误诊为腺瘤时，错误主要是由于未能意识到独立的垂体腺，但当大病变破坏了这一鉴别特征时，就会发生不可避免的错误。在将腺瘤误诊为非腺瘤性病变时，可避免的错误是因为读者未能识别更典型的腺瘤影像学特征，并且囊性腺瘤与颅咽管瘤和 Rathke 裂囊肿具有共同特征。意识到这些错误应该会导致鞍区病变的治疗得到改善。
