doi:10.1111/j.1750-3639.2009.00345.
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C O M J U LY 0 9 C A S E 2
59-YEAR OLD FEMALE WITH SUPRASELLAR MASS
Yun-Ho Lee, Young Seok Park, Dong-Seok Kim, Yong-Gou Park, Kyu-Won Shim
Department of Neurosurgery, Severance Hospital, Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
CLINICAL HISTORY AND IMAGING
STUDIES
A 59-year-old female presented with a severe headache for 3 weeks
and was admitted to another hospital for evaluation. Magnetic reso-
nance image (MRI) of the brain revealed a well-delineated homo-
geneous contrast-enhancing mass lesion within the infundibular
recess. Basal pituitary hormones were within normal limits. A
combined pituitary hormone test showed only a slightly decreased
fT4 (0.7 ng/dL). Because she was postmenopausal, LH (1.76 mIU/
mL) and FSH (1.02 mIU/mL) levels were subnormal. Other
endocrinological laboratory tests were not remarkable. Clinicians
decided to observe the patient due to the risk of the tissue diagno-
sis. She was discharged without any treatment recommended for
follow up at an outpatient clinic of another hospital. During follow
up at an outpatient clinic, she visited our emergency room due to
headache and an episode of syncope. The patient was referred to
the neurosurgical department for evaluation of a mass lesion in the
pituitary stalk and infundibular recess. MRI demonstrated a supra-
sellar mass measuring about 1 ¥ 1 cm in size. The lesion showed
iso-signal intensity on precontrast T1-weighted image with strong
homogeneous enhancement by gadolinium (Figure 1 and 2). Ini-
tially, we were highly suspicious of lymphoma or metastasis. We
Figure 1.
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performed endoscopic biopsy because the tumor was located
within the infundibular recess of the third ventricle. After the tumor
wall was coagulated with unipolar coagulator, biopsy of multiple
pieces was performed.
GROSS AND MICROSCOPIC
PATHOLOGY
On endoscopic view, a reddish, well-circumscribed mass from the
infundibular recess protruded into the third ventricle was not
adhered to the optic chiasm (Figure 3). The tumor appeared highly
vascular. Microscopically, the majority of the tumor showed a
lobular proliferation of closely packed, thin-walled capillaries that
did not show any malignant tumor cells (Figure 4 and 5). Differen-
tial diagnosis for solid- and low-grade tumors originating in the
infundibular recess and pituitary stalk should be included granular
cell tumor and pituicytoma. The tumor cells did not exhibit immu-
noreactivity for CD68 (KP-1) and S100 protein (Figure 6 and 7)
and were negative for glial fibrillary acidic protein (GFAP). Spindle
cells were not demonstrated in the tumor.
What is the diagnosis?
Figure 2.
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Figure 3.

Figure 4.

258 Brain Pathology 20 (2010) 257–260

© 2010 The Authors; Journal Compilation © 2010 International Society of Neuropathology
 Correspondence

Figure 5.

Figure 6. Figure 7.

Brain Pathology 20 (2010) 257–260 259

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Correspondence
DIAGNOSIS
Capillary hemangioma.
DISCUSSION
The majority of capillary hemangiomas arise in the skin, scalp, or
oral mucosa and typically appear within a few months of birth (9).
In these areas, such lesions have been reported to occur in 1.1 to
2.6% of full-term neonates, with an estimated frequency of 10 to
12% within the first year of life. They typically demonstrate rapid
growing up to 6 to 8 months, followed by a plateau phase between
8 and 12 months. Occasionally, these lesions are completely
regressed in 5 years (5). The natural history of capillary hemangio-
mas occurring outside the central nervous system has been well
characterized by proliferative and involutional phases (4). Only 14
microscopically proven cases have been reported in the literature.
Capillary hemangiomas are believed pathologically to be hamar-
tomatous proliferations of vascular endothelial cells. Histologi-
cally, a capillary hemangioma is composed of capillary-size
vessels lined by a single layer of benign endothelial cells (10).
Blood vessels vary widely in size from small lumina lined with
plump endothelial cells to dilated vessels lined with flattened
endothelium (1). GFAP immunostaining showed no glial tissue
present within the lesions (2). Microscopically, capillary heman-
giomas in the central nervous system must be distinguished from
highly vascular neoplasm, which include hemangioendotheliomas,
hemangiopericytomas, and hemangioblastomas (7). In this case,
histological examination failed to show large vacuolated stromal
cells characteristic of capillary hemangioblastomas, primitive vas-
cular differentiation characteristic of hemangioendotheliomas and
storiform architecture in hemangiopericytomas. Tumors occurring
in the infundibular recess or pituitary stalk include pituitary
adenomas, germ cell tumors, pituicytomas, and granular cell
tumors. Pituicytomas are noninfiltrative sellar or parasellar tumors
arising from the neurohypophysis. Pituicytoma is derived from
pituicyte, which is a specific glial cell that accounts for the majority
of nucleated cells in the neurohypophysis. Pituicytes have been
identified as GFAP positive, spindle, or stellate cells (8). Granular
cell tumors are composed of densely packed polygonal cells with
eosinophilic, granular, diastase-resistant cytoplasm and perivascu-
lar lymphocytic aggregates are a common feature (3). These tumors
typically express S100 protein and CD68 (KP-1) (6). Only thin-
walled capillaries were demonstrated in this case that was negative
for S100 protein, CD68 (KP-1) and GFAP. In summary, we have
reported on a capillary hemangioma in the infundibular recess and
pituitary stalk. Capillary hemangiomas should be included as a rare
differential diagnosis in patients with well-enhanced homogeneous
lesions in the infundibular recess and pituitary stalk.
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ABSTRACT
Intracranial capillary hemangiomas are extremely rare. Only 14
histologically proven cases have been reported in the literature. A
59-year-old-female presented with a severe headache for 3 weeks.
Brain MRI revealed a homogeneous contrast enhancing round
mass lesion in the pituitary stalk and infundibular recess. We per-
formed endoscopic biopsy. In the operative field, a reddish, well-
circumscribed mass from the infundibular recess protruded into the
third ventricle and it was separated from the optic chiasm. The
tumor appeared a highly vascular. Histopathological examination
demonstrated an aggregation of thin-walled capillaries, consistent
with capillary hemangioma.
Brain Pathology 20 (2010) 257–260