What is the management and treatment of a Sella Turcica (turkish saddle) mass?

Management of Sella Turcica Mass

MRI with high-resolution pituitary protocols (with and without IV contrast) is the gold standard for initial evaluation, followed immediately by comprehensive hormonal screening and ophthalmologic assessment to guide definitive treatment planning. 1, 2

Initial Diagnostic Imaging

Obtain dedicated pituitary MRI if not already performed:

• High-resolution MRI of the sella with thin-section imaging (≤0.5 cm slice thickness) using pre- and post-contrast T1-weighted sequences is mandatory 2
• MRI provides superior visualization of the pituitary gland, infundibulum, optic chiasm, cavernous sinus invasion, and parasellar structures compared to CT 1
• IV contrast increases conspicuity of small adenomas (typically hypoenhancing) and helps characterize lesion vascularity 1
• CT is inferior and should only be used when MRI is contraindicated; it can identify large tumors and bony changes but misses microadenomas 1

Mandatory Concurrent Workup

Comprehensive endocrine testing must include: 2

• Thyroid function: TSH, free T4
• Adrenal axis: morning cortisol and ACTH
• Gonadal axis: LH, FSH, testosterone (males) or estradiol (females)
• Growth hormone axis: GH and IGF-1
• Prolactin level

Ophthalmologic evaluation is non-negotiable: 2, 3

• Visual acuity testing (logarithm of minimum angle of resolution)
• Visual field testing (critical for all macroadenomas and post-surgical microadenomas)
• Fundoscopic examination

Treatment Algorithm

For most sellar masses (except prolactinomas): 2, 3

• Transsphenoidal resection is the mainstay of treatment
• Complete resection is the treatment of choice when feasible
• Modern image-guided surgery improves precision and reduces complications

Critical exception - Prolactinomas:

• Medical management with dopamine agonists is first-line 1
• Surgery reserved for medication failure or intolerance

Surgical contraindications: 2, 3

• Tumors enveloping major vessels (carotid arteries)
• Involvement of vital neural structures where risks outweigh benefits
• In these cases, avoid attempting complete resection

Specialized Testing Scenarios

Bilateral inferior petrosal sinus sampling (BIPSS) is indicated when: 2

• Pituitary lesions <6 mm are detected on imaging
• MRI is negative or equivocal despite biochemical evidence of hormone excess
• Discordance exists between biochemical testing and imaging findings
• Medical management has failed and surgery is planned 1

Critical Time-Sensitive Considerations

Do not delay surgical planning for resectable non-prolactinoma lesions causing visual symptoms - visual recovery becomes unlikely after one month postoperatively 2, 3

Asymptomatic patients require different management: 4

• 50% of asymptomatic patients with enlarged sella do not require treatment
• However, patients with initial visual involvement invariably develop progressive impairment
• 66% of patients with clinical pituitary insufficiency develop visual field defects requiring treatment

Postoperative Management

Histopathological assessment is mandatory: 3

• Immunostaining for pituitary hormones
• Ki-67 proliferation index (≥3% combined with local invasion predicts 25% recurrence rate in pediatric cases)
• Additional immuno-profiling when clinically relevant

Surveillance imaging protocol: 1

• Delayed surveillance >3 months following transsphenoidal surgery
• Frequency guided by tumor pathology (functioning vs. nonfunctioning), extent of resection (gross total vs. subtotal), and patient symptoms
• Immediate postoperative imaging (<3 months) makes complications difficult to discern from normal postoperative changes

Lifelong endocrine surveillance is non-negotiable - hormonal deficiencies may develop or progress over time even after successful treatment 2, 3

Common Pitfalls to Avoid

• Never use CT as first-line imaging - it is insensitive for microadenomas and soft-tissue characterization 1
• Do not obtain CTA or MRA routinely - these are reserved for suspected vascular lesions (aneurysms) or preoperative planning, not initial diagnosis 1
• Avoid delaying treatment in symptomatic patients - particularly those with visual symptoms, as outcomes worsen significantly after one month 2, 3
• Do not assume "empty sella" is benign - up to 30% demonstrate hypopituitarism on testing 1
• Never skip ophthalmologic evaluation - visual field defects may be subclinical initially but progress rapidly 2, 3