Management of Sellar Masses in Children
Initial Diagnostic Workup
- The American College of Radiology recommends MRI with high-resolution pituitary protocols as the gold standard for evaluating pediatric sellar masses, providing superior tissue characterization compared to CT 2, 3
- Obtain thin-section imaging (≤0.5 cm slice thickness) with pre- and post-contrast T1-weighted sequences to define tumor extent and relationship to critical structures 4, 1
- MRI can directly visualize the pituitary gland and characterize lesions even without IV contrast, though contrast increases conspicuity of small adenomas 2, 3
- The Endocrine Society recommends performing comprehensive hormonal screening including thyroid function tests, morning cortisol and ACTH, prolactin, sex hormones, and growth hormone/IGF-1 1, 5
Ophthalmologic Evaluation
- Measure visual acuity with age-specific tests recorded as logarithm of the minimum angle of resolution 1
- Perform age-appropriate visual field testing, which is critical for macroadenomas and post-surgical microadenomas 1
Treatment Approach
- The British Journal of Neurosurgery recommends transsphenoidal resection as the mainstay of treatment for most sellar tumors except prolactinomas 4
- Complete resection is the treatment of choice when feasible, with modern techniques including image-guided surgery improving precision and reducing surgical side-effects 4
Histopathological Assessment
- Obtain histopathological assessment of operated tissue including immunostaining for pituitary hormones and Ki-67, with additional immuno-profiling when relevant 1
- Ki-67 ≥3% combined with local invasion on imaging predicts a 25% recurrence rate after surgery in pediatric cases 1
Critical Pitfalls to Avoid
- Do not delay surgical planning for resectable lesions, as visual recovery is unlikely after the first post-operative month and younger children have worse visual outcomes 1
- Avoid attempting complete resection of tumors enveloping major vessels or involving vital neural structures, as risks may outweigh benefits 4
- Do not overlook the need for lifelong endocrine surveillance, as hormonal deficiencies may develop or progress over time 1, 5