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Inoue E, Kesumayadi I, Fujio S, Makino R, Hanada T, Masuda K, Higa N, Kawade S, Niihara Y, Takagi H, Kitazono I, Takahashi Y, Hanaya R. Secondary hypophysitis associated with Rathke's cleft cyst resembling a pituitary abscess. Surg Neurol Int 2024; 15:69. [PMID: 38468645 PMCID: PMC10927231 DOI: 10.25259/sni_947_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
Background Although rare, cases of hypophysitis resembling a pituitary abscess (PA) have been reported. Differential diagnosis between hypophysitis and PA is crucial as the two diseases require different treatments. Case Description A 38-year-old woman with headaches underwent head magnetic resonance imaging (MRI), which revealed an 11-mm mass lesion in the sella turcica. Due to breastfeeding, contrast-enhanced MRI was avoided. Pituitary adenomas and Rathke's cleft cyst (RCC) were suspected, and she was initially treated conservatively. Five months later, she acquired syndrome coronavirus two infections, and while the fever subsided with acetaminophen, the headache persisted. One month later, the headache worsened, followed by fever and diabetes insipidus. MRI revealed a pituitary cystic mass with ring-shaped contrast enhancement on T1-weighted MRI and increased signal intensity on diffusion-weighted imaging (DWI). PA was suspected, and emergency endoscopic transsphenoidal surgery was performed. The microbiological examination of the yellowish-brown content drained from the cystic mass was negative. Microscopically, the cystic lesion was covered with ciliated columnar epithelium and stratified squamous epithelium, with a dense inflammatory cell infiltrate consisting mainly of lymphocytes and plasma cells observed around the cyst. This supported the diagnosis of secondary hypophysitis associated with RCC without PA. Conclusion We report a case of hypophysitis secondary to RCC resembling PA with ring-shaped contrast enhancement on MRI and increased signal intensity on DWI. This case emphasizes the need for cautious diagnosis of secondary hypophysitis due to RCC in individuals with MRIs and clinical manifestations resembling an abscess.
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Affiliation(s)
- Eri Inoue
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
| | - Irfan Kesumayadi
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Department of Neurosurgery, Diponegoro University, Tembalang, Semarang, Indonesia
| | - Shingo Fujio
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Ryutaro Makino
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Tomoko Hanada
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Keisuke Masuda
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
| | - Nayuta Higa
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
| | - Shigeru Kawade
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
- Department of Diabetes and Endocrine Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuichiro Niihara
- Pituitary Disorders Center, Kagoshima University Hospital, Kagoshima, Japan
- Department of Obstetrics and Gynecology, Kagoshima University, Kagoshima, Japan
| | - Hirosuke Takagi
- Department of Hematology and Rheumatology, Kagoshima University, Kagoshima, Japan
| | - Ikumi Kitazono
- Department of Pathology, Kagoshima University, Kagoshima, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Nara, Japan
| | - Ryosuke Hanaya
- Department of Neurosurgery, Kagoshima University, Kagoshima, Japan
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Stringer F, Foong YC, Tan A, Hayman S, Zajac JD, Grossmann M, Zane JNY, Zhu J, Ayyappan S. Pituitary abscess: a case report and systematic review of 488 cases. Orphanet J Rare Dis 2023; 18:165. [PMID: 37365629 DOI: 10.1186/s13023-023-02788-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/18/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Pituitary abscess (PA) is a rare condition and not well understood. We aimed to describe a case and perform a comprehensive systematic review to explore presenting symptoms, radiological findings, endocrine abnormalities and mortality. AIM To identify presenting symptoms, radiological findings, endocrinological abnormalities and predictors of mortality for PA. METHODS We systematically reviewed the literature to identify all case reports of PA. Data regarding presentation, mortality, radiological findings, endocrinological abnormalities and treatment was extracted. RESULTS We identified 488 patients from 218 articles meeting the inclusion criteria. Mortality was 5.1%, with days to presentation (OR 1.0005, 95% CI 1.0001-1.0008, p < 0.01) being the only identified independent predictor of mortality. Mortality rates have decreased over time, with cases published prior to 2000 having higher mortality rates (OR 6.92, 95% CI 2.80-17.90, p < 0.001). The most common symptom was headache (76.2%), followed by visual field defects (47.3%). Classical signs of infection were only present in 43%. The most common imaging feature on magnetic resonance imaging (MRI) was high T2 and low T1 signal of the pituitary gland with peripheral contrast enhancement. Over half (54.8%) were culture negative, with the most common bacterial organism being staphylococcus aureus (7.8%) and fungal organism being aspergillus (8.8%). The most common endocrine abnormality was hypopituitarism (41.1%), followed by diabetes insipidus (24.8%). Whilst symptoms resolved in most patients, persistent endocrine abnormalities were present in over half of patients (61.0%). CONCLUSION PA is associated with significant mortality, with delayed presentation increasing risk of mortality. Ongoing endocrinological abnormalities are common. Given the non-specific clinical presentation, the appearance of high T2, low T1 and peripheral contrast enhancement of the pituitary on MRI should prompt consideration of this rare disease.
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Affiliation(s)
- Felicity Stringer
- Barwon Health, Geelong, VIC, Australia
- St Vincent's Health, Melbourne, VIC, Australia
| | - Yi Chao Foong
- Barwon Health, Geelong, VIC, Australia.
- Monash Health, Melbourne, VIC, Australia.
- Alfred Health, Melbourne, VIC, Australia.
- Eastern Health, Melbourne, VIC, Australia.
| | - Alanna Tan
- Austin Health, Melbourne, VIC, Australia
| | | | | | | | - Justin Ng Yau Zane
- Monash Health, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
- Royal Hobart Hospital, Hobart, TAS, Australia
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Chong GYC, Tan KCB, Lau EYF, Lai AYT, Man KKY, Chan TM, Leung WKW, Leung JYY. A study on clinical outcomes of Rathke's cleft cyst in patients managed conservatively. Pituitary 2022; 25:258-266. [PMID: 34807360 DOI: 10.1007/s11102-021-01194-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The primary objective was to investigate the clinical presentation, hormonal dysfunction, imaging characteristics and natural history of RCCs that were managed conservatively. Secondary objective was to identify factors associated with cyst progression. METHODS A retrospective review of patients with the clinical diagnosis of RCC-identified from word search from radiology reports that were followed up from January 1999 to March 2019 was performed. The demographics, clinical data, radiological features and outcomes were reviewed and analyzed. RESULTS 105 patients were identified with a median follow up of 6 years. 68 patients (64.8%) were managed conservatively from diagnosis till last follow up while 37 patients (35.2%) underwent surgery, with 26 operated at time of diagnosis and 11 operated upon monitoring. For patients managed conservatively from diagnosis till last follow up, incidental finding was the most common presentation. 19.1% had either one or more axes of hormonal dysfunction, with hypogonadism and hypocortisolemia being the commonest ones. Imaging features were variable. 66.2% of patients had T2W hyperintensity on MRI. Pathognomonic feature of intracystic nodule was present in only 14.7% of patients. Among the 79 patients with repeated MRI imaging (68 from conservative group and 11 from surgical group), 32.9% of patients developed cyst progression while 67.1% had either static disease or regression in size of RCC. Median time to progression of cyst was 14 months. Longer median follow up duration and presence of pituitary stalk displacement at presentation were associated with cyst progression. Only one patient developed new endocrine dysfunction. CONCLUSION 2/3 of the RCCs had static disease or even regression in the size of the cyst. They rarely gave rise to additional endocrine dysfunction by adopting observant approach. Cyst progression was demonstrated in 1/3 of patients. Conservative treatment remained a reasonable treatment for patients without significant symptoms.
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Affiliation(s)
- Gigi Y C Chong
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Wan Chai, Hong Kong.
| | - Kathryn C B Tan
- Department of Medicine, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Emmy Y F Lau
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Alta Y T Lai
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Kenyon K Y Man
- Department of Radiology, Queen Mary Hospital, Pokfulam, Hong Kong
| | - T M Chan
- Department of Radiology, Ruttonjee Hospital, Wan Chai, Hong Kong
| | - Warren K W Leung
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Jenny Y Y Leung
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Wan Chai, Hong Kong
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4
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Gezer E, Çabuk B, Bayrak BY, Cantürk Z, Çetinarslan B, Selek A, Sözen M, Köksalan D, Ceylan S. Xanthomatous Hypophysitis Secondary to a Ruptured Rathke's Cleft Cyst: A Case Report. Brain Tumor Res Treat 2022; 10:48-54. [PMID: 35118849 PMCID: PMC8819468 DOI: 10.14791/btrt.2022.10.e24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/25/2021] [Accepted: 11/12/2021] [Indexed: 11/20/2022] Open
Abstract
Hypophysitis (HP) is a rare disease which develops secondary to chronic or acute inflammation of the pituitary gland and may cause symptoms related to pituitary dysfunction and mass compression. Lymphocytic HP is the most common subtype of primary HP, while xanthomatous HP (XHP) is considered the rarest form, with 35 reported cases, to date. A 35-year-old woman was initially admitted to a Gynecology clinic with a 2-year history of amenorrhea and headache. She was started on cabergoline 0.5 mg twice a week for macroprolactinoma. Due to persistent amenorrhea with low gonadotropins, she was referred to our Endocrinology clinic. Her pituitary function profile revealed panhypopituitarism and a 13×11×12 mm sized sellar mass with diffuse enhancement which sustained toward the infundibulum and dura was observed on the gadolinium-enhanced pituitary MRI. The patient underwent an endoscopic endonasal transsphenoidal approach for tumor resection and thick yellowish fluid draining from the lesion was observed. The histopathological diagnosis was reported as a rupture of an Rathke’s cleft cyst and an XHP. The surgery did not improve the symptoms/pituitary functions, however, headache recovered immediately after the first dose of high dose methylprednisolone treatment. The inflammatory process in a xanthomatous lesion may actually be a secondary response to mucous fluid content release from a ruptured cyst, thus recommended to classify XHP as secondary hypophysitis. Since the differentiation of XHP from other pituitary tumors may be challenging preoperatively, surgery is the major diagnostic tool and also, the most recommended therapeutic option.
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Affiliation(s)
- Emre Gezer
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey.
| | - Burak Çabuk
- Department of Neurosurgery, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Büsra Yaprak Bayrak
- Department of Pathology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Zeynep Cantürk
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Berrin Çetinarslan
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Alev Selek
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Mehmet Sözen
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Damla Köksalan
- Department of Endocrinology and Metabolism, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Savas Ceylan
- Department of Neurosurgery, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
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Lodha P, Rao P S, Danda VSR, Rao GP. Rathke’s Cleft Cyst Abscess—An Unusual Guest in The Sella. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0041-1726600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractAbscess formation within a Rathkes’s cleft cyst (RCC) is extremely rare, particularly at a young age. We report the case of a young girl with abscess formation in RCC. A 21-year-old female presented with headache, vomiting, visual deterioration and features suggestive of hypopituitarism. She had bitemporal hemianopia with impairment of visual acuity. MRI revealed a cystic lesion in the sella with suprasellar extension and peripheral rim enhancement. On the basis of history and imaging, this was indistinguishable from more commonly encountered pituitary pathology. She underwent transsphenoidal decompression, which revealed yellowish purulent material that when cultured grew Staphylococcus epidermidis. Histological examination revealed numerous neutrophils and cyst wall lining with features characteristic of RCC. Postoperatively, she received antibiotics and replacement therapy for hypopituitarism. Three months later, she experienced deterioration in visual fields. Considering persistent disease, she underwent redo surgery which revealed similar findings. Postsurgery, pituitary MRI revealed an empty sella syndrome. Thereafter, follow-up for 1 year was stable with permanent diabetes insipidus and multiple pituitary hormone deficiency on supplementation. Although uncommon, we recommend considering RCC abscess as a differential diagnosis of a pituitary mass lesion, as predicting its presence can be difficult preoperatively. Persistent or recurrent disease is common in these cases, so timely diagnosis and adequate surgical drainage leads to lower morbidity and mortality.
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Affiliation(s)
- Piyush Lodha
- Department of Endocrinology, Gandhi Medical College/Gandhi Hospital, Musheerabad, Secunderabad, Hyderabad, India
| | - Srinivas Rao P
- Department of Endocrinology, Gandhi Medical College/Gandhi Hospital, Musheerabad, Secunderabad, Hyderabad, India
| | - Vijay Sheker Reddy Danda
- Department of Endocrinology, Gandhi Medical College/Gandhi Hospital, Musheerabad, Secunderabad, Hyderabad, India
| | - Gollapudi Prakash Rao
- Department of Neurosurgery, Gandhi Medical College/Gandhi Hospital, Musheerabad, Secunderabad, Hyderabad, India
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Prolonged Postoperative Pyrexia and Transient Nonnephrogenic Vasopressin-Analogue-Resistant Polyuria following Endoscopic Transsphenoidal Resection of an Infundibular Epidermoid Cyst. Case Rep Neurol Med 2021; 2021:6690372. [PMID: 33936824 PMCID: PMC8060105 DOI: 10.1155/2021/6690372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/11/2021] [Accepted: 03/22/2021] [Indexed: 12/03/2022] Open
Abstract
Prolonged postoperative pyrexia (PPP) due to Mollaret's meningitis following endoscopic transsphenoidal surgery (eTSS) for an intracranial epidermoid cyst can be confused with postoperative meningeal infection after transsphenoidal resection, especially in the middle of the COVID-19 pandemic. Anosmia, as well as dysgeusia, cannot be evaluated in patients of eTSS for a while after surgery. We report a case of an infundibular epidermoid cyst with post-eTSS Mollaret's meningitis (MM). The post-eTSS MM caused vasopressin-analogue-resistant polyuria (VARP) in synchronization with PPP. A 59-year-old man experiencing recurrent headaches and irregular bitemporal hemianopsia over three months was diagnosed with a suprasellar tumor. The suprasellar tumor was an infundibular cyst from the infundibular recess to the posterior lobe of the pituitary, which was gross-totally resected including the neurohypophysis via an extended eTSS. Since awakening from general anesthesia after the gross total resection (GTR) of the tumor, the patient continuously had suffered from headache until the 13th postoperative day (POD13). The patient took analgesics once a day before the surgery and three times a day after the surgery until POD11. Pyrexia (37.5–39.5 degree Celsius) in synchronization with nonnephrogenic VARP remitted on POD18. Intravenous antibiotics had little effect on changes of pyrexia. Serum procalcitonin values (reference range <0.5 ng/mL) are 0.07 ng/mL on POD12 and 0.06 ng/mL on POD18. His polyuria came to react with sublingual desmopressin after alleviation of pyrexia. He left the hospital under hormone replacement therapy without newly added neurological sequelae other than hypopituitarism. After GTR of an infundibular epidermoid cyst, based on values of serum procalcitonin, post-eTSS MM can be distinguished from infection and can be treated with symptomatic treatments. The postoperative transient nonnephrogenic VARP that differs from usual central diabetes insipidus can react with sublingual desmopressin after alleviation of PPP in the clinical course of post-eTSS MM. An infundibular epidermoid cyst should be sufficiently resected in one sitting to minimize comorbidities, its recurrence, or postoperative MM to the utmost.
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Deguchi-Horiuchi H, Koide H, Sakuma I, Gao Y, Higuchi S, Nagano H, Hashimoto N, Horiguchi K, Iwadate Y, Inoshita N, Yokote K, Tanaka T. Two cases of symptomatic secondary hypophysitis due to Rathke's cleft cysts treated with glucocorticoids: long-term follow-up. Endocr J 2021; 68:269-279. [PMID: 33087628 DOI: 10.1507/endocrj.ej20-0361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Rathke's cleft cyst (RCC) is a common incidental tumor in the hypothalamic-pituitary region. Some reports have shown that the clinical symptoms and endocrine functions of symptomatic RCCs are temporarily improved by glucocorticoid administration. However, it is still unknown whether glucocorticoid treatment is effective for symptomatic RCCs according to long-term observations. In this study, we describe the long-term clinical outcomes of two cases of glucocorticoid-treated biopsy-proven secondary hypophysitis caused by RCCs. We summarize the symptoms, imaging findings, and endocrine evaluations of two symptomatic RCC patients with concomitant hypophysitis before and after prednisolone treatment. In both evaluated cases, visual impairments and altered endocrine parameters were present due to chiasm and stalk compression; these outcomes improved after shrinkage of RCCs in response to prednisolone administration, and partial recovery of anterior pituitary hormone secretion was observed. However, in both cases, the deficits in anterior pituitary hormone secretion recurred, possibly due to persistent inflammatory infiltration in the RCCs and pituitary glands. After relapse of hypophysitis, anterior hormone secretion did not fully recover. In our cases of secondary hypophysitis caused by RCCs, prednisolone administration had an early effect of cyst shrinkage, followed by partial improvements in clinical symptoms and pituitary functions. However, long-term observation showed that prednisolone treatment did not contribute to complete improvement in anterior pituitary hormone dysfunction.
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Affiliation(s)
- Hanna Deguchi-Horiuchi
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Hisashi Koide
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Ikki Sakuma
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Yue Gao
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
- Department of Neurological Surgery, Chiba University Hospital, Chiba 260-8670, Japan
| | - Seiichiro Higuchi
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Hidekazu Nagano
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Naoko Hashimoto
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Kentaro Horiguchi
- Department of Neurological Surgery, Chiba University Hospital, Chiba 260-8670, Japan
| | - Yasuo Iwadate
- Department of Neurological Surgery, Chiba University Hospital, Chiba 260-8670, Japan
| | - Naoko Inoshita
- Department of Pathology, Tokyo Metropolitan Geriatric Hospital, Tokyo 173-0015, Japan
| | - Koutaro Yokote
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
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Tsujino K, Ikeda N, Kimura S, Higashiyama A, Furuse M, Nonoguchi N, Hiramatsu R, Yagi R, Kawabata S, Osuga K, Wanibuchi M. Optic Nerve Root Enhancement in Gadolinium-Enhanced Magnetic Resonance Imaging of Rathke's Cleft Cyst. World Neurosurg 2020; 146:157-161. [PMID: 33181383 DOI: 10.1016/j.wneu.2020.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although most patients with Rathke's cleft cysts (RCCs) remain asymptomatic throughout their lives, visual impairment in RCCs usually indicates surgical interventions, including endoscopic drainage of the cyst. We report a case of RCC with unique findings in the optic nerve root (ONR) by magnetic resonance imaging (MRI). CASE DESCRIPTION A 58-year-old man admitted to our hospital complained of progressive left visual impairment. Preoperative computed tomography MRI revealed a suprasellar cystic lesion that extended anteriorly, and the bilateral ONRs were lateralized with the cyst and were partially enhanced with gadolinium administration. The cyst content was drained, and the cyst wall was partially removed by endoscopic transsphenoidal surgery. Postoperatively, the patient was administered corticosteroid intravenously for 3 days, and his visual acuity improved dramatically. Postoperative MRI revealed that the volume of the cyst decreased, and the position of the bilateral ONRs normalized. Additionally, enhancement of the ONRs with gadolinium administration was not observed. Histological examination of the surgical specimen revealed a ciliated single-layer columnar epithelium with inflammatory cell infiltration. CONCLUSIONS To our knowledge, we report the first case of a patient with RCC with ONR enhancement with gadolinium administration on MRI. This unique finding might prove that inflammation is one of the causes of visual impairment in RCC as in optic neuritis.
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Affiliation(s)
- Kohei Tsujino
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Naokado Ikeda
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical College, Osaka, Japan.
| | - Seigo Kimura
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Akira Higashiyama
- Department of Diagnostic Radiology, Osaka Medical College, Osaka, Japan
| | - Motomasa Furuse
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Naosuke Nonoguchi
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Ryo Hiramatsu
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Ryokichi Yagi
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Shinji Kawabata
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical College, Osaka, Japan
| | - Keigo Osuga
- Department of Diagnostic Radiology, Osaka Medical College, Osaka, Japan
| | - Masahiko Wanibuchi
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical College, Osaka, Japan
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Jung HN, Kim ST, Kong DS, Suh SI, Ryoo I. Rathke Cleft Cysts with Apoplexy-Like Symptoms: Clinicoradiologic Comparisons with Pituitary Adenomas with Apoplexy. World Neurosurg 2020; 142:e1-e9. [PMID: 32217176 DOI: 10.1016/j.wneu.2020.03.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/13/2020] [Accepted: 03/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Rathke cleft cyst (RCC) can cause acute symptoms mimicking pituitary adenoma (PA) apoplexy. We evaluated the clinicoradiologic features for distinguishing RCC from PA apoplexy. METHODS We retrospectively evaluated 22 patients with RCC and 24 patients with PA with apoplexy-like symptoms who underwent surgery via a transsphenoidal approach between November 1999 and December 2016. We compared the clinical data and magnetic resonance (MR) images between the 2 groups. RESULTS The RCC group was younger and had smaller tumors compared with the PA group (P = 0.02 and 0.001, respectively). The incidences of visual deficits and cranial nerve palsy were lower in the RCCs than in the PAs (P ≤ 0.02 for all). MR images showed more frequent intracystic nodules in the RCCs (P < 0.001), whereas nodular enhancement and lateral deviation of the pituitary stalk were more commonly seen in the PAs (P ≤ 0.003 for both). However, the presence of endocrine dysfunction or decreased consciousness, and the recurrence ratio, were not significantly different between the groups (P ≥ 0.48 for all). In the multivariable logistic regression analysis, patients without nodular enhancement had a 15.84-fold greater risk of RCC than did those with nodular enhancement (P = 0.031). The probability of RCC decreased 0.59-fold with each 1-cm3 increase in tumor volume. CONCLUSIONS RCC with apoplexy-like symptoms has different clinicoradiologic features compared with PA apoplexy. Patients with RCC present with milder ocular symptoms and smaller tumor volumes compared with those with PA apoplexy. The absence of nodular enhancement on MR images could suggest RCC.
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Affiliation(s)
- Hye Na Jung
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Guro, Seoul, South Korea; Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Sungkyunkwan, South Korea
| | - Sung Tae Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Sungkyunkwan, South Korea.
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Sungkyunkwan, South Korea
| | - Sang-Il Suh
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Guro, Seoul, South Korea
| | - Inseon Ryoo
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Guro, Seoul, South Korea
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Fujio S, Takajo T, Kinoshita Y, Hanaya R, Arimura H, Sugata J, Sugata S, Bohara M, Hiraki T, Yoshimoto K, Arita K. Sellar Xanthogranuloma: A Quest Based on Nine Cases Assessed with an Anterior Pituitary Provocation Test. World Neurosurg 2019; 130:e150-e159. [DOI: 10.1016/j.wneu.2019.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
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11
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Chang CF, Chen YM. Rathke’s cleft cyst presenting as incomplete cavernous sinus syndrome and disc edema: a case report with literature review. Doc Ophthalmol 2019; 140:55-65. [DOI: 10.1007/s10633-019-09713-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 08/15/2019] [Indexed: 10/26/2022]
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Korkmaz OP, Sahin S, Ozkaya HM, Apaydin T, Durmaz ES, Haliloglu O, Durcan E, Kadioglu P. Primary hypophysitis: Experience of a Single Tertiary Center. Exp Clin Endocrinol Diabetes 2019; 129:14-21. [PMID: 31234218 DOI: 10.1055/a-0919-4388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The authors review the clinical outcomes of patients with primary hypophysitis (PH). METHODS Patients with PH who were followed up between 2007 and 2018 at our clinic were evaluated. Clinical, endocrinologic, pathologic, radiologic findings and treatment modalities were assessed. RESULTS Seventeen patients with PH were assessed. The median follow-up was 24 (range, 6-84) months. Histologic confirmation was available in 8 patients (6 lymphocytic hypophysitis, 1 lymphocytic-granulomatous hypophysitis, 1 xanthomatous hypophysitis). None of the cases were diagnosed after pregnancy. Two patients had an autoimmune disease. The most commonly seen symptom was headache. The most common anterior pituitary deficiencies were hypocortisolemia and hypothyroidism. The radiologic findings of the patients at the time of diagnosis revealed various results including space-occupying lesion (41.2%), loss of posterior hypophysis bright spot (47.1%), pituitary stalk thickening (41.2%), uniform contrast enhancement (17.6%), partially empty sella (11.8%), optic chiasm compression (11.8%). The most frequent initial treatment modality was observation. Ten patients who were followed up conservatively had no endocrinologic deterioration; additional treatment was not needed in 8 of these 10 patients. The second most frequent initial treatment modality was pituitary surgery. Five patients received steroid treatment. We found serious adverse effects during steroid treatment in 3 of 5 (60%) patients; unilateral avascular necrosis of the femoral head (n=2), diabetes mellitus(n=1). CONCLUSION Correctly diagnosing PH and giving appropriate treatment is challenging. It is unclear whether active treatment with steroids improves clinical outcomes. The serious adverse effects of steroids are also taken into account. Observation, surgery and/or radiotherapy can be appropriate treatment modalities for selected patients.
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Affiliation(s)
- Ozge Polat Korkmaz
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Serdar Sahin
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hande Mefkure Ozkaya
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Tugce Apaydin
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University- Cerrahpasa, Istanbul, Turkey
| | - Emine Sebnem Durmaz
- Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University- Cerrahpasa, Istanbul, Turkey
| | - Ozlem Haliloglu
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Emre Durcan
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Pinar Kadioglu
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Langlois F, Manea A, Lim DST, McCartney S, Yedinak CG, Cetas JS, Fleseriu M. High prevalence of adrenal insufficiency at diagnosis and headache recovery in surgically resected Rathke's cleft cysts-a large retrospective single center study. Endocrine 2019; 63:463-469. [PMID: 30338480 DOI: 10.1007/s12020-018-1784-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/03/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Rathke's cleft cysts (RCC) are lesions that arise from Rathke's pouch. Though frequently incidental, resulting symptoms in a minority of cases are indicators for surgical resection, which may prove beneficial. OBJECTIVE To characterize a cohort of surgically-resected RCC cases at Oregon Health & Science University; tabulate associated hormonal imbalances and symptoms, possible symptom reversal with surgery, determine recurrence risk; identify predictors of recurrence and headache improvement. METHOD Electronic records of all RCC resected cases (from 2006-2016; 11 years) were retrospectively reviewed. Patients had been evaluated by one neuroendocrinologist using a uniform protocol. RESULTS A pathological RCC diagnosis was established in 73 of 814 (9%) surgical pituitary cases. The RCC cohort was 77% (n = 56/73) female, mean age was 39.5 ± 14.9 years at first surgery, and at presentation headache was reported in 88% and visual defects/diplopia in 18% of patients. Initial RCC maximum diameter was 1.3 ± 0.7 cm. The most frequent hormonal deficit was cortisol; 24% of patients had a new adrenal insufficiency (AI) diagnosis, however, 36% also had AI at 3 months post-operatively. Mean follow up was 4.0 ± 4.5 years. Two-thirds of patients (41/62) had headache improvement 3 months post-operatively. Post-operative imaging revealed no residual cyst in 58% (38/65). In those patients with no residual RCC, 29% had recurrence and 71% had long lasting cure. From the 42% (27/65) of patients with residual cyst on post-operative imaging; 59% (16/27) remained stable, 26% (7/27) progressed and 15% (4/27) regressed. CONCLUSION Symptomatic RCC present mostly in women, with a high proportion reporting headaches. Prevalence of AI at diagnosis is high. Surgery may not achieve adrenal axis recovery, but renders a high percentage of headache improvement. Approximately 25% of RCC will recur by 4 years postoperatively. Clinicians should cautiously screen patients with symptomatic RCC, regardless of lesion size for AI.
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Affiliation(s)
- Fabienne Langlois
- Department of Endocrinology, Centre hospitalier universitaire de Sherbrooke, Fleurimont, QC, Canada
| | - Anamaria Manea
- Pediatric Endocrinology, Oregon Health & Science University, Portland, OR, USA
| | - Dawn Shao Ting Lim
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Shirley McCartney
- Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | | | - Justin S Cetas
- Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Maria Fleseriu
- Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
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Aguilar S, Thoo YS, Giammattei L, Roukain A, Agrebi Y, Aellen J, Schiemann U. [Not Available]. PRAXIS 2019; 108:1061-1063. [PMID: 31822227 DOI: 10.1024/1661-8157/a003327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Sergio Aguilar
- Service de médecine interne HFR Riaz, Hôpital fribourgeois
| | - Yong Shun Thoo
- Service de médecine interne HFR Riaz, Hôpital fribourgeois
| | | | | | - Yahya Agrebi
- Service de radiologie HFR Riaz, Hôpital fribourgeois
| | - Jerôme Aellen
- Service de radiologie HFR Riaz, Hôpital fribourgeois
| | - Uwe Schiemann
- Service de médecine interne HFR Riaz, Hôpital fribourgeois
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Oishi M, Hayashi Y, Sasagawa Y, Kita D, Tachibana O, Nakada M. Outcome of diabetes insipidus in patients with Rathke’s cleft cysts. Clin Neurol Neurosurg 2018; 167:141-146. [DOI: 10.1016/j.clineuro.2018.02.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 10/18/2022]
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16
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Kleinschmidt-DeMasters BK, Lillehei KO, Hankinson TC. Review of xanthomatous lesions of the sella. Brain Pathol 2017; 27:377-395. [PMID: 28236350 DOI: 10.1111/bpa.12498] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 12/28/2022] Open
Abstract
Xanthomatous lesions of the sellar region have traditionally been divided into two separate categories, xanthomatous hypophysitis (XH) and xanthogranuloma (XG) of the sellar region. The seminal article on XH, a condition typified by foamy histiocytes and lymphoplasmacytic infiltrates in the pituitary gland/sellar region, but usually little or no hemosiderin pigment, detailed three patients. However, most reports since that time have been single cases, making understanding of the entity difficult. In contrast, the seminal report on XG, characterized by sellar region cholesterol clefts, lymphoplasmacytic infiltrates, marked hemosiderin deposits, fibrosis, multinucleated giant cells around cholesterol clefts, eosinophilic granular necrotic debris, and accumulation of macrophages, included 37 patients, allowing more insights into etiology. Few examples could be linked to adamantinomatous craniopharyngioma, and although ciliated epithelium similar to that of Rathke cleft cyst (RCC) was identified up to 35% of the 37 cases, it could not be proven that XG was related to hemorrhage into RCC. Case reports since that time, however, occasionally linked XG to RCC when an etiology could be identified at all, and a few recognized that a spectrum exists in xanthomatous lesions of the sella. They review literature, adding 23 cases from our own experience, to confirm that overlap occurs between XH and XG, and that the majority-but not all-can be linked to RCC leakage/rupture/hemorrhage. It was suggested that progressive accumulation of hemosiderin pigment in the lesion, possibly caused by the multiple episodes of bleeding, could account for the transition of at least some cases of XH to XG.
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Affiliation(s)
- B K Kleinschmidt-DeMasters
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO.,Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO.,Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kevin O Lillehei
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO.,Morgan Adams Foundation Pediatric Brian Tumor Research Program
| | - Todd C Hankinson
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO.,Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
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Duan K, Asa SL, Winer D, Gelareh Z, Gentili F, Mete O. Xanthomatous Hypophysitis Is Associated with Ruptured Rathke's Cleft Cyst. Endocr Pathol 2017; 28:83-90. [PMID: 28120170 DOI: 10.1007/s12022-017-9471-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Xanthomatous hypophysitis is a rare inflammatory disease of the pituitary gland that can mimic a neoplastic lesion clinically and radiologically. Its pathogenesis remains largely unknown, although recent evidence suggests that pituitary inflammation may occur as a secondary reaction to mucous content released from a ruptured cyst. In a series of 1221 pituitary specimens, we identified seven cases of xanthomatous hypophysitis. Six patients had complete radiological and biochemical workup preoperatively: a cystic-appearing pituitary mass was identified in all six patients (100%) with a mean size of 2.0 cm (range 1.4-2.5 cm) on imaging, and pituitary endocrine dysfunction was noted in five patients (83.3%). In all cases, the pituitary mass was resected through an endoscopic transsphenoidal approach. Pathological examination revealed the presence of foamy macrophages admixed with variable amounts of giant cells and chronic inflammatory cells, confirming the diagnosis of xanthomatous hypophysitis. Additionally, all cases presented with concurrent findings of ruptured Rathke's cleft cyst, with the exception of one patient who had previous surgery for a Rathke's cleft cyst, followed by recurrence and diagnosis of xanthomatous hypophysitis. While accurate distinction of hypophysitis from a pituitary neoplasm can be problematic in the preoperative setting, the identification of a cystic lesion in the sella turcica should raise the possibility of such an entity in the clinical and radiological differential diagnosis. The current series provides further evidence that xanthomatous hypophysitis predominantly occurs as a secondary reaction to a ruptured Rathke's cleft cyst; thus, it is best classified as a secondary (reactive) hypophysitis.
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Affiliation(s)
- Kai Duan
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Sylvia L Asa
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Daniel Winer
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Zadeh Gelareh
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Neurosurgery, University Health Network, Toronto, ON, Canada
| | - Fred Gentili
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Neurosurgery, University Health Network, Toronto, ON, Canada
| | - Ozgur Mete
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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18
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Significant Improvement in Chronic Persistent Headaches Caused by Small Rathke Cleft Cysts After Transsphenoidal Surgery. World Neurosurg 2017; 99:362-368. [DOI: 10.1016/j.wneu.2016.12.111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 11/23/2022]
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Budinich M, Johal J, Oskouian RJ, Thamburaj K, Tubbs RS, Rizk E. Appearing-disappearing-reappearing Rathke's cleft cyst: An extraordinary finding and review of the literature. TRANSLATIONAL RESEARCH IN ANATOMY 2016. [DOI: 10.1016/j.tria.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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20
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Wajima D, Yonezawa T, Masui K, Aketa S. Relationship Between Clinical Features and T2-Weighted Magnetic Resonance Images in Symptomatic Rathke Cleft Cysts. World Neurosurg 2015; 88:421-427. [PMID: 26485415 DOI: 10.1016/j.wneu.2015.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 10/07/2015] [Accepted: 10/07/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is not known when surgery is appropriate for the treatment for incidental Rathke cleft cysts because knowledge of their natural history is lacking. In this study, we sought to determine whether symptomatic Rathke cleft cysts could be distinguished by their signal intensities in magnetic resonance (MR) images. We analyzed the relationship between these signal intensities and clinical manifestations of the cysts and their patterns of expansion. METHODS MR signal intensities on T1-weighted (T1W) and T2-weighted (T2W) images for 52 cases were categorized into 3 types. Type 1 (20 cases) showed low signal intensities on T1W images and hyperintensity on T2W images. Type 2 (10 cases) showed hyperintensity on both T1W and T2W images. Type 3 (22 cases) showed hypointensity on T2W images. RESULTS A significantly higher proportion of patients with type 1 signal intensities had large cysts compressing their third ventricle than patients with the other 2 types of signal intensities. Patients with type 1 signal intensities also frequently had visual disturbances. Anterior pituitary dysfunction was observed more often in patients with type 2 or 3 signal intensities than in patients with type 1 intensities. CONCLUSIONS We conclude that Rathke cleft cysts that show an MR signal intensity similar to that of cerebrospinal fluid grow slowly and are frequently diagnosed as cysts associated with visual disturbance when they become large. It may be possible to predict the clinical progression of Rathke cleft cysts by assessing MR signal intensities.
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Affiliation(s)
- Daisuke Wajima
- Department of Neurosurgery, Osaka Police Hospital, Tennoji, Osaka, Japan.
| | - Taiji Yonezawa
- Department of Neurosurgery, Osaka Police Hospital, Tennoji, Osaka, Japan
| | - Katsuya Masui
- Department of Neurosurgery, Osaka Police Hospital, Tennoji, Osaka, Japan
| | - Shuta Aketa
- Department of Neurosurgery, Osaka Police Hospital, Tennoji, Osaka, Japan
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Abstract
PURPOSE The authors review their treatment experience and summarize clinical outcomes for patients with hypophysitis over the past 15 years. METHODS A retrospective analysis was conducted on patients with lymphocytic, granulomatous or IgG4-related hypophysitis treated from 1997 to 2014 at a single academic center. Patients' medical records were reviewed and binary logistic regression analysis was used to assess whether various clinical parameters were associated with improved outcomes including endocrine function, radiographic appearance and disease recurrence. RESULTS Twenty-one patients (13 women and 8 men) were identified with a median diagnosis age of 37.4 years. All but two patients (90%) were diagnosed histopathologically and the remaining two were diagnosed clinically with lymphocytic hypophysitis. 16 patients (76%) had lymphocytic hypophysitis, 3 (14%) had granulomatous hypophysitis, 1 (5%) had IgG4-related hypophysitis and 1 (5%) had mixed lymphocytic-granulomatous. Patients presented with various symptoms of expanding sellar mass with most common signs including headache (57%), polyuria/polydipsia (52%), vision changes (52%) and amenorrhea or decreased libido (48%). Pre-treatment endocrine evaluation revealed that 12 (57%) patients had complete anterior hypopituitarism, 11 patients (52%) had diabetes insipidus, ten patients (48%) had mild hyperprolactinemia and three patients (14%) had isolated endocrine axis deficiencies with partial gland function. We observed a broad diversity in pre-treatment imaging with common findings including uniform contrast enhancement (62%), thickened infundibulum (57%) and loss of hypophysis bright spot on T1 imaging (43%). Patients were treated with steroids and hormone supplementation as needed. 16 patients (76%) had recorded post-treatment MRI scans which revealed that half had radiographic improvement and half had stable or worsened post-treatment imaging. Only female gender was found to significantly predict improved odds of post-steroid radiographic improvement. For post-treatment endocrine evaluation, six patients (29%) did not have an evaluation on record, four patients (19%) had some improvement in at least one axis, seven patients (33%) had stable but non-worsened endocrine function and four patients (19%) had worsened endocrine function post-steroids. CONCLUSIONS Hypophysitis is an increasingly recognized diagnosis that can present with a broad array of radiographic and clinical features. Surgical biopsy can be helpful to make definitive diagnosis and may guide treatment decision-making.
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Affiliation(s)
- Brandon S Imber
- Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Ave. Room M779, San Francisco, CA, 94143, USA
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Guo SY, Cai XQ, Ma J, Wang WY, Lu G. Diagnosis of concomitant pituitary adenoma and Rathke's cleft cyst with magnetic resonance imaging. Int J Surg 2015; 18:191-5. [PMID: 25959251 DOI: 10.1016/j.ijsu.2015.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/29/2015] [Accepted: 05/04/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The diagnosis of concomitant pituitary adenoma (PA) and Rathke's cleft cyst (RCC) is difficult because PA and RCC cause similar symptoms. This study aimed to investigate magnetic resonance imaging (MRI) characteristics and surgical management of sellar lesions for concomitant PA and RCC. METHODS A retrospective study was performed in 18 patients with concomitant PA and RCC who visited our hospital between June 2008 and May 2014. MRI features, surgical management, histopathological diagnosis and prognosis of concomitant PA and RCC were summarized. RESULTS Of the 18 patients, 3 cases were diagnosed with concomitant PA and RCC and 2 with concomitant PA and intermedia cyst by preoperative MRI. The remaining 8 cases were misdiagnosed as cystic formation of PA, 3 cases were bleeding of PA, and 2 cases were RCC. Surgery via the trans-sphenoidal route was performed in 17 cases and trans-frontal approach was chosen for one patient. All PAs resected were diagnosed by histological examination and the diagnosis of concomitant PA and RCC was histologically confirmed. CONCLUSION A non-enhancing cyst-like structure within the pars intermedia of PA usually located in the midline is a prominent MRI feature of coexisted PA and RCC. Total resection of coexisted RCC must be achieved and fat graft should be avoided during surgery because of high recurrence rate of RCC and complicated hypophysitis.
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Affiliation(s)
- Shun-yuan Guo
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China
| | - Xue-qiang Cai
- Department of Radiology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China
| | - Jie Ma
- Department of Pathology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China
| | - Wei-yu Wang
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China
| | - Gang Lu
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China.
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Chotai S, Liu Y, Pan J, Qi S. Characteristics of Rathke's cleft cyst based on cyst location with a primary focus on recurrence after resection. J Neurosurg 2015; 122:1380-9. [PMID: 25679272 DOI: 10.3171/2014.12.jns14596] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Rathke's cleft cysts (RCCs) are benign lesions with a location that is entirely intrasellar, intrasellar with suprasellar extension (intrasuprasellar), or purely suprasellar. The recurrence of RCC is relatively uncommon. The present study was conducted to report clinical characteristics, histological features, and outcomes based on location of the cyst with a primary focus on analyzing the predictors of squamous metaplasia and recurrence in these 3 types of RCCs. METHODS A retrospective review of the medical records of patients with symptomatic RCCs who had undergone resection at the authors' institution was conducted. Data points, including clinical presentation, preoperative endocrine status, operative details, imaging findings, pathology, and clinical outcomes, were reviewed. A multivariable regression model was used to identify predictors of recurrence. RESULTS The mean age of the 87 eligible patients, 64 females and 23 males, was 41 ± 14 years (range 10-73 years). Sixteen patients (18%) had an entirely intrasellar RCC, 21 (24%) had a purely suprasellar cyst, and 50 (58%) had an intrasuprasellar RCC. The mean cyst volume was 2.4 ± 0.9 cm(3) (range 0.36-4.9 cm(3)). Headache was the most frequent initial symptom (76%) followed by visual disturbance (45%). The transsphenoidal approach was performed for all intrasellar RCCs (16 cysts) and 33 of 50 intrasuprasellar RCCs. The transcranial route was used for all suprasellar cysts (21 cysts) and 17 of 50 intrasuprasellar RCCs. Squamous metaplasia was present in 27 (31%) of 87 RCCs. The occurrence of squamous metaplasia was associated with cyst location (p = 0.027), T1 signal intensity (p = 0.004) and ring enhancement on Gd-enhanced MRI (p = 0.017), and cyst volume (p = 0.045). A suprasellar location (p = 0.048, OR 3.89, 95% CI 1.010-15.020), ring enhancement on Gd-enhanced MRI (p = 0.028, OR 3.922, 95% CI 1.158-13.288), hypointensity on T1-weighted MRI (p = 0.002, OR 6.86, 95% CI 1.972-23.909), and cyst volume (p = 0.01, OR 0.367, 95% CI 0.170-0.789) were independent predictors of squamous metaplasia. The mean time to reaccumulation (11 [12.6%] of 87 cases) and recurrence (7 [8%] of 87 cases) was 14 ± 6 months. Recurrence-free survival was 84.5% at a mean of 98.2 ± 4.6 months after treatment. A suprasellar cyst location (p = 0.007, OR 7.7, 95% CI 1.75-34.54), the occurrence of squamous metaplasia (p = 0.007, OR 19.3, 95% CI 2.25-165.18), and isointensity on T2-weighted MRI (p = 0.041, OR 10.29, 95% CI 1.094-96.872) were the independent predictors of RCC recurrence. CONCLUSIONS A suprasellar cyst location, the occurrence of squamous metaplasia, and isointensity on T2-weighted MRI were independent predictors of RCC recurrence. The extent of resection and type of surgical approach used were not associated with recurrence. A tailored extent of resection based on cyst location and predictive factors is recommended.
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Affiliation(s)
- Silky Chotai
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Yi Liu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Jun Pan
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
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Naama O, Gazzaz M, Boulahroud O, Elmoustarchid B. Infection of a Rathke Cleft Cyst: A Rare Cause of Pituitary Abscess. Surg Infect (Larchmt) 2014; 15:358-60. [DOI: 10.1089/sur.2013.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Okacha Naama
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Mohammed V-Souissi University, Rabat, Morocco
| | - Miloudi Gazzaz
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Mohammed V-Souissi University, Rabat, Morocco
| | - Omar Boulahroud
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Mohammed V-Souissi University, Rabat, Morocco
| | - Brahim Elmoustarchid
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Mohammed V-Souissi University, Rabat, Morocco
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25
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Rathke’s cleft cysts: review of natural history and surgical outcomes. J Neurooncol 2013; 117:197-203. [DOI: 10.1007/s11060-013-1272-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
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26
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Supratentorial neurenteric cyst with spontaneous repetitive intracystic hemorrhage mimicking brain abscess: a case report. Neurosurg Rev 2013; 37:153-9. [DOI: 10.1007/s10143-013-0476-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 01/17/2013] [Accepted: 03/10/2013] [Indexed: 11/30/2022]
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Kim E. A Rathke's Cleft Cyst Presenting with Apoplexy. J Korean Neurosurg Soc 2012; 52:404-6. [PMID: 23133732 PMCID: PMC3488652 DOI: 10.3340/jkns.2012.52.4.404] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 09/15/2012] [Accepted: 10/10/2012] [Indexed: 11/27/2022] Open
Abstract
The occurrence of symptomatic pituitary hemorrhage into a Rathke's cleft cyst (RCC) is extremely rare. The author reports an interesting case of intra- and suprasellar RCC presented with features of pituitary apoplexy. This 62-year-old woman suffered acute headache, mental confusion, and partial hypopituitarism. The characteristics of the magnetic resonance imaging seemed most compatible with a hemorrhagic pituitary adenoma. Transsphenoidal drainage of the cyst contents confirmed the diagnosis of hemorrhagic RCC and resolved the symptoms. All published data on this rare clinical entity are extracted and reviewed.
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Affiliation(s)
- Ealmaan Kim
- Department of Neurosurgery, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea
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Zhong W, You C, Jiang S, Huang S, Chen H, Liu J, Zhou P, Liu Y, Cai B. Symptomatic Rathke cleft cyst. J Clin Neurosci 2012; 19:501-8. [DOI: 10.1016/j.jocn.2011.07.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 07/09/2011] [Accepted: 07/16/2011] [Indexed: 10/14/2022]
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Wang SS, Xiao DY, Yu YH, Jing JJ, Zhao L, Wang RM. Diagnostic Significance of Intracystic Nodules on MRI in Rathke's Cleft Cyst. Int J Endocrinol 2012; 2012:958732. [PMID: 23008711 PMCID: PMC3447369 DOI: 10.1155/2012/958732] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 08/09/2012] [Accepted: 08/13/2012] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose. To explore strategies for the diagnosis and treatment of Rathke's cleft cyst (RCC). Methods. The medical records of 24 patients with sellar RCC were retrospectively reviewed. Two patients had concomitant pituitary adenoma, 2 underwent transcranial surgery, and 22 underwent transsphenoidal surgery. The clinical features, especially the findings of intracystic nodules on MRI, were evaluated and compared with the pathological findings. Results. Preoperatively, only 2 patients were diagnosed with RCC or suspected RCC. Pre- and postoperative MRI images revealed 10 intracystic nodules in 9 (37.5%) patients. Two nodules had bull's eyelike changes. The signal intensity of the intracystic nodules varied on T1- and T2-weighted images. Not all nodules on T2-weighted images were visualized. Postoperative MRI revealed recurrence or residual lesion in 5 patients; none had new symptoms and a second surgery was not required. Conclusions. Identifying intracystic nodules is important in patients with sellar cystic lesions. Bull's eyelike change in an intracystic nodule on MRI, which is reported here for the first time, potentially might have value for confirming the diagnosis.
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Affiliation(s)
- Shou-sen Wang
- Department of Neurosurgery, Fuzhou General Hospital, Fuzong Clinical College, Fujian Medical University, 156 Xihuanbei Road, Fuzhou 350025, China
- *Shou-sen Wang:
| | - De-yong Xiao
- Department of Neurosurgery, Fuzhou General Hospital, Fuzong Clinical College, Fujian Medical University, 156 Xihuanbei Road, Fuzhou 350025, China
| | - Ying-hao Yu
- Department of Pathology, Fuzhou General Hospital, Fuzong Clinical College, Fujian Medical University, 156 Xihuanbei Road, Fuzhou 350025, China
| | - Jun-jie Jing
- Department of Neurosurgery, Fuzhou General Hospital, Fuzong Clinical College, Fujian Medical University, 156 Xihuanbei Road, Fuzhou 350025, China
| | - Lin Zhao
- Department of Neurosurgery, Fuzhou General Hospital, Fuzong Clinical College, Fujian Medical University, 156 Xihuanbei Road, Fuzhou 350025, China
| | - Ru-mi Wang
- Department of Neurosurgery, Fuzhou General Hospital, Fuzong Clinical College, Fujian Medical University, 156 Xihuanbei Road, Fuzhou 350025, China
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