Symptomatic Rathke's cleft cyst coexisting with central diabetes insipidus and hypophysitis: case report

Optic Nerve Root Enhancement in Gadolinium-Enhanced Magnetic Resonance Imaging of Rathke's Cleft Cyst

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.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

FROM DIABETES INSIPIDUS TO SELLAR XANTHOGRANULOMA - A "YELLOW BRICK ROAD" DEMANDING TEAM-WORK

Xanthogranulomas are inflammatory lesions exceptionally rarely occurring in the sellar region. Sellar xanthogranulomas (SXG) result from secondary hemorrhage, infarction, inflammation or necrosis upon existing craniopharyngioma (CP), Rathkès cleft cyst (RCC) or pituitary adenoma (PA), or represent a stage in xanthomatous hypophysitis evolution. "Pure SXG" are independent of a preexisting lesion. A 70 year old male patient, laryngeal cancer survivor, presented with central diabetes insipidus (CDI). MRI revealed an intra-suprasellar mass of uncertain origin. Transsphenoidal surgery resulted in an efficient lesion resection with maximal pituitary sparing. Pathological report has confirmed SXG without conclusive identification of preexisting sellar lesion. Age at presentation and gender were atypical for SXG. The most frequent presenting signs of SXG were absent. Most SXG are initially misdiagnosed as CP, RCC or PA. Preoperative clinical and radiological uncertainty may impact operative planning. Differentiating from CP is crucial, due to divergent operative target goals and prognosis. Intraoperative frozen section analysis could guide surgical extensiveness. Close collaboration must include endocrinologist, neuroradiologist, neurosurgeon and pathologist. Quantity and quality of provided tissue are essential for avoiding bias in pathohistological analysis of cystic or heterogenous lesions. Awareness is needed of new pathological entities in the sellar-parasellar region. SXG should be considered in differential diagnosis of CDI-causing sellar lesions.

A case of neck xanthogranulomatous inflammation-suspected malignant tumor

Xanthogranulomatous inflammation (XGI) is an uncommon chronic inflammatory disease. A 59-year-old male presented with a neck mass which had been diagnosed as an undifferentiated carcinoma. From CD68 staining, XGI was confirmed. It is important to consider the possibility of XGI for a neck mass mimicking a malignant tumor.

Granulomatous hypophysitis caused by Rathke's cleft cyst mimicking a growth hormone-secreting pituitary adenoma

We report a case of granulomatous hypophysitis caused by Rathke's cleft cyst (RCC) mimicking a growth hormone (GH)-secreting pituitary adenoma. Neuroradiological and endocrinological evaluations showed abnormal findings consistent with acromegaly: Magnetic resonance imaging demonstrated a pituitary mass lesion, and GH and insulin-like growth factor I levels were markedly elevated, and GH levels were not suppressed in oral glucose tolerance test. Transsphenoidal surgery was performed, but no adenomatous tissue could be detected. Histological examination revealed RCC and concurrent granulomatous giant cell inflammatory reaction of the anterior hypophysis. To the authors’ knowledge, this is the first documented case of granulomatous hypophysitis caused by RCC mimicking a GH-secreting pituitary adenoma.

Rathke cleft cyst masquerading as pituitary abscess: A case report

BACKGROUND

Rathke cleft cyst (RCC) is a rare cystic sellar entity, which is usually small in size and asymptomatic in most patients. RCC presenting panhypopituitarism and a cystic lesion with rim enhancement on magnetic resonance imaging is extremely rare. Therefore, it is easy to be misdiagnosed as pituitary abscess because of the similar clinical manifestations and neuroimaging changes.

CASE SUMMARY

We report a rare case of RCC masquerading as pituitary abscess clinically and radiologically with no evidence of central nervous system infection. The patient was initially suspected to be diagnosed with pituitary abscess, which was denied by the histopathological findings of RCC with no intraoperative drainage of abscess.We present an uncommon case of RCC masquerading as pituitary abscess in a 62-year-old Chinese male patient. The patient was admitted to Peking Union Medical College Hospital complaining of severe frontal pulsatile headache, visual acuity deficit, polyuria, polydipsia, and slight disturbance of consciousness. The biochemical and endocrinological examinations revealed severe hyponatremia and panhypopituitarism. Magnetic resonance imaging showed a sellar lesion with the apparent cystic change and rim enhancement. Accordingly, pituitary abscess was misdiagnosed at the beginning.The patient received hormone replacement therapy and underwent a trans-sphenoidal surgery. The surgical findings were uneventful. The histopathological examinations showed no infiltration of inflammatory cells or pus, and proved the lesion to be RCC.

CONCLUSION

Through this rare case, we aim to emphasize that the differential diagnosis of sellar lesions requires constant vigilance and that RCC may lead to clinical and radiological changes similar with pituitary abscess.

Restored vision in a young dog following corticosteroid treatment of presumptive hypophysitis

Background

Hypophysitis is an umbrella term for a group of disorders involving inflammation of the pituitary gland. A rare occurrence in humans, hypophysitis can produce a range of clinical signs including (but not limited to) visual deficits and diabetes insipidus. Only five cases of canine hypophysitis exist in the literature, all presenting in mature dogs with no visual deficits and a grave outcome. This case report describes the clinical and advanced imaging features of blindness-inducing presumptive hypophysitis in a dog, which rapidly resolved with medical management.

Case presentation

A 1-year-and-seven-month-old neutered male Standard Poodle presented with subacute blindness, ataxia, and polyuria/polydipsia (PUPD). Magnetic resonance imaging (MRI) detected a contrast-enhancing pituitary mass with perilesional oedema compromising the optic chiasm. Suspecting neoplasia, anti-inflammatory corticosteroid was commenced prior to radiation therapy planning. Complete resolution of neurological and visual deficits occurred within 12 days of starting steroid treatment. Repeated advanced imaging indicated macroscopic resolution of the lesion. An extended thyroid panel with insulin-like growth factor-1 analysis supported a diagnosis of hypophysitis. Resolution of PUPD was achieved with tapering courses of prednisolone and desmopressin; the dog has since been clinically normal for 14 months and treatment-free for 11 months.

Conclusions

To the authors’ knowledge, this is the first instance in which a canine pituitary mass has demonstrated long-term resolution with palliative medical treatment alone, alongside reversal of associated blindness and presumptive diabetes insipidus. We suspect this lesion to be a form of hypophysitis, which should be included among differential diagnoses for pituitary masses, and for subacute blindness in dogs. Where possible, we advocate biopsy-confirmation of hypophysitis prior to timely intervention with anti-inflammatory treatment.

Hypophysitis: Evaluation and Management

Hypophysitis is the acute or chronic inflammation of the pituitary gland. The spectrum of hypophysitis has expanded in recent years with the addition of two histologic subtypes and recognition as a complication of treatment with immune checkpoint inhibitors. Despite the increased number of published cases, the pathogenesis of hypophysitis is poorly understood, and treatment strategies are diverse and controversial. The diagnosis of hypophysitis generally requires histopathologic confirmation. The presentation and clinical course of hypophysitis varies. Hypophysitis can resolve spontaneously, relapse may occur, and some cases can be refractory to treatment.

Hypophysitis: a single-center case series

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.

[Tumors of the sellar and pineal regions]

The (supra) sellar and pineal regions are relatively common sites for pediatric brain tumors; however, the distinct spectrum of space-occupying lesions is in marked contrast to that of the adult population. Craniopharyngeoma represents the most common intrasellar and/or suprasellar lesion in children, whereas the pituitary adenoma typical for adults- is generally rare. The pineal region is a predilection site for germ cell tumors in pediatric patients, while in adults this cancer category is largely confined to the gonads. The role of imaging is in the early detection of lesions, adequate demonstration of the characteristics and delineation of the complex anatomical relationship to adjacent vital structures.

Parasellar xanthogranulomas

OBJECT

Xanthogranulomas are rare inflammatory masses most often found in the skin and eye. The incidence of intracranial xanthogranulomas is 1.6%–7%, with those found in the sellar and parasellar region being exceedingly rare and their etiology controversial. Sellar and parasellar xanthogranulomas are rarely reported in the western hemisphere, and their incidence in Western countries is unknown.

METHODS

A prospectively acquired database of all endonasal endoscopic transsphenoidal surgeries performed at Weill Cornell Medical College was queried. Patients with histologically confirmed xanthogranulomas who were diagnosed and treated between 2003 and 2013 were included in the study. Patient history, demographic data, histological findings, and surgical approach were also evaluated.

RESULTS

A total of 643 endonasal endoscopic procedures had been performed at the time of this study. Four patients (0.6%) were identified as having a histologically confirmed xanthogranuloma of the parasellar region, compared with an incidence of 6.7% for craniopharyngioma (CP) and 2% for Rathke cleft cyst (RCC). The most common symptom was visual loss, followed by headache. Preoperative diagnosis was CP in all cases. All patients underwent extended endonasal endoscopic transsphenoidal surgery with gross-total resection. Two patients developed panhypopituitarism after surgery. There were no CSF leaks. The mean follow-up was 61 months, at which time there were no recurrences. The key histological features differentiating xanthogranulomas from CPs were accumulation of foamy macrophages, multinucleated foreign body giant cells, cholesterol clefts, and hemosiderin deposits without stratified squamous epithelium. These histological features appear commonly as part of the spectrum of a secondary inflammatory response in an RCC.

CONCLUSIONS

Parasellar xanthogranulomas most closely approximate CPs clinically but pathological evidence may suggest an RCC origin. Gross-total resection can be achieved through extended endonasal endoscopic transsphenoidal approaches, and is curative.

A Case of Apoplexy of Rathke's Cleft Cyst Followed by Cerebral Infarction

Rathke's cleft cyst (RCC) apoplexy is a rare clinical entity. We report a case of apoplexy of an RCC followed by cerebral infarction. A 67-year-old woman was found lying on the street unconscious. She had fallen from her motorbike. On referral to our hospital she gradually regained consciousness and presented with no neurological deficits. CT showed a round and slightly hyperdense area in the suprasellar region. However, the attending physician did not find this abnormal finding on CT and the patient was discharged the same day. Thirteen days after the first emergency visit she developed left hemiparesis and dysarthria. CT showed a round hypodense area in the suprasellar region. The change of the density in the suprasellar region on CT suggested the pituitary apoplexy. CT also showed a low density area in the territory of the right middle cerebral artery, which indicated the cerebral infarction. MR angiography revealed poor visibility and stenotic changes of right middle cerebral arteries. Transsphenoidal surgery was performed. Histopathological findings confirmed a hemorrhagic RCC. Postoperative MR angiography showed that the visibility and stenosis of right middle cerebral arteries were recovered. This is the rare case of apoplexy of an RCC followed by cerebral infarction.

Xanthogranulomatous hypophysitis: a rare and often mistaken pituitary lesion

Xanthogranulomatous hypophysitis (XGH) is a very rare form of pituitary hypophysitis that may present both clinically and radiologically as a neoplastic lesion. It may either be primary with an autoimmune aetiology and can occur in isolation or as a part of autoimmune systemic disease or secondary as a reactive degenerative response to an epithelial lesion (e.g. craniopharyngioma (CP), Rathke's cleft cyst, germinoma and pituitary adenomas) or as a part of a multiorgan systemic involvement such as tuberculosis, sarcoidosis or granulomatosis. It may also present with a variation of symptoms in children and adults. Our case series compares the paediatric and adult presentations of XGH and the differential diagnoses considered in one child and two adult patients, highlighting the wide spectrum of this condition. Endocrine investigations suggested panhypopituitarism in all three patients and imaging revealed a suprasellar mass compressing the optic chiasm suggestive of CP or Rathke's cleft cyst in one patient and non-functioning pituitary macroadenoma in two patients. Magnetic resonance imaging (MRI) demonstrated mixed signal intensities on T1- and T2-weighted sequences. Following endoscopic transsphenoidal surgery, histological analysis revealed necrotic material with a xanthogranulomatous reaction confirming XGH in two patients and a necrobiotic granulomatous chronic inflammatory infiltrate with neutrophils in one patient, which is not typical of current descriptions of this disorder. This case series describes the wide spectrum of XGH disease that is yet to be defined. Mixed signal intensities on T1- and T2-weighted MRI sequences may indicate XGH and diagnosis is confirmed by histology. Histological variation may indicate an underlying systemic process.

LEARNING POINTS

XGH is a rare form of pituitary hypophysitis with a wide clinical and histological spectrum and can mimic a neoplastic lesion.XGH primarily presents with growth arrest in children and pubertal arrest in adolescents. In adults, the presentation may vary.A combination of hypopituitarism and mixed signal intensity lesion on MRI is suggestive of XGH and should be considered in the differential diagnosis of sellar lesions.Radical surgery is the treatment of choice and carries an excellent prognosis with no recurrence.

A Case of Rathke's Cleft Cyst Associated with Transient Central Adrenal Insufficiency and Masked Diabetes Insipidus

A 73-year-old woman admitted to our hospital because of headache, poor appetite, malaise, weight loss, and vomiting was found to have central adrenal insufficiency and thyrotoxicosis due to silent thyroiditis. Polyuria developed after replacement with glucocorticoid (masked diabetes insipidus), which was controlled with nasal administration of desmopressin. Magnetic resonance imaging of the brain showed a large cystic pituitary mass (18 × 18 × 12 mm) extending suprasellarly to the optic chiasm. Transsphenoidal surgery revealed that the pituitary tumor was Rathke's cleft cyst. Following surgery, replacement with neither glucocorticoid nor desmopressin was needed any more. Therefore, it is suggested that Rathke's cleft cyst is responsible for the masked diabetes insipidus and the central insufficiency. Furthermore, it is speculated that thyrotoxicosis with painless thyroiditis might induce changes from subclinical adrenal insufficiency to transiently overt insufficiency.

Update on hypophysitis and TTF-1 expressing sellar region masses

This article reviews recent literature on sellar region masses that most closely mimic nonsecretory pituitary adenomas: hypophysitis, pituicytoma, spindle cell oncocytoma, and granular cell tumor of neurohypophysis. Even today, these four entities often cannot be confidently distinguished from each other clinically or by preoperative neuroimaging features. Thus, they often come to biopsy/surgical resection and require tissue confirmation of diagnosis. Causes of secondary and primary hypophysitis will be discussed, including two newly described types, IgG4 plasma cell hypophysitis and hypophysitis caused by anti-cytotoxic T-lymphocyte antigen 4 antibody therapy for cancer. For the neoplastic conditions, emphasis will be placed on literature that has emerged since these entities were first codified in the 2007 World Health Organization fascicle. The finding that immunohistochemical staining for thyroid transcription factor-1 is shared by pituicytoma, spindle cell oncocytoma, and granular cell tumor of neurohypophysis suggests common lineage and explains why histological overlap can be encountered. We incorporate our own experiences over the last 30 years from two referral institutions with specialty practices in pituitary region masses.

A rare association between Rathke's cyst and hypophysitis in a patient with delayed sex development and growth failure

We report an 18-year-old Japanese male with a lack of secondary sex characterization and growth failure caused by a rare association between Rathke's cyst and hypophysitis. He was referred to us because of delayed secondary sex characterization. Endocrinological examination showed panhypopituitarism, and the replacement of hydrocortisone, levothyroxine, and desmopressin acetate (DDAVP) was initiated. Brain magnetic resonance imaging (MRI) showed a suprasellar region and a swollen pituitary stalk. The mass was partially resected using the transsphenoidal approach. The pathological diagnosis was hypophysitis and Rathke's cyst. Follow-up MRI performed 1 year after surgery showed that the size of sellar region had not changed. After surgery, in addition to pre-operative hormonal replacement, growth hormone and testosterone were initiated. Two years later, the size of sellar region remains unchanged. In conclusion, while an association between Rathke's cyst and hypophysitis is rare, we suggest that this condition should be included in differential diagnosis of the sellar region, even in adolescents.

Branchial cleft cyst with xanthogranulomatous inflammation

Xanthogranulomatous inflammation (XGI) is a special type of inflammation presenting as mass lesions and mimicking malignant tumors. It is rarely described in the head and neck region, and to the best of our knowledge, there are no cases associated with branchial cleft cyst. A 39-year-old woman with an infiltrative cystic neck mass that radiologically mimicks a malignant tumor is herein presented. The histopathologic diagnosis was a branchial cleft cyst with XGI. XGI may be associated wih branchial cleft cysts. Patients may present with radiologic findings mimicking an invasive malignant tumor, and should be taken into account during the differential diagnosis with cystic squamous cell carcinoma.

Azathioprine as an alternative treatment in primary hypophysitis

Primary hypophysitis (PH) is an unusual disorder characterized by inflammatory infiltration of the pituitary gland with various degree of pituitary dysfunction. Glucocorticoids are the treatment of choice in the majority of patients. Still, in patients with poor response in glucocorticoids or when their administration is accompanied with serious side effects, the use of alternative agents should be considered; up to now, data on other therapeutic approaches remains scant mainly due to the rarity of the disease. Among them, the immunosuppressant azathioprine could represent an effective and safe alternative. In this article, we present our clinical experience of two cases with PH successfully treated with azathioprine following serious side effects after initial treatment with glucocorticoids and provide a brief review of the existing literature.

Spontaneous Rupture, Disappearance, and Reaccumulation of a Rathke's Cleft Cyst

Rathke's cleft cysts (RCCs) are benign epithelium-lined intrasellar cysts containing mucoid material and are believed to originate from the remnants of Rathke's pouch. Most are asymptomatic but may cause symptoms secondary to compression of adjacent structures such as visual disturbances and endocrinopathies, especially hypopituitary. Furthermore, inflammation such as an aseptic meningitis syndrome may be associated with these tumors, presumably resulting from leakage of cyst material into the subarachnoid space. We present a unique case of spontaneous rupture and complete disappearance of a known sella-suprasellar cyst associated with a severe headache syndrome, followed by cyst reaccumulation requiring surgery. Although this phenomenon is well accepted, to our knowledge, this is the first report of the complete disappearance of a Rathke's cyst presenting with the classic syndrome. Furthermore, it was remarkable how quickly it recurred and became symptomatic, providing evidence that an “empty sella syndrome” may indeed need clinical follow-up.

Clinicopathological characteristics in patients presenting with acute onset of symptoms caused by Rathke's cleft cysts

BACKGROUND

Symptomatic Rathke's cleft cyst is usually accompanied by a long history of headache, visual disturbance, and hypopituitarism; however, rare cases present with acute onset and the clinical features in such cases remain uncertain. We report herein the clinical features of Rathke's cleft cyst with acute onset and discuss the clinical significance.

METHOD

In this study, we defined acute onset as the clinical course with clinical symptoms within a 7-day history. From among 35 cases of symptomatic Rathke's cleft cyst that were pathologically diagnosed at Fukuoka University Hospital between 1990 and 2009, five cases presented with acute onset. The symptoms, endocrinological findings, MR image findings, and pathological findings of these cases were analyzed retrospectively.

FINDINGS

Mean age was 56.8 years. Initial symptoms included headache (n = 3), general malaise (n = 2), polyuria (n = 2), and fever (n = 1). MR imaging revealed an intrasellar cystic lesion with suprasellar extension in all cases and showed rim enhancement in three cases. All cases were treated by transsphenoidal surgery. Pathological findings included hemorrhage (n = 2), hypophysitis (n = 2), and abscess formation in the cyst (n = 1). Postoperatively, all symptoms, except for hypopituitarism, improved in all cases.

CONCLUSIONS

Rathke's cleft cysts sometimes present with acute onset, and the presentation is consistent with the features of pituitary apoplexy caused by pituitary adenoma. Although pituitary apoplexy due to hemorrhage, inflammation, or infection due to an underlying Rathke's cleft cyst is difficult to diagnose pre-operatively, Rathke's cleft cyst should be included in the differential diagnosis, and early surgical treatment is needed, as for pituitary apoplexy caused by pituitary adenoma.

Clinical features, management and recurrence of symptomatic Rathke's cleft cyst

Rathke's cleft cyst (RCC) is a rare lesion of the pituitary gland that is often asymptomatic. The objective of this study was to further characterise the presenting symptoms, endocrinopathy and potential for recurrence of this lesion in an Australian population. The files of 12 patients with pathologically confirmed RCCs were reviewed retrospectively. Common presentations included headache, endocrinopathy, and visual disturbance. Uncommon presentations included 1 patient with pituitary apoplexy. The cysts varied in size from 6 mm to 20 mm; 8 had a suprasellar component. 1 patient had evidence of a RCC with xanthogranulomatous change. RCC recurrence was noted on follow-up MRI in 5 patients. In conclusion, RCCs are rare lesions that can present with an array of clinical symptoms. The relatively high rate of recurrence may indicate a link between this pathology and craniopharyngioma, although many patients with recurrent RCC do not require repeat resection and remain asymptomatic.

Concurrent lymphocytic hypophysitis and pituitary adenoma. Case report and review of the literature

Lymphocytic hypophysitis (LyH) is an uncommon intrasellar lesion characterized by lymphocytic infiltration of the adenohypophysis. Evidence suggests that the cause is autoimmune, and the symptoms are usually related to either a mass effect or endocrine dysfunction. Lymphocytic hypophysitis has been described rarely in the setting of other simultaneous pathological processes that involve the pituitary and sella turcica, and is postulated to arise from an intrinsic inflammatory response. The authors report the case of a 43-year-old woman who presented with a 2-month history of galactorrhea and pseudohyperprolactinemia secondary to a 10-mm lesion within an enlarged pituitary gland. She was nulliparous and had no contributory medical history. Serial neuroimaging performed over a 2-year period demonstrated lesion growth, and visual deficits had developed; together these warranted surgical intervention. A transsphenoidal resection was performed. Microscopic and immunohistopathological examinations revealed a nonsecreting pituitary adenoma with concurrent lymphocytic adenohypophysitis. This is the first documented case of LyH in the setting of a null-cell pituitary adenoma. The authors review the related literature and outline potential mechanisms for the concurrent development of LyH and a pituitary adenoma.

Clinicopathological and Endocrinological Study of Rathke's Cleft Cyst Manifesting as Hyponatremia

Rathke's cleft cyst becomes symptomatic in a few cases. Increasing experience has identified previously unrecognized clinical effects including pituitary dysfunction. This study retrospectively investigated eight patients with Rathke's cleft cyst manifesting as hyponatremia and treated surgically with histological confirmation to clarify the mechanism of hyponatremia. All patients suffered from physical symptoms caused by the hyponatremia. All patients underwent magnetic resonance (MR) imaging and screening of pituitary hormones in addition to cortisol and thyroid hormones. All patients had cysts of more than 10 mm in diameter and MR imaging frequently showed irregularly thickened cyst wall. Histological examination disclosed various phases of inflammation and significant fibrosis. Endocrinological examination showed low concentrations of both serum cortisol in all eight patients and urinary cortisol in six of six patients examined. The major cause of hyponatremia was hypocortisolemia, induced by damage to the anterior pituitary gland.

Hypophysitis Caused by Rathke's Cleft Cyst-Case Report-

A 62-year-old woman presented with general malaise persisting for 2 months and narrowing of her visual field. T1-weighted magnetic resonance (MR) imaging showed swelling of the pituitary gland and stalk, and a homogeneous isointense intra- and suprasellar mass enhanced by gadolinium. During outpatient follow up, her condition deteriorated rapidly and she developed diabetes insipidus and panhypopituitarism. T1-weighted MR imaging demonstrated shrinkage of the lesion and disappearance of the central hypointense area indicating the cyst cavity, especially in the pituitary stalk. She underwent surgical exploration via the transsphenoidal approach under a provisional diagnosis of lymphocytic hypophysitis. Histological examination revealed ciliated columnar cells and squamous metaplasia on the inner surface of the cyst wall, with many foamy cells, infiltration by many lymphoid cells and some eosinophils, and fibrosis in the adenohypophysitis and inflammatory hypophysitis in the anterior and posterior pituitary gland. The present neuroimaging findings of cyst shrinkage associated with rapid clinical deterioration strongly support the suggestion that rupture of Rathke's cleft cyst causes inflammatory hypophysitis.

Hypophysitis associated with a ruptured Rathke's cleft cyst in a woman, during pregnancy

We report the case of a 29-yr-old woman who first presented an aseptic meningitis at the beginning of a pregnancy. She was admitted one month later with headaches and vomiting. Panhypopituitarism with diabetes insipidus was diagnosed. Magnetic resonance imaging (MRI) data suggested the existence of lymphocytic infundibulohypophysitis, with inflammation of the suprasellar area. No new symptoms were noticed until 6 months later when this patient pointed out troubles of the visual field, due to a compression of the optic chiasma. Three boluses of 1 g methylprednisolone were prescribed, with no effects. After delivery, the defects of the visual field increased. A neurosurgical intervention was decided. Diagnosis of Rathke's cleft cyst (RCC) was made. We concluded that this patient presented a rupture of a RCC, which occurred at the beginning of pregnancy, associated later with panhypopituitarism with diabetes insipidus, due to a probable hypophysitis. The end of the pregnancy was marked by consequences of an increased volume of the RCC. To our knowledge, this case is the first described during pregnancy.

Magnetic resonance imaging, clinical manifestations, and management of Rathke's cleft cyst

OBJECTIVE

The management of Rathke's cleft cyst (RCC), particularly in patients with no symptoms or with only minor endocrinopathies, has not yet been established. We retrospectively analysed patients with RCC to elucidate correlations between the clinical manifestations, magnetic resonance imaging (MRI) findings, histology and therapeutic outcomes.

METHODS

We retrospectively studied 37 patients with RCC, who underwent computed tomography (CT), MRI and endocrinological examinations, of whom 27 patients underwent surgical intervention.

RESULTS

The presence of frontal headaches and anterior pituitary dysfunction was unrelated to the cyst size but was more frequent in patients with high- and isointensity cysts on T1-weighted images (WIs) than those with low-intensity cysts (P=0.0159 and P=0.0249, respectively). All three patients with posterior pituitary dysfunction had a high-intensity cyst on T1-WI (P=0.0385), whereas pituitary dysfunction was not observed in patients with a low-intensity cyst on T1-WI. In contrast to the excellent therapeutic outcomes with regard to visual disturbance and hyperprolactinaemia, recovery of pituitary dysfunction was rare; only three of nine patients with hypopituitarism showed improvement. Among six patients with histologically recognized intense chronic inflammation in the cyst wall, five patients had an RCC of T1 high intensity (P=0.0161), two patients had distinct rim enhancement on MRI (P=0.0060), all patients had frontal headaches (P=0.0130), and four patients had associated hypopituitarism (P=0.0243), none of which improved after surgical intervention.

CONCLUSION

RCCs of high- and isointensity on T1-weighted images, which contain mucous material within the cyst, may be associated with chronic inflammation that can potentially cause irreversible endocrine dysfunction. In asymptomatic patients with RCCs of these MR intensities, close follow-up with precise endocrinological evaluation and gadolinium-enhanced MRI is necessary to avoid occult progression of the inflammation.

Autoimmune hypophysitis

Autoimmune (lymphocytic) hypophysitis is a rare disease that should be considered in the differential diagnosis of any nonsecreting pituitary mass, especially when occurring during pregnancy or postpartum. We have analyzed 370 articles published from January 1962 to October 2004 and identified a total of 379 patients with primary lymphocytic hypophysitis. The present review synthesizes the clinical and research data reported in this body of scientific literature.

Immunopathology of Primary Hypophysitis

The etiology of primary hypophysitis is still not fully elucidated. Histologically, primary hypophysitis includes three different main subtypes: lymphocytic (LYH), granulomatous (GRH), and xanthomatous (XH) hypophysitis. Clinical and laboratory findings suggest an autoimmune basis in primary hypophysitis. Controversy still exists about the composition of the inflammatory infiltrate and the relevant immunopathogenic effector mechanisms. Therefore, 21 cases of primary hypophysitis of different subtypes were analyzed with respect to the expression of lymphocyte and macrophage antigens as well as MHC class I and II molecules of the inflammatory infiltrate and the resident pituitary acinar cells. Lymphocyte infiltration in LYH (n = 15), but also in GRH (n = 4) and XH (n = 2), mainly consisted of T cells, while B cells were rare. Independent from the histopathologic subtype, T cell subsets showed equal ratios of CD4+ to CD8+ T cells. Highest numbers of activated CD8+ T cells were observed in LYH presenting during pregnancy, surrounding or even infiltrating preserved pituitary acinar cells. Moreover, an increased rate of activated CD8+ T cells correlated with a shorter duration of clinical symptoms. In LYH, aberrant expression of MHC class II antigens as well as overexpression of MHC class I molecules on pituitary cells were observed. Independent of the histologic subtype, macrophages mostly expressed markers of chronic activation and showed MHC class II positivity. LYH, GRH, and XH, although heterogeneous in their histologic appearance and in age distribution, exhibit a similar if not identical immunohistologic profile. It is highly likely that direct T cell-mediated cytotoxicity through CD8+ T cells, with the initial help of CD4+ T cells, is pivotal in the pathogenesis of primary hypophysitis, implicating a target autoantigen expressed by pituitary cells.

Hyperprolactinaemia associated with a complex cystic pituitary mass: medical versus surgical therapy

A 39-year-old woman presented with visual loss and hyperprolactinaemia. Magnetic resonance imaging showed an intrasellar and suprasellar mass with a large cystic component that was hyperintense on T2-weighted imaging. Prolactin levels were up to 5400 mIU/L. Following trans-sphenoidal surgery, histology showed -elements of both a Rathke's cleft cyst and prolactinoma. We suggest primary surgical management of large cystic pituitary lesions with associated hyperprolactinaemia, particularly when there is hyperintensity on T2-weighted imaging.

Primary hypophysitis: a single-center experience in 16 cases

Object. The authors review their experience in the treatment of 16 patients with primary hypophysitis.

Methods. A retrospective study was undertaken to review cases of primary hypophysitis. The mean age of the patients was 47 years and there was an equal distribution of sexes. Recent pregnancy and underlying autoimmunity were noted in 50% of the patients. Two patients had undergone previous transsphenoidal operations at other centers, one for prolactinoma and another for hypophysitis. Headache, anterior pituitary deficiency, and suprasellar mass lesions were the most common presenting features. The initial presumptive diagnosis was pituitary adenoma in six patients (37.5%) and inflammatory hypophysitis in 10 (62.5%). Five patients received initial medical therapy for hypophysitis; although three (60%) responded satisfactorily, two (40%) did not and later underwent surgery.

Altogether 13 patients (81.2%) underwent transsphenoidal surgery. The histological diagnoses were lymphocytic hypophysitis in 10 (76.9%) and granulomatous hypophysitis in three (23.1%) of the surgically treated patients. A coexistent Rathke cleft cyst was noted in one patient. There was no death in this series. One patient experienced postoperative cerebrospinal fluid leakage and meningitis. One patient had bilateral internal carotid artery occlusion secondary to inflammatory involvement of the cavernous sinuses and arteritis. This patient recovered and is capable of independent functional activities.

Conclusions. All surgical patients experienced improvement in their headache and/or visual field defects and none had visual deterioration. None of the patients experienced any improvement in endocrine function and all required long-term hormone replacement. Transsphenoidal surgery was a safe and effective treatment especially for visual and pressure symptoms. A postoperative recurrence developed in two patients (15.4%) and the treatment modalities included steroid therapy, repeated surgery, and radiosurgery.

Surgical treatment of symptomatic Rathke cleft cysts: clinical features and results with special attention to recurrence

OBJECT

Rathke cleft cysts (RCCs) are rarely symptomatic. The purpose of this study was to clarify the clinical, neuroimaging, surgical, and pathological features of symptomatic RCCs with special attention to their recurrence.

METHODS

This retrospective study involved 53 patients with pathologically confirmed symptomatic RCCs. There were 28 female and 25 male patients, ranging in age from 11 to 68 years (mean 37 years). Common clinical presentations included headache, visual impairment, and endocrine disturbance. The most common endocrine disturbances were hyperprolactinemia and diabetes insipidus. Most of these improved or were resolved after surgery, with the exception of diabetes insipidus and panhypopituitarism. The cysts were intrasellar with suprasellar extension in 33 patients, and ranged in size from 5 to 40 mm (mean 17 mm). In the 50 magnetic resonance (MR) images that were reviewed, the signal intensities were quite variable. Fourteen MR images demonstrated enhancement after an injection of Gd. Intraoperatively, the cyst contents were found to be yellowish (18 patients [37%]) and mucoid (25 patients [51%]). Pathological examinations revealed a pseudostratified columnar epithelium in 26 patients (49%). Abundant squamous metaplasia and a stratified squamous epithelium were also found in 12 patients (23%). Follow-up MR images revealed cyst recurrences that required a repeated operation in six patients. Statistically significant risk factors for a recurrence included enhancement of the lesion on MR images (p = 0.017), the extent of cyst removal (p = 0.012), and the presence of squamous epithelium (p = 0.008).

CONCLUSIONS

Rathke cleft cysts are associated with a variety of clinical presentations and sometimes confusing intraoperative and pathological findings. Close postoperative observation with neuroimaging and neuroophthalmological assessment is necessary, especially after a partial removal, as in cases with squamous metaplasia.

Changes in the epithelium of Rathke cleft cyst associated with inflammation

OBJECT

Rathke cleft cysts (RCCs) are composed of tall, well-differentiated, ciliated columnar epithelia. Their structures are altered by hyperplasia or squamous metaplasia, but their cause remains unknown.

METHODS

The authors studied pathological findings and anterior pituitary function in 20 patients harboring RCCs. They classified RCC epithelium as either single (a single ciliated columnar cell lining or a flattened cuboidal cell lining) or stratified (a stratified ciliated columnar cell lining, basal cell hyperplasia, columnar cell hyperplasia, or squamous metaplasia). Inflammation was classified as acute, subacute, chronic, or end stage. The epithelial cell lining was observed in 13 specimens obtained during surgery (six specimens contained single and seven contained stratified epithelia). Inflammation had penetrated the cyst epithelium or subjacent stroma in 10 patients, and the stage of inflammation correlated well with the type of epithelia group: early stages of inflammation in the single epithelium group and chronic or end-stage inflammation in the stratified epithelia (p = 0.0027). The adenohypophysis was identified in 21 surgical specimens. Postoperatively, growth hormone (p = 0.019), cortisol (p = 0.027), and thyroid-stimulating hormone (p = 0.039) responses significantly worsened as the inflammation progressed. The presence of diabetes insipidus correlated well with advanced stages of neurohypophysitis (p = 0.025).

CONCLUSIONS

Epithelial stratification in the RCC is caused by inflammation that may extend into the adjacent adenohypophysis or neurohypophysis and overwhelm the hypophysis, resulting in panhypopituitarism. Transsphenoidal excision may represent the best choice for treatment, at least for cases of RCC in which there is partial impairment of hypophysial function.

Rathke's cleft cyst presenting as pituitary apoplexy

Sellar lesions mainly constitute pituitary adenomas, craniopharyngiomas and benign cysts. Rathke's pouch cyst is a developmental sellar and/or suprasellar cystic lesion lined by a single layer of ciliated cuboidal or columnar epithelium, which rarely be comes symptomatic. The authors present an interesting case of intrasellar Rathke's pouch cyst, with a presenting feature of acute pituitary apoplexy. This was a 19 year old healthy male who had developed sudden headache and visual disturbance. Neuro-radiological imaging revealed a mass in the sella. Via transsphenoidal approach a haemorrhagic intrasellar cystic lesion was removed and was confirmed as a haemorrhagic Rathke's cleft cyst by histopathological examination. Interesting clinical presentations and the neuroimaging findings are described and discussed.

A case of Rathke's Cleft Cyst inflammation presenting with diabetes insipidus

Rathke's Cleft Cyst (RCC), which is located at the intrasellar region, is considered to be the distended remnants of Rathke's pouch, an invagination of the stomodeum. Lined with columnar or cuboidal epithelium of ectodermal origin, RCC usually contains mucoid material and it is found in 13-22% of normal pituitary glands. The cyst rarely leads to the development of symptoms but, when it does, the most common presenting symptoms are headache, visual impairment, hypopituitarism and hypothalamic dysfunction. However, in some cases it presents symptoms of diabetes insipidus, decreased libido and impotence. Recently we experienced a case of RCC inflammation presenting with diabetes insipidus and treated with transsphenoidal surgery. To our knowledge, this is the first report of RCC presenting with symptoms of diabetes insipidus in Korea.