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Brandel MG, Lin C, Rennert RC, Plonsker JH, Khan UA, Crawford JR, Nation J, Levy ML. Surgical management of Rathke cleft cysts in pediatric patients: a single institution experience. Childs Nerv Syst 2024; 40:1367-1375. [PMID: 38240786 PMCID: PMC11026193 DOI: 10.1007/s00381-024-06277-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/03/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Rathke cleft cysts (RCCs) are benign, epithelial-lined sellar lesions that arise from remnants of the craniopharyngeal duct. Due to their rarity in the pediatric population, data are limited regarding the natural history and optimal management of growing or symptomatic RCCs. We present our institutional experience with the surgical management of RCCs. METHODS We performed a retrospective study of consecutive RCC patients ≤ 18 years old treated surgically at our institution between 2006 and 2022. RESULTS Overall, 567 patients with a diagnosis of pituitary mass or cyst were identified. Of these, 31 had a histopathological diagnosis of RCC, 58% female and 42% male. The mean age was 13.2 ± 4.2 years. Presenting symptoms included headache (58%), visual changes (32%), and endocrinopathies or growth delay (26%); 13% were identified incidentally and subsequently demonstrated growth on serial imaging. Six percent presented with symptomatic intralesional hemorrhage. Surgical approach was transsphenoidal for 90% of patients and orbitozygomatic for 10%. Preoperative headaches resolved in 61% of patients and preoperative visual deficits improvement in 55% after surgery. New pituitary axis deficits were seen in 9.7% of patients. Only two complications occurred from a first-time surgery: one cerebrospinal fluid leak requiring lumbar drain placement, and one case of epistaxis requiring cauterization. No patients experienced new visual or neurological deficits. Patients were followed postoperatively with serial imaging at a mean follow-up was 62.9 ± 58.4 months. Recurrence requiring reoperation occurred in 32% of patients. Five-year progression-free survival was 47.9%. Except for one patient with multiple neurological deficits from a concurrent tectal glioma, all patients had a modified Rankin Scale score of 0 or 1 (good outcome) at last follow-up. CONCLUSION Due to their secretory epithelium, pediatric RCCs may demonstrate rapid growth and can cause symptoms due to local mass effect. Surgical management of symptomatic or growing pediatric RCCs via cyst fenestration or partial resection of the cyst wall can be performed safely, with good neurologic outcomes. There is a nontrivial risk of endocrinologic injury, and long-term follow up is needed due to high recurrence rates.
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Affiliation(s)
- Michael G Brandel
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Christine Lin
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, 84112, USA
| | - Jillian H Plonsker
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Usman A Khan
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - John R Crawford
- Division of Child Neurology and Neurosciences Institute, Children's Hospital of Orange County and University of California Irvine, Orange, CA, 92868, USA
- Division of Neurology, Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Javan Nation
- Department of Otolaryngology, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA.
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Wang HK, Lee CC, Wang YC, Hsu PW, Huang YC, Chang TW, Liu YT, Chuang CC. Rathke's cleft cyst classification and outcomes after endoscopic endonasal approach. Clin Neurol Neurosurg 2023; 233:107882. [PMID: 37517273 DOI: 10.1016/j.clineuro.2023.107882] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Rathke's cleft cyst is rare, with variable characteristics and no unified categorization system. This study aimed to evaluate long-term outcomes, based on different categorizations, of symptomatic Rathke's cleft cysts treated with endoscopic endonasal approach. METHODS This retrospective study of 38 patients with symptomatic Rathke's cleft cyst treated with endoscopic endonasal approach from 2006/06-2021/08 recorded pre- and post-operative clinical presentation, endocrine and visual tests, radiological findings, and resection status. Rathke's cleft cysts were categorized by both cyst consistency and radiological features and clinical characteristics were analyzed. RESULTS The most common pre-operative symptoms were visual field deficit (65.8%) and hypopituitarism (39.5 %). Visual field deficit improved in 84% of affected patients, and hyperprolactinemia improved in 80% of affected patients. Pre-operative hypothyroidism and hypogonadism were associated with radiological type 3 cysts, while headache was more common in type B and C. Type 3 cysts were also associated post-operative hypogonadism and hypothyroidism. Permanent Diabetes insipidus was found in 3 patients (7.9%). Cyst height was a significant factor related to pre-operative visual field deficit and post-operative Diabetes insipidus. Residual cysts were found in 11 cases (30.6%) and 9 patients experienced regrowth/recurrence. Residual cysts were a significant factor in regrowth/recurrence. Recurrence rate and post-operative complications were not correlated with different subtypes. CONCLUSIONS Endoscopic endonasal approach for removal of Rathke's cleft cyst is a safe and effective intervention. It leads to significant improvement in visual field deficit and recovery of hyperprolactinemia. Although the incidence of post-operative Diabetes insipidus is high, it is usually temporary. Although different categorizations are not correlated to recurrence rate, they could help predict the status of hormone deficit.
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Affiliation(s)
- Hong Kai Wang
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; Chang Gung university, School of Medicine, Taoyuan City 333, Taiwan
| | - Cheng Chi Lee
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; Chang Gung university, School of Medicine, Taoyuan City 333, Taiwan
| | - Yu Chi Wang
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; Chang Gung university, School of Medicine, Taoyuan City 333, Taiwan
| | - Peng Wei Hsu
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; Chang Gung university, School of Medicine, Taoyuan City 333, Taiwan
| | - Yin Cheng Huang
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; Chang Gung university, School of Medicine, Taoyuan City 333, Taiwan
| | - Ting-Wei Chang
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; Chang Gung university, School of Medicine, Taoyuan City 333, Taiwan
| | - Yu-Tse Liu
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; Chang Gung university, School of Medicine, Taoyuan City 333, Taiwan
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan; Chang Gung university, School of Medicine, Taoyuan City 333, Taiwan.
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Krasnow MD, Krasnow NA, McGuirk L, Patale TP, Manely S, Sayegh E, Epstein B, Hanif SA, Mehta S, Tenner M, Schefflein J, Mehta H, Noto RA. The evolution of pituitary cysts in growth hormone-treated children. J Pediatr Endocrinol Metab 2023; 36:36-42. [PMID: 36394493 DOI: 10.1515/jpem-2022-0333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We have previously shown that pituitary cysts may affect growth hormone secretion. This study sought to determine cyst evolution during growth hormone treatment in children. METHODS Forty-nine patients with short stature, a pituitary cyst, and at least two brain MRI scans were included. The percent of the pituitary gland occupied by the cyst (POGO) was calculated, and a cyst with a POGO of ≤15% was considered small, while a POGO >15% was considered large. RESULTS Thirty-five cysts were small, and 14 were large. Five of the 35 small cysts grew into large cysts, while 6 of the 14 large cysts shrunk into small cysts. Of 4 cysts that fluctuated between large and small, 3 presented as large and 1 as small. Small cysts experienced greater change in cyst volume (CV) (mean=61.5%) than large cysts (mean=-0.4%). However, large cysts had a greater net change in CV (mean=44.2 mm3) than small cysts (mean=21.0 mm3). Older patients had significantly larger mean pituitary volume than younger patients (435.4 mm3 vs. 317.9 mm3) and significantly larger mean CV than younger patients (77.4 mm3 vs. 45.2 mm3), but there was no significant difference in POGO between groups. CONCLUSIONS Pituitary cyst size can vary greatly over time. Determination of POGO over time is a useful marker for determining the possibility of a pathologic effect on pituitary function since it factors both cyst and gland volume. Large cysts should be monitored closely, given their extreme, erratic behavior.
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Affiliation(s)
- Matthew D Krasnow
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Nicholas A Krasnow
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Liam McGuirk
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Tara P Patale
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Sarah Manely
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Emily Sayegh
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Benjamin Epstein
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Sarriyah A Hanif
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Shilpa Mehta
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Michael Tenner
- Department of Radiology, Division of Neuroradiology, New York Medical College, Valhalla, NY, USA
| | - Javin Schefflein
- Department of Radiology, Division of Neuroradiology, New York Medical College, Valhalla, NY, USA
| | - Hasit Mehta
- Department of Radiology, Division of Neuroradiology, New York Medical College, Valhalla, NY, USA
| | - Richard A Noto
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
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Qian A, Zhou J, Zhang X, Yu J, Wang X. Incidence and factors associated with the recurrence of Rathke's cleft cyst after surgery: A systematic review and meta-analysis. Front Surg 2023; 9:1065316. [PMID: 36684167 PMCID: PMC9849585 DOI: 10.3389/fsurg.2022.1065316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023] Open
Abstract
Backgroud Recurrence of Rathke's cleft cyst (RCC) is not uncommon after surgery, and the associated factors and incidence of relapse deserve a systematic summary. Methods This study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The Pubmed, Embase, Cochrane, and Web of Science databases were searched until September 12, 2022. Studies with significant results of recurrent factors or specific incidences of RCC recurrence and mean/median follow-up time were included. Based on a protocol of a 2-year interval grouping, included studies were categorized into four groups with follow-up periods <24 months, 24-48 months, 48-72 months, and ≥72 months, respectively. Quality assessment was performed using the NOS score. Pooled estimations were computed by using a random-effects model in the STATA "metaprop" command. Publication bias was assessed visually through a funnel plot and statistically through Egger's linear regression test and Begg's correlation test. Results A total of 44 studies were included containing 2,539 cases. Squamous metaplasia was the most commonly reported factor, followed by the extent of cyst removal. The other factors were reported individually. The pooled overall incidences of RCC recurrence after surgery in four groups of the follow-up period were 7.4% (95%CI = 4.1-11.3%) in <24 months, 13.1% (95%CI = 9.7-17.0%) in 24-48 months, 13.7% (95%CI = 7.7-21.0%) in 48-72 months, and 33.8% (95%CI = 19.6-49.6%) in ≥72 months. The pooled symptomatic incidences were 2.3% (95%CI = 0.4-5.1%) in <24 months, 5.6% (95%CI = 3.6-7.9%) in 24-48 months, 5.9% (95%CI = 2.4-10.6%) in 48-72 months, and 14.1% (95%CI = 6.0-24.5%) in ≥72 months. A dramatic increase in recurrent incidence was observed when the follow-up period was more than 72 months in both overall and symptomatic recurrence. A similar trend of recurrence was found in subgroup analyses stratified by publication year, cohort size, and cyst resection strategy. Conclusion This study systematically reviewed recurrent factors and described the profile of trends in RCC recurrent incidence after surgery with a follow-up time based on a protocol of a 2-year interval, finding a dramatic increase in recurrent rates with a follow-up period of more than 72 months. This encouraged us to put forward a recommendation of at least a 6-year follow-up after surgery for patients with RCC. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42021278970.
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Choo YH, Seo Y, Kim OL. The surgical outcomes following transsphenoidal surgery for Rathke cleft cysts: Comparison of the surgical approaches at a single institution. Medicine (Baltimore) 2022; 101:e32421. [PMID: 36595816 PMCID: PMC9794344 DOI: 10.1097/md.0000000000032421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The aim of the present study is to retrospectively analyze the surgical outcomes and complications of microscopic and endoscopic transsphenoidal surgery in the management of Rathke cleft cysts (RCCs) at a single institution. A total of 38 patients were enrolled in this study. All patients were diagnosed with RCCs, which were confirmed histopathologically. Endocrine function, radiological, and clinical outcomes were evaluated following surgery. This cohort study consisted of 16 male and 22 female patients. The median age was 48 years (range, 21-72). The median clinical follow-up duration was 57 months (range, 3-187). Twenty-five patients underwent microscopic transsphenoidal surgery and 13 patients underwent endoscopic surgery. The cysts were located within the intrasellar area in 18 (47.4%) patients, and extended to the suprasellar area in 20 (52.6%) patients. The radiological characteristics were similar in the microscope and endoscope groups, except mass volume (1.40 vs 0.65 mm3; P = .003) and peripheral rim enhancement (P = .036). After surgery, 30 (78.9%) of the 38 patients had no residual cysts. There was no significant difference in outcomes between both groups (76.0% vs 84.6%; P = .689). Four (10.5%) patients experienced cyst recurrence in only the microscope group. Twenty-four of the 25 patients who presented with headache showed improvement after surgery. Four patients with visual field defects recovered after surgery. Among the 8 patients with hormonal deficiencies, hormone levels normalized in 5 patients, did not change in 2 patients and worsened in 1 patient. New hormonal deficiencies occurred in 3 patients. Microscopic or endoscopic transsphenoidal surgery for RCCs is a safe and effective treatment option. Complete aspiration of the cyst contents with wide fenestration and wall biopsy, regardless of the surgical approach used, is usually a sufficient treatment for RCCs.
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Affiliation(s)
- Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hostpital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Republic of Korea
- * Correspondence: Youngbeom Seo, Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung-ro, Nam-gu, Daegu 42415, Republic of Korea (e-mail: )
| | - Oh Lyong Kim
- Health Insurance Review and Assessment Service, Daegu, Republic of Korea
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Millesi M, Lai C, Lau R, Ye VC, Yang K, Leite M, Mohan N, Mete O, Ezzat S, Gentili F, Zadeh G, Kalyvas A. Endoscopic Treatment of Rathke’s Cleft Cysts: The Case for Simple Fenestration. Brain Sci 2022; 12:1482. [DOI: 10.3390/brainsci12111482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Rathke’s cleft cysts (RCC) arise from the pars intermedia because of incomplete regression of the embryologic Rathke pouch. A subset of RCC becomes symptomatic causing headaches, visual and endocrinological disturbances such that surgical intervention is indicated. Several points in surgical management remain controversial including operative strategy (simple fenestration (SF) vs complete cyst wall resection (CWR)) as well as reconstructive techniques. Methods: A retrospective analysis was conducted of pathologically confirmed RCC operated on by endoscopic endonasal approach from 2006 to 2019. Pre-operative symptoms, imaging characteristics, operative strategy, symptom response, complications and recurrences were recorded. Results: Thirty-nine patients were identified. Thirty-three underwent SF and six underwent CWR. Worsening pituitary function was significantly increased with CWR (50%) compared to SF (3%) (p = 0.008). All patients underwent “closed” reconstruction with a post-operative CSF leak rate of 5% (3% SF vs 16% CWR, p = 0.287). Six (15%) recurrences necessitating surgery were reported. Recurrence rates stratified by surgical technique (18% SF vs 0% CWR, p = 0.564) were not found to be significantly different. Conclusions: The current series illustrates variability in the surgical management of RCCs. SF with closed reconstruction is a reasonable operative strategy for most symptomatic RCCs cases while CWR can be reserved for selected cases.
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Tosaka M, Yamaguchi R, Yamazaki A, Mukada N, Shimauchi-Otaki H, Osawa S, Nakata S, Yokoo H, Yoshimoto Y. Endoscopic Extended Transsphenoidal Approach for Sellar and Suprasellar Xanthogranuloma: Potential Implications for Surgical Strategies in Adult Craniopharyngioma. World Neurosurg 2022; 167:e27-e39. [PMID: 35948227 DOI: 10.1016/j.wneu.2022.07.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Differentiation of suprasellar xanthogranuloma (XG) from adult craniopharyngioma (CP) can be problematic in endoscopic extended transsphenoidal surgery. METHODS We reviewed the clinical data, preoperative imaging, intraoperative endoscopic findings, and intraoperative frozen section pathology in newly diagnosed adult CPs (19 patients) and XGs (6 patients). RESULTS Intracystic signal intensity was often high on T1-weighted magnetic resonance images in the XGs but low in the CPs (P = 0.015). Capsular intensity was low on T2-weighted imaging in XGs but iso to high in CPs (P < 0.001). Capsular gadolinium enhancement was often seen in CPs and not in XGs (P < 0.001). CPs often had a solid component with contrast enhancement but none in XGs (P < 0.001). Intraoperative endoscopic observations frequently found a whitish solid component in the CPs but yellow to brown fibrous granulomatous lesions in XGs (P < 0.001). The tumor capsule was dark grayish and soft in CPs, whereas it was fibrously hard in XGs (P = 0.002). Yellowish hemosiderin deposits were seen in all XGs (P = 0.003). Intraoperative pathologic diagnosis of CP was all verified whereas no evidence of tumor was found in XGs (P < 0.001). Partial removal was performed in 4 patients with XGs. No recurrence was observed in these patients during the follow-up period (1.5-8 years). CONCLUSIONS Careful interpretation of preoperative magnetic resonance imaging, intraoperative endoscopic findings, and intraoperative frozen section diagnosis may be important for the differential diagnosis between XG and CP. In endoscopic-extended transsphenoidal surgery, intentional partial removal can be effective for XG after careful diagnosis.
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Affiliation(s)
- Masahiko Tosaka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Ayako Yamazaki
- Department of Human Pathology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Naoto Mukada
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hiroya Shimauchi-Otaki
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Sho Osawa
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Satoshi Nakata
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hideaki Yokoo
- Department of Human Pathology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Gadelha MR, Wildemberg LE, Lamback EB, Barbosa MA, Kasuki L, Ventura N. Approach to the Patient: Differential Diagnosis of Cystic Sellar Lesions. J Clin Endocrinol Metab 2022; 107:1751-1758. [PMID: 35092687 DOI: 10.1210/clinem/dgac033] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Indexed: 02/13/2023]
Abstract
Cystic lesions arising in the sellar region are not uncommon and encompass cystic pituitary adenomas, Rathke cleft cysts, craniopharyngiomas, and arachnoid cysts. Their clinical presentation may be similar, including headache, visual field defects, and anterior pituitary hormone deficits, which makes differential diagnosis challenging. On the other hand, imaging features may indicate certain pathologies. In this approach to the patient, we describe the case of a patient who presented with right temporal hemianopsia and a sellar/suprasellar cystic lesion, which was determined to be Rathke cleft cyst. We discuss the imaging characteristics that may suggest a particular diagnosis between Rathke cleft cyst, cystic pituitary adenoma, craniopharyngioma, and arachnoid cyst and propose a flowchart for aiding in the imaging differential diagnosis.
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Affiliation(s)
- Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Elisa Baranski Lamback
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Monique Alvares Barbosa
- Radiology Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Radiology Unit, Instituto Nacional de Câncer José Alencar Gomes da Silva, Rio de Janeiro, Brazil
- MRI Unit, Clínica de Diagnóstico por imagem, DASA, Rio de Janeiro, Brazil
| | - Leandro Kasuki
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Endocrinology Division, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Nina Ventura
- Radiology Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Neuroradiology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuroradiology Unit, Samaritano Hospital, Grupo Fleury, Rio de Janeiro, Brazil
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Castle-Kirszbaum M, Kam J, Wang YY, King J, Fryer K, Goldschlager T. Surgical outcomes and quality of life in Rathke's cleft cysts undergoing endoscopic transsphenoidal resection: a multicentre study and systematic review of the literature. Pituitary 2022; 25:285-295. [PMID: 35001297 DOI: 10.1007/s11102-021-01197-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To establish the effect of endoscopic endonasal surgery (EES) on quality-of-life (QoL) in symptomatic Rathke cleft cyst (RCC). METHODS Analysis of 38 patients with RCC treated by EES, with regular overall (ASBQ-35) and sinonasal-specific (SNOT-22) QoL assessment during the first postoperative year. A systematic literature review of large case series was performed with pooled analysis. RESULTS In our series, mean age was 53.6 years with a female predominance (73.7%). Larger cysts were seen in males (p < 0.01), those with hypogonadism (p = 0.04), and visual dysfunction (p = 0.04). Complete normalisation of vision was seen in 83.3%. Persistence of visual dysfunction postoperatively was associated with diabetes (p = 0.005), hypertension (p = 0.02), suprasellar only location (p = 0.001), and monocular field cut (p = 0.02). Surgery did not significantly effect hormonal function. Sinonasal QoL transiently worsened after surgery, resolving within 3 weeks. A parallel transient worsening of overall QoL normalised by 6 weeks, and remained at preoperative baseline thereafter. These results were comparable to the literature, where 76.4% demonstrated improvement of vision and 13.1% had recurrence after treatment. There was no significant difference in outcomes between EES and microscopic approaches. CONCLUSIONS We report longitudinal QoL outcomes in RCC for the first time. Vision commonly improves with surgery, but endocrinopathy is likely to persist. Microvascular risk-factors may compromise visual improvement. Surgery causes a transient worsening of sinonasal symptoms that resolves within 3-6 weeks, but patients may not experience significant improvement in QoL within the first postoperative year.
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Affiliation(s)
- Mendel Castle-Kirszbaum
- Department of Neurosurgery, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC 3168, Australia.
| | - Jeremy Kam
- Department of Neurosurgery, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC 3168, Australia
| | - Yi Yuen Wang
- Department of Neurosurgery, St Vincent's Health, Melbourne, Australia
| | - James King
- Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Kylie Fryer
- Department of Neurosurgery, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC 3168, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC 3168, Australia
- Department of Surgery, Monash University, Melbourne, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Petersson M, Berinder K, Eden Engström B, Tsatsaris E, Ekman B, Wahlberg J, Burman P, Borg H, Siesjö P, Dahlqvist P, Åkerman AK, Ragnarsson O, Olsson M, Förander P, Bensing S, Höybye C. Natural history and surgical outcome of Rathke's cleft cysts-A study from the Swedish Pituitary Registry. Clin Endocrinol (Oxf) 2022; 96:54-61. [PMID: 34724249 DOI: 10.1111/cen.14622] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Rathke's cleft cysts are benign, embryological remnants in the pituitary gland. The majority of them are small and asymptomatic but a few may become large, and cause mass effects, pituitary hormone deficiencies and visual impairment. Recommendations for the follow-up of Rathke's cleft cysts vary since data on the natural history are sparse. PATIENTS AND DESIGN Data at diagnosis and at 1, 5 and 10 years for patients with a Rathke's cleft cyst (434 at diagnosis, 317 females) were retrieved from the Swedish Pituitary Registry. Cysts ≤3 mm in diameter were excluded from the study. MEASUREMENTS Data included demographics, cyst size, pituitary function, visual defects and surgery. RESULTS The mean age at diagnosis was 45 years. In patients with cysts <10 mm in diameter (n = 204) 2.9% had pituitary hormone deficiencies and 2% had visual field impairments. Cyst size did not progress during the 5 years. Cysts with a diameter of ≥10 mm that were not operated (n = 174) decreased in size over the years (p < .01). Pituitary hormone deficiencies and visual impairments were more frequent (18% and 5.7%, respectively) but were stable over time. Transphenoidal surgery was performed in 56 patients of whom 51 underwent surgery before the 1-year follow-up. The mean cyst diameter at diagnosis was 18 mm (range: 9─30 mm), 36% had pituitary hormone deficiency, 45% had visual field defects and 20% had impaired visual acuity. One year after surgery 60% had no cyst remnants, 50% had a pituitary deficiency, 26% had visual field defects and 12% had impaired visual acuity. No major changes were observed after 5 years. Twelve of the operated patients had a follow-up at 10 years, in eight the cyst remnants or recurrences increased in size over time (p < .05). CONCLUSIONS Rathke's cleft cysts with a size less than 10 mm rarely grow and our results indicate that radiological follow-up can be restricted to 5 years. In contrast, progression of postoperative remnants or recurrent cysts is more likely and require long-term follow-up.
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Affiliation(s)
- Maria Petersson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Berinder
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Britt Eden Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Erika Tsatsaris
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Bertil Ekman
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - Henrik Borg
- Department of Endocrinology, Skåne University Hospital, University of Lund, Lund, Sweden
| | - Peter Siesjö
- Department of Neurosurgery, Skåne University Hospital, University of Lund, Lund, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Anna-Karin Åkerman
- Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Martin Olsson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Petter Förander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
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12
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Zhang X, Yang J, Huang Y, Liu Y, Chen L, Chen F, Huang G. Endoscopic Endonasal Resection of Symptomatic Rathke Cleft Cysts: Total Resection or Partial Resection. Front Neurol 2021; 12:701177. [PMID: 34630280 PMCID: PMC8498327 DOI: 10.3389/fneur.2021.701177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/12/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: Rathke cleft cysts (RCC) are benign sellar lesions, and endoscopic endonasal surgery (EES) for symptomatic RCC is becoming increasingly popular, but total resection or partial resection (TR or PR) of the cyst wall is still inconclusive. The aim of this study was to review the complications and clinical prognoses associated with total and partial resection of the cyst wall by EES. Methods: We retrospectively analyzed a series of 72 patients with symptomatic RCC treated by EES from -January 2011 to June 2019 at Shenzhen University First Affiliated Hospital. For these 72 cases, 30 were treated with TR and 42 were treated with PR. Intra- and post-operative complications and clinical prognosis were investigated. Results: All 72 patients underwent a pure EES. In the TR group, 10 patients (33.3%) had intraoperative cerebrospinal fluid leakage (CSF leak), three patients (10%) had postoperative CSF leak, eight patients (26.7%) had postoperative diabetes insipidus (DI), eight patients (26.7%) had postoperative electrolyte disturbance, and 12 patients (40%) had temporary hypopituitarism postoperatively. While in the PR group, three patients (7.1%) had intraoperative CSF leak, two patients (4.8%) had postoperative DI, three patients (7.1%) had postoperative electrolyte disturbance, four patients (9.5%) had temporary hypopituitarism postoperatively, and no cases experienced postoperative CSF leak. The intra- and post-operative complications were significantly higher in TR group then PR group (P IntraoperativeCSFleak = 0.004, P Post−operativeCSFleak =0.036, P TransientDI = 0.008, P Temporaryhypopituitarism = 0.002, P Permanenthypopituitarism = 0.036, P Electrolytedisturbance = 0.023). No significant differences in post-operative improvement and recurrence. Conclusions: EES is a safe and effective approach for the treatment of symptomatic RCC. Complete sucking out the cyst contents and partial resection of the cyst wall may be sufficient for treatment, and total resection of the cyst wall is associated with a higher incidence of complications.
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Affiliation(s)
- Xiejun Zhang
- Department of Neurosurgery, Health Science Center, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, China
| | - Jihu Yang
- Department of Neurosurgery, Health Science Center, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, China
| | - Yan Huang
- Department of Endocrinology, Health Science Center, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, China
| | - Yufei Liu
- Department of Neurosurgery, Health Science Center, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, China
| | - Lei Chen
- Department of Neurosurgery, Health Science Center, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, China
| | - Fanfan Chen
- Department of Neurosurgery, Health Science Center, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, China
| | - Guodong Huang
- Department of Neurosurgery, Health Science Center, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, China
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Truong LUF, Bazin C, Gomis P, Decoudier B, Delemer B, Litré CF. Surgery versus conservative care for Rathke's cleft cyst. Neurochirurgie 2021; 67:104-111. [PMID: 33450264 DOI: 10.1016/j.neuchi.2020.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/15/2020] [Accepted: 12/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rathke's cleft cysts are benign cystic lesions of the sellar region, which may cause headache, pituitary deficiencies and visual disturbances from mass effect. Their management is not standardized yet. This study is about establishing a consensus for medical care of RCC. MATERIAL AND METHODS We performed a retrospective observational study of all patients that were diagnosed or followed for RCC between 2008 and 2018 (11 years), in the neurosurgical and the adult endocrine departments of our institution. The study's average time length of follow-up is 72.9 months (from 2 to 385 months). RESULTS The 57 included patients were divided into 2 groups: group A, which included 39 patients that were conservatively managed and group B, which included 18 surgically treated patients. Group A showed either an improvement or a spontaneous resolution of headaches in 56.1% of the cases (P<0.01); a resolution of hyperprolactinemia in 70% of the cases (P=0.21); and of hypogonadism, ACTH deficiency, growth hormone deficiency in 100% of the cases. There was no spontaneous improvement of visual disturbances (P<0.01) or diabetes insipidus (P=0.29) during follow-up. Regarding group B, surgery allowed improvement or complete resolution of headaches in 60% of the cases; visual troubles in 100% of the cases (P<0.01); and hyperprolactinemia in 100% of the cases. Pituitary deficiencies were not improved by surgery. CONCLUSIONS This study offers guidance in decision-making regarding the management of RCC patients. Surgery is particularly suitable for treating visual disturbances caused by RCC. Regular follow-up is more appropriate than surgery concerning headaches, hyperprolactinemia, endocrine disruptions and diabetes insipidus.
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Affiliation(s)
- L U F Truong
- Department of neurosurgery of the CHU of Reims, hôpital Maison Blanche, 45, rue Cognacq-Jay, 51100 Reims, France.
| | - C Bazin
- University of Reims Champagne Ardennes, 51, rue Cognacq-Jay, 51100 Reims, France
| | - P Gomis
- Department of anesthesia of the CHU of Reims, hôpital Maison Blanche, 45, rue Cognacq-Jay, 51100 Reims, France
| | - B Decoudier
- Department of endocrinology of the CHU of Reims, hôpital Robert-Debré, rue du Général Koenig, 51100 Reims, France
| | - B Delemer
- Department of endocrinology of the CHU of Reims, hôpital Robert-Debré, rue du Général Koenig, 51100 Reims, France
| | - C F Litré
- Department of neurosurgery of the CHU of Reims, hôpital Maison Blanche, 45, rue Cognacq-Jay, 51100 Reims, France
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Marcus HJ, Borg A, Hussein Z, Jaunmuktane Z, Baldeweg SE, Grieve J, Dorward NL. Rathke's cleft cysts following transsphenoidal surgery: long-term outcomes and development of an optimal follow-up strategy. Acta Neurochir (Wien) 2020; 162:853-861. [PMID: 31982988 PMCID: PMC7066099 DOI: 10.1007/s00701-020-04237-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/18/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND In patients with symptomatic Rathke's cleft cyst, transsphenoidal surgery is highly effective at preventing further visual loss and usually allows for some recovery of vision. However, cyst recurrence and the need for re-operation are well recognized. To this end, the aim of this study was to investigate patterns of recurrence and long-term outcomes and to use this information to develop an optimal follow-up strategy. METHOD A prospectively maintained database was searched over a 10-year period between 1 January 2008 and the 1 January 2018 to identify all adults that underwent transsphenoidal surgery with a new diagnosis of Rathke's cleft cyst. A retrospective case note review was performed for each patient to extract data on their presentation, investigation, treatment, and outcome. RESULTS In all, 61 eligible patients were identified. The median follow-up was 34 months (range 2-112 months). In the 22 patients with pre-operative visual loss, the outcomes at 6 months were as follows: normal vision (2/22; 9.1%), improved but not normal (7/22; 31.8%), stable (12/22; 54.5%), worse but not blind (1/22; 4.5%), and blind (0/22; 0%). The overall rate of regrowth and re-operation in our study was 19.7 and 11.5%, respectively. The only factor that was significantly associated with recurrence was the presence of residual cystic disease on the post-operative MRI (p < 0.001). CONCLUSIONS We propose a follow-up strategy that stratifies patients at "low risk" if there is no residual cyst, with increasing interval scans, or "high risk" if there is residual cyst, with annual visual assessment and scans.
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Affiliation(s)
- Hani J Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
- Wellcome EPSRC centre for Interventional and Surgical Sciences, University College London, 8.02 Malet Place Building, Gower Street, London, WC1E 6BT, UK.
| | - Anouk Borg
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Ziad Hussein
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Endocrinology, University College London Hospital, London, UK
| | - Zane Jaunmuktane
- Department of Neuropathology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Stephanie E Baldeweg
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Endocrinology, University College London Hospital, London, UK
| | - Joan Grieve
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Neil L Dorward
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Wellcome EPSRC centre for Interventional and Surgical Sciences, University College London, 8.02 Malet Place Building, Gower Street, London, WC1E 6BT, UK
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15
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Farrash FA, Hassounah M, Helmi HA, Othman E, Alotaibi NH. Rathke's cleft cyst presentation mimicking craniopharyngioma: Case report. Int J Surg Case Rep 2020; 68:104-106. [PMID: 32143151 PMCID: PMC7056600 DOI: 10.1016/j.ijscr.2020.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/22/2019] [Accepted: 01/28/2020] [Indexed: 11/17/2022] Open
Abstract
Rathke’s cleft cysts are benign lesions from the remnants of the craniopharyngeal duct. Its diagnosis is often confused with craniopharyngioma. Our case of this cyst demonstrates the importance of proper diagnosis and management.
Introduction Rathke’s cleft cysts (RCCs) are benign cystic lesions from the remnant cells of the craniopharyngeal duct within Rathke’s pouch. Anticipation of such condition will help planning the treatment course. Presentation of case We present a case of a 46-year-old male, referred to our tertiary center with a history of seizures, confusion and agitation for the past two weeks. After thorough investigations, he was found to have hyponatremia with low serum cortisol and hypothyroidism. After being sedated, intubated and stabilized, Magnetic Resonance Imaging (MRI) brain showed relatively medium to large sellar lesion which was highly suspicious of a craniopharyngioma (CP). However, after performing an endoscopic transphenoidal surgical resection of the lesion, clinical diagnosis supported RCC. Discussion The best treatment approach for CP is a complete surgical resection via a transphenoidal approach. Considering the fluid component of RCC, it may be treated with a more conservative surgery and does not necessitate a surgery as invasive as that of CP. Conclusion Given the mixed solid and cystic nature of CPs, it is possible to confuse it with RCC and vice versa. The presented case highlights that Rathke’s cyst may be challenging in terms of pre-operative diagnosis, peri-surgical management and histopathological examination.
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Affiliation(s)
- Faisal A Farrash
- Neurosurgery Department King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Maher Hassounah
- Neurosurgery Department King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hala A Helmi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Eyas Othman
- Otolaryngology, Head & Neck Surgery King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Naif H Alotaibi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Otolaryngology, Head & Neck Surgery King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 08/15/2019] [Indexed: 10/26/2022]
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17
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Ung TH, Yang M, Wang M, Harland T, Lillehei KO. Benefit of Intracystic Bleomycin for Symptomatic Recurrent Rathke Cleft Cyst. Oper Neurosurg (Hagerstown) 2019; 17:268-272. [PMID: 30445570 DOI: 10.1093/ons/opy361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 10/20/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Management of recurrent Rathke cleft cysts (RCC) is problematic. The mainstay of treatment has been reoperation with cyst drainage. Radical cyst resection, although effective, results in a high incidence of diabetes insipidus. Several case reports suggest a potential benefit to radiation therapy or the use of intracystic bleomycin. The intracystic application of bleomycin is known to be beneficial in the treatment of cystic craniopharyngioma; however, its usefulness in the treatment of recurrent RCC has yet to be proven. OBJECTIVE To present our 6-yr experience using intracystic bleomycin for recurrent RCC. METHODS We performed a retrospective chart review of patients with RCC who underwent surgical resection between January 2010 and May 2016 by a single surgeon. Specific attention was paid to patients with recurrent RCC. RESULTS Of the 59 patients operated on for RCC during this 6-yr interval, 6 patients with symptomatic recurrent RCC were identified and received intracystic bleomycin at the time of reoperation. To date, no symptomatic cyst recurrence has been documented in the patients receiving bleomycin (mean = 38.8 mo, range 21.2-79.8 mo). CONCLUSION The use of intracystic bleomycin appears to be a safe and potentially effective treatment option in patients with recurrent RCC. Additional studies with longer follow-up are needed to further define the role of bleomycin in recurrent RCC.
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Affiliation(s)
- Timothy H Ung
- School of Medicine, University of Colorado, Aurora, Colorado.,Department of Neurosurgery, University of Colorado, Aurora, Colorado
| | - Michael Yang
- School of Medicine, University of Colorado, Aurora, Colorado
| | - Mary Wang
- Department of Neurosurgery, University of Colorado, Aurora, Colorado
| | - Tessa Harland
- School of Medicine, University of Colorado, Aurora, Colorado
| | - Kevin O Lillehei
- School of Medicine, University of Colorado, Aurora, Colorado.,Department of Neurosurgery, University of Colorado, Aurora, Colorado
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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19
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Jiang Z, Yu M, Jiang Y, Peng Y. Endoscopic endonasal resection of symptomatic Rathke cleft cysts: clinical outcomes and prognosis. Neurosurg Rev 2019; 42:699-704. [PMID: 30535966 DOI: 10.1007/s10143-018-01058-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/01/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
Abstract
The aim of this study is to investigate the clinical presentation and outcomes associated with endoscopic endonasal resection of Rathke cleft cysts (RCCs). The authors retrospectively studied a series of 13 patients who were diagnosed with RCCs after endoscopic endonasal resection at the Second Xiangya Hospital between June 2016 and December 2017. All 13 patients (8 women) underwent a purely endoscopic endonasal approach (EEA) for fenestration and aspiration of RCCs with excision of the cystic wall. The patient ages varied from 25 to 67 years (mean, 45.1 years), and the follow-up period ranged from 8 to 25 months (mean, 16.6 months). Headache was a presenting symptom in all 13 patients, with 11 (80%) out of the 13 having experienced postoperative improvement of their headaches. Six (46%) of the 13 patients were admitted with pituitary dysfunction, all of them had postoperative improvement. Four (31%) of the 13 patients had temporary postoperative pituitary dysfunction, although there was not any permanent pituitary dysfunction. Six patients had intraoperative complications with CSF leaks, and after the operation, three of them developed temporary diabetes insipidly, one of them had a postoperative infection, and another one had postoperative cerebrospinal fluid leaks, who was treated with absolute bed rest for 7 days. No patient experienced recurrent cysts. EEA is a safe and effective approach for the treatment of symptomatic RCCs. Notably, it is appreciated for protecting and restoring pituitary function; however, the postoperative recurrence rate still lacks a large sample related to the long time follow-up study. Complete aspiration of the cysts' contents with partial excision of the cyst wall is usually sufficient for treatment.
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Ference EH, Badran KW, Kuan EC, Bergsneider M, Heaney AP, Wang MB. Bioabsorbable Steroid Eluting Stents in the Treatment of Recurrent Rathke's Cleft Cyst. J Neurol Surg B Skull Base 2018; 80:505-510. [PMID: 31534893 DOI: 10.1055/s-0038-1675558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 09/27/2018] [Indexed: 10/27/2022] Open
Abstract
Objectives Bioabsorbable steroid eluting stents may prevent the stenosis of ostia after sinus surgery. We describe a technique utilizing this technology to prevent the reformation of Rathke's cleft cysts (RCC) after transnasal transsphenoidal surgical drainage. Design This study is based on retrospective review. Setting The research took place at Tertiary academic medical center. Participants Patients who underwent endoscopic marsupialization of RCC with stent placement were participated in this study. Main Outcome Measures Demographics, surgical history, outcomes, and complications were primary measures of this study. Results Four patients underwent drainage of a recurrent RCC with subsequent stent placement. All patients consented to off-label use of the stent. The mean age of patients was 42 years old and the number of prior drainage procedures ranged from 1 to 3. The stent was placed directly into the opening of the cyst after drainage with no other tissue placed into the cyst cavity or opening. The stents are bioabsorbable and were not removed after surgery but were evaluated endoscopically at 2 and 6 weeks after surgery. The patients have been followed for a mean of 14 months after surgery with no evidence of recurrence on endoscopic exam or imaging. No patient had cerebrospinal fluid leak during or after the operation or permanent endocrinopathy. Conclusion The use of a bioabsorbable steroid eluting stent had no unanticipated consequences and all drainage pathways of all the RCCs remain patent. The use of this technology may decrease recurrence rates in revision or complex cases where patients have extensive scarring of the operative field from prior drainage procedures. Further follow-up of the current cases and study in a larger cohort are warranted.
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Affiliation(s)
- Elisabeth H Ference
- Rick and Tina Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, United States
| | - Karam W Badran
- Department of Otolaryngology-Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, United States
| | - Edward C Kuan
- Department of Otorhinolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, United States
| | - Marvin Bergsneider
- Department of Neurosurgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, United States
| | - Anthony P Heaney
- Department of Endocrinology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, United States
| | - Marilene B Wang
- Department of Otolaryngology-Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, United States
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Krasnow N, Pogostin B, Haigney J, Groh B, Weiler W, Tenner M, Kessler M, Frey M, Noto RA. The prevalence and volumetry of pituitary cysts in children with growth hormone deficiency and idiopathic short stature. J Pediatr Endocrinol Metab 2018; 31:1267-1271. [PMID: 30367806 DOI: 10.1515/jpem-2017-0437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 09/25/2018] [Indexed: 12/28/2022]
Abstract
Background Pituitary cysts have been speculated to cause endocrinopathies. We sought to describe the prevalence and volumetry of pituitary cysts in patients with growth hormone deficiency (GHD) and idiopathic short stature (ISS). Methods Six hundred and eighteen children evaluated for growth failure at the Division of Pediatric Endocrinology at New York Medical College between the years 2002 and 2012, who underwent GH stimulation testing and had a brain magnetic resonance imaging (MRI) prior to initiating GH treatment were randomly selected to be a part of this study. High resolution MRI was used to evaluate the pituitary gland for size and the presence of a cyst. Cyst prevalence, cyst volume and percentage of the gland occupied by the cyst (POGO) were documented. Results Fifty-six patients had a cyst, giving an overall prevalence of 9.1%. The prevalence of cysts in GHD patients compared to ISS patients was not significant (13.5% vs. 5.7%, p=0.46). Mean cyst volume was greater in GHD patients than ISS patients (62.0 mm3 vs. 29.4 mm3, p=0.01). POGO for GHD patients was significantly greater (p=0.003) than for ISS patients (15.3%±12.8 vs. 7.1%±8.0). Observers were blinded to patient groups. Conclusions GHD patients had a significantly greater volume and POGO compared to ISS patients. This raises the question of whether cysts are implicated in the pathology of growth failure.
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Affiliation(s)
- Nicholas Krasnow
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Bradley Pogostin
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - James Haigney
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Brittany Groh
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Winston Weiler
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Michael Tenner
- Department of Radiology, New York Medical College, Valhalla, NY, USA
| | - Marion Kessler
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Michael Frey
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Richard A Noto
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
- Diabetes and Endocrine Center for Children and Young Adults, 755 North Broadway, Suite 400, Sleepy Hollow, NY 10591, USA
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Wu W, Jia G, Jia W, Li G, Zhang J, Zhang L. Pituitary Adenoma Associated With Rathke’s Cleft Cyst: Report of 15 Cases. Can J Neurol Sci 2018; 45:68-75. [DOI: 10.1017/cjn.2017.252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjective: The concomitant presence of pituitary adenoma (PA) with Rathke’s cleft cyst (RCC) is rare, and most of the literature published is case reports. RCC’s clinicopathological features have not been well described. Methods: We retrospectively reviewed the data of 15 patients with PA associated with RCC. We also provide a systematic review of the literature. Results: The patients included males and seven females. The transsphenoidal approach was adopted for all patients except one, who underwent right frontal craniotomy. Complete resection was achieved in nine cases, with grossly complete resection in five and partial removal in one. Of the PA subtypes available, five patients had nonfunctional pituitary adenomas, three had multiple-hormone secreting PAs, three had prolactin-producing adenomas, and one had a growth hormone-secreting adenoma. All of the patients’ symptoms and abnormal endocrine test results resolved or were relieved after surgery. The mean follow-up time was 27.6±16.6 months. All of the patients recovered well and had no signs of recurrence during their follow-up, except for one patient. Conclusions: A cyst-like signal indicated on images or cystic materials encountered during operation in a patient with PA suggest the possibility of PA associated with RCC. Transsphenoidal surgery is the preferred approach and can resolve or relieve patients’ symptoms to a great extent. Histologically, nonfunctional PA and prolactinoma are the most common types of PA coexisting with RCC; the mechanisms of PA associated with RCC need to be investigated further.
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Kinoshita Y, Tominaga A, Usui S, Arita K, Sakoguchi T, Sugiyama K, Kurisu K. The long-term recurrence of Rathke's cleft cysts as predicted by histology but not by surgical procedure. J Neurosurg 2016; 125:1002-1007. [DOI: 10.3171/2015.8.jns151282] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Patients with symptomatic Rathke's cleft cysts (RCCs) managed by surgical treatment often experience recurrence. The authors attempted to clarify the outcome of surgically treated RCCs over a long-term follow-up period.
METHODS
Ninety-one consecutive RCC patients with a follow-up period of more than 12 months (mean 80.2 months, range 12–297 months) were retrospectively studied. The authors examined the clinical features and postoperative course of patients who experienced a reaccumulation of cyst contents visible on MRI after the initial surgery, and they investigated data from the patients who underwent reoperation for symptomatic recurrent RCCs.
RESULTS
Reaccumulation of cyst contents occurred in 36 patients (39.6%). In 34 of these patients, a reaccumulation occurred in the first 5 years after surgery. The initial cysts in these patients were most often large, with squamous metaplasia in the cyst walls. Thirteen patients (14.3%) with recurrent symptoms underwent a reoperation, and 10 of the 13 patients had a reaccumulation of RCCs within the 1st year after surgery. The reoperations were performed in the 1st year (61.5%) or several years later (23.1%). Patients were likely to initially have had a visual disturbance and the cyst walls likely included squamous metaplasia. However, no association was observed between the incidence of reaccumulation/reoperation of RCCs and the surgical procedure for RCCs.
CONCLUSIONS
The reaccumulation rate of RCC is high in the long-term period, and it is associated with the histological findings but not with the surgical procedure. Long-term monitoring, for a period of at least 5 years, should therefore be conducted to identify and assess any RCC reaccumulation.
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Affiliation(s)
- Yasuyuki Kinoshita
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Atsushi Tominaga
- 2Department of Neurosurgery, Hiroshima Prefectural Hospital; and
| | - Satoshi Usui
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Kazunori Arita
- 3Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | | | - Kazuhiko Sugiyama
- 4Department of Clinical Oncology and Neuro-oncology Program, Hiroshima University Hospital, Hiroshima; and
| | - Kaoru Kurisu
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University
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Tamura R, Takahashi S, Emoto K, Nagashima H, Toda M, Yoshida K. GH-Producing Pituitary Adenoma and Concomitant Rathke's Cleft Cyst: A Case Report and Short Review. Case Rep Neurol Med 2015; 2015:948025. [PMID: 25883817 DOI: 10.1155/2015/948025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 03/13/2015] [Accepted: 03/15/2015] [Indexed: 11/17/2022] Open
Abstract
Concomitant pituitary adenoma (PA) and Rathke's cleft cyst (RCC) are rare. In some cases, such PA is known to produce pituitary hormones. A 53-year-old man was admitted to our hospital with a diagnosis of lacunar infarction in the left basal ganglia. Magnetic resonance imaging (MRI) incidentally showed a suprasellar mass with radiographic features of RCC. When he consulted with a neurosurgical outpatient clinic, acromegaly was suspected based on his appearance. A diagnosis of growth hormone- (GH-) producing PA was confirmed from hormonal examinations and additional MRI. Retrospectively, initial MR images also showed intrasellar mass that is compatible with the diagnosis of PA other than suprasellar RCC. The patient underwent endonasal-endoscopic removal of the PA. Since we judged that the RCC of the patient was asymptomatic, only the PA was completely removed. The postoperative course of the patient was uneventful and GH levels gradually normalized. Only 40 cases of PA with concomitant RCC have been reported to date, including 13 cases of GH-producing PA. In those 13 cases, RCC tended to be located in the sella turcica, and suprasellar RCC like this case appears rare. In a few cases, concomitant RCCs were fenestrated, but GH levels normalized postoperatively as in the cases without RCC fenestration. If radiographic imaging shows typical RCC, and PA is not obvious at first glance, the possibility of concomitant PA still needs to be considered. In terms of treatment, removal of the RCC is not needed to achieve hormone normalization.
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Abstract
OBJECT An assessment regarding both surgical approaches and the extent of resection for Rathke cleft cysts (RCCs) based on their locations has not been reported. The aim of this study was to report the results of a large series of surgically treated patients with RCCs and to evaluate the feasibility of individualized surgical strategies for different RCCs. METHODS We retrospectively reviewed 87 cases involving patients with RCCs (16 intrasellar, 50 intra- and suprasellar, and 21 purely suprasellar lesions). Forty-nine patients were treated via a transsphenoidal (TS) approach, and 38 were treated via a transcranial (TC) approach (traditional craniotomy in 21 cases and supraorbital keyhole craniotomy in 17). The extent of resection was classified as gross-total resection (GTR) or subtotal resection (STR) of the cyst wall. Patients were thus divided into 3 groups according to the approach selected and the extent of resection: TS/STR (n = 49), TC/STR (n = 23), and TC/GTR (n = 15). RESULTS Preoperative headaches, visual dysfunction, hypopituitarism, and diabetes insipidus (DI) resolved in 85%, 95%, 55%, and 65% of patients, respectively. These rates did not differ significantly among the 3 groups. Overall, complications occurred in 8% of patients in TS/STR group, 9% in TC/STR group, and 47% in TC/GTR group, respectively (p = 0.002). Cerebrospinal fluid (CSF) leakage (3%), new hypopituitarism (9%), and DI (6%) were observed after surgery. All CSF leaks occurred in the endonasal group, while the TC/GTR group showed a higher rate of postoperative hypopituitarism (p = 0.7 and p < 0.001, respectively). It should be particularly noted that preoperative hypopituitarism and DI returned to normal, respectively, in 100% and 83% of patients who underwent supraorbital surgery, and with the exception of 1 patient who had transient postoperative DI, there were no complications in patients treated with supraorbital surgery. Kaplan-Meier 3-year recurrence-free rates were 84%, 87%, and 86% in the TS/STR, TC/STR, and TC/GTR groups, respectively (p = 0.9). CONCLUSIONS It is reasonable to adopt individualized surgical strategies for RCCs based on cyst location. Gross-total resection does not appear to reduce the recurrence rate but increase the risk of postoperative complications. The endonasal approach seems more appropriate for primarily intrasellar RCCs, while the craniotomy is recommended for purely or mainly suprasellar cysts. The supraorbital route appears to be preferred over traditional craniotomy for its minimal invasiveness and favorable outcomes. The endoscopic technique is helpful for either endonasal or supraorbital surgery.
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Affiliation(s)
- Jun Fan
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Maiza JC, Schneebeli S. Activité physique intense responsable d’une insuffisance anté-hypophysaire chez un patient atteint d’un kyste de la poche de Rathke. Presse Med 2013; 42:108-10. [DOI: 10.1016/j.lpm.2012.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 01/06/2012] [Accepted: 01/19/2012] [Indexed: 11/30/2022] Open
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Abstract
Rathke's cleft cysts (RCCs) are benign, sellar and/or suprasellar lesions originating from the remnants of Rathke's pouch. Although a common finding in routine autopsies (12-33% of normal pituitary glands), symptomatic cases are rare and comprise 5-15% of all surgically resected sellar lesions. Small, asymptomatic RCC do not require surgical intervention, and their natural history is not clear. In series of nonoperated presumed RCCs, 26-94% did not progress during follow-up periods up to 9 years. In symptomatic ones, surgery is indicated, aiming to drain the cyst content and safely remove as much of the capsule as possible. Following surgical intervention, headaches and visual field defects improve or resolve in a significant number of patients (40-100% and 33-100%, respectively) and partial hypopituitarism recovers in 14-50%. Data on relapse rates published in the last 15 years are based on variable follow-up periods and show wide variation (between 0% and 33%). The lowest relapse rates have been described in reports with relatively short mean observation periods (<3 years), whereas in those with longer follow-up the relapse rates increase. Most of the relapses occur within 5-6 years, suggesting that follow-up is required for at least 5 years after surgery. Risk factors for relapse include the presence of squamous metaplasia in the cyst wall, cyst size and the presence of inflammation. Long-term sufficiently powered studies aiming to clarify the natural history of asymptomatic RCCs and of those relapsing postoperatively are required.
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Affiliation(s)
- Raluca Trifanescu
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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