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West JL, Soike MH, Renfrow JJ, Chan MD, Laxton AW, Tatter SB. Successful application of stereotactic radiosurgery for multiply recurrent Rathke's cleft cysts. J Neurosurg 2020; 132:832-836. [PMID: 30717059 DOI: 10.3171/2018.9.jns181703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rathke's cleft cysts (RCCs) are benign lesions of the sella turcica that usually come to neurosurgical attention due to compression of the optic apparatus (OA) and headaches. Treatment options for these lesions include observation, aspiration of cyst contents, or open resection of the cyst with the cyst wall. All of these options involve the potential for cyst recurrence or enlargement. In this study the authors report on a potential new therapeutic option for RCCs, i.e., stereotactic radiosurgery (SRS). METHODS A retrospective review was conducted of 5 patients with histologically confirmed, multiply recurrent RCCs who were treated with single-fraction SRS at a tertiary referral academic medical center. RESULTS The total cohort consisted of 5 female patients with an average age of 31.8 years. The most common presenting symptom was headache followed by blurry vision. The symptoms were present on average for 7 months before intervention. The median number of surgeries prior to radiosurgery was 2. The average volume of lesion treated was 0.34 cm3. The median SRS dose was 12.5 Gy prescribed to the 50% isodose line with an average prescription coverage of 96.6%. The median dose to the OA was 5 Gy. At last follow-up, 3 of 5 cysts had completely regressed, 1 had regressed by more than 50% but was still present, and 1 was stable, with an overall mean follow-up duration of 34.2 months. There were no neurological, endocrinological, or visual complications attributable to SRS during the follow-up period. CONCLUSIONS RCCs can be a challenging clinical entity to treat, especially when they are multiply recurrent. In patients with an average of 2 previous surgeries for resection, a single SRS session prevented recurrence universally, with an average follow-up of almost 3 years. These results indicate that further investigation of the treatment of RCCs with SRS is indicated.
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Affiliation(s)
| | - Michael H Soike
- 2Radiation Oncology, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | | | - Michael D Chan
- 2Radiation Oncology, Wake Forest Baptist Health, Winston-Salem, North Carolina
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Gatto F, Perez-Rivas LG, Olarescu NC, Khandeva P, Chachlaki K, Trivellin G, Gahete MD, Cuny T. Diagnosis and Treatment of Parasellar Lesions. Neuroendocrinology 2020; 110:728-739. [PMID: 32126547 DOI: 10.1159/000506905] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
The parasellar region, located around the sella turcica, is an anatomically complex area representing a crossroads for important adjacent structures. Several lesions, including tumoral, inflammatory vascular, and infectious diseases may affect this area. Although invasive pituitary tumors are the most common neoplasms encountered within the parasellar region, other tumoral (and cystic) lesions can also be detected. Craniopharyngiomas, meningiomas, as well as Rathke's cleft cysts, chordomas, and ectopic pituitary tumors can primarily originate from the parasellar region. Except for hormone-producing ectopic pituitary tumors, signs and symptoms of these lesions are usually nonspecific, due to a mass effect on the surrounding anatomical structures (i.e., headache, visual defects), while a clinically relevant impairment of endocrine function (mainly anterior hypopituitarism and/or diabetes insipidus) can be present if the pituitary gland is displaced or compressed. Differential diagnosis of parasellar lesions mainly relies on magnetic resonance imaging, which should be interpreted by neuroradiologists skilled in base skull imaging. Neurosurgery is the main treatment, alone or in combination with radiotherapy. Of note, recent studies have identified gene mutations or signaling pathway modulators that represent potential candidates for the development of targeted therapies, particularly for craniopharyngiomas and meningiomas. In summary, parasellar lesions still represent a diagnostic and therapeutic challenge. A deeper knowledge of this complex anatomical site, the improvement of imaging tools, as well as novel insights into the pathophysiology of presenting lesions are strongly needed to improve the management of parasellar lesions.
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Affiliation(s)
- Federico Gatto
- Endocrinology Unit, Department of Specialist Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luis G Perez-Rivas
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Nicoleta Cristina Olarescu
- Section of Specialized Endocrinology, Department of Endocrinology, Medical Clinic, Oslo University Hospital, and University of Oslo, Oslo, Norway
- Department of Medical Biochemistry, Oslo University, Oslo, Norway
| | - Pati Khandeva
- Endocrinology Research Center, Moscow, Russian Federation
| | - Konstantina Chachlaki
- Inserm, Laboratory of Development and Plasticity of the Neuroendocrine Brain, Jean-Pierre Aubert Research Centre, UMR-S 1172, Lille, France
| | - Giampaolo Trivellin
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Manuel D Gahete
- Maimónides Institute of Biomedical Research of Córdoba (IMIBIC), Córdoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Córdoba, Córdoba, Spain
- Reina Sofía University Hospital, Córdoba, Spain
- CIBER Pathophysiology of Obesity and Nutrition (CIBERobn), Córdoba, Spain
| | - Thomas Cuny
- Department of Endocrinology, Hospital La Conception, Aix Marseille University, APHM, INSERM, MMG, Marseille, France,
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Differentiation of Pituitary Adenoma from Rathke Cleft Cyst: Combining MR Image Features with Texture Features. CONTRAST MEDIA & MOLECULAR IMAGING 2019; 2019:6584636. [PMID: 31741657 PMCID: PMC6854938 DOI: 10.1155/2019/6584636] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/26/2019] [Indexed: 02/05/2023]
Abstract
Objectives To differentiate pituitary adenoma from Rathke cleft cyst in magnetic resonance (MR) scan by combing MR image features with texture features. Methods A total number of 133 patients were included in this study, 83 with pituitary adenoma and 50 with Rathke cleft cyst. Qualitative MR image features and quantitative texture features were evaluated by using the chi-square tests or Mann–Whitney U test. Binary logistic regression analysis was conducted to investigate their ability as independent predictors. ROC analysis was conducted subsequently on the independent predictors to assess their practical value in discrimination and was used to investigate the association between two types of features. Results Signal intensity on the contrast-enhanced image was found to be the only significantly different MR image feature between the two lesions. Two texture features from the contrast-enhanced images (Histo-Skewness and GLCM-Correlation) were found to be the independent predictors in discrimination, of which AUC values were 0.80 and 0.75, respectively. Besides, the above two texture features (Histo-Skewness and GLCM-Contrast) were suggested to be associated with signal intensity on the contrast-enhanced image. Conclusion Signal intensity on the contrast-enhanced image was the most significant MR image feature in differentiation between pituitary adenoma and Rathke cleft cyst, and texture features also showed promising and practical ability in discrimination. Moreover, two types of features could be coordinated with each other.
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Chang CF, Chen YM. Rathke’s cleft cyst presenting as incomplete cavernous sinus syndrome and disc edema: a case report with literature review. Doc Ophthalmol 2019; 140:55-65. [DOI: 10.1007/s10633-019-09713-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 08/15/2019] [Indexed: 10/26/2022]
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Kaltsas GA, Kolomodi D, Randeva H, Grossman A. Nonneuroendocrine Neoplasms of the Pituitary Region. J Clin Endocrinol Metab 2019; 104:3108-3123. [PMID: 30779850 DOI: 10.1210/jc.2018-01871] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 02/14/2019] [Indexed: 12/18/2022]
Abstract
CONTEXT Although most sellar lesions are related to pituitary adenomas, the region gives rise to a variety of neoplasms that can be associated with substantial morbidity and/or mortality. DESIGN Information from reviews and guidelines of relevant societies dealing with such neoplasms, as well as articles that have provided new developments that made important contributions to their pathogenesis and treatment up to 2018, were obtained: public indexes such as PubMed/MEDLINE were used with the relevant search items. RESULTS Sellar neoplasms have a worse outcome than pituitary adenomas that is related not only to their natural history but also to side effects of therapies and evolving endocrine and/or hypothalamic deficiencies. Recent imaging advances have established the radiological fingerprint of some of these neoplasms, and several chromosomal aberrations have also been identified. Although established approaches along with new surgical and radiotherapeutic approaches remain the main treatment modalities, recent evidence has provided insight into their molecular pathogenesis involving, other than chemotherapy, treatments with targeted agents as in gliomas and craniopharyngiomas bearing BRAF mutations. Development of predictive markers of recurrences may also identify high-risk patients, including proliferative markers and expression of the progesterone receptor in meningiomas, and lead to less aggressive surgery. Owing to the rarity and complexity of these neoplasms, patients should be managed in dedicated centers. CONCLUSIONS The diagnosis and management of sellar neoplasms necessitate a multidisciplinary approach. Following evolving recent advances in their diagnosis and therapy, such a multidisciplinary approach needs to be extended to establish evidence-based diagnostic and management plans.
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Affiliation(s)
- Gregory A Kaltsas
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- WISDEM Centre, University Hospital of Coventry and Warwickshire, Coventry, United Kingdom
| | - Dionysia Kolomodi
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harpal Randeva
- WISDEM Centre, University Hospital of Coventry and Warwickshire, Coventry, United Kingdom
| | - Ashley Grossman
- Centre for Endocrinology, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
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Barkhoudarian G, Palejwala SK, Ansari S, Eisenberg AA, Huang X, Griffiths CF, Cohan P, Rettinger S, Lavin N, Kelly DF. Rathke's cleft cysts: a 6-year experience of surgery vs. observation with comparative volumetric analysis. Pituitary 2019; 22:362-371. [PMID: 31016554 DOI: 10.1007/s11102-019-00962-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rathke's cleft cysts (RCCs) are common sellar lesions. Their management remains controversial, particularly when small or asymptomatic. Herein we review a consecutive series of RCC patients managed with surgery or observation. METHODS All patients with a new diagnosis of presumed RCC, based on MRI, from February 2012-March 2018 were retrospectively divided into observational and surgical cohorts based on an intent-to-treat model. The cohorts were compared for clinical presentation, and cyst volume. The observational cohort was followed for change in cyst size. The surgical cohort was followed for changes in endocrinopathy, visual symptoms, headache and recurrence. RESULTS Of 90 patients (mean age 36.7 ± 19.4 years; 68% female), 60% (n = 54) were in the observational cohort and 40% (n = 36) in the surgical cohort. Average follow-up was 13 ± 23 months in the observational cohort and 24 ± 19 months in the surgical group. In comparing the cohorts, mean ages were similar with more women in the surgical group (81% vs. 56%, p = 0.04). Most patients in the observational cohort had incidentally-discovered RCCs (n = 50, 88%) as opposed to the surgical cohort (n = 6, 17%). The surgical cohort had higher rates of headache (89% vs 26%, p < 0.001), endocrinopathy (36% vs 0%, p < 0.001), and visual dysfunction (19% vs 0%, p = 0.001). Mean cyst volume and maximal cyst dimensions were greater in the surgical cohort (0.94 ± 0.77 cm3 and 14.2 ± 4.1 mm), compared to the observational cohort (0.1 ± 0.14 cm3 and 6.4 ± 3 mm), (p < 0.001). Among the 53% (n = 30/54) of patients in the observational group with follow-up, 3 (10%) had spontaneous RCC shrinkage, 1 (3%) had modest asymptomatic growth (at 10 months from initial MRI), and 87% had stable cyst size. Of the 36 patients recommended to have surgery, 89% (n = 32) did so. Post-operatively, complete or partial resolution of headache, endocrinopathy and visual dysfunction were documented in 90% (n = 28/30), 75% (n = 10/12), and 100% (n = 7/7), respectively. On follow-up MRI, 8 (22%) patients had some cyst reaccumulation, of whom 3 (8%) were symptomatic and underwent uneventful reoperation. No major complications such as hematoma, CSF leak, new endocrinopathy or visual deficits occurred. CONCLUSION From this consecutive series, a majority (60%) of RCCs do not appear to warrant surgical intervention and have a low risk of cyst progression. However, surgical cyst removal appears to be indicated and safe for patients with larger, symptomatic RCCs. Simple cyst drainage has a high rate of improvement in pituitary gland function, visual function and headache resolution with low complication rates and symptomatic recurrence risk. These findings stress the importance of careful case selection and potential utility of volumetric assessment for patients with RCCs.
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Affiliation(s)
- Garni Barkhoudarian
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA.
| | - Sheri K Palejwala
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Shaheryar Ansari
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Amalia A Eisenberg
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Xiang Huang
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Chester F Griffiths
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Sarah Rettinger
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Norman Lavin
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
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[Rathke cysts, craniopharyngioma, and colloid cysts : What are the differences between these pathologies?]. Radiologe 2019; 58:646-652. [PMID: 29777270 DOI: 10.1007/s00117-018-0398-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
CLINICAL ISSUE Headache is the most common symptom of colloid cysts, Rathke cysts, and craniopharyngioma due to their location in the midline, being extra-axial and typically presenting in the parasellar region. THERAPEUTIC PROBLEMS Although these tumors are generally considered benign, each has its typical characteristics defined by its location and histology. These individual characteristics define whether surgery is necessary at all and if so, the preferred surgical approach and resection's totality. The histopathological findings primarily indicate that embryonic malformations-at the first glance, ectodermal in nature-cause these tumors. ACHIEVEMENT Due to the fact that these disturbances occur at the boundary between ectodermal stomodeum and endodermal cephalogaster, however, does leave some doubts.
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Abstract
METHODICAL ISSUE The anatomy of the sellar region is complex and tumors of the sellar region are very variable because they arise from the many different tissue types in the sellar region, ranging from benign to life-threatening. Despite this variety, approximately 80% of sellar region tumors are due to the 5 most common lesions: adenomas, meningiomas, aneurysms, astrocytomas and craniopharyngiomas. STANDARD RADIOLOGICAL METHODS In addition to clinical and laboratory results, the magnetic resonance imaging (MRI) and computed tomography (CT) results including the exact anatomical position and the proliferation pattern of the lesion are decisive for the diagnosis. The gold standard for diagnostic imaging is multiplanar, thin section, contrast-enhanced MRI with soft tissue contrast. Vessel imaging and CT are complementary modalities in selected cases and often for preoperative planning. METHODICAL INNOVATIONS Whereas most sellar region tumors can be well visualized with multiplanar, contrast-enhanced MRI, for very small intrapituitary microadenomas dynamic contrast-enhanced T1-weighted sequences can be necessary. Microadenomas can often only be clearly demarcated from the rest of the pituitary tissue due to the different perfusion pattern. Optimized diffusion-weighted images can also be useful for narrowing down the differential diagnoses of sellar region tumors. PERFORMANCE AND ACHIEVEMENTS Tumors of the sellar region can be subdivided in intrahypophysial and extrahypophysial lesions as well as intrinsic skull base lesions. The most common sellar tumors are adenomas of the pituitary gland, which can be subdivided into microadenoma and macroadenoma and into secretory and non-secretory. PRACTICAL RECOMMENDATIONS If there is suspicion of a sellar region lesion due to clinical or laboratory results, multiplanar contrast enhanced thin section MRI of the sellar region should be used as the primary imaging modality. The keys to the diagnosis are the precise anatomical location of the lesion and the proliferation pattern. The most common lesions in the sellar region are pituitary gland adenomas, which can be small and often secretory or larger and often non-secretory.
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Affiliation(s)
- J M Lieb
- Imamed Radiologie Nordwest, Sternengasse 18, 4051, Basel, Schweiz.
| | - F J Ahlhelm
- Abteilung für Neuroradiologie, Kantonsspital Baden, Baden, Schweiz
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Ling SY, Zhao ZY, Tao B, Zhao HY, Su TW, Jiang YR, Xie J, Sun QF, Bian LG, Sun K, He NY, Yan FH, Wang WQ, Ning G, Sun LH, Liu JM. PITUITARY STALK THICKENING IN A LARGE COHORT: TOWARD MORE ACCURATE PREDICTORS OF PITUITARY DYSFUNCTION AND ETIOLOGY. Endocr Pract 2019; 25:534-544. [PMID: 30865546 DOI: 10.4158/ep-2018-0550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective: To summarize the characteristics of patients with pituitary stalk thickening, analyze the association between pituitary stalk width and hypopituitarism, and develop a diagnostic model to differentiate neoplastic and inflammatory origins. Methods: A total of 325 patients with pituitary stalk thickening in a tertiary teaching hospital between January 2012 and February 2018 were enrolled. Basic characteristics and hormonal status were evaluated. Indicators to predict etiology in patients with histologic diagnoses were analyzed. Results: Of the 325 patients, 62.5% were female. Deficiency in gonadotropin was most common, followed by corticotropin, growth hormone, and thyrotropin. The increase in pituitary stalk width was associated with a risk of central diabetes insipidus (odds ratio [OR], 3.57; P<.001) and with a combination of central diabetes insipidus and anterior pituitary deficiency (OR, 2.28; P = .029). The cut-off pituitary stalk width of 4.75 mm had a sensitivity of 69.2% and a specificity of 71.4% for the presence of central diabetes insipidus together with anterior pituitary deficiency. Six indicators (central diabetes insipidus, pattern of pituitary stalk thickening, pituitary stalk width, neutrophilic granulocyte percentage, serum sodium level, and gender) were used to develop a model having an accuracy of 95.7% to differentiate neoplastic from inflammatory causes. Conclusion: Pituitary stalk width could indicate the presence of anterior pituitary dysfunction, especially in central diabetes insipidus patients. With the use of a diagnostic model, the neoplastic and inflammatory causes of pituitary stalk thickening could be preliminarily differentiated. Abbreviations: APD = anterior pituitary dysfunction; AUC = area under the curve; CDI = central diabetes insipidus; GH = growth hormone; MRI = magnetic resonance imaging; OR = odd ratio; PHBS = posterior hypophyseal bright spots; PST = pituitary stalk thickening; PSW = pituitary stalk width.
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Langlois F, Manea A, Lim DST, McCartney S, Yedinak CG, Cetas JS, Fleseriu M. High prevalence of adrenal insufficiency at diagnosis and headache recovery in surgically resected Rathke's cleft cysts-a large retrospective single center study. Endocrine 2019; 63:463-469. [PMID: 30338480 DOI: 10.1007/s12020-018-1784-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/03/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Rathke's cleft cysts (RCC) are lesions that arise from Rathke's pouch. Though frequently incidental, resulting symptoms in a minority of cases are indicators for surgical resection, which may prove beneficial. OBJECTIVE To characterize a cohort of surgically-resected RCC cases at Oregon Health & Science University; tabulate associated hormonal imbalances and symptoms, possible symptom reversal with surgery, determine recurrence risk; identify predictors of recurrence and headache improvement. METHOD Electronic records of all RCC resected cases (from 2006-2016; 11 years) were retrospectively reviewed. Patients had been evaluated by one neuroendocrinologist using a uniform protocol. RESULTS A pathological RCC diagnosis was established in 73 of 814 (9%) surgical pituitary cases. The RCC cohort was 77% (n = 56/73) female, mean age was 39.5 ± 14.9 years at first surgery, and at presentation headache was reported in 88% and visual defects/diplopia in 18% of patients. Initial RCC maximum diameter was 1.3 ± 0.7 cm. The most frequent hormonal deficit was cortisol; 24% of patients had a new adrenal insufficiency (AI) diagnosis, however, 36% also had AI at 3 months post-operatively. Mean follow up was 4.0 ± 4.5 years. Two-thirds of patients (41/62) had headache improvement 3 months post-operatively. Post-operative imaging revealed no residual cyst in 58% (38/65). In those patients with no residual RCC, 29% had recurrence and 71% had long lasting cure. From the 42% (27/65) of patients with residual cyst on post-operative imaging; 59% (16/27) remained stable, 26% (7/27) progressed and 15% (4/27) regressed. CONCLUSION Symptomatic RCC present mostly in women, with a high proportion reporting headaches. Prevalence of AI at diagnosis is high. Surgery may not achieve adrenal axis recovery, but renders a high percentage of headache improvement. Approximately 25% of RCC will recur by 4 years postoperatively. Clinicians should cautiously screen patients with symptomatic RCC, regardless of lesion size for AI.
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Affiliation(s)
- Fabienne Langlois
- Department of Endocrinology, Centre hospitalier universitaire de Sherbrooke, Fleurimont, QC, Canada
| | - Anamaria Manea
- Pediatric Endocrinology, Oregon Health & Science University, Portland, OR, USA
| | - Dawn Shao Ting Lim
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Shirley McCartney
- Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | | | - Justin S Cetas
- Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Maria Fleseriu
- Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
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Yoon JS, So CH, Lee HS, Lim JS, Hwang JS. Prevalence of Pathological Brain Lesions in Girls with Central Precocious Puberty: Possible Overestimation? J Korean Med Sci 2018; 33:e329. [PMID: 30546283 PMCID: PMC6291406 DOI: 10.3346/jkms.2018.33.e329] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 09/20/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Brain magnetic resonance imaging (MRI) is routinely performed to identify brain lesions in girls with central precocious puberty (CPP). We aimed to investigate the prevalence and type of brain lesions among Korean girls with CPP and evaluate the need for routine brain MRI examinations. METHODS This retrospective cross-sectional study evaluated data on 3,528 girls diagnosed with CPP from April 2003 to December 2016, and identified 317 girls who underwent sellar MRI. Exclusion criteria were patients with a known brain tumor or who did not undergo brain MRI due to refusal or the decision of the pediatric endocrinologist. RESULTS Normal sellar MRI findings were observed in 291 of the 317 girls (91.8%). Incidental findings were observed in 26 girls (8.2%). None of the patients had pathological brain lesions. CONCLUSION The prevalence of intracranial lesions among girls who were generally healthy and without neurological symptoms but diagnosed with CPP was lower than that previously reported. Furthermore, none of the identified lesions required treatment. It may be prudent to reconsider the routine use of brain MRI to screen all patients with CPP, especially if they are healthy and neurologically asymptomatic, and are girls aged 6-8 years.
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Affiliation(s)
- Jong Seo Yoon
- Department of Pediatrics, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
| | - Cheol Hwan So
- Department of Pediatrics, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Hae Sang Lee
- Department of Pediatrics, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
| | - Jung Sub Lim
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
| | - Jin Soon Hwang
- Department of Pediatrics, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
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Endoscopic endonasal resection of symptomatic Rathke cleft cysts: clinical outcomes and prognosis. Neurosurg Rev 2018; 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] [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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Choi HS, Kim YH, Kim CS, Ma SK, Kim SW, Bae EH. Diabetes Insipidus Presenting with Oligohydramnios and Polyuria During Pregnancy. J NIPPON MED SCH 2018; 85:191-193. [DOI: 10.1272/jnms.jnms.2018_85-29] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Hong Sang Choi
- Department of Internal Medicine, Chonnam National University Medical School
| | - Yoon Ha Kim
- Department of Obstetrics and Gynecology, Chonnam National University Medical School
| | - Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School
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Yang C, Wu H, Bao X, Wang R. Lymphocytic Hypophysitis Secondary to Ruptured Rathke Cleft Cyst: Case Report and Literature Review. World Neurosurg 2018; 114:172-177. [DOI: 10.1016/j.wneu.2018.03.086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/10/2018] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
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The prevalence of brain abnormalities in boys with central precocious puberty may be overestimated. PLoS One 2018; 13:e0195209. [PMID: 29614125 PMCID: PMC5882100 DOI: 10.1371/journal.pone.0195209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 03/19/2018] [Indexed: 01/15/2023] Open
Abstract
Brain magnetic resonance imaging (MRI) is routinely performed to identify brain lesions in boys with central precocious puberty (CPP). We investigated the prevalence of CPP in Korean boys and the necessity for routine brain MRI examinations. This retrospective cross-sectional study was conducted from April 2003 to December 2016 at a Korean university hospital. Among 151 boys who were diagnosed with CPP, the data of 138 boys who underwent sellar MRI were evaluated. The mean age of the study subjects was 9.51 ± 0.56 years (<8 years [n = 4] and ≥8 years [n = 134]). We excluded patients who had been previously diagnosed with brain tumors and those who did not undergo a sellar MRI because of refusal or the decision of the pediatric endocrinologist. The main outcome measure was the prevalence of intracranial lesions among boys with CPP. Normal sellar MRI findings were observed in 128 of the 138 boys (93%). Mild brain abnormalities were found in 10 boys (7%), while none of the patients had pathological brain lesions. The prevalence (7%) of intracranial lesions among boys who were healthy, did not have neurological symptoms, and were diagnosed with CPP was different from that previously reported. None of the identified lesions necessitated treatment. Although this was a single country study, we found that the previously reported prevalence of brain lesions in boys with CPP is much higher than the prevalence observed in Korea. This study suggests the need to globally reevaluate the prevalence of pathological brain lesions among male pediatric patients with CPP.
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Oishi M, Hayashi Y, Sasagawa Y, Kita D, Tachibana O, Nakada M. Outcome of diabetes insipidus in patients with Rathke’s cleft cysts. Clin Neurol Neurosurg 2018; 167:141-146. [DOI: 10.1016/j.clineuro.2018.02.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 10/18/2022]
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Draghi R, Mantovani G, Runza L, Carrabba G, Fusco N, Rampini P, Costa A, Locatelli M. Rathke's cleft cyst associated with pituitary granulomatosis with polyangiitis: An unusual combination of hypothalamus-pituitary region pathologies. Radiol Case Rep 2018; 13:233-236. [PMID: 29552263 PMCID: PMC5853151 DOI: 10.1016/j.radcr.2017.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 09/12/2017] [Accepted: 09/25/2017] [Indexed: 11/25/2022] Open
Abstract
The authors present an unusual case of a patient suffering from visual deficit due to pituitary granulomatosis with polyangiitis (GPA) associated with Rathke's cleft cyst (RCC). The patient was referred to our Neurosurgery Department presenting right eye amaurosis, third cranial nerve palsy, and left temporal hemianopsia. Magnetic resonance imaging documented a sellar or suprasellar lesion with solid and cystic components. The dura mater of the skull base was also strongly enhanced. The patient underwent surgery. Histologic examination revealed RCC associated with pituitary GPA. To our knowledge, this is the first reported case of concomitant pituitary GPA and RCC. Pituitary involvement in GPA is rare, usually diagnosed in hormonal dysfunctions. The patient in case first presented optic chiasm compression, probably due to inflammation of both the pituitary gland and the previously asymptomatic RCC. We focus on the symptoms that led us to diagnose GPA pituitary involvement and on the peculiar and unusual Magnetic resonance imaging of the case presented.
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Affiliation(s)
- Riccardo Draghi
- Neurosurgery Unit, Department of Medical and Surgical Pathophysiology of Organs and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Letterio Runza
- Division of Pathology, Fondazione IRCCS "Ca' Granda" Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Carrabba
- Department of Neurosurgery, Fondazione IRCCS "Ca' Granda" Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Fusco
- Division of Pathology, Fondazione IRCCS "Ca' Granda" Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Rampini
- Department of Neurosurgery, Fondazione IRCCS "Ca' Granda" Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonella Costa
- Neuroradiology, Fondazione IRCCS "Ca' Granda" Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Locatelli
- Department of Neurosurgery, Fondazione IRCCS "Ca' Granda" Ospedale Maggiore Policlinico, Milan, Italy
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Schlaffer SM, Buchfelder M, Stoehr R, Buslei R, Hölsken A. Rathke's Cleft Cyst as Origin of a Pediatric Papillary Craniopharyngioma. Front Genet 2018; 9:49. [PMID: 29520296 PMCID: PMC5826961 DOI: 10.3389/fgene.2018.00049] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 01/31/2018] [Indexed: 12/18/2022] Open
Abstract
A 6-year old patient presented with an intra and suprasellar cystic lesion accompanied with impairment of the hypothalamic-pituitary axis and partial hypopituitarism. The most likely cause of sellar lesions in this age group are adamantinomatous craniopharyngioma (adaCP) or Rathke´s cleft cysts (RCCs). AdaCP are characterized by CTNNB1 mutations accompanied with aberrant nuclear beta-catenin expression. RCC show neither nuclear beta-catenin expression nor BRAF mutation. The latter is a hallmark of papillary craniopharyngiomas (papCP) that exhibit remarkable histological similarity with metaplasia of RCC. Diagnosis of the patient was elucidated by CTNNB1 and BRAF mutation screening, utilizing different approaches, as well as histological examination of markers, e.g., beta-catenin, claudin-1, EpCAM and the mutated BRAFV600E protein, which are known to be differentially expressed in sellar lesions. The case presented reveals extraordinary aspects for two reasons. Firstly, the lesion appeared clinically, on MRI, intraoperatively and histologically as RCC with prominent squamous metaplasia, but showing an expression pattern of markers also found in papCP, whilst exhibiting a hitherto undescribed BRAFV600E mutation. This important result documents a supposable transition of RCC metaplasia into a papillary craniopharyngioma (papCP). Secondly, this intriguing case shows unexpectedly that although papCP usually occurs almost exclusively in adults, it can also arise in childhood.
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Affiliation(s)
- Sven-Martin Schlaffer
- Department of Neurosurgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Robert Stoehr
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Rolf Buslei
- Institute of Neuropathology, University Hospital Erlangen Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Institute of Pathology, Sozialstiftung Bamberg, Bamberg, Germany
| | - Annett Hölsken
- Institute of Neuropathology, University Hospital Erlangen Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
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Ranjan R, Nath S, Mohapatra D, Mishra BR. "I am a sinner": Rathke's cleft cyst masquerading as delusion of guilt. Asian J Psychiatr 2018; 32:159-160. [PMID: 29289857 DOI: 10.1016/j.ajp.2017.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Rajeev Ranjan
- Department of Psychiatry, Room No. 411, Academic Block, All India Institute of Medical Sciences, Bhubaneswar, 751019, India.
| | - Santanu Nath
- Department of Psychiatry, Room No. 411, Academic Block, All India Institute of Medical Sciences, Bhubaneswar, 751019, India.
| | - Debadatta Mohapatra
- Department of Psychiatry, Room No. 411, Academic Block, All India Institute of Medical Sciences, Bhubaneswar, 751019, India.
| | - Biswa Ranjan Mishra
- Department of Psychiatry, Room No. 411, Academic Block, All India Institute of Medical Sciences, Bhubaneswar, 751019, India.
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Marques P, Barry S, Ronaldson A, Ogilvie A, Storr HL, Goadsby PJ, Powell M, Dang MN, Chahal HS, Evanson J, Kumar AV, Grieve J, Korbonits M. Emergence of Pituitary Adenoma in a Child during Surveillance: Clinical Challenges and the Family Members' View in an AIP Mutation-Positive Family. Int J Endocrinol 2018; 2018:8581626. [PMID: 29849625 PMCID: PMC5904812 DOI: 10.1155/2018/8581626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 01/30/2018] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Germline aryl hydrocarbon receptor-interacting protein (AIP) mutations are responsible for 15-30% of familial isolated pituitary adenomas (FIPAs). We report a FIPA kindred with a heterozygous deletion in AIP, aiming to highlight the indications and benefits of genetic screening, variability in clinical presentations, and management challenges in this setting. PATIENTS An 18-year-old male was diagnosed with a clinically nonfunctioning pituitary adenoma (NFPA). Two years later, his brother was diagnosed with a somatolactotrophinoma, and a small Rathke's cleft cyst and a microadenoma were detected on screening in their 17-year-old sister. Following amenorrhoea, their maternal cousin was diagnosed with hyperprolactinaemia and two distinct pituitary microadenomas. A 12-year-old niece developed headache and her MRI showed a microadenoma, not seen on a pituitary MRI scan 3 years earlier. DISCUSSION Out of the 14 members harbouring germline AIP mutations in this kindred, 5 have pituitary adenoma. Affected members had different features and courses of disease. Bulky pituitary and not fully suppressed GH on OGTT can be challenging in the evaluation of females in teenage years. Multiple pituitary adenomas with different secretory profiles may arise in the pituitary of these patients. Small, stable NFPAs can be present in mutation carriers, similar to incidentalomas in the general population. Genetic screening and baseline review, with follow-up of younger subjects, are recommended in AIP mutation-positive families.
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Affiliation(s)
- Pedro Marques
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sayka Barry
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Amy Ronaldson
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Arla Ogilvie
- West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Helen L. Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Peter J. Goadsby
- Basic & Clinical Neuroscience and NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK
| | - Michael Powell
- The National Hospital for Neurology and Neurosurgery, UCLH, NHS Trust, London, UK
| | - Mary N. Dang
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Harvinder S. Chahal
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Jane Evanson
- Department of Radiology, Barts and the London School of Medicine, Queen Mary University of London, London EC1M 6BQ, UK
| | - Ajith V. Kumar
- North East Thames Regional Genetics Service, Great Ormond Street Hospital, London, UK
| | - Joan Grieve
- The National Hospital for Neurology and Neurosurgery, UCLH, NHS Trust, London, UK
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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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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Jung JE, Jin J, Jung MK, Kwon A, Chae HW, Kim DH, Kim HS. Clinical manifestations of Rathke's cleft cysts and their natural progression during 2 years in children and adolescents. Ann Pediatr Endocrinol Metab 2017; 22:164-169. [PMID: 29025202 PMCID: PMC5642082 DOI: 10.6065/apem.2017.22.3.164] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/14/2016] [Accepted: 03/20/2017] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Rathke's cleft cyst (RCC) is an asymptomatic benign lesion. With increased interest in pediatric endocrinology, the prevalence of RCCs in children is also increasing. However, the clinical relevance and proper management of RCC is not well defined in children. Therefore, we investigated the clinical manifestations and radiologic features of RCC in children and adolescents, as well as the natural progression of RCC. METHODS We retrospectively reviewed the medical records of 91 children and adolescents with RCC diagnosed with magnetic resonance imaging (MRI) in Severance Children's Hospital from January 2006 to December 2015. The clinical, hormonal, and imaging findings were analyzed in patient groups classified according to age. The size of each cyst was assessed in sixty patients who underwent follow-up MRI during the 2 years. RESULTS Female patients were predominant (64 vs. 27). The common clinical features at presentation were endocrine dysfunction (59.3%), headache (23.0%), and dizziness (4.4%). Symptoms related to endocrine disorders were more frequent in younger patients. In 7 patients managed surgically, the cysts were significantly larger and more frequently located in the suprasellar region. Of 60 nonsurgical patients with a follow-up MRI performed within 2 years after the diagnosis, the RCC size increased in about 26.7% (n=16). CONCLUSIONS Although 94.4% of the patients with RCC had clinical symptoms, surgery was performed in only about 7.5% of patients. RCC is associated with pituitary insufficiency, thus, baseline and follow-up endocrine function tests are required. Additionally, regular MRI follow-up is required in long-term period to monitor change in size.
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Affiliation(s)
- Jo Eun Jung
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Juhyun Jin
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Mo Kyung Jung
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ahreum Kwon
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Wook Chae
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duk Hee Kim
- Department of Pediatrics, Sowha Children’s Hospital, Seoul, Korea
| | - Ho-Seong Kim
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea,Address for correspondence: Ho-Seong Kim, MD, PhD https://orcid.org/0000-0003-1135-099X Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-2069 Fax: +82-2-393-9118 E-mail:
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Normal neuroanatomical variants that may be misinterpreted as disease entities. Clin Radiol 2017; 72:810-825. [PMID: 28747250 DOI: 10.1016/j.crad.2017.06.118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 05/12/2017] [Accepted: 06/19/2017] [Indexed: 12/23/2022]
Abstract
Variations of normal development and benign incidental anomalies are frequently observed on diagnostic neuroimaging. It is important these are recognised for what they are, as misinterpretation may result in unnecessary further investigation, follow-up imaging and anxiety. In this article, we review benign intracranial anomalies commonly referred to our unit for specialist neuroradiology advice or multidisciplinary discussion, concerning cysts of the pineal gland and pituitary fossa, vascular anomalies, and perivascular spaces. This article outlines the embryology and development, the various imaging features as well as the clinical relevance and differential diagnoses of each normal neuroanatomical variant.
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Abstract
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.
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Uppal S, Jee YH, Lightbourne M, Han JC, Stratakis CA. Combined pituitary hormone deficiency in a girl with 48, XXXX and Rathke's cleft cyst. Hormones (Athens) 2017; 16:92-98. [PMID: 28500832 PMCID: PMC6369518 DOI: 10.14310/horm.2002.1723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/02/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Tetrasomy X is a rare chromosomal aneuploidy seen in girls, associated with facial dysmorphism, premature ovarian insufficiency and intellectual disability. A Rathke's cleft cyst (RCC) is a remnant of Rathke's pouch which may cause multiple pituitary hormone deficiencies by exerting pressure on the pituitary gland in the sella. METHODS/RESULTS The patient was diagnosed with tetrasomy X by karyotyping during infancy. Brain MRI and multiple endocrine stimulation tests revealed RCC and combined pituitary hormone deficiency (growth hormone deficiency, secondary adrenal insufficiency and central hypothyroidism) likely due to RCC. CONCLUSION We report the first case in the literature of a girl with 48, XXXX and combined pituitary hormone deficiency due to Rathke's cyst.
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Affiliation(s)
- Surabhi Uppal
- Section on Genetics & Endocrinology (SEGEN), Program on Developmental Endocrinology & Genetics (PDEGEN), NICHD, NIH, Building 10, CRC, East Laboratories, Rm. 1-3330 (1-3216 lab), 10 Center Drive, Bethesda, MD, 20892, USA
- Pediatric endocrinology training program, NICHD, National Institutes of Health, Bethesda, MD, USA
| | - Youn Hee Jee
- Section on Genetics & Endocrinology (SEGEN), Program on Developmental Endocrinology & Genetics (PDEGEN), NICHD, NIH, Building 10, CRC, East Laboratories, Rm. 1-3330 (1-3216 lab), 10 Center Drive, Bethesda, MD, 20892, USA
- Pediatric endocrinology training program, NICHD, National Institutes of Health, Bethesda, MD, USA
| | - Marissa Lightbourne
- Pediatric endocrinology training program, NICHD, National Institutes of Health, Bethesda, MD, USA
| | - Joan C Han
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Constantine A Stratakis
- Section on Genetics & Endocrinology (SEGEN), Program on Developmental Endocrinology & Genetics (PDEGEN), NICHD, NIH, Building 10, CRC, East Laboratories, Rm. 1-3330 (1-3216 lab), 10 Center Drive, Bethesda, MD, 20892, USA.
- Pediatric endocrinology training program, NICHD, National Institutes of Health, Bethesda, MD, USA.
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Fleseriu M, Hashim IA, Karavitaki N, Melmed S, Murad MH, Salvatori R, Samuels MH. Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101:3888-3921. [PMID: 27736313 DOI: 10.1210/jc.2016-2118] [Citation(s) in RCA: 474] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To formulate clinical practice guidelines for hormonal replacement in hypopituitarism in adults. PARTICIPANTS The participants include an Endocrine Society-appointed Task Force of six experts, a methodologist, and a medical writer. The American Association for Clinical Chemistry, the Pituitary Society, and the European Society of Endocrinology co-sponsored this guideline. EVIDENCE The Task Force developed this evidence-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, the American Association for Clinical Chemistry, the Pituitary Society, and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. CONCLUSIONS Using an evidence-based approach, this guideline addresses important clinical issues regarding the evaluation and management of hypopituitarism in adults, including appropriate biochemical assessments, specific therapeutic decisions to decrease the risk of co-morbidities due to hormonal over-replacement or under-replacement, and managing hypopituitarism during pregnancy, pituitary surgery, and other types of surgeries.
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Affiliation(s)
- Maria Fleseriu
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Ibrahim A Hashim
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Niki Karavitaki
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Shlomo Melmed
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - M Hassan Murad
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Roberto Salvatori
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Mary H Samuels
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
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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] [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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79
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Yang CX, Feng M, Liu XH, Bao XJ, Deng K, Yao Y, Lian W, Xing B, Wang RZ. Symptomatic Rathke's Cleft Cyst with Rapid Enlargement Masquerading as Rathke's Cleft Cyst Apoplexy. Chin Med J (Engl) 2016; 129:2009-10. [PMID: 27503031 PMCID: PMC4989437 DOI: 10.4103/0366-6999.187841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Cheng-Xian Yang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiao-Hai Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xin-Jie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei Lian
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ren-Zhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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80
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Rasmussen Z, Abode-Iyamah KO, Kirby P, Greenlee JDW. Rathke's cleft cyst: A case report of recurrence and spontaneous involution. J Clin Neurosci 2016; 32:122-5. [PMID: 27369087 DOI: 10.1016/j.jocn.2015.12.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/10/2015] [Indexed: 11/18/2022]
Abstract
Rathke's cleft cysts (RCC) are sellar lesions that typically remain asymptomatic throughout life. Symptomatic patients present with headache, visual disturbance and/or pituitary dysfunction and are treated with resection. We present a 61-year-old woman diagnosed with RCC which was resected twice then recurred before undergoing spontaneous resolution. RCC are often managed without surgical intervention. Some of these lesions may spontaneously resolve without surgical intervention while others may become symptomatic. In patients with asymptomatic recurrent RCC conservative management is recommended. Spontaneous involution may occur following initial resection and recurrence of RCC.
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Affiliation(s)
- Zachary Rasmussen
- University of Iowa Carver College of Medicine,Iowa City, IA 52242, USA
| | - Kingsley O Abode-Iyamah
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52245, USA.
| | - Patricia Kirby
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA 52245, USA
| | - Jeremy D W Greenlee
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52245, USA
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81
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Karagiannis AKA, Dimitropoulou F, Papatheodorou A, Lyra S, Seretis A, Vryonidou A. Pituitary abscess: a case report and review of the literature. Endocrinol Diabetes Metab Case Rep 2016; 2016:160014. [PMID: 27274845 PMCID: PMC4890076 DOI: 10.1530/edm-16-0014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 05/04/2016] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED Pituitary abscess is a rare life-threating entity that is usually misdiagnosed as a pituitary tumor with a definite diagnosis only made postoperatively. Over the last several decades, advances in healthcare have led to a significant decrease in morbidity and mortality due to pituitary abscess. We report a case of a 34-year-old woman who was admitted to our department for investigation of a pituitary mass and with symptoms of pituitary dysfunction, headaches and impaired vision. During her admission, she developed meningitis-like symptoms and was treated with antibiotics. She eventually underwent transsphenoidal surgery for excision of the pituitary mass. A significant amount of pus was evident intraoperatively; however, no pathogen was isolated. Six months later, the patient was well and had full recovery of the anterior pituitary function. Her menses returned, and she was only on treatment with desmopressin for diabetes insipidus that developed postoperatively. LEARNING POINTS Pituitary abscess is a rare disease and the reported clinical features vary mimicking other pituitary lesions.The diagnosis of pituitary abscess is often very difficult to make and rarely included in the differential.The histological findings of acute inflammatory infiltration confirm the diagnosis of pituitary abscess.Medical and surgical treatment is usually recommended upon diagnosis of a pituitary abscess.
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Affiliation(s)
- Apostolos K A Karagiannis
- Department of Endocrinology, Diabetes and Metabolism, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece
| | - Fotini Dimitropoulou
- Department of Endocrinology, Diabetes and Metabolism, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece
| | - Athanasios Papatheodorou
- Department of Radiology, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece
| | - Stavroula Lyra
- Department of Radiology, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece
| | - Andreas Seretis
- Department of Neurosurgery, General Hospital of Athens ‘G. Gennimatas’, Athens, Greece
| | - Andromachi Vryonidou
- Department of Endocrinology, Diabetes and Metabolism, Korgialeneio Benakeio EES, Peripheral General Hospital Athens, Athens, Greece
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Abstract
INTRODUCTION Primary intracranial and sellar squamous cell carcinoma is an extremely rare entity, usually caused by malignant transformation of epidermoid cysts, or very rarely other non-malignant epithelial cysts. Malignant transformation of a Rathke's cleft cyst has never been described. CASE DESCRIPTION We present a 49-year-old male patient who presented with a 3-month history of progressive frontotemporal headaches. Imaging revealed a 1.2 cm cystic pituitary mass consistent with a hemorrhagic Rathke's cleft cyst. The patient underwent trans-sphenoidal resection of the pituitary cyst, and pathologic analysis revealed a squamous cell carcinoma lining a Rathke's cleft cyst. Extensive imaging and otorhinolaryngologic evaluation revealed no primary source for metastasis. CONCLUSIONS We feel this represents the first case of a patient with a pituitary lesion in which presentation and MRI imaging were consistent with Rathke's cleft cyst, yet histology revealed squamous cell carcinoma in situ.
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Affiliation(s)
- Brian T O'Neill
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. brian.o'
- Section on Integrative Physiology and Metabolism, Joslin Diabetes Center, Harvard Medical School, 1 Joslin Pl, Rm 605, Boston, MA, 02215, USA. brian.o'
| | | | - Ekkehard M Kasper
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Johanna A Pallotta
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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83
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Abstract
Rathke's cleft cysts are known to cause hormone-related abnormalities. However, the natural history of this disorder is obscure, so it is rarely associated with acute adrenal insufficiency. We herein describe a case of Rathke's cleft cyst associated with acute adrenal insufficiency in a 27-year-old man. The patient experienced severe headaches due to acute adrenal insufficiency without changes in the size of the cyst. Glucocorticoid administration improved these symptoms, and the cyst spontaneously shrank before operation. This case led us to conclude that Rathke's cleft cysts should be considered in the differential diagnosis of patients who present with adrenal insufficiency, and that the cysts can be reduced by glucocorticoids.
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Affiliation(s)
- Yoji Hirayama
- Department of Endocrinology and Diabetes, Hachinohe City Hospital, Japan
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84
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Ikeda H, Ohhashi G. Demonstration of high coincidence of pituitary adenoma in patients with ruptured Rathke's cleft cyst: Results of a prospective study. Clin Neurol Neurosurg 2015; 139:144-51. [DOI: 10.1016/j.clineuro.2015.09.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 08/30/2015] [Accepted: 09/22/2015] [Indexed: 10/22/2022]
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85
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Solari D, Cavallo LM, Somma T, Chiaramonte C, Esposito F, Del Basso De Caro M, Cappabianca P. Endoscopic Endonasal Approach in the Management of Rathke's Cleft Cysts. PLoS One 2015; 10:e0139609. [PMID: 26474185 PMCID: PMC4608689 DOI: 10.1371/journal.pone.0139609] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 09/14/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Rathke's cleft cysts (RCCs) are quite uncommon sellar lesions that can extend or even arise in the suprasellar area. The purpose of this study is to evaluate the effectiveness of both standard and extended endoscopic endonasal approaches in the management of different located RCCs. METHODS We retrospectively analyzed a series of 29 patients (9 males, 20 females) complaining of a RCC, who underwent a standard or an extended endoscopic transsphenoidal approach at the Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, of the Università degli Studi di Napoli "Federico II". Data regarding patients' demographics, clinical evaluation, cyst characteristics, surgical treatments, complications and outcomes were extracted from our electronic database (Filemaker Pro 11, File Maker Inc., Santa Clara, California, USA). RESULTS A standard transsphenoidal approach was used in 19 cases, while the extended variation of the approach in 10 cases (5 purely suprasellar and 5 intra-suprasellar RCC). Cysts contents was fully drained in all the 29 cases, whilst a gross total removal, that accounts on the complete cyst wall removal, was achieved in an overall 55,1% of patients (16/29), specifically 36,8% (7/19) that received standard approach and 90% (9/10) of those that underwent to extended approach. We reported a 56.2% of recovery from headache, 38.5% of complete recovery and 53.8% of improvement from visual field defect and an overall 46.7% of improvement of the endocrine functions. Postoperative permanent DI rate was 10.3%, overall post-operative CSF leak rate 6.9%; recurrence/regrowth occurred in 4 patients (4/29, 13.8%), but only one required a second surgery. CONCLUSION The endoscopic transsphenoidal approach for the removal of a symptomatic RCC offers several advantages in terms of visualization of the surgical field during both the exposure and removal of the lesion. The "extended" variation of the endoscopic approach provides a direct access to the supradiaphragmatic space, allowing adequate view and room for the safe removal of selected supradiaphragmatic RCCs, regardless of the sellar size (even a not enlarged sella), and provides a higher likelihood of preserving normal pituitary tissue and functions.
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Affiliation(s)
- Domenico Solari
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi Maria Cavallo
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Teresa Somma
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Carmela Chiaramonte
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Felice Esposito
- Department of Neurosciences, Division of Neurosurgery, Università degli Studi di Messina, Messina, Italy
| | - Marialaura Del Basso De Caro
- Department of Biomorphological and Functional Sciences, Division of Pathology and Cytopathology, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Cappabianca
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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86
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Culver SA, Grober Y, Ornan DA, Patrie JT, Oldfield EH, Jane JA, Thorner MO. A Case for Conservative Management: Characterizing the Natural History of Radiographically Diagnosed Rathke Cleft Cysts. J Clin Endocrinol Metab 2015; 100:3943-8. [PMID: 26305621 PMCID: PMC5399501 DOI: 10.1210/jc.2015-2604] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Rathke cleft cysts (RCCs) are benign embryonic remnants of the Rathke's pouch found in 13% to 33% of the general population. When symptomatic, they manifest themselves by compressing adjacent structures, causing pressure effects such as headache, visual disturbance, or pituitary hormone deficits. Most RCCs are asymptomatic, and their management remains controversial. Surgical resection has generally been indicated to treat symptomatic RCCs but carries the risk of complications. OBJECTIVE Our objective was to better characterize the outcomes for patients with presumed RCCs undergoing conservative management. DESIGN This was a retrospective cohort study. SETTING The setting was a pituitary program at a university medical center. PARTICIPANTS The participants were 75 patients with radiographically diagnosed RCCs. METHODS All brain magnetic resonance imaging (MRI) scans performed at the University of Virginia from 2006 through 2013 were searched for the words "Rathke cleft cyst," and pituitary clinic notes from 2007 to 2012 were reviewed for patients identified as probably having an RCC. Images for all patients were reviewed by the interpreting neuroradiologist, and those patients with at least 2 MRI scans were included. The dimensions of each cyst were assessed by the same neuroradiologist, and the volume of each cyst was analyzed as a function of the time from the first image obtained. RESULTS A total of 75 patients (4-76 years old) met our inclusion criteria. The length of follow-up was 1 to 126 months (median 24 months). In 43 patients (57%) no detectable change in the size of their cysts was seen, in 21 patients (28%) cysts increased in size, and in 11 patients (15%) cysts decreased in size. The predicted mean cyst growth rate was not significantly different from 0. CONCLUSION The increasingly prevalent use of brain imaging modalities such as MRI has resulted in an increase in the incidental discovery of pituitary lesions. Our study demonstrates that the majority of radiologically diagnosed RCCs remain unchanged or decrease in size over time. These results suggest that, in the absence of pressure symptoms, it is reasonable to manage patients with RCCs conservatively.
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87
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Guo SY, Cai XQ, Ma J, Wang WY, Lu G. Diagnosis of concomitant pituitary adenoma and Rathke's cleft cyst with magnetic resonance imaging. Int J Surg 2015; 18:191-5. [PMID: 25959251 DOI: 10.1016/j.ijsu.2015.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/29/2015] [Accepted: 05/04/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The diagnosis of concomitant pituitary adenoma (PA) and Rathke's cleft cyst (RCC) is difficult because PA and RCC cause similar symptoms. This study aimed to investigate magnetic resonance imaging (MRI) characteristics and surgical management of sellar lesions for concomitant PA and RCC. METHODS A retrospective study was performed in 18 patients with concomitant PA and RCC who visited our hospital between June 2008 and May 2014. MRI features, surgical management, histopathological diagnosis and prognosis of concomitant PA and RCC were summarized. RESULTS Of the 18 patients, 3 cases were diagnosed with concomitant PA and RCC and 2 with concomitant PA and intermedia cyst by preoperative MRI. The remaining 8 cases were misdiagnosed as cystic formation of PA, 3 cases were bleeding of PA, and 2 cases were RCC. Surgery via the trans-sphenoidal route was performed in 17 cases and trans-frontal approach was chosen for one patient. All PAs resected were diagnosed by histological examination and the diagnosis of concomitant PA and RCC was histologically confirmed. CONCLUSION A non-enhancing cyst-like structure within the pars intermedia of PA usually located in the midline is a prominent MRI feature of coexisted PA and RCC. Total resection of coexisted RCC must be achieved and fat graft should be avoided during surgery because of high recurrence rate of RCC and complicated hypophysitis.
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Affiliation(s)
- Shun-yuan Guo
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China
| | - Xue-qiang Cai
- Department of Radiology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China
| | - Jie Ma
- Department of Pathology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China
| | - Wei-yu Wang
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China
| | - Gang Lu
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China.
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88
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Capatina C, Inder W, Karavitaki N, Wass JAH. Management of endocrine disease: pituitary tumour apoplexy. Eur J Endocrinol 2015; 172:R179-90. [PMID: 25452466 DOI: 10.1530/eje-14-0794] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pituitary tumour apoplexy (PA) is a rare clinical syndrome that occurs as a result of acute haemorrhage and/or infarction within a frequently undiagnosed pituitary tumour. The sudden enlargement of the pituitary mass undergoing PA is responsible for a wide range of acute symptoms/signs (severe headache, visual loss, diplopia, hypopituitarism, impaired consciousness) which, together with the radiological evidence of a pituitary lesion, establish the diagnosis. The optimal care of PA requires involvement of a multidisciplinary team including endocrinologist, neurosurgeon, neuroophthalmologist and the management strategy that depends on the clinical manifestations, as well as the presence of co-morbidities. Prompt surgical decompression is initially indicated in cases with severe or progressive impairment of the visual acuity or the visual fields or with altered mental state and leads to visual and neurological recovery in most of the patients. The patients with mild, stable clinical picture (including those with isolated ocular palsies) can be managed conservatively (support of fluid and electrolyte balance and stress doses of steroids in most cases) with favourable visual and neurological outcome. Frequent reassessment is mandatory because the clinical course can be unpredictable; if progression of symptoms occurs, later elective surgery is indicated and is beneficial, especially in terms of visual outcome. The endocrinological outcome is less favourable, irrespective of the treatment option, with many patients remaining on long-term replacement therapy. Despite the above guidelines, clear proof of optimal outcomes in the form of randomised controlled trials is lacking. Regrowth of the pituitary tumour years after a PA episode is possible and patients require long-term surveillance.
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Affiliation(s)
- Cristina Capatina
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaDepartment of Diabetes and EndocrinologyPrincess Alexandra Hospital, Brisbane, Queensland, AustraliaDepartment of Diabetes and EndocrinologySchool of Medicine, The University of Queensland, Brisbane, Queensland, AustraliaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - Warrick Inder
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaDepartment of Diabetes and EndocrinologyPrincess Alexandra Hospital, Brisbane, Queensland, AustraliaDepartment of Diabetes and EndocrinologySchool of Medicine, The University of Queensland, Brisbane, Queensland, AustraliaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaDepartment of Diabetes and EndocrinologyPrincess Alexandra Hospital, Brisbane, Queensland, AustraliaDepartment of Diabetes and EndocrinologySchool of Medicine, The University of Queensland, Brisbane, Queensland, AustraliaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - Niki Karavitaki
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaDepartment of Diabetes and EndocrinologyPrincess Alexandra Hospital, Brisbane, Queensland, AustraliaDepartment of Diabetes and EndocrinologySchool of Medicine, The University of Queensland, Brisbane, Queensland, AustraliaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - John A H Wass
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaDepartment of Diabetes and EndocrinologyPrincess Alexandra Hospital, Brisbane, Queensland, AustraliaDepartment of Diabetes and EndocrinologySchool of Medicine, The University of Queensland, Brisbane, Queensland, AustraliaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
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89
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Rathke cleft cyst presenting as unilateral progressive oculomotor nerve palsy. Can J Ophthalmol 2015; 50:e31-3. [DOI: 10.1016/j.jcjo.2014.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/14/2014] [Accepted: 11/22/2014] [Indexed: 11/19/2022]
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90
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Chotai S, Liu Y, Pan J, Qi S. Characteristics of Rathke's cleft cyst based on cyst location with a primary focus on recurrence after resection. J Neurosurg 2015; 122:1380-9. [PMID: 25679272 DOI: 10.3171/2014.12.jns14596] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Rathke's cleft cysts (RCCs) are benign lesions with a location that is entirely intrasellar, intrasellar with suprasellar extension (intrasuprasellar), or purely suprasellar. The recurrence of RCC is relatively uncommon. The present study was conducted to report clinical characteristics, histological features, and outcomes based on location of the cyst with a primary focus on analyzing the predictors of squamous metaplasia and recurrence in these 3 types of RCCs. METHODS A retrospective review of the medical records of patients with symptomatic RCCs who had undergone resection at the authors' institution was conducted. Data points, including clinical presentation, preoperative endocrine status, operative details, imaging findings, pathology, and clinical outcomes, were reviewed. A multivariable regression model was used to identify predictors of recurrence. RESULTS The mean age of the 87 eligible patients, 64 females and 23 males, was 41 ± 14 years (range 10-73 years). Sixteen patients (18%) had an entirely intrasellar RCC, 21 (24%) had a purely suprasellar cyst, and 50 (58%) had an intrasuprasellar RCC. The mean cyst volume was 2.4 ± 0.9 cm(3) (range 0.36-4.9 cm(3)). Headache was the most frequent initial symptom (76%) followed by visual disturbance (45%). The transsphenoidal approach was performed for all intrasellar RCCs (16 cysts) and 33 of 50 intrasuprasellar RCCs. The transcranial route was used for all suprasellar cysts (21 cysts) and 17 of 50 intrasuprasellar RCCs. Squamous metaplasia was present in 27 (31%) of 87 RCCs. The occurrence of squamous metaplasia was associated with cyst location (p = 0.027), T1 signal intensity (p = 0.004) and ring enhancement on Gd-enhanced MRI (p = 0.017), and cyst volume (p = 0.045). A suprasellar location (p = 0.048, OR 3.89, 95% CI 1.010-15.020), ring enhancement on Gd-enhanced MRI (p = 0.028, OR 3.922, 95% CI 1.158-13.288), hypointensity on T1-weighted MRI (p = 0.002, OR 6.86, 95% CI 1.972-23.909), and cyst volume (p = 0.01, OR 0.367, 95% CI 0.170-0.789) were independent predictors of squamous metaplasia. The mean time to reaccumulation (11 [12.6%] of 87 cases) and recurrence (7 [8%] of 87 cases) was 14 ± 6 months. Recurrence-free survival was 84.5% at a mean of 98.2 ± 4.6 months after treatment. A suprasellar cyst location (p = 0.007, OR 7.7, 95% CI 1.75-34.54), the occurrence of squamous metaplasia (p = 0.007, OR 19.3, 95% CI 2.25-165.18), and isointensity on T2-weighted MRI (p = 0.041, OR 10.29, 95% CI 1.094-96.872) were the independent predictors of RCC recurrence. CONCLUSIONS A suprasellar cyst location, the occurrence of squamous metaplasia, and isointensity on T2-weighted MRI were independent predictors of RCC recurrence. The extent of resection and type of surgical approach used were not associated with recurrence. A tailored extent of resection based on cyst location and predictive factors is recommended.
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Affiliation(s)
- Silky Chotai
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Yi Liu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Jun Pan
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
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91
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Modroño Móstoles N, Pavón de Paz I, Guijarro de Armas G, Orgaz Álvarez M, Torán Ranero C, Gómez Rodríguez S, Navea Aguilera C, Merino Viveros M. A case of hypopituitarism and porphyria cutanea tarda in relation to estrogen therapy in a patient with empty sella syndrome. Rev Clin Esp 2015; 215:e11-3. [PMID: 25572312 DOI: 10.1016/j.rce.2014.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 11/19/2014] [Accepted: 11/23/2014] [Indexed: 10/24/2022]
Affiliation(s)
- N Modroño Móstoles
- Departamento de Endocrinología y Nutrición, Hospital Universitario de Getafe, Getafe, Madrid, España.
| | - I Pavón de Paz
- Departamento de Endocrinología y Nutrición, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - G Guijarro de Armas
- Departamento de Endocrinología y Nutrición, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - M Orgaz Álvarez
- Departamento de Radiodiagnóstico, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - C Torán Ranero
- Departamento de Radiodiagnóstico, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - S Gómez Rodríguez
- Departamento de Radiodiagnóstico, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - C Navea Aguilera
- Departamento de Radiodiagnóstico, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - M Merino Viveros
- Departamento de Radiodiagnóstico, Hospital Universitario de Getafe, Getafe, Madrid, España
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92
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DeMonaco SM, Koch MW, Southard TL. Syndrome of inappropriate antidiuretic hormone secretion in a cat with a putative Rathke's cleft cyst. J Feline Med Surg 2014; 16:1010-5. [PMID: 24657877 PMCID: PMC11104091 DOI: 10.1177/1098612x14528192] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
An 11-year-old spayed female domestic shorthair cat was evaluated for anorexia, lethargy and weight loss of 6 days' duration. Bilateral mydriasis, absent menace response, slow-to-absent pupillary light reflexes, bilateral retinal detachment, intermittent horizontal nystagmus, intermittent ventral strabismus and systemic hypertension were present. Biochemical analysis revealed severe hyponatremia, severe hypochloremia and mild hypokalemia. Multifocal central nervous system disease was suspected based on optic, trigeminal sensory (ophthalmic branch), vestibulocochlear and possible oculomotor nerve dysfunction. Thoracic radiographs showed mild cardiomegaly without evidence of congestive heart failure. Ultrasound revealed mild pleural and peritoneal effusion. A cause of the severe hyponatremia was not identified, and it persisted despite fluid therapy. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) was suspected as the cause of hyponatremia. Humane euthanasia was elected owing to continued clinical decline. Serum hyposmolality, urine hyperosmolality, natriuresis and lack of confirmed renal, thyroid and pulmonary disease aided in the presumed diagnosis of SIADH. Post-mortem histopathology of the brain revealed degeneration of the hypothalamus and optic tracts, along with a prominent fluid-filled craniopharyngeal duct (putative Rathke's cleft cyst) separating the pars distalis and the pars intermedius. The hypothalamic degeneration, possibly secondary to a Rathke's cleft cyst, was hypothesized to be the cause of presumptive SIADH in the patient. Although rare in occurrence, Rathke's cleft cyst should be included as a differential diagnosis in dogs and cats with signs of pituitary dysfunction.
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Affiliation(s)
| | - Michael W Koch
- Veterinary Specialists and Emergency Services, Rochester, NY, USA
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93
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Maltby VE, Crock PA, Lüdecke DK. A rare case of pituitary infarction leading to spontaneous tumour resolution and CSF-sella syndrome in an 11-year-old girl and a review of the paediatric literature. J Pediatr Endocrinol Metab 2014; 27:939-46. [PMID: 24859515 DOI: 10.1515/jpem-2014-0143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 04/16/2014] [Indexed: 11/15/2022]
Abstract
Pituitary infarction or apoplexy with spontaneous cure of the underlying pituitary adenoma is rare. In the paediatric population, we found only a few reported cases. We report a rare case of pituitary infarction progressing to CSF-sella syndrome (or empty sella) in an 11-year-old girl. She presented with sudden onset vomiting, moderate headaches, lethargy, weight loss, and tall stature above her mid-parental height. She did not have any severe symptoms of apoplexy. Her clinical and radiological findings suggested infarction of a pituitary lesion, such as a pituitary adenoma or infarction of a cystic lesion, such as a Rathke's cleft cyst. In this report, we discuss her case of probable infarction of a growth hormone secreting adenoma with a phase of accelerated growth ending up with total anterior pituitary insufficiency. The differential diagnosis and review of the rare cases of paediatric pituitary infarction in the literature will be discussed.
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94
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Triphasic pattern of diabetes insipidus in a pregnant woman with a Rathke's cleft cyst and hypophysitis. Am J Med Sci 2014; 348:441-3. [PMID: 25171548 DOI: 10.1097/maj.0000000000000330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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95
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Oh YJ, Park HK, Yang S, Song JH, Hwang IT. Clinical and radiological findings of incidental Rathke's cleft cysts in children and adolescents. Ann Pediatr Endocrinol Metab 2014; 19:20-6. [PMID: 24926459 PMCID: PMC4049548 DOI: 10.6065/apem.2014.19.1.20] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 03/13/2014] [Accepted: 03/24/2014] [Indexed: 12/21/2022] Open
Abstract
PURPOSE In the pediatric population, Rathke's cleft cysts (RCCs) are known to be an infrequent cause of headaches, visual disturbances, and pituitary dysfunction. We investigated the clinical characteristics of children in whom RCCs were incidentally discovered and evaluated whether RCCs influence the treatment response of patients with proven endocrinopathy. METHODS A retrospective analysis was conducted in 34 patients with RCCs who were diagnosed between 2006 and 2013 at Hallym University Medical Center. Their clinical, hormonal, and imaging findings were reviewed. We evaluated the clinical outcomes of the patients with concomitant RCCs and endocrinopathy compared to matched controls. RESULTS Twenty-six of 34 patients with radiologically proven RCCs had endocrine disorders. They were 9 boys and 17 girls, with ages ranging from 4.8 to 17.4 years at the time of the diagnosis. Of these, 7 (27%) had idiopathic short stature, 7 (27%) had growth hormone deficiency (GHD), and 12 (46%) had central precocious puberty (CPP). Nineteen of 26 patients (73.1%) showed low signal intensities on T1-weighted images (T1WI) and high signal intensities on T2-weighted images. The incidence of hypointensity on T1WI was higher in the patients with RCCs accompanied by endocrinopathy than in those without endocrinopathy (P=0.033). The treatment outcomes of the patients with CPP and GHD with and without RCCs were similar. CONCLUSION CPP and GHD patients with a small RCC (less than 20 mm) expressing cystic magnetic resonance intensity can be managed with medical treatment, although the RCCs need to be closely monitored in radiological studies to observe their growth.
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Affiliation(s)
- Yeon Joung Oh
- Department of Pediatrics, Hallym University College of Medicine, Seoul, Korea
| | - Hong Kyu Park
- Department of Pediatrics, Hallym University College of Medicine, Seoul, Korea
| | - Seung Yang
- Department of Pediatrics, Hallym University College of Medicine, Seoul, Korea
| | - Jun Ho Song
- Department of Neurosurgery, Hallym University College of Medicine, Seoul, Korea
| | - Il Tae Hwang
- Department of Pediatrics, Hallym University College of Medicine, Seoul, Korea
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97
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Choi KH, Chung SJ, Kang MJ, Yoon JY, Lee JE, Lee YA, Shin CH, Yang SW. Boys with precocious or early puberty: incidence of pathological brain magnetic resonance imaging findings and factors related to newly developed brain lesions. Ann Pediatr Endocrinol Metab 2013; 18:183-90. [PMID: 24904875 PMCID: PMC4027080 DOI: 10.6065/apem.2013.18.4.183] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 10/16/2013] [Accepted: 12/18/2013] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Brain magnetic resonance imaging (MRI) findings and factors predictive of pathological brain lesions in boys with precocious puberty (PP) or early puberty (EP) were investigated. METHODS Sixty-one boys with PP or EP who had brain MRI performed were included. PP was classified into the central or peripheral type. Brain MRI findings were categorized into group I (pathological brain lesion known to cause puberty; newly diagnosed [group Ia] or previously diagnosed [group Ib]); group II (brain lesion possibly related to puberty); and group III (incidental or normal findings). Medical history, height, weight, hormone test results, and bone age were reviewed. RESULTS Brain lesions in groups I and II were detected in 17 of 23 boys (74%) with central PP, 9 of 30 boys (30%) with EP, and 7 of 8 boys (88%) with peripheral PP. All brain lesions in boys with peripheral PP were germ cell tumors (GCT), and 3 lesions developed later during follow-up. Group I showed earlier pubertal onset (P<0.01) and greater bone age advancement (P<0.05) than group III. Group III had lower birth weight and fewer neurological symptoms than "Ia and II" (all P<0.05). CONCLUSION Earlier onset of puberty, greater bone age advancement, and/or neurological symptoms suggested a greater chance of pathological brain lesions in boys with central PP or EP. All boys with peripheral PP, even those with normal initial MRI findings, should be evaluated for the emergence of GCT during follow-up.
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Affiliation(s)
- Keun Hee Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Joon Chung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Min Jae Kang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ju Young Yoon
- Center for Pediatric Oncology, National Cancer Center, Goyang, Korea
| | - Ji Eun Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sei Won Yang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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98
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Mrelashvili A, Braksick SA, Murphy LL, Morparia NP, Natt N, Kumar N. Chemical meningitis: a rare presentation of Rathke's cleft cyst. J Clin Neurosci 2013; 21:692-4. [PMID: 24100110 DOI: 10.1016/j.jocn.2013.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 06/14/2013] [Indexed: 12/01/2022]
Abstract
Rathke's cleft cysts (RCC) are usually benign, sellar and/or suprasellar lesions originating from the remnants of Rathke's pouch. Rarely, RCC can present with chemical meningitis, sellar abscess, lymphocytic hypophysitis, or intracystic hemorrhage. We describe an unusual presentation of RCC in which the patient presented with a clinical picture of chemical meningitis consisting of meningeal irritation, inflammatory cerebrospinal fluid profile, and enhancing pituitary and hypothalamic lesions, in addition to involvement of the optic tracts and optic nerve.
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Affiliation(s)
- Anna Mrelashvili
- Division of Child and Adolescent Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | | | | | | | - Neena Natt
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - Neeraj Kumar
- Division of Neurology, Mayo Clinic, Rochester, MN, USA
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99
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Fan J, Peng Y, Qi S, Zhang XA, Qiu B, Pan J. Individualized surgical strategies for Rathke cleft cyst based on cyst location. J Neurosurg 2013; 119:1437-46. [PMID: 24053502 DOI: 10.3171/2013.8.jns13777] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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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100
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Rathke's pouch remnant and its regression process in the prenatal period. Childs Nerv Syst 2013; 29:761-9. [PMID: 23314691 DOI: 10.1007/s00381-012-2015-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 12/22/2012] [Indexed: 10/27/2022]
Abstract
OBJECTS During ontogeny, part of Rathke's pouch, a physiologically superior pouching of the stomodeal ectoderm, may remain, forming the usual anomaly known as Rathke's cleft cyst. More rarely, however, the entire pouch (i.e., the craniopharyngeal canal) remains, resulting in transsphenoidal meningoencephalocele. This study is aimed to provide a better understanding of the pathogenesis. MATERIALS AND METHODS We histologically evaluated the inferior protrusion of the putative hypophysial fossa in 35 embryonic and fetal heads, respectively (15 at 5-8 weeks and 20 at 12-16 weeks of gestation). RESULTS In 3 of the 35 specimens, we observed a complete cleft originating from the adenohypophysis, passing through the sphenoid and connecting with the pharyngeal epithelium or pharyngobasilar fascia. In another 18 specimens, we observed a duct-like structure protruding from the fossa and ending in the sphenoid. The sellar protrusion contained vein-like structures and debris of red blood cells. The protrusion was located on the anterior or anterosuperior side of the notochord. No ossification center was observed around the sellar region of the embryos. Although ossification occurred in 12 of the 20 fetuses, nine of the latter showed no evidence of cleft or protrusion, indicating that the incidence of Rathke's pouch remnant was lower in the fetuses (11/20) than in the embryos (11/15). CONCLUSION Rathke's pouch may be closed by ossification of the sphenoid, but increased cell proliferation and/or large amounts of degenerated veins may provide a structure resistant to the mechanical pressure caused by ossification.
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