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Nugent BD, Weimer J, Choi CJ, Bradley CJ, Bender CM, Ryan CM, Gardner P, Sherwood PR. Work productivity and neuropsychological function in persons with skull base tumors. Neurooncol Pract 2014; 1:106-113. [PMID: 25789168 DOI: 10.1093/nop/npu015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Skull base tumors comprise many common benign brain tumors. Treatment has advanced, allowing many survivors to return to work. However, literature is limited about the neuropsychological status of these patients prior to treatment. Literature pertaining to the relationship between neuropsychological functioning and occupational ability prior to surgical intervention is even more limited. The purpose of this analysis was to evaluate the impact of neuropsychological function on work productivity in persons with skull base tumors prior to resection. METHODS Neuropsychological function and work productivity were assessed in adults newly diagnosed with skull base tumors (n = 45) prior to surgical intervention. Univariate analyses identified potential predictors of work limitations; variables with P < .10 were analyzed using multivariate regression analyses controlled for age, sex, tumor type, and education. RESULTS Poorer mental attention and flexibility (MF) and higher depressive symptoms (DS) were significantly associated with poor time management at work (MF: β = -0.59, P = .01; DS: β = 3.42, P < .01; R2 = 0.54). Difficulty meeting physical work demands was significantly associated with poorer visuospatial ability (VA) and higher depressive symptoms (VA: β = -3.30, P = .05; DS: β = 2.29, P < .01; R2 = 0.29). Lower learning and memory scores (LM) and higher depressive symptoms were significantly associated with difficulty meeting mental-interpersonal work demands (LM: β = -3.39, P = .04; DS: β = 3.25, P < .01; R2 = 0.47) and overall health-related loss of work productivity (LM: β = -0.72, P = .05; DS: β = 0.659, P < .001; R2 = 0.43). CONCLUSION Domains of neuropsychological function that predicted work productivity were identified. Future research should examine neuropsychological function, depressive symptoms, and work productivity across the care trajectory from diagnosis through long-term survivorship.
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Affiliation(s)
- Bethany D Nugent
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (B.D.N., J.W., C.J.C., C.M.B., P.R.S.); Virginia Commonwealth University Department of Healthcare Policy and Research, Richmond, Virginia (C.J.B.); University of Pittsburgh Department of Psychology, Pittsburgh, Pennsylvania (C.M.R.); University of Pittsburgh Department of Neurological Surgery, Pittsburgh, Pennsylvania (P.G)
| | - Jason Weimer
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (B.D.N., J.W., C.J.C., C.M.B., P.R.S.); Virginia Commonwealth University Department of Healthcare Policy and Research, Richmond, Virginia (C.J.B.); University of Pittsburgh Department of Psychology, Pittsburgh, Pennsylvania (C.M.R.); University of Pittsburgh Department of Neurological Surgery, Pittsburgh, Pennsylvania (P.G)
| | - Chienwen J Choi
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (B.D.N., J.W., C.J.C., C.M.B., P.R.S.); Virginia Commonwealth University Department of Healthcare Policy and Research, Richmond, Virginia (C.J.B.); University of Pittsburgh Department of Psychology, Pittsburgh, Pennsylvania (C.M.R.); University of Pittsburgh Department of Neurological Surgery, Pittsburgh, Pennsylvania (P.G)
| | - Cathy J Bradley
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (B.D.N., J.W., C.J.C., C.M.B., P.R.S.); Virginia Commonwealth University Department of Healthcare Policy and Research, Richmond, Virginia (C.J.B.); University of Pittsburgh Department of Psychology, Pittsburgh, Pennsylvania (C.M.R.); University of Pittsburgh Department of Neurological Surgery, Pittsburgh, Pennsylvania (P.G)
| | - Catherine M Bender
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (B.D.N., J.W., C.J.C., C.M.B., P.R.S.); Virginia Commonwealth University Department of Healthcare Policy and Research, Richmond, Virginia (C.J.B.); University of Pittsburgh Department of Psychology, Pittsburgh, Pennsylvania (C.M.R.); University of Pittsburgh Department of Neurological Surgery, Pittsburgh, Pennsylvania (P.G)
| | - Christopher M Ryan
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (B.D.N., J.W., C.J.C., C.M.B., P.R.S.); Virginia Commonwealth University Department of Healthcare Policy and Research, Richmond, Virginia (C.J.B.); University of Pittsburgh Department of Psychology, Pittsburgh, Pennsylvania (C.M.R.); University of Pittsburgh Department of Neurological Surgery, Pittsburgh, Pennsylvania (P.G)
| | - Paul Gardner
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (B.D.N., J.W., C.J.C., C.M.B., P.R.S.); Virginia Commonwealth University Department of Healthcare Policy and Research, Richmond, Virginia (C.J.B.); University of Pittsburgh Department of Psychology, Pittsburgh, Pennsylvania (C.M.R.); University of Pittsburgh Department of Neurological Surgery, Pittsburgh, Pennsylvania (P.G)
| | - Paula R Sherwood
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (B.D.N., J.W., C.J.C., C.M.B., P.R.S.); Virginia Commonwealth University Department of Healthcare Policy and Research, Richmond, Virginia (C.J.B.); University of Pittsburgh Department of Psychology, Pittsburgh, Pennsylvania (C.M.R.); University of Pittsburgh Department of Neurological Surgery, Pittsburgh, Pennsylvania (P.G)
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Kidd D. The optic chiasm. Clin Anat 2014; 27:1149-58. [PMID: 24824063 DOI: 10.1002/ca.22385] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 01/22/2014] [Accepted: 02/01/2014] [Indexed: 11/08/2022]
Abstract
The optic chiasm is formed when the optic nerves come together in order to allow for the crossing of fibers from the nasal retina to the optic tract on the other side. This enables vision from one side of both the eyes to be appreciated by the occipital cortex of the opposite side. This review makes note of the embryology, anatomy and vascular supply of the optic chiasm, then discusses the clinical syndromes associated with chiasmal disease, and the diseases which commonly influence its function.
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Affiliation(s)
- Desmond Kidd
- Department of Neuro-Ophthalmology, Royal Free Hospital, Pond Street, London, NW3 2QG, United Kingdom; University College Hospital Medical School, United Kingdom
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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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Hanmayyagari BR, Guntaka M, Paladugu S. An interesting case of Rathke's cleft cyst presenting as bilateral cryptorchidism. J Pediatr Neurosci 2014; 8:217-20. [PMID: 24470817 PMCID: PMC3888040 DOI: 10.4103/1817-1745.123677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Rathke's cleft cyst (RCC) are benign, epithelium-lined sellar and suprasellar cysts believed to originate from remnants of the Rathke pouch. Here, we report a rare case of entirely suprasellar RCC in a 4.5-year-old child causing hypopituitarism, who presented to us with bilateral cryptorchidism. Subsequently we discuss the distinct rarity of entirely suprasellar RCC presenting in this fashion and the relevant literature is also discussed.
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Affiliation(s)
| | - Mounika Guntaka
- Consultant Biochemist, Department of Lab Medicine, Prime hospital, Kukatpally-Hyderabad, Hyderabad, India
| | - Sridevi Paladugu
- Department of Endocrinology, Apollo Hospital, Hyderguda, Hyderabad, Andhra Pradesh, India
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Jahangiri A, Potts M, Kunwar S, Blevins L, El-Sayed IH, Aghi MK. Extended endoscopic endonasal approach for suprasellar Rathke's cleft cysts. J Clin Neurosci 2013; 21:779-85. [PMID: 24308953 DOI: 10.1016/j.jocn.2013.07.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/02/2013] [Accepted: 07/04/2013] [Indexed: 12/01/2022]
Abstract
Purely suprasellar Rathke's cleft cysts (RCC) treated with a microscopic endonasal approach have increased operative morbidity and poorer outcomes compared to purely sellar RCC. We sought to determine if the extended endoscopic endonasal approach improved outcomes for suprasellar RCC. We retrospectively reviewed RCC patients at our institution over a 10 year period comparing outcomes of purely sellar RCC treated microsurgically (n=68), purely suprasellar RCC treated microsurgically (n=22), and purely suprasellar RCC treated endoscopically (n=9). Suprasellar RCC treated endoscopically were similar in size to those treated microscopically (0.9 versus 1.1cm; p=0.4). Complete cyst drainage occurred in 78% of suprasellar RCC approached endoscopically versus 25% approached microsurgically (p=0.02), approaching the 84% complete drainage rate seen with sellar microsurgically approached RCC. Visual normalization occurred in 67% of suprasellar RCC patients treated endoscopically versus 29% treated microsurgically (p=0.5). Headache improved in 71% of suprasellar RCC treated endoscopically, more than the 33% of suprasellar RCC treated microsurgically and the 53% of sellar RCC treated microsurgically (p=0.4). Diabetes insipidus (all temporary) occurred in 22% of patients with suprasellar RCC treated endoscopically, slightly greater than the 14% in suprasellar microsurgical patients and 9% in sellar RCC treated microsurgically (p>0.05). Cerebrospinal fluid (CSF) leak did not occur in any of the suprasellar RCC treated endoscopically, while 14% treated microsurgically experienced a CSF leak (p>0.05). Suprasellar RCC are neurosurgically challenging due to their proximity to the optic chiasm and infundibulum. Compared to microsurgery, endoscopy improves rate of complete removal and visual outcomes.
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Affiliation(s)
- Arman Jahangiri
- California Center for Pituitary Disorders, Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0112, USA; Center for Minimally Invasive Skull Base Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Matthew Potts
- California Center for Pituitary Disorders, Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0112, USA; Center for Minimally Invasive Skull Base Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Sandeep Kunwar
- California Center for Pituitary Disorders, Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0112, USA
| | - Lewis Blevins
- California Center for Pituitary Disorders, Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0112, USA
| | - Ivan H El-Sayed
- Department of Otolaryngology, University of California at San Francisco, San Francisco, CA, USA; Center for Minimally Invasive Skull Base Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Manish K Aghi
- California Center for Pituitary Disorders, Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0112, USA; Center for Minimally Invasive Skull Base Surgery, University of California at San Francisco, San Francisco, CA, USA.
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Mendelson ZS, Husain Q, Elmoursi S, Svider PF, Eloy JA, Liu JK. Rathke's cleft cyst recurrence after transsphenoidal surgery: a meta-analysis of 1151 cases. J Clin Neurosci 2013; 21:378-85. [PMID: 24269553 DOI: 10.1016/j.jocn.2013.07.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/16/2013] [Indexed: 10/26/2022]
Abstract
Rathke's cleft cysts (RCC) arise from the development of the Rathke's cleft pouch. These commonly occurring cysts are typically asymptomatic, but sometimes present with headaches, endocrine dysfunction, and visual loss. Recurrence is common after either drainage or surgical removal. The purpose of this study was to review published outcomes for RCC management, and determine whether specific factors, including patient demographics, cyst pathology, radiologic parameters, or surgical techniques predispose to their recurrence. A systematic review of studies for RCC from 1990 to 2012 was conducted. Patients were identified using a Medline/PubMed search, and from the bibliographies of relevant articles obtained from the primary search. Relevant studies reporting recurrence rate were identified, and data were extracted regarding patient demographics, presenting symptoms, cyst characteristics, surgical treatment, and outcomes. A meta-analysis for recurrence rates was also performed. Twenty-eight journal articles comprising a total of 1151 RCC revealed an average follow-up of 38 months (range 16-79 months). In the studies reviewed, there was a relatively equal distribution of treatment approaches, with 35% subtotal resection, 33% gross total resection, and 32% complete drainage with wall biopsy. The microsurgical transsphenoidal approach was found to have a higher recurrence rate (14% versus 8%) and new endocrine dysfunction rate (25% versus 10%) compared to the endoscopic approach. The data demonstrates a notable overall recurrence rate for RCC (12.5%). However, there appears to be no conclusive evidence that more aggressive resection of the cyst wall results in lower rates of recurrence.
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Affiliation(s)
- Zachary S Mendelson
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA
| | - Qasim Husain
- Department of Otolaryngology, Head & Neck Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Sedeek Elmoursi
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA
| | - Peter F Svider
- Department of Otolaryngology, Head & Neck Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Jean Anderson Eloy
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA; Department of Otolaryngology, Head & Neck Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - James K Liu
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA; Department of Otolaryngology, Head & Neck Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers University, New Jersey Medical School, Newark, NJ, USA.
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Rathke’s cleft cysts: review of natural history and surgical outcomes. J Neurooncol 2013; 117:197-203. [DOI: 10.1007/s11060-013-1272-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
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Kumar M, Dutta D, Shivaprasad KS, Jain R, Sen A, Biswas D, Mukhopadhyay M, Ghosh S, Mukhopadhyay S, Chowdhury S. Diabetes insipidus as a presenting manifestation of Rathke's cleft cyst. Indian J Endocrinol Metab 2013; 17:S127-S129. [PMID: 24251131 PMCID: PMC3830277 DOI: 10.4103/2230-8210.119529] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rathke's cleft cysts (RCC) are cystic sellar and suprasellar lesions derived from remnants of Rathke's pouch, lined by cuboidal or columnar epithelium. RCC are usually asymptomatic but can present with headache, visual impairment, panhypopituitarism and hypothalamic dysfunction. Diabetes Insipidus as a presenting symptom of RCC is reported, but rare. We present a case of a 48-year-old male presenting with polyuria and on investigations found to have central diabetes insipidus due to a sellar RCC. Patient underwent transsphenoidal surgery with complete excision with resolution of his symptoms. His polyuria resolved post-surgery without vasopressin replacement, which has never been reported.
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Affiliation(s)
- Manoj Kumar
- Department of Endocrinology and Metabolism, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Deep Dutta
- Department of Endocrinology and Metabolism, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - K. S. Shivaprasad
- Department of Endocrinology and Metabolism, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Rajesh Jain
- Department of Endocrinology and Metabolism, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Ankita Sen
- Department of Pathology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Dibakar Biswas
- Department of Endocrinology and Metabolism, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | | | - Sujoy Ghosh
- Department of Endocrinology and Metabolism, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Satinath Mukhopadhyay
- Department of Endocrinology and Metabolism, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Subhankar Chowdhury
- Department of Endocrinology and Metabolism, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
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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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Bizzarri C, Marini R, Ubertini G, Cappa M. Partially reversible hypopituitarism in an adolescent with a rathke cleft cyst. Clin Pediatr Endocrinol 2013; 21:75-80. [PMID: 23926414 PMCID: PMC3687652 DOI: 10.1297/cpe.21.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 07/23/2012] [Indexed: 11/17/2022] Open
Abstract
Rathke cleft cysts are remnants of the Rathke pouch. Most of them are asymptomatic, but
sometimes they can grow enough to cause compression of structures within and/or close to
the sella, thus eliciting symptoms such as visual disturbance, pituitary defects, and
headache. Asymptomatic cysts can safely be followed up with serial imaging, while the
standard treatment for symptomatic lesions is surgical removal. We describe a 14-yr-old
boy, admitted for anorexia, fatigue, weight loss, recurrent headache and vomiting.
Magnetic resonance imaging showed an intra- and suprasellar cystic lesion, which was
surgically removed. Histology was consistent with Rathke’s cleft cyst. Diabetes insipidus
and multiple anterior pituitary defects (GH, ACTH and TSH) were found preoperatively, and
substitutive therapy was started. No additional hormonal defect appeared after surgery.
After 4 yr of follow up, pituitary function was retested, and there were no confirmed GH
or ACTH defects, allowing a partial withdrawal of replacement therapy. Our report confirms
that pituitary defects, in patients with a Rathke cleft cyst, may recover even year after
surgery. Thus, retesting of pituitary axes is indicated during long-term follow up.
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Affiliation(s)
- Carla Bizzarri
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Ogawa Y, Watanabe M, Tominaga T. Rathke's cleft cysts with significant squamous metaplasia--high risk of postoperative deterioration and close origins to craniopharyngioma. Acta Neurochir (Wien) 2013; 155:1069-75. [PMID: 23371400 DOI: 10.1007/s00701-012-1593-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 12/13/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND Rathke's cleft cyst (RCC) with significant squamous and/or stratified epithelium including smooth transition from single cuboidal to squamous epithelium (tRCC) is rare and possibly represents an intermediate form to craniopharyngioma. METHODS Twelve patients with histologically confirmed tRCC were retrospectively investigated from a series of 167 cases of RCC and 96 cases of craniopharyngiomas. Clinical data were reviewed, and immunohistochemistry findings for cytokeratins and β-catenin were examined. RESULTS All lesions were located in the sella turcica with marked extension to suprasellar cistern. Six of the 12 patients had suffered postoperative re-enlargement, and three of these six patients required more than two additional operations and irradiation. CAM5.2 was positive in the glandular epithelium in all tRCCs and focally positive in the squamous epithelium of all these tRCCs. 34βE12 was positive in the squamous epithelium in all tRCCs and focally positive in the glandular epithelium in all but one tRCC. The findings of cytokeratin expression of tRCCs were very similar to those of craniopharyngioma. β-Catenin showed nuclear translocation in five cases. All patients with nuclear translocation of β-catenin suffered postoperative re-enlargement. CONCLUSIONS tRCC carries an extremely high risk of re-enlargement. Cytokeratin expression resembles that in craniopharyngioma, which might indicate a very close origin of these pathologies. Nuclear translocation of β-catenin may be related to the aggressive clinical course.
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Affiliation(s)
- Yoshikazu Ogawa
- Department of Neurosurgery, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku-ku, Sendai, Miyagi, 982-8523, Japan.
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Abstract
Rathke's cleft cyst is a benign growth found on the pituitary gland in the brain, specifically a fluid-filled cyst in the posterior portion of the anterior pituitary gland. It occurs when the Rathke's pouch does not develop properly, and ranges in size from 2 to 40 mm in diameter. Asymptomatic cysts are common, detected during autopsies of 2-26% of individuals who have died of unrelated causes. Symptomatic cysts are rare and only approximately 150 cases have been reported. Females are twice as likely as males to have a cyst. Symptomatic cysts can trigger visual disturbances, pituitary dysfunction and headaches. Here we present a case of a 40-year-old female patient who presented with complains of visual disturbances, headache and amenorrhoea. On investigations, MRI of brain revealed findings suggestive of Rathke's cleft cyst.
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Affiliation(s)
- Vismay Dinesh Naik
- Department of Medicine, Sheth K. M. School of Post Graduate Medicine and Research, Smt. N. H. L Municipal Medical College, V. S. Hospital, Ahmedabad, Gujarat, India.
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Amano K, Kubo O, Komori T, Tanaka M, Kawamata T, Hori T, Okada Y. Clinicopathological features of sellar region xanthogranuloma: correlation with Rathke’s cleft cyst. Brain Tumor Pathol 2013; 30:233-41. [DOI: 10.1007/s10014-012-0130-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/20/2012] [Indexed: 11/28/2022]
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Sarmiento JM, Wi MS, Piao Z, Boon-Unge K, Stiner ES. Two collision sellar lesions: Rathke's cleft cyst with non-functional pituitary adenoma and Rathke's cleft cyst with plurihormonal adenoma. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2049-7962-2-14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Dutta D, Roy A, Ghosh S, Mukhopadhyay P, Dasgupta R, Mukhopadhyay S, Chowdhury S. Rathke's cyst with ectopic neurohypophysis presenting as severe short stature with delayed puberty. Indian J Endocrinol Metab 2012; 16:S288-S290. [PMID: 23565402 PMCID: PMC3603050 DOI: 10.4103/2230-8210.104062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Ectopic neurohypophysis (EN) is found in nearly half of children with growth hormone deficiency (GHD). Rathke's cyst (RC) is uncommon in children and when present, hypopituitarism is found in nearly half of them. We present a fourteen and half-year-old girl with severe short stature and delayed puberty who on evaluation was found to have GHD, secondary hypocortisolism, and hypogonadism. Imaging revealed hypoplastic anterior pituitary, stalk agenesis, EN at tuber cinereum and intrapituitary RC. This is perhaps the first report of simultaneous occurrence of EN and RC, which was seen in a girl with multiple pituitary hormone deficiency. A primary defect in pituitary development may explain this simultaneous occurrence of EN and RC and hence this severe anterior pituitary function deficit.
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Affiliation(s)
- Deep Dutta
- Department of Endocrinology & Metabolism, IPGMER & SSKM Hospital, Kolkata, India
| | - Ajitesh Roy
- Department of Endocrinology & Metabolism, IPGMER & SSKM Hospital, Kolkata, India
| | - Sujoy Ghosh
- Department of Endocrinology & Metabolism, IPGMER & SSKM Hospital, Kolkata, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology & Metabolism, IPGMER & SSKM Hospital, Kolkata, India
| | - Ranen Dasgupta
- Department of Endocrinology & Metabolism, IPGMER & SSKM Hospital, Kolkata, India
| | | | - Subhankar Chowdhury
- Department of Endocrinology & Metabolism, IPGMER & SSKM Hospital, Kolkata, India
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67
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Kim E. Symptomatic Rathke Cleft Cyst: Clinical Features and Surgical Outcomes. World Neurosurg 2012; 78:527-34. [DOI: 10.1016/j.wneu.2011.12.091] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 12/20/2011] [Indexed: 11/28/2022]
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68
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Kim E. A Case of Ectopic Rathke's Cleft Cyst in the Prepontine Cistern. J Korean Neurosurg Soc 2012; 52:152-5. [PMID: 23091676 PMCID: PMC3467375 DOI: 10.3340/jkns.2012.52.2.152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 06/06/2012] [Accepted: 08/17/2012] [Indexed: 11/27/2022] Open
Abstract
A Rathke's cleft cyst (RCC) is a benign pituitary cyst derived from the remnant of Rathke's pouch, and usually presents as an intrasellar lesion with varying degrees of suprasellar extension. However, to date, a description of a primary prepontine RCC with no intrasellar component has not been reported. The author describes an exceptional case of a symptomatic RCC located behind the sella turcica in a 41-year-old woman who presented with severe headache. The author also provides an embryological hypothesis of the development of an ectopic RCC, with a special emphasis on radiologic characteristics.
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Affiliation(s)
- Ealmaan Kim
- Department of Neurosurgery, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea
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69
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Potts MB, Jahangiri A, Lamborn KR, Blevins LS, Kunwar S, Aghi MK. Suprasellar Rathke cleft cysts: clinical presentation and treatment outcomes. Neurosurgery 2012; 69:1058-68; discussion 1068-7. [PMID: 21673610 DOI: 10.1227/neu.0b013e318228bcea] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Rathke cleft cysts (RCCs), benign remnants of the Rathke pouch typically arising in the sella, sometimes have suprasellar extension. Purely suprasellar RCCs are rarely reported. OBJECTIVE To compare the presentations, surgical outcomes, and pathology of purely suprasellar RCCs and sellar-based RCCs. METHODS We retrospectively reviewed records, magnetic resonance images, laboratory results, and pathology of 151 RCC patients surgically managed at our institution from 1989 to 2009. The RCCs were classified as purely sellar (type I, n = 76), sellar with suprasellar extension (type II, n = 56), or purely suprasellar (type III, n = 19). RESULTS The RCCs with a suprasellar component (types II and III) more commonly presented with visual dysfunction (P < .001). Complete cyst drainage occurred in 89%, 55%, and 38% of type I, II, and III RCCs, respectively (P < .001). Vision improved in 100%, 55%, and 33% and headache improved in 74%, 64%, and 29% of type I, II, and III patients, respectively (P = .02). Temporary or permanent postoperative diabetes insipidus occurred in 5%, 16%, and 21% of type I, II, and III patients, respectively. (P < .001). In a multivariate analysis, RCC type was the only factor predicting recurrence. Kaplan-Meier 3-year recurrence/progression rates were 0%, 16%, and 29% for type I, II, and III RCCs, respectively (P < .001, type I vs II, type I vs III; P = .5 type II vs III). CONCLUSION The RCCs with a suprasellar component are neurosurgically challenging because of their proximity to the optic chiasm and infundibulum. Compared with sellar-based RCCs, RCCs with a suprasellar component more frequently present with visual dysfunction, are more difficult to completely eliminate, recur more frequently, and are associated with higher postoperative endocrine morbidity, and their preoperative visual dysfunction and headache less frequently improve with surgery. These factors must be considered during the treatment of RCCs with a suprasellar component.
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Affiliation(s)
- Matthew B Potts
- Department of Neurosurgery and California Center for Pituitary Disorders, University of California, San Francisco, California 94143-0112, USA
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70
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Acute, monocular vision loss from Rathke’s cleft cyst. J Clin Neurosci 2012; 19:904-6. [DOI: 10.1016/j.jocn.2011.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 09/04/2011] [Indexed: 11/19/2022]
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71
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Munich SA, Leonardo J. Spontaneous involution of a Rathke's cleft cyst in a patient with normal cortisol secretion. Surg Neurol Int 2012; 3:42. [PMID: 22574251 PMCID: PMC3347493 DOI: 10.4103/2152-7806.94925] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 03/12/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Rathke's cleft cyst (RCC) is a lesion derived from maldeveloped remnants of a dorsal invagination of the stomodeal ectoderm (Rathke's pouch). Although commonly found on autopsy, these lesions rarely become symptomatic during an individual's lifetime. When symptoms occur, they most often include headaches, visual disturbances, and/or varying degrees of hypopituitarism. The natural history remains unclear. The current standard of care includes surgical drainage and biopsy of the cyst wall or surgical resection of symptomatic lesions; however, debate exists regarding the management of asymptomatic lesions. Rare reports of spontaneously resolving RCC can be found in the literature. CASE DESCRIPTION We describe the management of a case of RCC in an 8½-year-old girl who presented with a history of growth deceleration since 4 years of age and near-growth arrest since 7 years of age. Her parents also described a tendency towards polydipsia since she was 2 years of age. Endocrine evaluation revealed growth hormone deficiency, central hypothyroidism, and diabetes insipidus, but normal cortisol secretion. The patient experienced no symptoms characteristic of intracranial or sellar mass. Neurologic examination was normal; formal ophthalmologic examination revealed no deficits. The magnetic resonance imaging (MRI) was consistent with RCC. The patient was treated medically for her hormone deficiencies. Over the next year, her sellar mass spontaneously involuted. Twenty-seven months after her initial presentation to our clinic, imaging revealed no sellar mass; the patient remained on hormone replacement therapy. CONCLUSION Although the natural history of RCC requires further study, observation with serial MRI may be an acceptable management strategy in the absence of debilitating symptoms.
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Affiliation(s)
- Stephan A Munich
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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72
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Zhong W, You C, Jiang S, Huang S, Chen H, Liu J, Zhou P, Liu Y, Cai B. Symptomatic Rathke cleft cyst. J Clin Neurosci 2012; 19:501-8. [DOI: 10.1016/j.jocn.2011.07.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 07/09/2011] [Accepted: 07/16/2011] [Indexed: 10/14/2022]
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Yu X, Huang R, Qian W, Fang J, Wu C, Liu S. Stereotactic radiosurgery to treat presumed Rathke's cleft cysts. Br J Neurosurg 2012; 26:684-91. [DOI: 10.3109/02688697.2012.671975] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Xin Yu
- Department of Neurosurgery, Navy General Hospital, Beijing, China.
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74
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Higgins DM, Van Gompel JJ, Nippoldt TB, Meyer FB. Symptomatic Rathke cleft cysts: extent of resection and surgical complications. Neurosurg Focus 2012; 31:E2. [PMID: 21721867 DOI: 10.3171/2011.5.focus1175] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Rathke cleft cysts (RCCs) are benign masses arising from the embryological Rathke pouch, and are commonly treated by transsphenoidal surgery. The authors retrospectively compared RCC extent of resection-either gross-total resection (GTR) or decompression-to the primary outcome measure, which was recurrences resulting in repeat surgery, and the secondary outcome measure, which was complications. METHODS Seventy-four patients presenting to the neurosurgical department with RCC were analyzed retrospectively. Sixty-eight patients had a total of 78 surgical procedures, with the diagnosis of RCC confirmed by histological investigation; of these, 61 patients had adequate operative notes for the authors to evaluate extent of resection. Groups were separated into GTR (32 patients) or decompression (subtotal resection or fenestration into the sphenoid sinus; 29 patients) based on operative notes and postoperative imaging. The mean follow-up duration was 60.5 ± 72.1 months (the mean is expressed ± SD throughout). RESULTS The average age at the time of the initial surgery was 42.8 ± 17.4 years, and 70% of patients were female. The mean cyst diameter preoperatively was 16.9 ± 17.8 mm. Eight patients had repeat surgery, our primary outcome measure; 3 repeat operations occurred in the GTR group, and 5 in the decompression group. There was no significant difference in recurrence when comparing groups (GTR 9%, decompression 17%; p = 0.36). There were no major complications; however, analysis of postoperative minor complications revealed that 11 (34%) GTRs resulted in surgical complications, whereas the decompression cohort accounted for only 3 complications (10%) (p = 0.03), with diabetes insipidus (6) and CSF leaks (5) being the most common. Gross-total resection also resulted in an increase in postoperative hyperprolactinemia compared with decompression (p = 0.03). CONCLUSIONS It appears that RCCs require repeat surgery in 13% of cases, and attempted GTR does not appear to reduce the overall rate of recurrence. However, more aggressive resections are associated with more complications in this series.
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75
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Jahangiri A, Molinaro AM, Tarapore PE, Blevins L, Auguste KI, Gupta N, Kunwar S, Aghi MK. Rathke cleft cysts in pediatric patients: presentation, surgical management, and postoperative outcomes. Neurosurg Focus 2012; 31:E3. [PMID: 21721868 DOI: 10.3171/2011.5.focus1178] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Rathke cleft cysts (RCC) are benign sellar lesions most often found in adults, and more infrequently in children. They are generally asymptomatic but sometimes require surgical treatment through a transsphenoidal corridor. The purpose of this study was to compare adult versus pediatric cases of RCC. METHODS The authors retrospectively reviewed presenting symptoms, MR imaging findings, laboratory study results, and pathological findings in 147 adult and 14 pediatric patients who underwent surgery for treatment of RCCs at the University of Californial at San Francisco between 1996 and 2008. RESULTS In both the adult and pediatric groups, most patients were female (78% of adults, 79% of pediatric patients, p = 0.9). Headache was the most common symptom in both groups (reported by 50% of pediatric patients and 33% of adults, p = 0.2). Preoperative hypopituitarism occurred in 41% of adults and 45% of pediatric patients (p = 0.8). Growth delay, a uniquely pediatric finding, was a presenting sign in 29% of pediatric patients. Visual complaints were a presenting symptom in 16% of adult and 7% of pediatric patients (p = 0.4). There was no difference between median cyst size in adults versus pediatric patients (1.2 cm in both, p = 0.7). Temporary or permanent postoperative diabetes insipidus occurred in 12% of adults and 21% of pediatric patients (p = 0.4). Kaplan-Meier analysis revealed an 8% RCC recurrence rate at 2 years for each group (p = 0.5). CONCLUSIONS The incidence of RCCs is much lower in the pediatric population; however, symptoms, imaging findings, and outcomes are similar, suggesting that pediatric RCCs arise from growth of remnants of the embryonic Rathke pouch earlier in life than adult RCCs but do not differ in any other way. It is important to consider RCCs in the differential diagnosis when pediatric patients present with visual impairment, unexplained headache, or hypopituitarism including growth delay. Although the average RCC size was similar in our pediatric and adult patient groups, the smaller size of the pituitary gland in pediatric patients suggests an increased relative RCC size.
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Affiliation(s)
- Arman Jahangiri
- University of Texas Southwestern Medical School, Dallas, Texas, USA
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76
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Abstract
Rathke's cleft cysts (RCCs) are benign, sellar and/or suprasellar lesions originating from the remnants of Rathke's pouch. Although a common finding in routine autopsies (12-33% of normal pituitary glands), symptomatic cases are rare and comprise 5-15% of all surgically resected sellar lesions. Small, asymptomatic RCC do not require surgical intervention, and their natural history is not clear. In series of nonoperated presumed RCCs, 26-94% did not progress during follow-up periods up to 9 years. In symptomatic ones, surgery is indicated, aiming to drain the cyst content and safely remove as much of the capsule as possible. Following surgical intervention, headaches and visual field defects improve or resolve in a significant number of patients (40-100% and 33-100%, respectively) and partial hypopituitarism recovers in 14-50%. Data on relapse rates published in the last 15 years are based on variable follow-up periods and show wide variation (between 0% and 33%). The lowest relapse rates have been described in reports with relatively short mean observation periods (<3 years), whereas in those with longer follow-up the relapse rates increase. Most of the relapses occur within 5-6 years, suggesting that follow-up is required for at least 5 years after surgery. Risk factors for relapse include the presence of squamous metaplasia in the cyst wall, cyst size and the presence of inflammation. Long-term sufficiently powered studies aiming to clarify the natural history of asymptomatic RCCs and of those relapsing postoperatively are required.
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Affiliation(s)
- Raluca Trifanescu
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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77
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Iannelli A, Martini C, Cosottini M, Castagna M, Bogazzi F, Muscatello L. Rathke's cleft cysts in children: clinical, diagnostic, and surgical features. Childs Nerv Syst 2012; 28:297-303. [PMID: 22057478 DOI: 10.1007/s00381-011-1626-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 10/18/2011] [Indexed: 11/26/2022]
Affiliation(s)
- A Iannelli
- Neurochirurgia Pediatrica Universitaria, Azienda Ospedaliera Universitaria Pisana Nuovo Santa Chiara, Pisa, Italy.
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78
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Prognostic factors of operated Rathke's cleft cysts with special reference to re-accumulation and recommended surgical strategy. Acta Neurochir (Wien) 2011; 153:2427-33; discussion 2433. [PMID: 21725869 DOI: 10.1007/s00701-011-1072-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 06/09/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Rathke's cleft cyst is known as an indolent disease, but has become intractable in a few cases. In this clinical investigation, the initial operative outcomes of Rathke's cleft cyst and the mechanism of re-accumulation were investigated to identify the optimum surgical strategy for the second operation. METHODS We conducted a retrospective review of 155 patients with Rathke's cleft cyst (58 males and 97 females, aged from 13 to 84 years) surgically treated between April 1996 and March 2010. The same initial operative strategy was adopted in all patients. Operative outcomes and prognostic factors were investigated. FINDINGS Re-accumulation occurred in 27 patients (17.4%), and re-operation was required in eight patients because of neurological deficits (5.2%). Three types of re-accumulating mechanism were identified. First, cysts with cerebrospinal fluid (CSF)-like intensity on magnetic resonance imaging had a higher risk of re-accumulation (logrank test, p < 0.001). The cyst wall should be extensively removed in the suprasellar cistern to allow communication between the cyst and CSF spaces at the second operation. Second, cysts with epithelial transition had a significant higher risk of re-accumulation compared to other types of epithelium (logrank test, p < 0.001). Aggressive removal and irradiation should be performed at the second treatment. Third, classic Rathke's cleft cyst was found in the majority of cases. No change in operative strategy is required at the second treatment with lower risk of intractability. CONCLUSIONS Enlargement of Rathke's cleft cyst requiring re-treatment needs selection of surgical strategy according to the individual re-accumulation mechanism.
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Abstract
We present a patient with a Rathke's cleft cyst who presented with rapidly progressive bilateral 6th nerve palsy. A 20-year-old woman with a history of cleft palate, hypertension, and hydronephrotic kidneys presented with a one month history of headache, associated with dizziness and diplopia on horizontal gaze. Examination was significant for profound bilateral 6th nerve palsies. Magnetic resonance imaging showed a hypodense mass that filled the sella and compressed the right cavernous sinus without contacting the optic chiasm. Pituitary function was normal. An endoscopic, transnasal transsphenoidal resection of the lesion was performed; microscopic examination revealed a Rathke's cleft cyst. Surgical excision resulted in near complete resolution of the bilateral 6th nerve palsy. Rathke's cleft cysts are an unusual cause of bilateral sixth nerve palsy and represent a potential cause of cranial neuropathy.
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Affiliation(s)
- Vinni Grover
- Department of Endocrinology, Diabetes and Metabolism, Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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80
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Choi JS, Kim CS, Park JW, Bae EH, Ma SK, Kim SW. Hyponatremia in a patient with a sellar mass. Chonnam Med J 2011; 47:122-3. [PMID: 22111072 PMCID: PMC3214876 DOI: 10.4068/cmj.2011.47.2.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 08/09/2011] [Indexed: 11/06/2022] Open
Abstract
A 59-year-old man with confused mental status was admitted to our hospital. Laboratory reports showed him to have severe hyponatremia, and additional studies revealed panhypopituitarism. Brain magnetic resonance imaging showed a sellar cystic lesion, which consisted of a Rathke cleft cyst. Thus, the mass effect of the Rathke cleft cyst resulted in panhypopituitarism and finally induced euvolemic hyponatremia. On the basis of these results, supplementation with thyroid hormone and glucocorticoid was started, and the patient's serum sodium level was gradually corrected and maintained within the normal range. Here, we report this case of euvolemic hyponatremia caused by a Rathke cleft cyst.
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Affiliation(s)
- Joon Seok Choi
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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81
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Park JK, Lee EJ, Kim SH. Optimal surgical approaches for Rathke cleft cyst with consideration of endocrine function. Neurosurgery 2011; 70:250-6; discussion 256-7. [PMID: 22089758 DOI: 10.1227/neu.0b013e3182418034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Surgical indications for Rathke cleft cyst are not clear. OBJECTIVE To evaluate postoperative outcomes in terms of endocrine function. METHODS The study analyzed a total 73 patients who underwent transsphenoidal surgery. All patients underwent a visual field test, combined pituitary function test, and magnetic resonance imaging before and after surgery. A follow-up combined pituitary function test was performed at 1.5-year intervals. RESULTS The mean age at the time of surgery was 35 ± 14 years, and the male/female ratio was 1:1.25 (33/40). The mean follow-up duration after surgery was 59 ± 39 months. The most common symptoms were headache (84%), visual disturbance (48%), and polyuria (38%). After transsphenoidal surgery, 75% of polyuria and 96% of visual field defects were resolved, and pituitary function improved in 42% of patients. The mean age of patients who exhibited worsened hypopituitarism was significantly higher than that of patients who exhibited unchanged or improved hypopituitarism (44 ± 15.7 vs 33 ± 13.5 years; P = .02). Twelve patients (16%) experienced recollection of cyst, but none required reoperation. Five of the recollected cysts presented with characteristics that were different from those of the initial lesions, and 2 recollected cysts underwent spontaneous regression. CONCLUSION Minimal incision with radical removal of cyst content is reasonable to prevent the development of endocrine disturbances and other complications. Individualized risks and benefits must be assessed before a decision is reached regarding surgery and surgical method. Patients with recurrent Rathke cleft cyst require careful follow-up with special attention rather than a hasty operation.
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Abstract
In the first part of this chapter the anatomy and vascular supply of the chiasm are recounted, and the visual symptoms that may arise in chiasmal disease are noted. The neuro-ophthalmic signs, including the pattern of visual field defects, appearance of the optic disc, and various uncommon clinical accompaniments, are described. The second part deals with a comprehensive list of disease processes that may directly or indirectly affect the chiasm. These are divided into inflammatory disorders, including sarcoidosis, multiple sclerosis, and idiopathic chiasmitis; infective disorders, including tuberculosis; and a large section on tumors, including pituitary adenomas, cysts, and choristomas, malignant disorders, including germ cell tumors and glioma, and meningioma; and finally vascular disorders and compression due to hydrocephalus. In each case the clinical features and management of the disorder are noted, as well as the prognosis for visual improvement following treatment.
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Affiliation(s)
- Desmond Kidd
- Department of Neuro-ophthalmology, Royal Free Hospital and Royal Free and University College Hospital Medical School, London, UK.
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83
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Rincon JL, Nunes J, Camuto P, Goodrich I. Intracranial Approach to Suprasellar Rathke's Cleft Cyst. Skull Base 2011; 9:71-3. [PMID: 17171085 PMCID: PMC1656719 DOI: 10.1055/s-2008-1058176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The occurrence of a symptomatic Rathke's cleft cyst without extension into the sella turcica is rare. The purpose of this report is to present such a case, with its clinical manifestation, diagnostic imaging characteristics, operative approach, pathology and review of the literature.
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84
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Sivakumar W, Cole CD, Couldwell WT. Rathke cleft cyst presenting with hyponatremia: an unusual presentation. Neurosurg Focus 2011; 31:E4. [DOI: 10.3171/2011.4.focus1180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report a case of Rathke cleft cyst presenting with severe hyponatremia. A 33-year-old man suffered sudden severe headaches, visual changes, dizziness, nausea, vomiting, and a metallic taste in his mouth. Initial laboratory values demonstrated severe hyponatremia. Magnetic resonance imaging revealed a cystic lesion with questionable intracystic hemorrhage, concerning for pituitary apoplexy. Transsphenoidal decompression and drainage of the cyst confirmed the diagnosis of Rathke cleft cyst and resolved the symptoms. Postoperative follow-up studies at 6 months demonstrated normal endocrine function and no evidence of a cyst.
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85
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Lillehei KO, Widdel L, Arias Astete CA, Wierman ME, Kleinschmidt-DeMasters BK, Kerr JM. Transsphenoidal resection of 82 Rathke cleft cysts: limited value of alcohol cauterization in reducing recurrence rates. J Neurosurg 2011; 114:310-7. [DOI: 10.3171/2010.7.jns091793] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to report the results of a large clinical series of patients with symptomatic Rathke cleft cysts (RCCs) who underwent resection by a single neurosurgeon using intraoperative alcohol cauterization, and to review any possible differences in recurrence rates in those treated with this chemically ablative technique.
Methods
The authors performed a retrospective database review of 82 patients (age range 10–74 years) with symptomatic RCCs who underwent surgery between 1993 and 2009.
Results
Preoperative symptoms of headaches, vision disturbances, and hormone dysfunction were observed in 68%, 35%, and 56% of patients, respectively. All 82 patients underwent treatment by a single surgeon. Surgery consisting of simple cyst drainage followed by cyst wall biopsy without vigorous cyst wall removal was performed. A subset of these patients (62) received intraoperative alcohol instillation. Perioperative complication rates were low: CSF leakage, symptomatic hyponatremia, and permanent diabetes insipidus (DI) in 2%, 5%, and 0% of patients, respectively. Headaches and vision problems improved or resolved in 71% and 83% of patients, respectively. In addition, hyperprolactinemia, hypothyroidism, panhypopituitarism, DI, and adrenal insufficiency improved or resolved in 94%, 90%, 50%, 33%, and 67% of patients, respectively. Recurrence, as defined by enlargement of the cyst as compared with its appearance on baseline 3-month postoperative MR imaging, was noted in 10.7% of the primary surgery group. There was a trend toward increased recurrence rates in the alcohol-treated (12.9%) versus no–alcohol treatment groups (0%), although not statistically significant (p = 0.20).
Conclusions
This large, single-surgeon/single-institution series of patients with symptomatic RCCs confirms that significant postoperative improvement in headaches, vision, and pituitary hormone dysfunction can be achieved via a conservative surgical approach, with low complication and recurrence rates. The data also demonstrate a limited role for alcohol cauterization in the treatment of symptomatic RCCs.
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Affiliation(s)
| | | | | | - Margaret E. Wierman
- 2Medicine, and
- 4Denver Veterans Administration Medical Center, Denver, Colorado
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86
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Chaiban JT, Abdelmannan D, Cohen M, Selman WR, Arafah BM. Rathke cleft cyst apoplexy: a newly characterized distinct clinical entity. J Neurosurg 2011; 114:318-24. [DOI: 10.3171/2010.5.jns091905] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Although most Rathke cleft cysts (RCCs) remain asymptomatic, some present with compression of surrounding structures and pituitary hormone dysfunction. A rare, but distinct presentation of the RCC includes hemorrhage into the cyst—a presentation that mimics the clinical syndrome of pituitary tumor apoplexy. The objective of this article is to present the authors' experience on the prevalence and the clinical, biochemical, pathological, and imaging characteristics of hemorrhage into an RCC and review published reports on this entity.
Methods
An institutional database for patients with pituitary masses was reviewed and data on cases involving surgery for a subsequently documented RCC were identified. Patients with documented hemorrhage within the RCC were included in the analysis. Documentation included intraoperative visualization of hemorrhage by the surgeon and/or pathological confirmation of hemorrhage within the RCC. The clinical, biochemical, pathological, and imaging characteristics of these patients were extracted from the database. All published data on RCC were also reviewed and confirmed cases of hemorrhage were extracted and included in the review.
Results
A total of 11 cases with hemorrhage within an RCC were identified to have been managed at the authors' institution over a 10-year span. This figure represented 20% of all surgically treated cases of RCC from that period. Among published reports, a total of 10 confirmed cases were evaluated. The clinical presentation of patients with hemorrhage within an RCC are classical and include sudden onset of severe headache—or a sudden increase in headache severity—associated with visual disturbances, impairment in pituitary function, and occasionally alterations in mental status. Leakage of the cystic contents into the subarachnoid space can occur rarely and may lead to associated chemical meningitis. There are no known precipitating factors for this phenomenon. The clinical presentation of such patients is difficult to distinguish from that of patients with pituitary tumor apoplexy. However, patients with RCC apoplexy often present with less severe symptoms, have a lower prevalence of pituitary dysfunction, and generally have smaller mass lesions than those with pituitary tumor apoplexy. Management of patients with RCC apoplexy is similar to that of those with pituitary tumor apoplexy. Surgery can provide definitive diagnosis and relief of symptoms and often leads to recovery from hypopituitarism. All patients with this syndrome require long-term follow-up to treat any residual sequelae.
Conclusions
This article provides the first thorough review and characterization of patients with hemorrhage within an RCC. Based on the clinical manifestations of this presentation, we recommend using the term “Rathke cleft cyst apoplexy” to describe the syndrome.
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Affiliation(s)
- Joumana T. Chaiban
- 1The Pituitary Center,
- 2Division of Clinical and Molecular Endocrinology, and
| | - Dima Abdelmannan
- 1The Pituitary Center,
- 2Division of Clinical and Molecular Endocrinology, and
| | | | - Warren R. Selman
- 4Neurological Surgery, University Hospitals Case Medical Center, The Louis Stokes Department of Veterans Affairs Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Baha M. Arafah
- 1The Pituitary Center,
- 2Division of Clinical and Molecular Endocrinology, and
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87
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Li ZS, Wei MQ, Fu X, Cheng H, Li Q. Chordoma coexisting with Rathke's cleft cyst: Case report and literature review. Neuropathology 2011; 31:66-70. [DOI: 10.1111/j.1440-1789.2010.01125.x] [Citation(s) in RCA: 4] [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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88
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ARAI T, HORIGUCHI K, SAEKI N, OKA H, SAITO T, TAKAHASHI-FUJIGASAKI J, SAKAMOTO H, KATO N, DOBASHI H, TANAKA T, HASEGAWA Y, ABE T. Surgical Treatment of a Calcified Rathke's Cleft Cyst With Endoscopic Extended Transsphenoidal Surgery-Case Report-. Neurol Med Chir (Tokyo) 2011; 51:535-8. [DOI: 10.2176/nmc.51.535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Takao ARAI
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital
| | - Kentaro HORIGUCHI
- Department of Neurosurgery, Chiba University Graduate School of Medicine
| | - Naokatsu SAEKI
- Department of Neurosurgery, Chiba University Graduate School of Medicine
| | - Hidehiro OKA
- Department of Neurosurgery, Kitasato University School of Medicine
| | - Takatoshi SAITO
- Department of Diabetes, Metabolism and Endocrinology, Jikei University School of Medicine
| | | | - Hiroki SAKAMOTO
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital
| | - Naoki KATO
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital
| | - Hisashi DOBASHI
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital
| | - Toshihide TANAKA
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital
| | - Yuzuru HASEGAWA
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital
| | - Toshiaki ABE
- Department of Neurosurgery, Jikei University School of Medicine
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89
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Chung JO, Cho DH, Chung DJ, Chung MY. Transient thyrotoxicosis accompanied by panhypopituitarism caused by ruptured Rathke's cleft cyst. Intern Med 2011; 50:2997-3001. [PMID: 22185992 DOI: 10.2169/internalmedicine.50.5693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a rare case of transient thyrotoxicosis secondary to painless thyroiditis accompanied by panhypopituitarism caused by ruptured Rathke's cleft cyst. A 32-year-old man presented with vomiting and diarrhea. Laboratory data showed that he had transient hypercalcemia, primary thyrotoxicosis due to painless thyroiditis and panhypopituitarism. The sellar magnetic resonance imaging showed cystic macroadenoma. He underwent surgical exploration. Histological examination showed a ruptured Rathke's cleft cyst. Our case suggests that, although rare, it is important to recognize the possibility of coexistence of hypopituitarism in patients with primary thyrotoxicosis.
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Affiliation(s)
- Jin Ook Chung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, Republic of Korea
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90
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Zhou L, Luo L, Hui X, Chen H, Yu B, Guo G, You C. Primary Rathke's cleft cyst in the cerebellopontine angle associated with apoplexy. Childs Nerv Syst 2010; 26:1813-7. [PMID: 20717684 DOI: 10.1007/s00381-010-1270-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 08/05/2010] [Indexed: 02/05/2023]
Abstract
Rathke's cleft cyst (RCC) is a congenital, benign, epithelial tumor and mainly occurs in sellar region and occasionally in suprasellar region; ectopic RCC is exceedingly rare. We report an uncommon RCC in cerebellopontine angle (CPA) associated with RCC apoplexy and investigated the possible hypothesis of its origin. A 12-year-old female student was admitted to hospital for 3-month history of vertigo, headache, nausea, and vomiting and aggravated for 1 week. Magnetic resonance imaging (MRI) revealed a space-occupying lesion with short T1 and long T2 signals in the left CPA and an intracystic floating nodule with hypointensity on T1- and T2-weighted imaging. The patient underwent the total tumor removal via the retrosigmoid approach with a good recovery. Primary RCC was confirmed by pathology. Follow-up MRI showed no recurrence 3.5 years after craniotomy. Primary RCC can occur in CPA and present special neuroimaging features associated with RCC apoplexy. We presumed that a mimicking mechanism of ectopic craniopharyngioma in CPA leads to the formation in the present case. Microsurgical resection is the optimal strategy for management. Further research and longer follow-up are helpful to better understanding the pathogenesis and development history of RCC in CPA.
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Affiliation(s)
- Liangxue Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
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91
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Valassi E, Biller BMK, Klibanski A, Swearingen B. Clinical features of nonpituitary sellar lesions in a large surgical series. Clin Endocrinol (Oxf) 2010; 73:798-807. [PMID: 20874772 PMCID: PMC2982869 DOI: 10.1111/j.1365-2265.2010.03881.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Pituitary adenomas are the most common lesions in the sellar region, but other pathologies need to be considered in the differential diagnosis. OBJECTIVE To assess the prevalence of unusual sellar masses in a large series of patients and identify clinicopathological factors that may aid the pre-operative diagnosis. DESIGN Retrospective case series. PATIENTS We analysed the records of 1469 transsphenoidal procedures performed between 1998 and 2009. One hundred sixteen cases (7·9%) were not pituitary adenomas. MEASUREMENTS Final pathological diagnosis. RESULTS One hundred sixteen patients (45 men, 71 women; mean age (±SD): 45 ± 17 years) with nonadenomatous lesions were divided into four major aetiological groups: cystic lesions (CYS) (53%); benign neoplasms (BEN) (22%); malignancies (MAL) (16%) and inflammatory lesions (INF) (9%). Rathke's cysts, the most common lesions, represented 42% of all cases. Twenty-five per cent of malignant lesions were metastases, and some of the MAL (e.g., fibrosarcoma, lung metastasis) had a radiographical appearance suggestive of a pituitary adenoma. The most common presenting symptoms were visual field impairment (51%) and headache (34%). Pre-operative pituitary dysfunction was present in 58% of cases, with hyperprolactinaemia (35%), hypogonadism (23%) and hypocortisolism (23%) found most frequently. Postoperative resolution of headache and visual symptoms occurred in 63% and 65% of patients, respectively. Hyperprolactinaemia resolved in 77% of cases. CONCLUSIONS A substantial minority of sellar masses are not pituitary adenomas. While they frequently present with the symptoms, hormone abnormalities and radiographical appearance typical of pituitary tumours, the possibility of a nonadenomatous lesion needs to be considered in the differential diagnosis.
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Affiliation(s)
- Elena Valassi
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Beverly MK Biller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Brooke Swearingen
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School Boston, MA 02114, USA
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Katavetin P, Cheunsuchon P, Grant E, Boepple PA, Hedley-Whyte ET, Misra M, Levitsky LL. Rathke's cleft cysts in children and adolescents: association with female puberty. J Pediatr Endocrinol Metab 2010; 23:1175-80. [PMID: 21284332 DOI: 10.1515/jpem.2010.184] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There are few pediatric data regarding manifestations and outcomes of Rathke's cleft cysts (RCC). We retrospectively reviewed 13 cases treated at Massachusetts General Hospital over 10 years. Age at presentation was 12-17 years, except for one 7-year-old who presented with sexual precocity. There was a female preponderance [11 females, 2 males, p = 0.01], and all were pubertal at diagnosis. Common features at presentation were headaches (11/13), endocrine abnormalities (5/13) and visual disturbances (2/13). Four patients underwent transsphenoidal surgery. Symptoms improved in all but one, in whom headaches persisted. Recurrent growth in one patient was treated successfully by excision. For conservatively treated patients, cyst size was unchanged over follow-up (6 months-5 years). Female preponderance and pubertal presentation suggest a possible link between sex hormones and RCC pathogenesis. Although estrogen and progesterone receptor immunostaining was negative in the cyst lining, estrogen receptor immunostaining was positive in adjacent pituitary cells. Further investigations regarding this issue are warranted.
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Affiliation(s)
- Paravee Katavetin
- Pediatric Endocrine Unit, MassGeneral Hospital for Children and Harvard Medical School, USA
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93
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Tate MC, Jahangiri A, Blevins L, Kunwar S, Aghi MK. Infected Rathke Cleft Cysts. Neurosurgery 2010; 67:762-9; discussion 769. [DOI: 10.1227/01.neu.0000377017.53294.b5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND
Rathke cleft cysts (RCCs) are benign sellar lesions that are generally asymptomatic but sometimes warrant transsphenoidal drainage. Small case reports have described infected RCCs, but this phenomenon remains uncharacterized.
OBJECTIVE
We reviewed RCCs over 23 years at our institution to determine factors predicting infection and recurrence.
METHODS
We retrospectively reviewed the magnetic resonance images, laboratory results, microbiology, and pathology of 176 RCC patients (1985–2008) who underwent initial operation at our institution (n = 170) or at another institution followed by recurrence managed at our institution (n = 6).
RESULTS
There were 3 RCC categories: cysts cultured intraoperatively during initial surgery (n = 21), cysts not cultured during initial surgery but cultured during subsequent surgery (n = 9), and cysts that were never cultured (n = 146). Cultured cysts were larger (1.6 vs 1.2 cm; P = .002) and had more frequent pituitary dysfunction (76% vs 30%; P < .001) than noncultured cysts. Restricted diffusion was also more common in cultured cysts (50% vs 0%; P = .02). Of cysts cultured at initial or subsequent surgery, 48% and 44%, respectively, had positive cultures (n = 14) and were treated with antibiotics. The most common organisms were Staphylococcus epidermidis (64%) and Propionibacterium acnes (57%). Kaplan-Meier recurrence rates were 13% (culture positive/antibiotic treated), 31% (culture negative/not antibiotic treated), and 9% (noncultured) (P = .002, cultured vs noncultured; P = .002, culture negative/not antibiotic treated vs non-cultured; P = .5 culture positive/antibiotic treated vs noncultured).
CONCLUSION
Suspected RCC infection, regardless of culture results, is a strong predictor of recurrence and may warrant antibiotic treatment. With antibiotic treatment, the recurrence rate of infected RCC approaches that of noninfected cysts. The higher recurrence rates reported in other series may reflect underrecognition of occult infection.
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Affiliation(s)
- Matthew C. Tate
- Department of Neurosurgery, University of California at San Francisco, San Francisco, California
| | - Arman Jahangiri
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Lewis Blevins
- Department of Neurosurgery, University of California at San Francisco, San Francisco, California
| | - Sandeep Kunwar
- Department of Neurosurgery, University of California at San Francisco, San Francisco, California
| | - Manish K. Aghi
- Department of Neurosurgery, University of California at San Francisco, San Francisco, California
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94
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Chuang CC, Chen YL, Jung SM, Pai PC. A giant retroclival Rathke’s cleft cyst. J Clin Neurosci 2010; 17:1189-91. [DOI: 10.1016/j.jocn.2009.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 12/24/2009] [Accepted: 12/29/2009] [Indexed: 11/25/2022]
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95
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Madhok R, Prevedello DM, Gardner P, Carrau RL, Snyderman CH, Kassam AB. Endoscopic endonasal resection of Rathke cleft cysts: clinical outcomes and surgical nuances. J Neurosurg 2010; 112:1333-9. [PMID: 19929190 DOI: 10.3171/2009.10.jns09348] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Rathke cleft cysts (RCCs) are benign lesions that can be diagnosed as an incidental finding associated with headaches, pituitary dysfunction, or vision deterioration. Typically, they occur in a sellar or suprasellar location. The aim of this study was to review the clinical presentation and outcomes associated with endoscopic endonasal resection of these lesions. METHODS The authors retrospectively reviewed a series of 35 patients with a diagnosis of RCC after endoscopic endonasal resection at the University of Pittsburgh between January 1998 and July 2008. RESULTS All 35 patients underwent a purely endoscopic endonasal approach (EEA). The average patient age was 34 years (range 12-67 years), and the average follow-up was 19 months (range 1-60 months). Clinical follow-up data were available for 32 patients, and radiographic follow-up data were accessible for 33 patients. All of the patients underwent complete removal of the cyst contents, and according to radiography studies 2 patients had a recurrence, neither of which required reoperation. The mean cyst volume was 1052.7 mm(3) (range 114-6044 mm(3)). Headache was a presenting symptom in 26 (81.2%) of 32 patients, with 25 (96.1%) of 26 having postoperative improvement in their headaches. Fifteen (57.7%) of the 26 patients had complete pain resolution, and 10 (38.5%) had a > 50% reduction in their pain scores. Six (18.8%) of 32 patients initially presented with pituitary dysfunction, although 2 (33.3%) had postoperative improvement. Three (9.4%) of 32 patients had temporary pituitary dysfunction postoperatively, although there was no permanent pituitary dysfunction. Neither were there any intraoperative complications, postoperative CSF leaks, or new neurological deficits. The average hospital stay was 1.8 days (range 1-5 days). CONCLUSIONS The EEA is a safe and effective approach in the treatment of RCCs. None of the patients in this study experienced any worsening of their preoperative symptoms or pituitary function, and 96% of the patients who had presented with headache experienced complete or significant pain relief following treatment.
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Affiliation(s)
- Ricky Madhok
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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96
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Amhaz HH, Chamoun RB, Waguespack SG, Shah K, McCutcheon IE. Spontaneous involution of Rathke cleft cysts: is it rare or just underreported? J Neurosurg 2010; 112:1327-32. [DOI: 10.3171/2009.10.jns091070] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Rathke cleft cysts (RCCs) are benign cystic lesions of the sella that arise from the remnants of Rathke pouch. Although most are asymptomatic, symptoms can result from mass effect and commonly include headache, endocrinopathy, or visual field disturbance. Although asymptomatic patients undergo conservative treatment, patients with symptoms are typically treated surgically. The authors report 9 patients with symptomatic cystic sellar lesions and imaging characteristics consistent with an RCC; in all cases there was spontaneous involution of the lesions, and in 5 of 7 patients presenting with headache the symptom resolved. Spontaneous involution of an RCC may be more common than the paucity of prior reports would suggest, especially because the natural history of both symptomatic and asymptomatic RCCs is poorly understood. The potential for spontaneous involution, together with the clinical course of the patients reported here, supports a conservative approach for patients with symptomatic RCCs presenting solely with headache.
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Affiliation(s)
| | | | | | - Komal Shah
- 3Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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97
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Zada G, Lin N, Ojerholm E, Ramkissoon S, Laws ER. Craniopharyngioma and other cystic epithelial lesions of the sellar region: a review of clinical, imaging, and histopathological relationships. Neurosurg Focus 2010; 28:E4. [PMID: 20367361 DOI: 10.3171/2010.2.focus09318] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Cystic epithelial masses of the sellar and parasellar region may be difficult to differentiate on a clinical, imaging, or even histopathological basis. The authors review the developmental relationships and differentiating features of various epithelial lesions of the sellar region.
Methods
The authors performed a review of the literature to identify previous studies describing the etiological relationships and differentiating features of various cystic sellar lesions, including craniopharyngioma (CP), Rathke cleft cyst, xanthogranuloma, and dermoid and epidermoid cysts.
Results
There is significant evidence in the literature to support a common ectodermal origin of selected sellar and suprasellar cystic lesions, which may account for the overlap of features and transitional states observed in some cases. Research obtained from animal studies and reports of transitional cystic epithelial masses or lesions crossing over from typical to more aggressive pathological subtypes have collectively provided a solid foundation for this theory. Histological features that signify transitional entities beyond simple benign Rathke cleft cysts include squamous metaplasia, stratified squamous epithelium, and ciliated or mucinous goblet cells in squamous-papillary CPs. Several studies have identified key clinical, imaging, and histopathological features that can be used in the differentiation of these lesions.
Conclusions
The pattern of embryological formation of the hypothalamic-pituitary axis plays a major role in its propensity for developing cystic epithelial lesions. Subsequent inflammatory, metaplastic, and neoplastic processes may promote further progression along the pathological continuum, ranging from benign epithelial cysts to aggressive neoplastic cystic CPs. Selected clinical, imaging, and histopathological features can be used collectively to help differentiate these lesions and assign a formal diagnosis, thus accurately guiding further treatment.
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Affiliation(s)
| | - Ning Lin
- 1Departments of Neurosurgery and
| | | | - Shakti Ramkissoon
- 2Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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99
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Gutenberg A, Landek-Salgado M, Tzou SC, Lupi I, Geis A, Kimura H, Caturegli P. Autoimmune hypophysitis: expanding the differential diagnosis to CTLA-4 blockade. Expert Rev Endocrinol Metab 2009; 4:681-698. [PMID: 30780785 DOI: 10.1586/eem.09.37] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Autoimmune hypophysitis is an increasingly recognized disorder that enters in the differential diagnosis of nonfunctioning pituitary masses. The differential diagnosis of these conditions is challenging because of similar clinical presentations and radiological signs. This review describes the essential features of hypophysitis and the other nonfunctioning pituitary masses. It also emphasizes a recently described feature of hypophysitis: its appearance with unexpectedly high frequency in patients receiving treatments that abrogate the function of cytotoxic T lymphocyte antigen 4.
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Affiliation(s)
- Angelika Gutenberg
- a Department of Neurosurgery, Georg-August University, Goettingen, Germany.
| | - Melissa Landek-Salgado
- b Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Shey-Cherng Tzou
- c Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Isabella Lupi
- d Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | - Abby Geis
- e Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Hiroaki Kimura
- f Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Patrizio Caturegli
- g Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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100
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Treatment of Rathke’s cleft cysts: Experience at a single centre. J Clin Neurosci 2009; 16:900-3. [PMID: 19362483 DOI: 10.1016/j.jocn.2008.10.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 10/08/2008] [Accepted: 10/09/2008] [Indexed: 11/24/2022]
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