High prevalence of adrenal insufficiency at diagnosis and headache recovery in surgically resected Rathke's cleft cysts-a large retrospective single center study

Hypopituitarism

Partial or complete deficiency of anterior or posterior pituitary hormone production leads to central hypoadrenalism, central hypothyroidism, hypogonadotropic hypogonadism, growth hormone deficiency, or arginine vasopressin deficiency depending on the hormones affected. Hypopituitarism is rare and likely to be underdiagnosed, with an unknown but rising incidence and prevalence. The most common cause is compressive growth or ablation of a pituitary or hypothalamic mass. Less common causes include genetic mutations, hypophysitis (especially in the context of cancer immunotherapy), infiltrative and infectious disease, and traumatic brain injury. Clinical features vary with timing of onset, cause, and number of pituitary axes disrupted. Diagnosis requires measurement of basal circulating hormone concentrations and confirmatory hormone stimulation testing as needed. Treatment is aimed at replacement of deficient hormones. Increased mortality might persist despite treatment, particularly in younger patients, females, and those with arginine vasopressin deficiency. Patients with complex diagnoses, pregnant patients, and adolescent pituitary-deficient patients transitioning to adulthood should ideally be managed at a pituitary tumour centre of excellence.

Endoscopic endonasal surgery of Rathke's cleft cysts-- preoperative imaging evaluation, personalized removal and multilevel sellar floor reconstruction

OBJECTIVES

The purpose of this study was to evaluate the effectiveness of endoscopic endonasal surgery (EES) for Rathke's cleft cysts (RCCs) and the advantages of detailed preoperative imaging evaluation, intraoperative personalized removal and multilevel sellar floor reconstruction.

METHODS

The clinical data of 43 patients with RCCs who were treated by EES in the neurosurgery department of affiliated hospital of Jiangnan University and Wuxi No.2 People's Hospital from January 2018 to January 2023 were retrospectively analyzed. The effectiveness of EES for RCCs was analyzed by imaging information, surgical procedures, symptom improvement and complications.

RESULTS

All 43 RCCs were completely removed by EES, and all clinical symptoms improved to varying degrees. Postoperative relief of headache was achieved in 23 out of 26 patients (88.5 %); there was improvement in 10 out of 13 patients with visual field disorders (76.9 %) and in 8 out of 10 patients with endocrine abnormalities (80 %). New hormonal deficiency was discovered in 7 of all the patients postoperatively. There were 8 patients with postoperative diabetes insipidus and 1 patient with cerebrospinal fluid leakage. The incidence of new hormonal dysfunction and postoperative DI in expanded EES (33.3 %, 33.3 %) was higher than it in conventional EES (4 %, 8 %) (P < 0.05). The average follow-up time was 29.1 ± 14.8 months, and there were no deaths or infections. Three patients presented with cyst recurrence on MRI.

CONCLUSIONS

The clinical manifestations and imaging characteristics of RCCs are variable, and a detailed preoperative review of the imaging is helpful for the development of surgical plans. RCCs can be treated more safely and thoroughly with less trauma and complications by intraoperative personalized removal and multilevel sellar floor reconstruction. The high incidence of new hormonal dysfunction and postoperative DI may be related to the disturbance of the pituitary stalk. EES has unique advantages and high clinical application value for the treatment of RCCs.

Symptoms at presentation in conservatively managed patients with non-functioning pituitary adenomas

PURPOSE

Hypopituitarism and tumor growth are rare in patients with non-functioning pituitary microadenomas (NFPmA). However, patients often present with non-specific symptoms. The aim of this brief report is to examine presenting symptomatology in patients with NFPmA compared to patients with non-functioning pituitary macroadenomas (NFPMA).

METHODS

We performed a retrospective review of 400 patients (347 NFPmA and 53 NFPMA) who were conservatively managed; no patients had indications for urgent surgical intervention.

RESULTS

Average tumor size was 4.5 ± 1.9 and 15.5 ± 5.5 mm for NFPmA and NFPMA, respectively (p < 0.001). At least one pituitary deficiency was present in 7.5% of patients with NFPmA and 25% of patients with NFPMA. Patients with NFPmA were younger (41.6 ± 15.3 vs. 54.4 ± 22.3 years, p < 0.001) and more commonly female (64.6 vs. 49.1%, p = 0.028). There was no significant difference reported for similarly high rates of fatigue (78.4% and 73.6%), headache (70% and 67.9%), and blurry vision (46.7% and 39.6%). There were no significant differences in comorbidities.

CONCLUSION

Despite smaller size and lower rate of hypopituitarism, patients with NFPmA presented with a high prevalence of headache, fatigue, and visual symptoms. This was not significantly different from patients with NFPMA who were conservatively managed. We conclude that symptoms of NFPmA cannot fully be attributed to pituitary dysfunction or mass effect.

Incidence and factors associated with the recurrence of Rathke's cleft cyst after surgery: A systematic review and meta-analysis

Backgroud

Recurrence of Rathke's cleft cyst (RCC) is not uncommon after surgery, and the associated factors and incidence of relapse deserve a systematic summary.

Methods

This study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The Pubmed, Embase, Cochrane, and Web of Science databases were searched until September 12, 2022. Studies with significant results of recurrent factors or specific incidences of RCC recurrence and mean/median follow-up time were included. Based on a protocol of a 2-year interval grouping, included studies were categorized into four groups with follow-up periods  <24 months, 24-48 months, 48-72 months, and ≥72 months, respectively. Quality assessment was performed using the NOS score. Pooled estimations were computed by using a random-effects model in the STATA "metaprop" command. Publication bias was assessed visually through a funnel plot and statistically through Egger's linear regression test and Begg's correlation test.

Results

A total of 44 studies were included containing 2,539 cases. Squamous metaplasia was the most commonly reported factor, followed by the extent of cyst removal. The other factors were reported individually. The pooled overall incidences of RCC recurrence after surgery in four groups of the follow-up period were 7.4% (95%CI = 4.1-11.3%) in <24 months, 13.1% (95%CI = 9.7-17.0%) in 24-48 months, 13.7% (95%CI = 7.7-21.0%) in 48-72 months, and 33.8% (95%CI = 19.6-49.6%) in ≥72 months. The pooled symptomatic incidences were 2.3% (95%CI = 0.4-5.1%) in <24 months, 5.6% (95%CI = 3.6-7.9%) in 24-48 months, 5.9% (95%CI = 2.4-10.6%) in 48-72 months, and 14.1% (95%CI = 6.0-24.5%) in ≥72 months. A dramatic increase in recurrent incidence was observed when the follow-up period was more than 72 months in both overall and symptomatic recurrence. A similar trend of recurrence was found in subgroup analyses stratified by publication year, cohort size, and cyst resection strategy.

Conclusion

This study systematically reviewed recurrent factors and described the profile of trends in RCC recurrent incidence after surgery with a follow-up time based on a protocol of a 2-year interval, finding a dramatic increase in recurrent rates with a follow-up period of more than 72 months. This encouraged us to put forward a recommendation of at least a 6-year follow-up after surgery for patients with RCC.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021278970.

Incidence and risk factors of delayed postoperative hyponatremia after endoscopic endonasal surgery for Rathke’s cleft cyst: A single-center study

Backgroud

Delayed postoperative hyponatremia (DPH) is common for sellar lesions. However, the true prevalence and associated factors of DPH after endoscopic endonasal surgery (EES) for Rathke’s cleft cyst (RCC) have not been studied in a large patient cohort.

Methods

A retrospective analysis was conducted over 6 years at our institution, and patients with RCC treated by EES were enrolled according to our inclusion criteria. Patient demographics, clinical characteristics, images, and surgical procedures were documented. Serum sodium was routinely measured before surgery, on postoperative day 1, and every 2 days thereafter until discharge. For patients with DPH, electrolyte, hematocrit, serum protein levels, and plasma and urinary osmolality were daily measured to explore potential etiology.

Results

Of the 149 eligible patients, 25 (16.8%) developed DPH, which was similar to other sellar lesions, except craniopharyngioma, in the same period in our institution. Significant risk factors suggested by univariate analysis were cyst location, requirement of postoperative hydrocortisone therapy, postoperative meningitis, intraoperative cerebrospinal fluid (CSF) leakage, and subtotal resection (STR) of the cyst wall (all p &lt; 0.05). In addition, other supplementary 11 cases of suprasellar RCC with different surgical strategies (aggressive resection) and relevant factors were enrolled into multivariate analysis. Suprasellar location [odds ratio (OR) 8.387, 95% confidence interval (CI) 1.014–69.365, p = 0.049], requirement of postoperative hydrocortisone therapy (OR 4.208, 95%CI 1.246–14.209, p = 0.021), and intraoperative CSF leakage (OR 6.631, 95%CI 1.728–25.440, p = 0.006) were found to be the independent predictors of DPH.

Conclusion

DPH is a common complication after EES for RCC. Suprasellar location, requirement of postoperative hydrocortisone therapy, and intraoperative CSF leakage are the most reliable risk factors. Cortisol deficiency and syndrome of inappropriate antidiuretic hormone (SIADH) are considered as the main etiologies of DPH in RCC. Conservative excision of the cyst wall may reduce DPH occurrence.

A study on clinical outcomes of Rathke's cleft cyst in patients managed conservatively

OBJECTIVES

The primary objective was to investigate the clinical presentation, hormonal dysfunction, imaging characteristics and natural history of RCCs that were managed conservatively. Secondary objective was to identify factors associated with cyst progression.

METHODS

A retrospective review of patients with the clinical diagnosis of RCC-identified from word search from radiology reports that were followed up from January 1999 to March 2019 was performed. The demographics, clinical data, radiological features and outcomes were reviewed and analyzed.

RESULTS

105 patients were identified with a median follow up of 6 years. 68 patients (64.8%) were managed conservatively from diagnosis till last follow up while 37 patients (35.2%) underwent surgery, with 26 operated at time of diagnosis and 11 operated upon monitoring. For patients managed conservatively from diagnosis till last follow up, incidental finding was the most common presentation. 19.1% had either one or more axes of hormonal dysfunction, with hypogonadism and hypocortisolemia being the commonest ones. Imaging features were variable. 66.2% of patients had T2W hyperintensity on MRI. Pathognomonic feature of intracystic nodule was present in only 14.7% of patients. Among the 79 patients with repeated MRI imaging (68 from conservative group and 11 from surgical group), 32.9% of patients developed cyst progression while 67.1% had either static disease or regression in size of RCC. Median time to progression of cyst was 14 months. Longer median follow up duration and presence of pituitary stalk displacement at presentation were associated with cyst progression. Only one patient developed new endocrine dysfunction.

CONCLUSION

2/3 of the RCCs had static disease or even regression in the size of the cyst. They rarely gave rise to additional endocrine dysfunction by adopting observant approach. Cyst progression was demonstrated in 1/3 of patients. Conservative treatment remained a reasonable treatment for patients without significant symptoms.

Nonfunctioning Pituitary Microadenomas: Should Imaging Interval be Extended? A Large Single-center Cohort Study

CONTEXT

Characterization of the clinical features and natural history of nonfunctioning pituitary microadenomas (NFPmAs) is limited by heterogeneous and small-scale studies.

OBJECTIVE

To characterize the clinical presentation and natural history of NFPmAs and evaluate if imaging follow-up interval can be extended.

METHODS

Retrospective single-center cohort study (years 2006-2021) of conservatively managed patients with NFPmAs. Initial symptoms, pituitary function, and tumor size were assessed. A change in NFPmA size ≥2 mm, as determined by pituitary or brain magnetic resonance imaging (MRI), was considered significant.

RESULTS

There were 347 patients in the study cohort. Headache (78.4%) and fatigue (70.0%) were commonly reported despite no evidence of mass effect or significant pituitary hypofunction. Pituitary deficiencies at baseline were rare, with hypogonadism being most common (5.1%). During a median imaging follow-up period of 29 months (range 3-154), 8.1% of NFPmAs grew. Growth incidence was 2.1 per 100 person-years with a mean and median time to growth of 38.1 (SD ± 36.4) and 24.5 (interquartile range 12.0-70.8) months, respectively. Tumor growth was mild and not associated with new pituitary deficiencies or visual deficits.

CONCLUSION

These data indicate that the natural history of NFPmAs is overall benign. Consequently, we propose that the initial MRI follow-up timeline for NFPmAs can be extended up to 3 years unless a lesion is close to the optic chiasm, there are worrisome mass effect symptoms, or new pituitary deficiencies.

Hypophysitis, the Growing Spectrum of a Rare Pituitary Disease

Hypophysitis is defined as inflammation of the pituitary gland that is primary or secondary to a local or systemic process. Differential diagnosis is broad (including primary tumors, metastases, and lympho-proliferative diseases) and multifaceted. Patients with hypophysitis typically present with headaches, some degree of anterior and/or posterior pituitary dysfunction, and enlargement of pituitary gland and/or stalk, as determined by imaging. Most hypophysitis causes are autoimmune, but other etiologies include inflammation secondary to sellar tumors or cysts, systemic diseases, and infection or drug-induced causes. Novel pathologies such as immunoglobulin G4-related hypophysitis, immunotherapy-induced hypophysitis, and paraneoplastic pituitary-directed autoimmunity are also included in a growing spectrum of this rare pituitary disease. Typical magnetic resonance imaging reveals stalk thickening and homogenous enlargement of the pituitary gland; however, imaging is not always specific. Diagnosis can be challenging, and ultimately, only a pituitary biopsy can confirm hypophysitis type and rule out other etiologies. A presumptive diagnosis can be made often without biopsy. Detailed history and clinical examination are essential, notably for signs of underlying etiology with systemic manifestations. Hormone replacement and, in selected cases, careful observation is advised with imaging follow-up. High-dose glucocorticoids are initiated mainly to help reduce mass effect. A response may be observed in all auto-immune etiologies, as well as in lymphoproliferative diseases, and, as such, should not be used for differential diagnosis. Surgery may be necessary in some cases to relieve mass effect and allow a definite diagnosis. Immunosuppressive therapy and radiation are sometimes also necessary in resistant cases.

What to Do with Incidentally Discovered Pituitary Abnormalities?

Pituitary incidentalomas are discovered in approximately 10% to 40% of brain images. A complete patient history, physical examination, and dedicated pituitary function testing are needed, and subsequent results should lead to appropriate patient management. However, most lesions are asymptomatic pituitary adenomas or Rathke cleft cysts with a benign course. Many lesions can be clinically significant, including prolactinomas or other pituitary adenomas that warrant specific pituitary disease treatment. In other cases, mass effect causing visual compromise or refractory headache indicates a need for surgery. Here, various facets of a complex evaluation and treatment algorithm for pituitary incidentalomas are reviewed.

Anterior pituitary function in Rathke's cleft cysts versus nonfunctioning pituitary adenomas

Although Rathke's cleft cysts (RCCs) are common sellar/parasellar lesions, studies examining pituitary function in patients with nonsurgical RCC are limited. This study aimed to clarify the importance of RCCs, including small nonsurgical ones, as a cause of hypopituitarism by determining the prevalence of pituitary hormone secretion impairment and its relationship to cyst/tumor size in patients with RCC and in those with nonfunctioning pituitary adenoma (NFA). We retrospectively investigated the basal levels of each anterior pituitary hormone, its responses in the stimulation test(s), and cyst/tumor size in patients with RCC (n = 67) and NFA (n = 111) who were consecutively admitted to our hospital for endocrinological evaluation. RCCs were much smaller than NFAs (median height, 12 vs. 26 mm). The prevalence of gonadotropin, PRL, and GH secretion impairment in RCC was lower in comparison to NFA (19% vs. 44%, 34% vs. 61%, and 24% vs. 46%, respectively), whereas the prevalence of TSH and ACTH secretion impairment was comparable (21-27% and 17-24%, respectively). A significant positive relationship between cyst/tumor size and number of impaired hormones was observed in both groups, but smaller cysts could cause hormone secretion impairment in RCC. Stimulation tests suggested that most hormone secretion impairment was attributable to the interrupted hypothalamic-pituitary axis in both groups. Therefore, RCC, even small ones, can cause pituitary dysfunction. Different mechanisms may underlie hypothalamic-pituitary interruption in RCC and NFA.

Recurrence of Rathke's cleft cysts based on gross total resection of cyst wall: a meta-analysis

Rathke's cleft cysts (RCCs) are benign growths of the embryological Rathke's pouch. Surgical decompression provides effective symptomatic relief in most cases; however, the effect of gross total resection (GTR) of the cyst wall on recurrence, as well as pituitary function, is unclear. The aim of this meta-analysis was to pool the current literature and ascertain the recurrence control afforded by GTR of the cyst wall compared with subtotal resection (STR). Searches of seven electronic databases from inception to January 2019 were conducted following PRISMA guidelines, resulting in 476 articles to be screened. Outcomes were analyzed using meta-analysis of proportions. A total of 10 retrospective cohort studies satisfied selection criteria, describing 655 surgically managed RCC cases, with 254 (39%) and 401 (61%) achieving GTR and STR of the cyst wall, respectively. GTR was associated with significantly reduced overall RCC recurrence by fixed-effects (FE) modeling (RR, 0.66; 95% CI, 0.45-0.96), but not by random effects (RE) modeling (RR, 0.75; 95% CI, 0.51-1.12). Based on both models, GTR was associated with significantly reduced symptomatic recurrence (RE model, RR, 0.37, 95% CI, 0.14-0.95) and significantly increased postoperative diabetes insipidus (RE model, RR, 2.60; 95% CI, 1.34-5.03). There was insufficient data to evaluate other pituitary axes in this context. The current evidence indicates that GTR of the RCC cyst wall has the potential to affect the incidence of overall and symptomatic RCC recurrences, as well as drive postoperative DI incidence. However, expectations of clinical and pragmatic benefit following cyst wall resection should be titrated carefully against the potential for postoperative and pituitary morbidities which currently remain poorly defined. Greater granularity is required to understand all factors that can influence recurrence and quality of life when evaluating resection of RCC.