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Brandel MG, Lin C, Rennert RC, Plonsker JH, Khan UA, Crawford JR, Nation J, Levy ML. Surgical management of Rathke cleft cysts in pediatric patients: a single institution experience. Childs Nerv Syst 2024; 40:1367-1375. [PMID: 38240786 PMCID: PMC11026193 DOI: 10.1007/s00381-024-06277-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/03/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Rathke cleft cysts (RCCs) are benign, epithelial-lined sellar lesions that arise from remnants of the craniopharyngeal duct. Due to their rarity in the pediatric population, data are limited regarding the natural history and optimal management of growing or symptomatic RCCs. We present our institutional experience with the surgical management of RCCs. METHODS We performed a retrospective study of consecutive RCC patients ≤ 18 years old treated surgically at our institution between 2006 and 2022. RESULTS Overall, 567 patients with a diagnosis of pituitary mass or cyst were identified. Of these, 31 had a histopathological diagnosis of RCC, 58% female and 42% male. The mean age was 13.2 ± 4.2 years. Presenting symptoms included headache (58%), visual changes (32%), and endocrinopathies or growth delay (26%); 13% were identified incidentally and subsequently demonstrated growth on serial imaging. Six percent presented with symptomatic intralesional hemorrhage. Surgical approach was transsphenoidal for 90% of patients and orbitozygomatic for 10%. Preoperative headaches resolved in 61% of patients and preoperative visual deficits improvement in 55% after surgery. New pituitary axis deficits were seen in 9.7% of patients. Only two complications occurred from a first-time surgery: one cerebrospinal fluid leak requiring lumbar drain placement, and one case of epistaxis requiring cauterization. No patients experienced new visual or neurological deficits. Patients were followed postoperatively with serial imaging at a mean follow-up was 62.9 ± 58.4 months. Recurrence requiring reoperation occurred in 32% of patients. Five-year progression-free survival was 47.9%. Except for one patient with multiple neurological deficits from a concurrent tectal glioma, all patients had a modified Rankin Scale score of 0 or 1 (good outcome) at last follow-up. CONCLUSION Due to their secretory epithelium, pediatric RCCs may demonstrate rapid growth and can cause symptoms due to local mass effect. Surgical management of symptomatic or growing pediatric RCCs via cyst fenestration or partial resection of the cyst wall can be performed safely, with good neurologic outcomes. There is a nontrivial risk of endocrinologic injury, and long-term follow up is needed due to high recurrence rates.
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Affiliation(s)
- Michael G Brandel
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Christine Lin
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, 84112, USA
| | - Jillian H Plonsker
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Usman A Khan
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - John R Crawford
- Division of Child Neurology and Neurosciences Institute, Children's Hospital of Orange County and University of California Irvine, Orange, CA, 92868, USA
- Division of Neurology, Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Javan Nation
- Department of Otolaryngology, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, San Diego-Rady Children's Hospital, San Diego, CA, 92123, USA.
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Guan H, Zhang Y, Wang X. Rathke's cleft cyst apoplexy in a boy treated by endoscopic endonasal surgery: case report and literature review. Neurochirurgie 2024; 70:101540. [PMID: 38354572 DOI: 10.1016/j.neuchi.2024.101540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/28/2023] [Accepted: 01/24/2024] [Indexed: 02/16/2024]
Abstract
Rathke's cleft cyst (RCC) apoplexy is an uncommon lesion attributed to abnormal vascular supply to the fragile RCC epithelial wall. It is rare in children and very difficult to diagnose without pathologic confirmation. Here, we report an 8-year-old boy who presented with headache and visual deficit. MRI and CT showed a cystic mass in the sellar region. He underwent endoscopic endonasal surgery, and the cystic mass was resected completely via a trans-sphenoidal approach. The lesion was confirmed as RCC apoplexy by intraoperative observation and histopathological examination. Headache was completely relieved and the visual field deficit improved remarkably after the operation. The authors recommend surgical management for pediatric RCC apoplexy patients who present with severe neuro-ophthalmic signs or deterioration of consciousness, although there are at present no standardized management guidelines for pediatric RCC apoplexy.
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Affiliation(s)
- Hongpeng Guan
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Zhang
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Pathology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuhui Wang
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Neurosurgery, Chongming Hospital Affiliated to Shanghai University of Medicine and Health Sciences, Shanghai, China.
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Kim G, Moon JH, Kim SH, Kim EH. MRI-Based Classification of Rathke's Cleft Cyst and Its Clinical Implication. Brain Tumor Res Treat 2023; 11:59-65. [PMID: 36762809 PMCID: PMC9911707 DOI: 10.14791/btrt.2022.0036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/28/2022] [Accepted: 01/02/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Rathke's cleft cysts (RCCs) are benign tumors of the pituitary gland. Small, asymptomatic RCCs do not require surgical treatment, whereas surgical treatment is required for symptomatic RCCs. METHODS We retrospectively reviewed medical records of patients with an RCC who were diagnosed and managed in our institution between April 2004 and April 2020 and generated two different cohorts: the observation (n=114) and the surgical group (n=99). Their initial MRI signal characteristics were analyzed. The natural course focusing on cyst size was observed in the observation group and postoperative visual and endocrine outcomes were evaluated in the surgical group. RESULTS The characterization of MRI signals of cyst contents in both T1-weighted (T1W) and T2-weighted (T2W) images revealed nine combinations for our 213 patients. Among 115 patients with a high T2W signal, the cysts showed hypo-, iso-, and hyper-intensity on T1W images in 72, 39, and 44 patients, respectively; Type S-low, Type S-iso, and Type S-high. One more major group of 35 patients showed RCCs with hyperintensity on the T1W images and hypointensity on the T2W images named as Type M. In the comparison between observation and surgical groups, we identified only two major groups in which the number of patients in the surgical and observation groups was statistically different: more Type S-low in a surgical group (p<0.001) and more Type M in an observation group (p=0.007). In subgroup analysis, the range of change in the cyst size was the highest in Type S-high in the observation group (p=0.028), and intergroup differences in visual and endocrine outcomes were not evident in the surgical group. CONCLUSION MRI characteristics help to predict the natural course of RCCs. We identified subgroups of RCCs which are more or less likely to require surgical intervention.
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Affiliation(s)
- Ginam Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ju Hyung Moon
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Pituitary Tumor Center, Severance Hospital, Seoul, Korea.,Yonsei Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Ho Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Ewha Woman’s University College of Medicine, Seoul, Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Pituitary Tumor Center, Severance Hospital, Seoul, Korea.,Yonsei Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Giraldi E, Allen JW, Ioachimescu AG. Pituitary Incidentalomas: Best Practices and Looking Ahead. Endocr Pract 2023; 29:60-68. [PMID: 36270609 DOI: 10.1016/j.eprac.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/30/2022] [Accepted: 10/11/2022] [Indexed: 01/11/2023]
Abstract
Pituitary Incidentalomas (PI) are pituitary lesions serendipitously identified on imaging. PIs have become common in clinical practice because of increased use of imaging and radiologic advances. The most frequently incidentally detected lesions in adults are pituitary adenomas, followed by cystic lesions, and rarely other types of tumors and infiltrative and inflammatory disorders. Biochemical screening for hyperprolactinemia and acromegaly is needed in all patients with PI, whereas testing for hyposecretion is recommended for lesions larger than 6.0 mm. Most PIs are small nonfunctioning adenomas or cysts, which can be conservatively managed. For larger lesions, a multidisciplinary approach including endocrinology, neurosurgery, and neuro-ophthalmology is required. For incidentally detected lactotroph, somatotroph, and corticotroph adenomas, disease-specific management guidelines apply. Prospective studies are needed to enhance our understanding of the long-term course and response to treatment.
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Affiliation(s)
- Erica Giraldi
- Department of Medicine (Endocrinology), Emory University School of Medicine, Atlanta, Georgia; Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jason W Allen
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Adriana G Ioachimescu
- Department of Medicine (Endocrinology), Emory University School of Medicine, Atlanta, Georgia; Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.
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Kinoshita Y, Taguchi A, Yamasaki F, Tominaga A, Arita K, Horie N. Natural course of Rathke's cleft cysts and risk factors for progression. J Neurosurg 2022; 138:1426-1432. [PMID: 36057119 DOI: 10.3171/2022.7.jns22716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rathke's cleft cysts (RCCs) are relatively common and often detected incidentally. They are usually asymptomatic and managed conservatively. However, little is known about their natural history. Thus, the authors aimed to examine the natural course of RCCs and identify the risk factors for their progression. METHODS This retrospective study examined 229 patients (median age 43.0 years) diagnosed with RCCs by MRI and followed up without surgery (median period 36.6 months). The median cyst height on the initial MRI was 10 mm. Progression or regression of RCC was defined as cyst height changes of ≥ 1 mm. RESULTS In total, 23 (10.0%) RCCs progressed, whereas 73 (31.9%) RCCs spontaneously regressed. The remaining 133 were noted to be stable throughout the follow-up period. Patients with progressed RCCs were significantly older than those with stable RCCs. In patients with acute headache as an initial symptom, RCCs were significantly more likely to spontaneously regress. New symptoms occurred in 6 patients, 5 of whom underwent surgery for RCC progression. Of these 6 patients, 1 patient had persistent adrenocorticotropic hormone deficiency and 1 patient developed diabetes insipidus. Kaplan-Meier analysis results showed RCC progression and new symptom development rates to be 12.0% and 4.1% at 5 years and 13.7% and 5.7% at 10 years, respectively. CONCLUSIONS RCCs rarely progress or cause new symptoms in the long term. Patients with asymptomatic RCC should be followed up for at least 5 years to ensure RCC inactivity. RCCs in older adults may require greater surveillance.
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Affiliation(s)
- Yasuyuki Kinoshita
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima
| | - Akira Taguchi
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima
| | - Fumiyuki Yamasaki
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima
| | - Atsushi Tominaga
- 2Department of Neurosurgery and Neuro-Endovascular Therapy, Hiroshima Prefectural Hospital, Hiroshima; and
| | - Kazunori Arita
- 3Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Nobutaka Horie
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima
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Gobara A, Katsube T, Asou H, Yoshida R, Yoshizako T, Kitagaki H. T2 hypointense signal discovered incidentally at the posterior edge of the adenohypophysis on MRI: its prevalence and morphology and their relationship to age. Neuroradiology 2022; 64:1755-1761. [PMID: 35357532 DOI: 10.1007/s00234-022-02935-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE T2 hypointense signal at the posterior edge of the adenohypophysis (T2HSPA) on magnetic resonance imaging (MRI) is incidentally encountered. We aimed to investigate the prevalence and morphology of T2HSPA and their relationship to age. METHODS A total of 212 cases between 3 and 88 years old were examined. Sagittal T2-weighted image (T2WI) was evaluated for the presence of T2HSPA, which classified by its morphology into two types (belt-like or nodal). The Wilcoxon rank sum test and chi-square test were used to evaluate the differences between the groups. The T2HSPA was extracted by ImageJ software and measured as a cross-sectional area (CSA) quantitatively by threshold setting. We examined the relationship between CSA of T2HSPA and age, and Spearman's correlation coefficients were used for statistical analysis. RESULTS Of the 212 cases, 80 (37.7%) were identified with T2HSPA. The groups with T2HSPA were significantly younger than the groups without it (p = .01). Groups with belt-like T2HSPA were significantly younger than the groups with nodal T2HSPA (p = .01). There was a weak negative correlation between CSA of T2HSPA and age (p = .02). CONCLUSION T2HSPAs were incidentally detected in 37.7% of all cases, tended to be more common in younger cases, and their morphology was related to age. They seem to have little clinical significance as they tend to decrease in size with age.
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Affiliation(s)
- Aiko Gobara
- Department of Radiology, Shimane University Faculty of Medicine, 89-1 Enyacho, P.O. Box 00693-8501, Izumo, Japan.
| | - Takashi Katsube
- Department of Radiology, Shimane University Faculty of Medicine, 89-1 Enyacho, P.O. Box 00693-8501, Izumo, Japan
| | - Hiroya Asou
- Department of Radiology, Shimane University Faculty of Medicine, 89-1 Enyacho, P.O. Box 00693-8501, Izumo, Japan
| | - Rika Yoshida
- Department of Radiology, Shimane University Faculty of Medicine, 89-1 Enyacho, P.O. Box 00693-8501, Izumo, Japan
| | - Takeshi Yoshizako
- Department of Radiology, Shimane University Faculty of Medicine, 89-1 Enyacho, P.O. Box 00693-8501, Izumo, Japan
| | - Hajime Kitagaki
- Department of Radiology, Shimane University Faculty of Medicine, 89-1 Enyacho, P.O. Box 00693-8501, Izumo, Japan
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Sbardella E, Puliani G, Feola T, Pofi R, Pirchio R, Sesti F, Verdecchia F, Gianfrilli D, Moffat D, Isidori AM, Grossman AB. A clinical approach to parasellar lesions in the transition age. J Neuroendocrinol 2021; 33:e12995. [PMID: 34138496 DOI: 10.1111/jne.12995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/23/2021] [Accepted: 05/11/2021] [Indexed: 12/16/2022]
Abstract
Many reviews have summarised the pathology and management of the parasellar region in adult patients, although an analysis of these aspects in the transition years, from puberty onset to the age of peak bone mass, has been lacking. A comprehensive search of English-language original articles, published from 2000 to 2020, was conducted in the MEDLINE database (December 2019 to March 2020). We selected all studies regarding epidemiology, diagnosis and management of the following parasellar lesions: germinoma, craniopharyngioma, Langerhans cell histiocytosis, optic glioma, hypothalamic hamartoma, tuber cinereum hamartoma, cranial chordoma, Rathke cleft cyst, hypophysitis and hypothalamitis during the transition age from childhood to adulthood. In the present review, we provide an overview of the principal parasellar lesions occurring in the transition age. Symptoms are usually a result of the mass effect of the lesions on nearby structures, as well as anterior pituitary deficits. Diabetes insipidus occurs frequently in these patients. In this age group, pubertal developmental disorders may be more evident compared to other stages of life. Parasellar lesions in the transition age mostly include neoplastic lesions such as germinomas, hamartomas, optic gliomas, craniopharyngiomas Langerhans cell histiocytosis and chordomas, and rarely inflammatory lesions (hypophysitis, hypothalamitis). There are limited data on the management of parasellar lesions in the transition age. Endocrine evaluation is crucial for identifying conditions that require hormonal treatment so that they can be treated early to improve the quality of life of the individual patient in this complex age range. The clinical approach to parasellar lesions involves a multidisciplinary effort.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Tiziana Feola
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Franz Sesti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Federica Verdecchia
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesù Children Hospital, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Daniel Moffat
- Department of Neurosurgery, Barts and the London NHS Trust, London, UK
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
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