Diagnosis of concomitant pituitary adenoma and Rathke's cleft cyst with magnetic resonance imaging

Proton Magnetic Resonance Spectroscopy Characterization of Rathke's Cleft Cysts (RCCs): Relevance to the Differential Diagnosis of Pituitary Adenomas and RCCs

BACKGROUND

Rathke's Cleft Cysts (RCCs) are rare epithelial cysts arising from remnants of the Rathke pouch in the pituitary gland. A subset of these lesions enlarge and produce a mass effect with consequent hypopituitarism, and may result in visual loss. Moreover, some RCCs with a high intra-cystic protein content may mimic cystic pituitary adenoma, which makes their differential diagnosis ambiguous. Currently, medical professionals have no definitive way to distinguish RCCs from pituitary adenomas. Therefore, preoperative confirmation of RCCs would be of help to medical professionals for the management and proper surgical decision making. The goal of this study is to identify molecular markers in RCCs.

METHODS

We characterized aqueous and chloroform extracts of surgically resected RCCs and pituitary adenomas using ex vivo ¹H NMR spectroscopy.

RESULTS

All RCCs exclusively showed the presence of mucopolysaccharides which are glycosaminoglycans (GAGs) made up of disaccharides of aminosugars and uronic sugars.

CONCLUSION

GAGs can be used as metabolite marker for the detection of RCCs and this knowledge will lay the groundwork for the development of a non-invasive, in vivo magnetic resonance spectroscopy methodology for the differential diagnosis of RCCs and pituitary adenomas using clinical MRI scanners.

Cushing's Syndrome in a Patient With Rathke's Cleft Cyst and ACTH Cell Hyperplasia Detected by 11C-Methionine PET Imaging-A Case Presentation

Background: Adrenocorticotropic Hormone (ACTH)-dependent Cushing's Syndrome (CS) is most often caused by a pituitary adenoma. Although rarely, it can also result from pituitary corticotroph cell hyperplasia (CH). Reports on concomitant pituitary lesions including ACTH-producing adenomas and Rathke's cleft cysts (RCCs) have been published. Positron emission tomography (PET), using ¹¹C-labelled-methionine (MET) as a tracer and co-registered with magnetic resonance imaging (MRI) has been shown to be useful in the diagnosis of pituitary collision lesions, however, its role is still under investigation. In this work we present the case of a patient in whom CS was caused by non-adenomatous CH within the wall of an RCC. Case Summary: In 2015 a patient with signs and symptoms of CS was referred to our Department. Biochemical studies repeatedly showed elevated midnight serum cortisol and ACTH levels. Magnetic resonance imaging of the sellar region revealed an RCC and MET-PET/MR showed heterogeneous labelled-methionine metabolism in the vicinity of the cyst's wall. Transsphenoidal surgery resulted in rapid, complete and lasting relief of symptoms. Histopathological examination demonstrated an RCC and CH. Conclusions: Concomitance of pituitary focal lesions is a rare phenomenon. Methionine-labelled PET/MR may be useful in the diagnosis of collision sellar lesions, including CH. Corticotroph cell hyperplasia can present as mild and fluctuating hypercortisolaemia.

The Coexistence of Growth Hormone-Producing Pituitary Adenoma and Rathke Cleft Cyst: How Can We Diagnosis Preoperation?

Pituitary adenoma (PA) rarely coexists with Rathke's cleft cyst (RCC). Previously, only 13 cases of patients with growth hormone (GH)-producing PA and concomitant RCC have been reported. Here, the authors report a 54-year-old female patient with a GH-secreting PA coexisting with an RCC. Acromegaly was diagnosed according to the physical examination and endocrine data. Preoperatively, the coronal magnetic resonance imaging (MRI) contained 2 different signal intensities, these unusually MRI findings for the intrasellar mass were rarely. According to our clinical experience for diagnosis of PA and RCC, besides GH-producing PA in this case, but the possibility of concomitant RCC should be considered. One-and-a-half nostril endoscopic transsphenoidal approach was performed. Intraoperatively, the adenoma was successfully removed and a large amount of grayish fluid from the cyst was released. The endocrine testing was normal soon after the operation and the patient remained well for a follow-up period of 3 months. The postoperative MRI (obtained 3 months after surgery) showed no intrasellar and suprasellar mass. The authors retrospectively analyzed the all 14 cases of concomitant GH-secreting PAs and RCCs and summarized MRI characteristics. When preoperative MRI contained 2 different signal intensities, one mass lesion showed low or isointense signal on the T1-weighted and T2-weighted images, whereas the other lesion showed low signal on the T1-weighted images and hyperintense on the T2-weighted images, the collision MRI features may be helpful for the preoperative diagnosis of concomitant PAs and RCCs.

Pituitary Adenoma Associated With Rathke’s Cleft Cyst: Report of 15 Cases

Objective: The concomitant presence of pituitary adenoma (PA) with Rathke’s cleft cyst (RCC) is rare, and most of the literature published is case reports. RCC’s clinicopathological features have not been well described. Methods: We retrospectively reviewed the data of 15 patients with PA associated with RCC. We also provide a systematic review of the literature. Results: The patients included males and seven females. The transsphenoidal approach was adopted for all patients except one, who underwent right frontal craniotomy. Complete resection was achieved in nine cases, with grossly complete resection in five and partial removal in one. Of the PA subtypes available, five patients had nonfunctional pituitary adenomas, three had multiple-hormone secreting PAs, three had prolactin-producing adenomas, and one had a growth hormone-secreting adenoma. All of the patients’ symptoms and abnormal endocrine test results resolved or were relieved after surgery. The mean follow-up time was 27.6±16.6 months. All of the patients recovered well and had no signs of recurrence during their follow-up, except for one patient. Conclusions: A cyst-like signal indicated on images or cystic materials encountered during operation in a patient with PA suggest the possibility of PA associated with RCC. Transsphenoidal surgery is the preferred approach and can resolve or relieve patients’ symptoms to a great extent. Histologically, nonfunctional PA and prolactinoma are the most common types of PA coexisting with RCC; the mechanisms of PA associated with RCC need to be investigated further.

First Report of Coexistence of Two Ectopic Pituitary Tumors: Rathke Cleft Cyst and Silent Adrenocorticotropic Hormone Adenoma

BACKGROUND

Rathke cleft cysts (RCCs) and pituitary adenomas (PAs) are thought to have a common embryonic ancestry; however, PAs with a concomitant RCC inside the sella turcica are rarely observed. Ectopic pituitary tumors are also rare.

CASE DESCRIPTION

We present the case of a 65-year-old woman with an ectopic RCC in the sphenoid sinus and outside the sella turcica concomitant with an adrenocorticotropic hormone (ACTH)-staining, clinically silent PA. The patient had headache but no endocrine or visual disturbances. Preoperative magnetic resonance imaging revealed infrasellar cystic lesion in the sphenoid sinus with erosion of the clivus and intact sellar floor. The patient underwent gross total microsurgical resection through the transnasal route with an uneventful postoperative course.

CONCLUSIONS

To our knowledge, this is the first reported ectopic RCC located outside the sella turcica with a concomitant ACTH-staining PA. This also appears to be the first ACTH-staining adenoma concomitant with RCC reported in the literature, regardless of location, not presenting with Cushing disease. This case shows that we can now include pituitary adenoma with or without a concomitant RCC in the differential diagnosis of processes in the sphenoid sinus. As both PAs and RCCs are benign sellar lesions, surgical management of a concomitant occurrence of these tumors mainly depends on the size of the lesions and their clinical manifestations. For patients with PA and concomitant RCC, surgical resection should be considered, as there is an approximatrely 20% recurrence rate of the cyst after resection and the possibility of future clival erosion, if left untreated.

Treatment Outcomes of Rathke's Cleft Cysts Managed with Marsupialization

Objectives Rathke's cleft cysts (RCC) are benign cystic lesions of the sella resulting from incomplete obliteration of Rathke's cleft. Symptomatic lesions often require surgical decompression, which is often amenable to a transnasal, transsphenoidal (TNTS) approach. We report our experience with marsupialization of RCC and describe a novel technique to promote re-epithelization of the cyst cavity. Design Retrospective review. Setting Tertiary academic medical center. Participants Patients who underwent TNTS for RCC between 2007 and 2015. Main Outcome Measures Demographics, lesion characteristics, and reconstruction and treatment outcomes. Results In total, 52 patients were identified. The mean age was 41 ± 18 years. The mean RCC size was 13 ± 5 mm. Intraoperative cerebrospinal fluid (CSF) leak was encountered in 14 (27%) patients; all were repaired. There were six complications (12%) and no deaths. Mean follow-up was 20 ± 18 months, with five (10%) recurrences. RCC size was associated with intraoperative CSF leak (p = 0.04). In 12 patients, the marsupialized cyst cavity was lined with a free mucosal graft (FMG) to promote healing and re-epithelialization. Conclusions The TNTS approach is safe and effective in surgical decompression of RCC. Lining the exposed cyst cavity with an FMG is a simple intervention without added morbidity that may promote formation of an epithelialized tract. Level of Evidence Not applicable.