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Fixman B, Peterson R, Shiroishi M, Carmichael JD, Zada G. Spontaneous regression of Rathke's cleft cysts with conservative management: patient series. JOURNAL OF NEUROSURGERY. CASE LESSONS 2024; 8:CASE24268. [PMID: 39312810 PMCID: PMC11418645 DOI: 10.3171/case24268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 06/21/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND Rathke's cleft cysts (RCCs) are benign fluid-filled cysts that develop in the pituitary gland because of the abnormal embryological development of Rathke's pouch. Most RCCs are small and asymptomatic; however, they can present with symptoms or documented growth, sometimes prompting surgical treatment. For smaller asymptomatic lesions, an unknown proportion demonstrates regression over time. This study describes 3 cases of spontaneous RCC regression. OBSERVATIONS Three patients with a diagnosis of RCC demonstrated an average decrease of 78% in cyst volume over a mean interval of 3.7 months. One patient experienced the resolution of chronic headaches, whereas the other 2 patients had persistent headaches and endocrinopathies at follow-up. A systematic review included 9 studies that reported results from observational cohorts of patients with RCC, totaling 619 observed patients, with 158 (25.5%) patients demonstrating spontaneous cyst regression. In the patients with cyst regression, the majority had a resolution of symptoms. LESSONS A substantial proportion of RCC patients managed nonsurgically demonstrated spontaneous regression. There is a role for the conservative management of RCCs in patients without significant symptoms, and surveillance should continue for a minimum of 5 years to confirm cyst stability. For patients undergoing planned surgery, same-day or recent imaging is recommended to prevent operating on involuted RCCs. https://thejns.org/doi/10.3171/CASE24268.
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Affiliation(s)
- Benjamin Fixman
- Departments of Neurosurgery, Keck School of University of Southern California, Los Angeles, California
| | - Racheal Peterson
- Departments of Neurosurgery, Keck School of University of Southern California, Los Angeles, California
| | - Mark Shiroishi
- Departments of Radiology, Keck School of University of Southern California, Los Angeles, California
| | - John D Carmichael
- Departments of Medicine, Keck School of University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Departments of Neurosurgery, Keck School of University of Southern California, Los Angeles, California
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2
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Marin M, Murru FM, Baldo F, Tamaro G, Faleschini E, Barbi E, Tornese G. Minimizing unnecessary brain magnetic resonance imaging in pediatric endocrinology: a retrospective cohort analysis. Front Endocrinol (Lausanne) 2024; 15:1456541. [PMID: 39290328 PMCID: PMC11405184 DOI: 10.3389/fendo.2024.1456541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 08/15/2024] [Indexed: 09/19/2024] Open
Abstract
Background Brain magnetic resonance imaging (MRI) is mandatory or highly recommended in many pediatric endocrinological conditions to detect causative anatomic anomalies and rule out neoplastic lesions. However, MRI can also show findings associated with the underlying clinical condition, as well as unrelated "incidentalomas". These latter findings are often abnormalities with a high incidence in the general population for which there is no clear literature regarding their management, especially in pediatric patients. The present study aimed to evaluate the number of unnecessary performed MRIs in pediatric endocrinology. Methods Retrospective analysis on 584 MRI scans performed in 414 patients (254 growth hormone deficiency, 41 other causes of short stature, 116 central precocious puberty). Results The MRI scans were completely normal in 67% of the individuals, and the prevalence of individuals who underwent more than one MRI was 18%, with no significant differences among the groups. The overall prevalence of incidentalomas was 17%. Among 170 repeated MRI scans, 147 (86%) were not required according to a dedicated protocol. Only five patients (four GHD, one Noonan) correctly repeated the MRI. All the repeated MRI scans did not reveal any progression in the findings. If we include the MRIs performed in cases of OCSS other than Noonan syndrome (n=32) and girls with CPP older than 6 years (n=89), an additional 121 MRIs could have been avoided, leading to a total number of unnecessary MRIs to 268 (46%). Conclusions Only a few specific neuroimaging findings in endocrinologic pediatric patients warrant further investigation, while too often repeated imaging is carried out unnecessarily. We advocate the importance of guidelines to reduce costs for both the healthcare system and patients' families, as well as to alleviate physical and psychological distress for patients and caregivers.
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Affiliation(s)
- Maura Marin
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Flora Maria Murru
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Francesco Baldo
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Gianluca Tamaro
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Elena Faleschini
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Gianluca Tornese
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
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3
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Linsler S, Schon L, Fischer G, Senger S, Oertel J. Endonasal endoscopic or endoscopic-assisted transcranial surgery of Rathke's cleft cysts: does the approach and surgical technique influence the radicality and recurrence rate? Neurosurg Rev 2024; 47:403. [PMID: 39102078 DOI: 10.1007/s10143-024-02545-3] [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: 02/07/2024] [Revised: 06/13/2024] [Accepted: 06/30/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVE Resections of symptomatic Rathke's cleft cysts (RCCs) are mainly performed via an endonasal transsphenoidal approach. However, there is a lack of equivalent data in current literature concerning transcranial keyhole approach in the treatment of RCCs. In order to find general recommendations for the surgical treatment of RCCs also with regard to recurrence, the object of this study is the analysis and comparison of both techniques. METHODS Twenty-nine patients having been surgically treated between January 2004 and August 2019 were retrospectively analysed. The transsphenoidal approach was chosen in 16 cases and the transcranial keyhole approach in 13 cases. Both surgical techniques were analyzed and compared concerning preoperative symptoms and cyst characteristics, complications, surgical radicality, endocrinological and ophthalmological outcome and recurrences in patients´ follow up. RESULTS The postoperative outcome of both techniques was identic and showed highly satisfying success rates with 92% for neurological deficits, 82% for endocrinological dysfunctions and 86% for visual deficits. In contrast, momentous postoperative complications were significantly more likely after transsphenoidal operations. After a mean follow-up time of 5.7 years, the recurrence rates of both cohorts were the same with 0% each. CONCLUSIONS Regarding its equal outcome with its lower complication rate, the authors suggest using the supraorbital keyhole approach for RCCs whose anatomical configuration allow both techniques. Yet, the decision should always consider the surgeon's personal experience and other individual patient characteristics. Further studies with higher numbers of cases and longer follow-up periods are necessary to analyse the effect of the selected approach on recurrence.
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Affiliation(s)
- Stefan Linsler
- Department of Neurosurgery, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Germany
| | - Laura Schon
- Department of Neurosurgery, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Germany
| | - Gerrit Fischer
- Department of Neurosurgery, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Germany
| | - Sebastian Senger
- Department of Neurosurgery, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Germany.
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Menéndez-Torre EL, Gutiérrez-Hurtado A, Ollero MD, Irigaray A, Martín P, Parra P, González-Molero I, Araujo-Castro M, Idrobo C, Moure MD, Molina AR, Biagetti B, Iglesias P, Paja M, Villar-Taibo R, Pena A, Vicente A, Guerrero-Pérez F, Cordido F, Aulinas A, Mateu M, Soto A. Natural history and surgical outcomes of Rathke's cleft cysts: a Spanish multicenter study. Front Endocrinol (Lausanne) 2024; 15:1413810. [PMID: 38952395 PMCID: PMC11215184 DOI: 10.3389/fendo.2024.1413810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 06/04/2024] [Indexed: 07/03/2024] Open
Abstract
Rathke's cleft cysts (RCC) are a common type of lesion found in the sellar or suprasellar area. They are usually monitored clinically, but in some cases, surgery may be required. However, their natural progression is not yet well understood, and the outcomes of surgery are uncertain. The objective of this study is to evaluate the natural history of Rathke's cleft cysts in patients who are clinically monitored without treatment, and to determine the outcomes of surgery and the incidence of recurrences over time. Design and patients National multicentric study of patients diagnosed of Rathke's cleft cyst (RCC- Spain) from 2000 onwards and followed in 15 tertiary centers of Spain. A total of 177 patients diagnosed of RCC followed for 67.3 months (6-215) and 88 patients who underwent surgery, (81 patients underwent immediate surgery after diagnosis and 7 later for subsequent growth) followed for 68.8 months (3-235). Results The cyst size remained stable or decreased in 73.5% (133) of the patients. Only 44 patients (24.3%) experienced a cyst increase and 9 of them (5.1%) experienced an increase greater than 3 mm. In most of the patients who underwent surgery headaches and visual alterations improved, recurrence was observed in 8 (9.1%) after a median time of 96 months, and no predictors of recurrence were discovered. Conclusions Rathke's cleft cysts without initial compressive symptoms have a low probability of growth, so conservative management is recommended. Patients who undergo transsphenoidal surgery experience rapid clinical improvement, and recurrences are infrequent. However, they can occur after a long period of time, although no predictors of recurrence have been identified.
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Affiliation(s)
- Edelmiro Luis Menéndez-Torre
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias, Oviedo, Spain
- Grupo ENDO, Instituto de Investigación Biomédica del Principado de Asturias (ISPA), Oviedo, Spain
- Departamento de Medicina, Universidad de Oviedo, Oviedo, Spain
| | - Alba Gutiérrez-Hurtado
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - María Dolores Ollero
- Department of Endocrinology and Nutrition, Hospital Universitario de Navarra, Pamplona, Spain
| | - Ana Irigaray
- Department of Endocrinology and Nutrition, Hospital Universitario de Navarra, Pamplona, Spain
| | - Patricia Martín
- Department of Endocrinology and Nutrition, Hospital Universitario La Paz, Madrid, Spain
| | - Paola Parra
- Department of Endocrinology and Nutrition, Hospital Universitario La Paz, Madrid, Spain
| | - Inmaculada González-Molero
- Department of Endocrinology and Nutrition, Hospital Regional Universitario de Málaga, IBIMA Plataforma Bionand, Málaga, Spain
| | - Marta Araujo-Castro
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Cindy Idrobo
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - María Dolores Moure
- Department of Endocrinology and Nutrition, Hospital Universitario de Cruces, Baracaldo, Spain
| | - Ana Rosa Molina
- Department of Endocrinology and Nutrition, Hospital Universitario de Cruces, Baracaldo, Spain
| | - Betina Biagetti
- Department of Endocrinology and Nutrition, Hospital Universitario Vall d’Hebrón, Barcelona, Spain
| | - Pedro Iglesias
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Miguel Paja
- Department of Endocrinology and Nutrition, Hospital Universitario de Basurto, Bilbao, Spain
| | - Rocío Villar-Taibo
- Department of Endocrinology and Nutrition, Hospital Universitario Santiago de Compostela, Santiago de Compostela, Spain
| | - Alberto Pena
- Department of Endocrinology and Nutrition, Hospital Universitario Santiago de Compostela, Santiago de Compostela, Spain
| | - Almudena Vicente
- Department of Endocrinology and Nutrition, Hospital Universitario de Toledo, Toledo, Spain
| | - Fernando Guerrero-Pérez
- Department of Endocrinology and Nutrition, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Fernando Cordido
- Department of Endocrinology and Nutrition, Hospital Universitario de Coruña, Coruña, Spain
| | - Anna Aulinas
- Department of Endocrinology and Nutrition, Hospital Sant Pau, Barcelona, Spain
| | - Manel Mateu
- Department of Endocrinology and Nutrition, Hospital Sant Pau, Barcelona, Spain
| | - Alfonso Soto
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Schmutzer-Sondergeld M, Weller J, Thorsteinsdottir J, Schichor C, Rachinger W, Thon N, Ueberschaer M. Long-term outcome of surgically treated and conservatively managed Rathke cleft cysts. Acta Neurochir (Wien) 2024; 166:159. [PMID: 38557782 PMCID: PMC10984884 DOI: 10.1007/s00701-024-06052-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/21/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Rathke cleft cysts (RCC) are benign lesions of the sellar region that require surgical treatment in case of visual deterioration or progression of the cyst. However, the natural course is often stable and asymptomatic. We aimed to investigate the characteristics of patients with cyst progression during follow-up (FU) and to compare the natural history of patients with RCC with patients who underwent surgery. METHODS Patients with an MR morphologic cystic sellar lesion classified as RCC between 04/2001 and 11/2020 were included. Functional outcomes, including ophthalmologic, endocrinologic, and MRI data, were retrospectively analyzed and compared between surgically treated patients, patients on a "watch and wait" strategy (WWS), and patients on a WWS who underwent secondary surgery due to cyst progression. RESULTS One hundred forty patients (median age 42.8 years) with RCC on MRI were identified. 52/140 (37.1%) underwent primary surgery. Of 88 patients (62.9%) with initial WWS, 21 (23.9%) underwent surgery for secondary cyst progression. Patients on the WWS had significantly smaller cyst volumes (p = 0.0001) and fewer visual disturbances (p = 0.0004), but a similar rate of hormone deficiencies (p = 0.99) compared with surgically treated patients preoperatively. Postoperatively patients suffered significantly more often from hormone deficiencies than WWS patients (p = 0.001). Patients who switched to the surgical group were significantly more likely to have preoperative T1 hyperintense signals on MRI (p = 0.0001) and visual disturbances (p = 0.001) than patients with continuous WWS. Postoperatively, these patients suffered more frequently from new hormonal deficiencies (p = 0.001). Endocrine and ophthalmologic outcomes in patients with primary and secondary surgery were comparable. Multivariate analysis showed that WWS patients were at a higher risk of requiring surgery for cyst progression when perimetric deficits (p = 0.006), hyperprolactinemia (p = 0.003), and corticotropic deficits (p = 0.005) were present. CONCLUSION Surgical treatment of RCC may cause new hormonal deficiencies, which are rare in the natural course. Therefore, the indication for surgery should be carefully evaluated. Hyperprolactinemia and corticotropic deficits were significant indicators for a secondary cyst progression in patients with RCC. However, a significant amount of almost 25% of initially conservatively managed cysts showed deterioration, necessary for surgical intervention.
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Affiliation(s)
| | - Jonathan Weller
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Jun Thorsteinsdottir
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Christian Schichor
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Walter Rachinger
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistr 15, 81377, Munich, Germany
| | - Moritz Ueberschaer
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistr 15, 81377, Munich, Germany
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
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Nakase K, Nishimura F, Yokoyama S, Kakutani M, Morisaki Y, Kotsugi M, Takeshima Y, Matsuda R, Young-Soo P, Nakagawa I. Long-term outcomes and potential predictive recurrence factors after endonasal endoscopic surgical treatment of symptomatic Rathke's cleft cysts. Neurosurg Rev 2024; 47:85. [PMID: 38366128 DOI: 10.1007/s10143-024-02322-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/22/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Abstract
Although patients with symptomatic Rathke's cleft cysts (RCCs) receive surgical treatment, recurrence sometimes occurs after surgery. However, the mechanism underlying recurrence remains unclear. We evaluated the outcomes of RCC decompression over a long-term follow-up period. We retrospectively reviewed the medical records of 35 patients with symptomatic RCC who underwent endonasal endoscopic surgery (EES) at our institution between 2008 and 2023. Patients' characteristics, intraoperative findings, and postoperative follow-up outcomes were evaluated. A univariate regression model was used to identify the predictors of recurrence. The median patient age was 48.0 years, and 74.2% of the patients were female. The mean follow-up duration was 94.7 ± 47.6 months. Cyst content recurrence was observed in 15 patients (42.8%). Five patients (14.2%) with symptomatic recurrence underwent reoperation. Postoperative vision improved in all 23 patients (100%); headaches improved in 20 patients (90.9%). A new hormonal deficit occurred in two patients (5.7%). Complications included intraoperative cerebrospinal fluid (CSF) leak in 10 patients (28.5%), postoperative CSF leak in two patients (5.7%), permanent diabetes insipidus in two patients (5.7%), and postoperative infection in three patients (8.5%). Univariate analyses revealed that the position of the anterior pituitary lobe (p = 0.019) and preoperative visual disturbances (p = 0.008) significantly affected recurrence after surgery. Although EES was efficient, the recurrence rate was relatively high over a long-term period. The anterior pituitary lobe position and preoperative visual disturbances were significantly associated with recurrence. The anterior-inferior position can predict a high risk of recurrence before surgery.
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Affiliation(s)
- Kenta Nakase
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Fumihiko Nishimura
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan.
| | - Shohei Yokoyama
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Miho Kakutani
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Yudai Morisaki
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Yasuhiro Takeshima
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Park Young-Soo
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
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Krasnow MD, Krasnow NA, McGuirk L, Patale TP, Manely S, Sayegh E, Epstein B, Hanif SA, Mehta S, Tenner M, Schefflein J, Mehta H, Noto RA. The evolution of pituitary cysts in growth hormone-treated children. J Pediatr Endocrinol Metab 2023; 36:36-42. [PMID: 36394493 DOI: 10.1515/jpem-2022-0333] [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: 07/01/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We have previously shown that pituitary cysts may affect growth hormone secretion. This study sought to determine cyst evolution during growth hormone treatment in children. METHODS Forty-nine patients with short stature, a pituitary cyst, and at least two brain MRI scans were included. The percent of the pituitary gland occupied by the cyst (POGO) was calculated, and a cyst with a POGO of ≤15% was considered small, while a POGO >15% was considered large. RESULTS Thirty-five cysts were small, and 14 were large. Five of the 35 small cysts grew into large cysts, while 6 of the 14 large cysts shrunk into small cysts. Of 4 cysts that fluctuated between large and small, 3 presented as large and 1 as small. Small cysts experienced greater change in cyst volume (CV) (mean=61.5%) than large cysts (mean=-0.4%). However, large cysts had a greater net change in CV (mean=44.2 mm3) than small cysts (mean=21.0 mm3). Older patients had significantly larger mean pituitary volume than younger patients (435.4 mm3 vs. 317.9 mm3) and significantly larger mean CV than younger patients (77.4 mm3 vs. 45.2 mm3), but there was no significant difference in POGO between groups. CONCLUSIONS Pituitary cyst size can vary greatly over time. Determination of POGO over time is a useful marker for determining the possibility of a pathologic effect on pituitary function since it factors both cyst and gland volume. Large cysts should be monitored closely, given their extreme, erratic behavior.
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Affiliation(s)
- Matthew D Krasnow
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Nicholas A Krasnow
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Liam McGuirk
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Tara P Patale
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Sarah Manely
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Emily Sayegh
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Benjamin Epstein
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Sarriyah A Hanif
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Shilpa Mehta
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
| | - Michael Tenner
- Department of Radiology, Division of Neuroradiology, New York Medical College, Valhalla, NY, USA
| | - Javin Schefflein
- Department of Radiology, Division of Neuroradiology, New York Medical College, Valhalla, NY, USA
| | - Hasit Mehta
- Department of Radiology, Division of Neuroradiology, New York Medical College, Valhalla, NY, USA
| | - Richard A Noto
- Department of Pediatrics, Division of Pediatric Endocrinology, New York Medical College, Valhalla, NY, USA
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Choo YH, Seo Y, Kim OL. The surgical outcomes following transsphenoidal surgery for Rathke cleft cysts: Comparison of the surgical approaches at a single institution. Medicine (Baltimore) 2022; 101:e32421. [PMID: 36595816 PMCID: PMC9794344 DOI: 10.1097/md.0000000000032421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The aim of the present study is to retrospectively analyze the surgical outcomes and complications of microscopic and endoscopic transsphenoidal surgery in the management of Rathke cleft cysts (RCCs) at a single institution. A total of 38 patients were enrolled in this study. All patients were diagnosed with RCCs, which were confirmed histopathologically. Endocrine function, radiological, and clinical outcomes were evaluated following surgery. This cohort study consisted of 16 male and 22 female patients. The median age was 48 years (range, 21-72). The median clinical follow-up duration was 57 months (range, 3-187). Twenty-five patients underwent microscopic transsphenoidal surgery and 13 patients underwent endoscopic surgery. The cysts were located within the intrasellar area in 18 (47.4%) patients, and extended to the suprasellar area in 20 (52.6%) patients. The radiological characteristics were similar in the microscope and endoscope groups, except mass volume (1.40 vs 0.65 mm3; P = .003) and peripheral rim enhancement (P = .036). After surgery, 30 (78.9%) of the 38 patients had no residual cysts. There was no significant difference in outcomes between both groups (76.0% vs 84.6%; P = .689). Four (10.5%) patients experienced cyst recurrence in only the microscope group. Twenty-four of the 25 patients who presented with headache showed improvement after surgery. Four patients with visual field defects recovered after surgery. Among the 8 patients with hormonal deficiencies, hormone levels normalized in 5 patients, did not change in 2 patients and worsened in 1 patient. New hormonal deficiencies occurred in 3 patients. Microscopic or endoscopic transsphenoidal surgery for RCCs is a safe and effective treatment option. Complete aspiration of the cyst contents with wide fenestration and wall biopsy, regardless of the surgical approach used, is usually a sufficient treatment for RCCs.
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Affiliation(s)
- Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hostpital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Republic of Korea
- * Correspondence: Youngbeom Seo, Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung-ro, Nam-gu, Daegu 42415, Republic of Korea (e-mail: )
| | - Oh Lyong Kim
- Health Insurance Review and Assessment Service, Daegu, Republic of Korea
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9
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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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10
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Madapoosi A, Uram Z, Tsiang J, Pecoraro N, Patel C, Germanwala AV. Rathke's cleft cyst marsupialization and repair with a free mucosal graft - Video case report and literature review. Am J Otolaryngol 2022; 43:103519. [PMID: 35690516 DOI: 10.1016/j.amjoto.2022.103519] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
Rathke's cleft cysts (RCCs) are sellar or suprasellar cystic lesions arising from the remnants of the embryological Rathke's pouch. When symptomatic, RCCs are usually treated surgically via marsupialization. Free mucosal graft (FMG) repair has shown promise in decreasing recurrence versus marsupialization alone. The authors present a case report with operative video of a patient with visual and endocrinological symptoms with a RCC treated with FMG following marsupialization. A search of the PubMed database from July 1997 through April 2022 was conducted using the terms 'Rathke's cleft cyst', 'Rathke's cleft cyst management', 'Rathke's cleft cyst repair', 'mucosal graft', 'mucosal coupling', 'transsphenoidal', and 'endoscopic endonasal'. Clinical and pathological aspects of the case presented were compared with information obtained from literature review. A 25-year-old female presented with a six-year history of amenorrhea, one-year history of anemia, headaches, and progressive visual loss. Imaging revealed an RCC. The patient underwent surgical treatment via an endoscopic endonasal approach. Marsupialization was achieved with placement of an FMG to help prevent restenosis. Post-operative examination revealed that the patient's OD vision returned to normal, although her OS vision was only slightly improved. Our review of the English literature resulted in 35 full-length articles that were published between 1997 and 2022. The literature suggests that FMG prevents scar formation by allowing for adequate epithelialization, thus decreasing the recurrence rate and being well tolerated by patients. Our findings support the utility of the FMG as a superior surgical treatment option for RCC management.
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Affiliation(s)
- Adrusht Madapoosi
- Chicago Medical School, Rosalind Franklin University, North Chicago, IL, United States of America
| | - Zachary Uram
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States of America
| | - John Tsiang
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, United States of America
| | - Nathan Pecoraro
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, United States of America
| | - Chirag Patel
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States of America; Department of Otolaryngology, Head and Neck Surgery, Loyola University Medical Center, Maywood, IL, United States of America
| | - Anand V Germanwala
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, United States of America; Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, United States of America; Department of Otolaryngology, Head and Neck Surgery, Loyola University Medical Center, Maywood, IL, United States of America.
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11
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Chong GYC, Tan KCB, Lau EYF, Lai AYT, Man KKY, Chan TM, Leung WKW, Leung JYY. A study on clinical outcomes of Rathke's cleft cyst in patients managed conservatively. Pituitary 2022; 25:258-266. [PMID: 34807360 DOI: 10.1007/s11102-021-01194-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Gigi Y C Chong
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Wan Chai, Hong Kong.
| | - Kathryn C B Tan
- Department of Medicine, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Emmy Y F Lau
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Alta Y T Lai
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Kenyon K Y Man
- Department of Radiology, Queen Mary Hospital, Pokfulam, Hong Kong
| | - T M Chan
- Department of Radiology, Ruttonjee Hospital, Wan Chai, Hong Kong
| | - Warren K W Leung
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Jenny Y Y Leung
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Wan Chai, Hong Kong
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12
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Yamada H, Ueda R, Ozawa H, Toda M. Long-Term Outcomes of Endoscopic Cyst Fenestration for Rathke Cleft Cyst. World Neurosurg 2022; 161:e282-e288. [PMID: 35131522 DOI: 10.1016/j.wneu.2022.01.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We sought to elucidate the long-term surgical outcomes and incidence of recurrence and reoperation of endoscopic endonasal cyst fenestration for Rathke cleft cyst (RCC). METHODS A retrospective review of the chart and operation record of RCC surgical cases between January 2008 and August 2021 at our institution was conducted. Patient characteristics, intraoperative findings, and postoperative follow-up outcomes were evaluated. RESULTS A total of 27 patients were analyzed, with a median postoperative follow-up period of 52 months (range, 1-150 months). Preoperative symptoms were visual dysfunction (59%), headache (41%), and pituitary dysfunction (22%). Endoscopic cyst fenestration was performed in all patients. Ten (37%) patients had intraoperative cerebrospinal fluid leakage. Among them, the only patient in whom sellar floor reconstruction was not performed experienced a repair operation due to postoperative cerebrospinal fluid leakage. No patients experienced postoperative hypopituitarism. Preoperative headache, visual dysfunction, and pituitary hormone disorder improved in 73%, 75%, and 67% of patients, respectively. Although postoperative cyst regrowth was observed in 8 patients (30%), no patient experienced worsening or novel symptoms and none required reoperation. CONCLUSIONS Patients with a symptomatic RCC can be effectively treated with endoscopic endonasal cyst fenestration. Reversal of the presenting symptoms resulted, including headache, visual dysfunction, and pituitary hormone dysfunction, in the majority of patients. In our series, appropriate reconstruction of the sellar floor reduced the risk of postoperative cerebrospinal fluid leakage without impacting cyst regrowth. This simple technique appears to effectively disrupt cyst progression in most cases, even after a relatively long-term follow-up period.
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Affiliation(s)
- Hiroki Yamada
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Ueda
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Ozawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan.
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13
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Higuchi Y, Hasegawa K, Kubo T, Tanaka H, Tsukahara H. The clinical course of Rathke's cleft cysts in pediatric patients: impact on growth and pubertal development. Clin Pediatr Endocrinol 2022; 31:38-43. [PMID: 35002067 PMCID: PMC8713062 DOI: 10.1297/cpe.2021-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/26/2021] [Indexed: 01/14/2023] Open
Abstract
Rathke's cleft cysts (RCCs) are non-neoplastic epithelial lesions in the sellar or suprasellar regions. RCCs are usually asymptomatic; however, some patients experience headaches, visual disturbances, and endocrine disorders. The best treatment for associated endocrinopathy remains elusive. We aimed to investigate the clinical course, magnetic resonance imaging findings, and response to therapy in 10 pediatric patients with RCCs and endocrinopathy. Growth impairment and precocious puberty were observed to be prevalent. One patient with suprasellar extension of RCC underwent surgery, while the others were treated medically. Of the nine patients, seven patients showed stable cyst size, while two patients displayed reduction in cyst size. Hormone replacement and gonadotropin suppression therapy were found to be effective. Imaging and endocrine follow-ups are warranted because of the potential for changes in the cyst size and hormonal changes.
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Affiliation(s)
- Yousuke Higuchi
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.,Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Kosei Hasegawa
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Toshihide Kubo
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiroyuki Tanaka
- Department of Pediatrics, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Hirokazu Tsukahara
- Department of Pediatrics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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14
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Petersson M, Berinder K, Eden Engström B, Tsatsaris E, Ekman B, Wahlberg J, Burman P, Borg H, Siesjö P, Dahlqvist P, Åkerman AK, Ragnarsson O, Olsson M, Förander P, Bensing S, Höybye C. Natural history and surgical outcome of Rathke's cleft cysts-A study from the Swedish Pituitary Registry. Clin Endocrinol (Oxf) 2022; 96:54-61. [PMID: 34724249 DOI: 10.1111/cen.14622] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Rathke's cleft cysts are benign, embryological remnants in the pituitary gland. The majority of them are small and asymptomatic but a few may become large, and cause mass effects, pituitary hormone deficiencies and visual impairment. Recommendations for the follow-up of Rathke's cleft cysts vary since data on the natural history are sparse. PATIENTS AND DESIGN Data at diagnosis and at 1, 5 and 10 years for patients with a Rathke's cleft cyst (434 at diagnosis, 317 females) were retrieved from the Swedish Pituitary Registry. Cysts ≤3 mm in diameter were excluded from the study. MEASUREMENTS Data included demographics, cyst size, pituitary function, visual defects and surgery. RESULTS The mean age at diagnosis was 45 years. In patients with cysts <10 mm in diameter (n = 204) 2.9% had pituitary hormone deficiencies and 2% had visual field impairments. Cyst size did not progress during the 5 years. Cysts with a diameter of ≥10 mm that were not operated (n = 174) decreased in size over the years (p < .01). Pituitary hormone deficiencies and visual impairments were more frequent (18% and 5.7%, respectively) but were stable over time. Transphenoidal surgery was performed in 56 patients of whom 51 underwent surgery before the 1-year follow-up. The mean cyst diameter at diagnosis was 18 mm (range: 9─30 mm), 36% had pituitary hormone deficiency, 45% had visual field defects and 20% had impaired visual acuity. One year after surgery 60% had no cyst remnants, 50% had a pituitary deficiency, 26% had visual field defects and 12% had impaired visual acuity. No major changes were observed after 5 years. Twelve of the operated patients had a follow-up at 10 years, in eight the cyst remnants or recurrences increased in size over time (p < .05). CONCLUSIONS Rathke's cleft cysts with a size less than 10 mm rarely grow and our results indicate that radiological follow-up can be restricted to 5 years. In contrast, progression of postoperative remnants or recurrent cysts is more likely and require long-term follow-up.
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Affiliation(s)
- Maria Petersson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Berinder
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Britt Eden Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Erika Tsatsaris
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Bertil Ekman
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - Henrik Borg
- Department of Endocrinology, Skåne University Hospital, University of Lund, Lund, Sweden
| | - Peter Siesjö
- Department of Neurosurgery, Skåne University Hospital, University of Lund, Lund, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Anna-Karin Åkerman
- Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Martin Olsson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Petter Förander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
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15
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Abstract
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.
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Affiliation(s)
- Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Maria Fleseriu
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition), and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, CH8N 3303 South Bond Avenue, Portland, OR, USA.
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16
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Abstract
Pituitary incidentalomas (PI) are lesions of the pituitary region discovered fortuitously by imaging for reasons unrelated to pituitary disease. They range from small cysts to large invasive adenomas. All over the world, improvements in the quality and availability of radiological examinations are leading to an increase in the discovery of PI. In the last four decades, significant advances have been made in the understanding of PI. Autopsy studies have shown that about 10% of deceased individuals harbour a PI, most often a non-functioning microadenoma. In contrast, modern patient series showed that among PIs that come to endocrinological attention, a significant proportion are macroadenomas, and many patients suffer from asymptomatic or pauci-symptomatic endocrine or ophthalmologic disturbances. Other than adenomas, empty sella, Rathke's cleft cyst, craniopharyngioma and meningioma are the most frequent types of PIs. About 10% of micro-incidentalomas and 25% of macro-incidentalomas grow over time. Most cases can be managed conservatively by mere surveillance. Follow-up is necessary in all patients with macroadenoma, but uncertainty remains for microadenomas as to the extent of endocrinological work-up as well as the necessity and duration of follow-up. Visual and endocrine anomalies constitute the most common indications for surgery. When needed, surgery yields better outcome in PIs than in symptomatic pituitary lesions.
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17
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Fujii M, Nakagawa A, Tachibana O, Iizuka H, Koya D. Anterior pituitary function in Rathke's cleft cysts versus nonfunctioning pituitary adenomas. Endocr J 2021; 68:943-952. [PMID: 33814485 DOI: 10.1507/endocrj.ej21-0050] [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] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Mizue Fujii
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada 920-0293, Japan
| | - Atsushi Nakagawa
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada 920-0293, Japan
| | - Osamu Tachibana
- Department of Neurosurgery, Kanazawa Medical University, Uchinada 920-0293, Japan
| | - Hideaki Iizuka
- Department of Neurosurgery, Kanazawa Medical University, Uchinada 920-0293, Japan
| | - Daisuke Koya
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada 920-0293, Japan
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18
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Findings of Brain Magnetic Resonance Imaging in Girls with Central Precocious Puberty Compared with Girls with Chronic or Recurrent Headache. J Clin Med 2021; 10:jcm10102206. [PMID: 34069752 PMCID: PMC8160955 DOI: 10.3390/jcm10102206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/04/2021] [Accepted: 05/15/2021] [Indexed: 11/29/2022] Open
Abstract
In the present study, the results of brain magnetic resonance imaging (MRI) in girls with central precocious puberty (CPP) were compared those in with girls evaluated for headaches. A total of 295 girls with CPP who underwent sellar MRI were enrolled. A total of 205 age-matched girls with chronic or recurrent headaches without neurological abnormality who had brain MRI were included as controls. The positive MRI findings were categorized as incidental non-hypothalamic–pituitary (H–P), incidental H–P, or pathological. Positive MRI findings were observed in 39 girls (13.2%) with CPP; 8 (2.7%) were classified as incidental non-H–P lesions, 30 (10.2%) as incidental H–P lesions, and 1 (0.3%) as a pathological lesion (tuber cinereum hamartoma). The prevalence of positive MRI findings in girls with CPP did not differ from girls with headaches (13.2% vs. 12.2%, p = 0.74). The prevalence of incidental H–P lesions in girls with CPP <6 years of age, 6–6.9 years of age, and 7–7.9 years of age was 21.2%, 13.5%, and 9.6%, respectively (p = 0.21). Known pathological lesions were detected in only one (3.0%) girl with CPP aged <6 years and in no girls with CPP aged 6–7.9 years. Microadenomas were detected in no girls with CPP aged <6 years and in 5 (1.9%) girls with CPP aged of 6–7.9 years. Our findings call into question the routine use of brain MRI in girls with CPP, especially in girls 6 years or older. Current guidelines recommend a follow-up MRI in cases of microadenoma, but few data exist to support this recommendation for children.
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Baldo F, Marin M, Murru FM, Barbi E, Tornese G. Dealing With Brain MRI Findings in Pediatric Patients With Endocrinological Conditions: Less Is More? Front Endocrinol (Lausanne) 2021; 12:780763. [PMID: 35095759 PMCID: PMC8791386 DOI: 10.3389/fendo.2021.780763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/20/2021] [Indexed: 12/22/2022] Open
Abstract
Neuroimaging is a key tool in the diagnostic process of various clinical conditions, especially in pediatric endocrinology. Thanks to continuous and remarkable technological developments, magnetic resonance imaging can precisely characterize numerous structural brain anomalies, including the pituitary gland and hypothalamus. Sometimes the use of radiological exams might become excessive and even disproportionate to the patients' medical needs, especially regarding the incidental findings, the so-called "incidentalomas". This unclarity is due to the absence of well-defined pediatric guidelines for managing and following these radiological findings. We review and summarize some indications on how to, and even if to, monitor these anomalies over time to avoid unnecessary, expensive, and time-consuming investigations and to encourage a more appropriate follow-up of brain MRI anomalies in the pediatric population with endocrinological conditions.
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Affiliation(s)
| | - Maura Marin
- University of Trieste, Trieste, Italy
- *Correspondence: Maura Marin,
| | - Flora Maria Murru
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Egidio Barbi
- University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Gianluca Tornese
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
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20
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Outcome of nonneoplastic pituitary cysts during conservative monitoring and after surgery-a SwissPit study. Acta Neurochir (Wien) 2020; 162:2389-2396. [PMID: 32577894 DOI: 10.1007/s00701-020-04467-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Nonneoplastic cysts of the pituitary are common incidental findings; however, best management remains controversial as they are often asymptomatic but eventually may cause symptoms. The aims of this study are to describe the course of conservative and surgical approaches, to assess timing and results of surgery, and to identify predictors for growth. METHODS This retrospective study reviewed medical records from the Swiss Pituitary registry. Fifty patients (68% females; median 44 years old) fulfilled the criteria for inclusion. Three cohorts were defined: a conservative group (n = 28), a group who initially needed surgery (n = 18), and a group who had surgery during follow-up (n = 4). Transsphenoidal cyst evacuation was used in 95%; 68% had intraoperative MRI. All patients had standardized neuroradiological, endocrinological, and ophthalmological follow-up (mean 44 (7-151) months). RESULTS Conservative follow-up of 30 (6-120) months showed cyst growth in 16% (4%/year) and spontaneous shrinkage in 19% (8%/year). Cyst-volumes changed - 0.95 to 1.45 cm3 per year. The probability of needing surgery was 5% per year. Larger cysts (> 1.4 cm3) and T1-hypo-/T2-hyper cyst contents were associated with higher probability for growth. Postoperatively, no remnant was seen in 82% during a follow-up of 53 months. Visual field deficiencies improved in 83%. Hypopituitarism recovered in up to 88%. But for a smaller complication rate, the outcome was not influenced by the use of the intraoperative MRI. CONCLUSIONS Asymptomatic nonneoplastic pituitary cysts may be monitored; many lesions may shrink with time. Larger or T1-hypo-/T2-hyper cysts have higher growth rates. If indicated, surgery for nonneoplastic sellar cysts is a safe and efficient.
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21
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Jung HN, Kim ST, Kong DS, Suh SI, Ryoo I. Rathke Cleft Cysts with Apoplexy-Like Symptoms: Clinicoradiologic Comparisons with Pituitary Adenomas with Apoplexy. World Neurosurg 2020; 142:e1-e9. [PMID: 32217176 DOI: 10.1016/j.wneu.2020.03.086] [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: 02/05/2020] [Revised: 03/13/2020] [Accepted: 03/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Rathke cleft cyst (RCC) can cause acute symptoms mimicking pituitary adenoma (PA) apoplexy. We evaluated the clinicoradiologic features for distinguishing RCC from PA apoplexy. METHODS We retrospectively evaluated 22 patients with RCC and 24 patients with PA with apoplexy-like symptoms who underwent surgery via a transsphenoidal approach between November 1999 and December 2016. We compared the clinical data and magnetic resonance (MR) images between the 2 groups. RESULTS The RCC group was younger and had smaller tumors compared with the PA group (P = 0.02 and 0.001, respectively). The incidences of visual deficits and cranial nerve palsy were lower in the RCCs than in the PAs (P ≤ 0.02 for all). MR images showed more frequent intracystic nodules in the RCCs (P < 0.001), whereas nodular enhancement and lateral deviation of the pituitary stalk were more commonly seen in the PAs (P ≤ 0.003 for both). However, the presence of endocrine dysfunction or decreased consciousness, and the recurrence ratio, were not significantly different between the groups (P ≥ 0.48 for all). In the multivariable logistic regression analysis, patients without nodular enhancement had a 15.84-fold greater risk of RCC than did those with nodular enhancement (P = 0.031). The probability of RCC decreased 0.59-fold with each 1-cm3 increase in tumor volume. CONCLUSIONS RCC with apoplexy-like symptoms has different clinicoradiologic features compared with PA apoplexy. Patients with RCC present with milder ocular symptoms and smaller tumor volumes compared with those with PA apoplexy. The absence of nodular enhancement on MR images could suggest RCC.
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Affiliation(s)
- Hye Na Jung
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Guro, Seoul, South Korea; Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Sungkyunkwan, South Korea
| | - Sung Tae Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Sungkyunkwan, South Korea.
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Sungkyunkwan, South Korea
| | - Sang-Il Suh
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Guro, Seoul, South Korea
| | - Inseon Ryoo
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Guro, Seoul, South Korea
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Barkhoudarian G, Palejwala SK, Ansari S, Eisenberg AA, Huang X, Griffiths CF, Cohan P, Rettinger S, Lavin N, Kelly DF. Rathke's cleft cysts: a 6-year experience of surgery vs. observation with comparative volumetric analysis. Pituitary 2019; 22:362-371. [PMID: 31016554 DOI: 10.1007/s11102-019-00962-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rathke's cleft cysts (RCCs) are common sellar lesions. Their management remains controversial, particularly when small or asymptomatic. Herein we review a consecutive series of RCC patients managed with surgery or observation. METHODS All patients with a new diagnosis of presumed RCC, based on MRI, from February 2012-March 2018 were retrospectively divided into observational and surgical cohorts based on an intent-to-treat model. The cohorts were compared for clinical presentation, and cyst volume. The observational cohort was followed for change in cyst size. The surgical cohort was followed for changes in endocrinopathy, visual symptoms, headache and recurrence. RESULTS Of 90 patients (mean age 36.7 ± 19.4 years; 68% female), 60% (n = 54) were in the observational cohort and 40% (n = 36) in the surgical cohort. Average follow-up was 13 ± 23 months in the observational cohort and 24 ± 19 months in the surgical group. In comparing the cohorts, mean ages were similar with more women in the surgical group (81% vs. 56%, p = 0.04). Most patients in the observational cohort had incidentally-discovered RCCs (n = 50, 88%) as opposed to the surgical cohort (n = 6, 17%). The surgical cohort had higher rates of headache (89% vs 26%, p < 0.001), endocrinopathy (36% vs 0%, p < 0.001), and visual dysfunction (19% vs 0%, p = 0.001). Mean cyst volume and maximal cyst dimensions were greater in the surgical cohort (0.94 ± 0.77 cm3 and 14.2 ± 4.1 mm), compared to the observational cohort (0.1 ± 0.14 cm3 and 6.4 ± 3 mm), (p < 0.001). Among the 53% (n = 30/54) of patients in the observational group with follow-up, 3 (10%) had spontaneous RCC shrinkage, 1 (3%) had modest asymptomatic growth (at 10 months from initial MRI), and 87% had stable cyst size. Of the 36 patients recommended to have surgery, 89% (n = 32) did so. Post-operatively, complete or partial resolution of headache, endocrinopathy and visual dysfunction were documented in 90% (n = 28/30), 75% (n = 10/12), and 100% (n = 7/7), respectively. On follow-up MRI, 8 (22%) patients had some cyst reaccumulation, of whom 3 (8%) were symptomatic and underwent uneventful reoperation. No major complications such as hematoma, CSF leak, new endocrinopathy or visual deficits occurred. CONCLUSION From this consecutive series, a majority (60%) of RCCs do not appear to warrant surgical intervention and have a low risk of cyst progression. However, surgical cyst removal appears to be indicated and safe for patients with larger, symptomatic RCCs. Simple cyst drainage has a high rate of improvement in pituitary gland function, visual function and headache resolution with low complication rates and symptomatic recurrence risk. These findings stress the importance of careful case selection and potential utility of volumetric assessment for patients with RCCs.
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Affiliation(s)
- Garni Barkhoudarian
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA.
| | - Sheri K Palejwala
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Shaheryar Ansari
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Amalia A Eisenberg
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Xiang Huang
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Chester F Griffiths
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Sarah Rettinger
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Norman Lavin
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, John Wayne Cancer Institute at Providence's Saint John's Health Center, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
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Langlois F, Manea A, Lim DST, McCartney S, Yedinak CG, Cetas JS, Fleseriu M. High prevalence of adrenal insufficiency at diagnosis and headache recovery in surgically resected Rathke's cleft cysts-a large retrospective single center study. Endocrine 2019; 63:463-469. [PMID: 30338480 DOI: 10.1007/s12020-018-1784-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/03/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Rathke's cleft cysts (RCC) are lesions that arise from Rathke's pouch. Though frequently incidental, resulting symptoms in a minority of cases are indicators for surgical resection, which may prove beneficial. OBJECTIVE To characterize a cohort of surgically-resected RCC cases at Oregon Health & Science University; tabulate associated hormonal imbalances and symptoms, possible symptom reversal with surgery, determine recurrence risk; identify predictors of recurrence and headache improvement. METHOD Electronic records of all RCC resected cases (from 2006-2016; 11 years) were retrospectively reviewed. Patients had been evaluated by one neuroendocrinologist using a uniform protocol. RESULTS A pathological RCC diagnosis was established in 73 of 814 (9%) surgical pituitary cases. The RCC cohort was 77% (n = 56/73) female, mean age was 39.5 ± 14.9 years at first surgery, and at presentation headache was reported in 88% and visual defects/diplopia in 18% of patients. Initial RCC maximum diameter was 1.3 ± 0.7 cm. The most frequent hormonal deficit was cortisol; 24% of patients had a new adrenal insufficiency (AI) diagnosis, however, 36% also had AI at 3 months post-operatively. Mean follow up was 4.0 ± 4.5 years. Two-thirds of patients (41/62) had headache improvement 3 months post-operatively. Post-operative imaging revealed no residual cyst in 58% (38/65). In those patients with no residual RCC, 29% had recurrence and 71% had long lasting cure. From the 42% (27/65) of patients with residual cyst on post-operative imaging; 59% (16/27) remained stable, 26% (7/27) progressed and 15% (4/27) regressed. CONCLUSION Symptomatic RCC present mostly in women, with a high proportion reporting headaches. Prevalence of AI at diagnosis is high. Surgery may not achieve adrenal axis recovery, but renders a high percentage of headache improvement. Approximately 25% of RCC will recur by 4 years postoperatively. Clinicians should cautiously screen patients with symptomatic RCC, regardless of lesion size for AI.
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Affiliation(s)
- Fabienne Langlois
- Department of Endocrinology, Centre hospitalier universitaire de Sherbrooke, Fleurimont, QC, Canada
| | - Anamaria Manea
- Pediatric Endocrinology, Oregon Health & Science University, Portland, OR, USA
| | - Dawn Shao Ting Lim
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Shirley McCartney
- Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | | | - Justin S Cetas
- Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Maria Fleseriu
- Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
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Derrick KM, Gomes WA, Gensure RC. Incidence and Outcomes of Pituitary Microadenomas in Children with Short Stature/Growth Hormone Deficiency. Horm Res Paediatr 2019; 90:151-160. [PMID: 30261514 DOI: 10.1159/000489456] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 04/17/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Patients with short stature (SS)/growth hormone deficiency (GHD) and precocious puberty (PP) undergo brain MRI to evaluate for structural brain abnormalities or pituitary lesions, and pituitary microadenomas are a common finding. Theoretically, a mass effect from these lesions could cause GHD and growth hormone treatment could cause them to enlarge, but they should not cause PP, at least in females. METHODS We investigated if pituitary microadenomas cause GHD by comparing their incidence in patients with SS/GHD to that in females with PP. We performed a retrospective chart review of patients with these disorders who had a brain MRI between 2000 and 2013. RESULTS The incidence of microadenoma was high in both groups, 18.5% for SS (n = 346) and 21.1% for PP females (n = 194), but did not differ between groups (p = 0.46). In patients with microadenomas, repeat imaging showed resolution in 58% (SS, n = 33) and 67% (PP females, n = 21). Importantly, none of the lesions grew, even in patients treated with growth hormone. CONCLUSIONS Pituitary microadenomas are common in children with GHD/SS and PP, but it does not appear that they are a cause of GHD. They appear to be of limited clinical significance and should not be considered a contraindication to growth hormone therapy.
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Affiliation(s)
- Kristina M Derrick
- Division of Pediatric Endocrinology, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York,
| | - William A Gomes
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Robert C Gensure
- Division of Pediatric Endocrinology, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York, USA
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25
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Endoscopic endonasal resection of symptomatic Rathke cleft cysts: clinical outcomes and prognosis. Neurosurg Rev 2018; 42:699-704. [PMID: 30535966 DOI: 10.1007/s10143-018-01058-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/01/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
Abstract
The aim of this study is to investigate the clinical presentation and outcomes associated with endoscopic endonasal resection of Rathke cleft cysts (RCCs). The authors retrospectively studied a series of 13 patients who were diagnosed with RCCs after endoscopic endonasal resection at the Second Xiangya Hospital between June 2016 and December 2017. All 13 patients (8 women) underwent a purely endoscopic endonasal approach (EEA) for fenestration and aspiration of RCCs with excision of the cystic wall. The patient ages varied from 25 to 67 years (mean, 45.1 years), and the follow-up period ranged from 8 to 25 months (mean, 16.6 months). Headache was a presenting symptom in all 13 patients, with 11 (80%) out of the 13 having experienced postoperative improvement of their headaches. Six (46%) of the 13 patients were admitted with pituitary dysfunction, all of them had postoperative improvement. Four (31%) of the 13 patients had temporary postoperative pituitary dysfunction, although there was not any permanent pituitary dysfunction. Six patients had intraoperative complications with CSF leaks, and after the operation, three of them developed temporary diabetes insipidly, one of them had a postoperative infection, and another one had postoperative cerebrospinal fluid leaks, who was treated with absolute bed rest for 7 days. No patient experienced recurrent cysts. EEA is a safe and effective approach for the treatment of symptomatic RCCs. Notably, it is appreciated for protecting and restoring pituitary function; however, the postoperative recurrence rate still lacks a large sample related to the long time follow-up study. Complete aspiration of the cysts' contents with partial excision of the cyst wall is usually sufficient for treatment.
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26
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Prokop-Piotrkowska M, Moszczyńska E, Daszkiewicz P, Roszkowski M, Szalecki M. Symptomatic Rathke cleft cyst in paediatric patients - clinical presentations, surgical treatment and postoperative outcomes - an analysis of 38 cases. J Pediatr Endocrinol Metab 2018; 31:903-910. [PMID: 29982239 DOI: 10.1515/jpem-2017-0540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/11/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Rathke cleft cysts (RCC) are benign, epithelium-lined intrasellar and/or suprasellar cysts believed to originate from the remnants of the Rathke pouch. The aim of this study was to analyse the symptoms and surgical outcome of patients with the diagnosis of RCC verified in a histopathological examination of the postoperative material. METHODS The study is a retrospective analysis of 38 cases of children who underwent a neurosurgical treatment due to RCC at the Children's Memorial Health Institute in Warsaw, Poland, between 1994 and 2015. RESULTS At diagnosis, the mean age was 13 years and 8 months (6 years and 11 months-17 years and 10 months, sex ratio was 1:0.9 with a female prevalence). The most common symptoms were the following: headache (50%), hypothyroidism (50%), short stature and/or decreased growth velocity (47%), delayed puberty and menstrual abnormalities (37%), diabetes insipidus or polydipsia and polyuria (26%), adrenal dysfunction (26%), sleepiness and general weakness (13%) and visual disturbances (11%). Due to the gravity of symptoms and size of the lesion, all the patients underwent a surgical treatment. All but one were successful (one patient died due to postoperative neurosurgical complications). The most common postoperative complications were the following: adenohypopituitarism (67%) and diabetes insipidus (45%). CONCLUSIONS RCC can present with serious symptoms that significantly deteriorate patients' quality of life. Despite a successful neurosurgical treatment in most of the analysed cases, patients required long-term pharmacological treatment.
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Affiliation(s)
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, Children's Memorial Health Institute, Warsaw, Poland
| | - Paweł Daszkiewicz
- Department of Neurosurgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Marcin Roszkowski
- Department of Neurosurgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, Children's Memorial Health Institute, Warsaw, Poland.,The Faculty of Medicine and Health Sciences, Jan Kochanowski University, Kielce, Poland
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27
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Sala E, Moore JM, Amorin A, Carosi G, Martinez H, Harsh GR, Arosio M, Mantovani G, Katznelson L. Natural history of Rathke's cleft cysts: A retrospective analysis of a two centres experience. Clin Endocrinol (Oxf) 2018; 89:178-186. [PMID: 29781512 DOI: 10.1111/cen.13744] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/12/2018] [Accepted: 05/15/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Rathke's cleft cyst (RCC) is a common sellar lesion which may cause visual impairment, hypopituitarism and headaches from mass effect. The natural history of these lesions is currently unclear. We investigated the natural history of RCCs and compared surgically treated patients with those treated conservatively. METHODS We performed a retrospective cohort study of patients diagnosed with a RCC between 1996 and 2016 at Stanford University and Ospedale Maggiore Policlinico di Milano. RESULTS Patients were divided into 2 cohorts: Group A, 72 subjects who underwent surgical resection of a symptomatic RCC, and Group B, 62 subjects managed conservatively. Compared to Group B, Group A subjects had larger RCCs (79% vs 22% had a largest diameter >10 mm, P < .001) and were more likely (41.5% vs 16%, P < .001) to present with hypopituitarism and diabetes insipidus (DI) (18% vs 1.6%, P = .002). In Group A, after a mean follow-up of 53.7 months, 12.5% of patients had recurrence and a second surgery. After surgery, 35% of patients recovered pituitary function. Hyperprolactinemia (26.6%) and hypogonadism (66.6%) resolved more commonly that did DI (20.1%). New pituitary deficits appeared in 16.6% of patients after surgery. In Group B, with a mean follow-up of 41 months, only 6.4% had cyst enlargement, none underwent surgery, and none developed a pituitary deficit. CONCLUSION Our data offer guidance in decision-making regarding the management of RCC patients and confirm the safety of conservative treatment in asymptomatic patients.
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Affiliation(s)
- Elisa Sala
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Neurological Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Justin M Moore
- Department of Neurological Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Alvaro Amorin
- Department of Neurological Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Giulia Carosi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Hector Martinez
- Department of Neurological Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Griffith R Harsh
- Department of Neurological Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Laurence Katznelson
- Department of Neurological Surgery, Stanford University Hospital, Stanford, CA, USA
- Department of Medicine, Stanford University Hospital, Stanford, CA, USA
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29
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Shepard MJ, Elzoghby MA, Kiehna EN, Payne SC, Jane JA. Presentation and outcomes in surgically and conservatively managed pediatric Rathke cleft cysts. J Neurosurg Pediatr 2018; 21:308-314. [PMID: 29271731 DOI: 10.3171/2017.9.peds17400] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rathke cleft cysts (RCCs) are sellar lesions that are commonly encountered in adults but infrequently diagnosed in the pediatric population. As a result, the optimal management of pediatric RCCs remains a subject of controversy. Only 2 prior surgical series have been published on pediatric RCCs and no study has compared the presentation and outcomes of surgically versus conservatively managed cases. The authors therefore performed a comparative analysis of pediatric cases of RCC in which patients were treated with surgery or managed in a conservative manner. METHODS All cases involving pediatric patients diagnosed with an RCC at the University of Virginia between 2000 and 2016 were included in this study. Patient medical records, operative notes, and neuroimaging findings were reviewed. Patients who developed visual field deficits, radiographic evidence of chiasmal compression, or medically refractory headaches were considered candidates for surgical intervention. All patients who were selected for surgery underwent an endoscopic endonasal approach with cyst fenestration. RESULTS A total of 24 pediatric patients were diagnosed with an RCC over a 16-year period. Seven patients ultimately underwent transsphenoidal cyst fenestration, and 17 were managed conservatively. The patients' age at diagnosis, cyst size, and pituitary function at the time of RCC diagnosis were similar in the conservatively and surgically managed cohorts. At diagnosis, 19 of 24 patients endorsed headaches that led to neuroimaging. All patients in the surgical cohort endorsed severe headaches at diagnosis compared with 71% in the conservative group. For the 7 patients treated with surgery, complete cyst evacuation was achieved in 86% of cases. Transient postoperative endocrinopathy occurred in 4 (57%) of 7 surgically treated individuals and resolved in all cases. In the conservative cohort, 1 patient developed a delayed pituitary-related endocrinopathy. Headache resolution occurred in 5 (71%) of the 7 patients who underwent surgery and 7 (58%) of the 12 who were treated without surgery. Cyst recurrence was documented in 1 individual in the surgical cohort who underwent a subtotal cyst fenestration that ultimately required re-intervention. In the conservative cohort, spontaneous cyst shrinkage occurred in 35% of patients with a median time to regression of 23.5 months. CONCLUSIONS Pediatric RCCs are benign sellar lesions that often present with headaches. While cyst fenestration mitigates headaches in most patients, the majority of conservatively managed pediatric patients with RCCs will have spontaneous headache resolution. Furthermore, spontaneous RCC regression occurs in a substantial number of individuals. Thus, in the absence of optic compression, visual field deficit, or diagnostic uncertainty, many pediatric cases of RCC can be managed conservatively.
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Affiliation(s)
| | - Mohamed A Elzoghby
- Departments of1Neurosurgery and.,4Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Erin N Kiehna
- 3Department of Neurosurgery, Children Hospital, Los Angeles, California; and
| | - Spencer C Payne
- 2Otolaryngology, University of Virginia Health System, Charlottesville, Virginia
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30
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Jung JE, Jin J, Jung MK, Kwon A, Chae HW, Kim DH, Kim HS. Clinical manifestations of Rathke's cleft cysts and their natural progression during 2 years in children and adolescents. Ann Pediatr Endocrinol Metab 2017; 22:164-169. [PMID: 29025202 PMCID: PMC5642082 DOI: 10.6065/apem.2017.22.3.164] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/14/2016] [Accepted: 03/20/2017] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Rathke's cleft cyst (RCC) is an asymptomatic benign lesion. With increased interest in pediatric endocrinology, the prevalence of RCCs in children is also increasing. However, the clinical relevance and proper management of RCC is not well defined in children. Therefore, we investigated the clinical manifestations and radiologic features of RCC in children and adolescents, as well as the natural progression of RCC. METHODS We retrospectively reviewed the medical records of 91 children and adolescents with RCC diagnosed with magnetic resonance imaging (MRI) in Severance Children's Hospital from January 2006 to December 2015. The clinical, hormonal, and imaging findings were analyzed in patient groups classified according to age. The size of each cyst was assessed in sixty patients who underwent follow-up MRI during the 2 years. RESULTS Female patients were predominant (64 vs. 27). The common clinical features at presentation were endocrine dysfunction (59.3%), headache (23.0%), and dizziness (4.4%). Symptoms related to endocrine disorders were more frequent in younger patients. In 7 patients managed surgically, the cysts were significantly larger and more frequently located in the suprasellar region. Of 60 nonsurgical patients with a follow-up MRI performed within 2 years after the diagnosis, the RCC size increased in about 26.7% (n=16). CONCLUSIONS Although 94.4% of the patients with RCC had clinical symptoms, surgery was performed in only about 7.5% of patients. RCC is associated with pituitary insufficiency, thus, baseline and follow-up endocrine function tests are required. Additionally, regular MRI follow-up is required in long-term period to monitor change in size.
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Affiliation(s)
- Jo Eun Jung
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Juhyun Jin
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Mo Kyung Jung
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ahreum Kwon
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Wook Chae
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duk Hee Kim
- Department of Pediatrics, Sowha Children’s Hospital, Seoul, Korea
| | - Ho-Seong Kim
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea,Address for correspondence: Ho-Seong Kim, MD, PhD https://orcid.org/0000-0003-1135-099X Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-2069 Fax: +82-2-393-9118 E-mail:
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Uppal S, Jee YH, Lightbourne M, Han JC, Stratakis CA. Combined pituitary hormone deficiency in a girl with 48, XXXX and Rathke's cleft cyst. Hormones (Athens) 2017; 16:92-98. [PMID: 28500832 PMCID: PMC6369518 DOI: 10.14310/horm.2002.1723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/02/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Tetrasomy X is a rare chromosomal aneuploidy seen in girls, associated with facial dysmorphism, premature ovarian insufficiency and intellectual disability. A Rathke's cleft cyst (RCC) is a remnant of Rathke's pouch which may cause multiple pituitary hormone deficiencies by exerting pressure on the pituitary gland in the sella. METHODS/RESULTS The patient was diagnosed with tetrasomy X by karyotyping during infancy. Brain MRI and multiple endocrine stimulation tests revealed RCC and combined pituitary hormone deficiency (growth hormone deficiency, secondary adrenal insufficiency and central hypothyroidism) likely due to RCC. CONCLUSION We report the first case in the literature of a girl with 48, XXXX and combined pituitary hormone deficiency due to Rathke's cyst.
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Affiliation(s)
- Surabhi Uppal
- Section on Genetics & Endocrinology (SEGEN), Program on Developmental Endocrinology & Genetics (PDEGEN), NICHD, NIH, Building 10, CRC, East Laboratories, Rm. 1-3330 (1-3216 lab), 10 Center Drive, Bethesda, MD, 20892, USA
- Pediatric endocrinology training program, NICHD, National Institutes of Health, Bethesda, MD, USA
| | - Youn Hee Jee
- Section on Genetics & Endocrinology (SEGEN), Program on Developmental Endocrinology & Genetics (PDEGEN), NICHD, NIH, Building 10, CRC, East Laboratories, Rm. 1-3330 (1-3216 lab), 10 Center Drive, Bethesda, MD, 20892, USA
- Pediatric endocrinology training program, NICHD, National Institutes of Health, Bethesda, MD, USA
| | - Marissa Lightbourne
- Pediatric endocrinology training program, NICHD, National Institutes of Health, Bethesda, MD, USA
| | - Joan C Han
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Constantine A Stratakis
- Section on Genetics & Endocrinology (SEGEN), Program on Developmental Endocrinology & Genetics (PDEGEN), NICHD, NIH, Building 10, CRC, East Laboratories, Rm. 1-3330 (1-3216 lab), 10 Center Drive, Bethesda, MD, 20892, USA.
- Pediatric endocrinology training program, NICHD, National Institutes of Health, Bethesda, MD, USA.
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