Craniopharyngioma and other cystic epithelial lesions of the sellar region: a review of clinical, imaging, and histopathological relationships

Rathke's cleft cysts: from pathophysiology to management

Rathke's cleft cysts (RCCs) are benign, non-neoplastic lesions located in the sellar and suprasellar regions of the brain, originating from remnants of Rathke's pouch, an embryonic precursor to the anterior pituitary gland. Although RCCs are frequently asymptomatic and discovered incidentally during imaging studies, they can present with a variety of symptoms, including headaches, visual disturbances, and endocrine dysfunction due to the compression of adjacent neural structures. The management of RCCs is particularly challenging, as the decision to pursue conservative monitoring or surgical intervention depends heavily on the cyst's size, growth potential, and the severity of symptoms. Transsphenoidal surgery is the primary treatment for symptomatic RCCs, offering effective relief from symptoms through decompression of the cyst. However, recurrence remains a significant issue, with rates reported up to 33%, prompting debates about the extent of cyst wall removal during surgery. Recent advancements in minimally invasive endoscopic techniques have improved surgical outcomes, yet the risk of postoperative complications such as hypopituitarism and cerebrospinal fluid leaks persists. Additionally, stereotactic radiosurgery has emerged as a potential alternative for patients with recurrent RCCs or those who are not suitable candidates for repeat surgery. Despite its promise, the long-term safety and efficacy of radiotherapy in RCC management require further investigation. This narrative review aims to provide a comprehensive overview of RCCs, integrating the latest research and clinical guidelines to discuss pathophysiology, clinical presentation, and management strategies, emphasizing the need for a personalized approach to treating this complex condition.

A Case of Papillary Craniopharyngioma Mimicking Rathke's Cleft Cyst

Craniopharyngioma (CP) and Rathke's cleft cyst (RCC) are both suprasellar lesions. They are sometimes difficult to distinguish due to their similar findings. We report a case of papillary craniopharyngioma (pCP) with the clinical findings suggesting RCC. A 42-year-old female with intellectual disability presented to our hospital with severe visual dysfunction. Preoperative images revealed a suprasellar cystic lesion without calcification. We performed transsphenoidal surgery. Since the cyst had condensed-milk-like content suggesting RCC, we performed cyst fenestration and wash without removal of the cyst wall. Thereafter, we found fish-egg-like structures on the cyst wall. The histopathological analysis revealed that they had papillary structures surrounded by hyperplastic squamous epithelium with parakeratosis. Immunostaining for BRAF V600E was positive, leading to the diagnosis of pCP. After the surgery, her visual function improved and follow-up Magnetic resonance imaging at 18 months postoperatively showed no apparent recurrence. The presence of condensed-milk-like content suggests a likelihood of RCC indicating that aggressive resection may not be necessary. In contrast, the existence of fish-egg-like structures suggests pCP and requires careful follow-up.

Proteomics study of primary and recurrent adamantinomatous craniopharyngiomas

BACKGROUND

Adamantinomatous craniopharyngiomas (ACPs) are rare benign epithelial tumours with high recurrence and poor prognosis. Biological differences between recurrent and primary ACPs that may be associated with disease recurrence and treatment have yet to be evaluated at the proteomic level. In this study, we aimed to determine the proteomic profiles of paired recurrent and primary ACP, gain biological insight into ACP recurrence, and identify potential targets for ACP treatment.

METHOD

Patients with ACP (n = 15) or Rathke's cleft cyst (RCC; n = 7) who underwent surgery at Sanbo Brain Hospital, Capital Medical University, Beijing, China and received pathological confirmation of ACP or RCC were enrolled in this study. We conducted a proteomic analysis to investigate the characteristics of primary ACP, paired recurrent ACP, and RCC. Western blotting was used to validate our proteomic results and assess the expression of key tumour-associated proteins in recurrent and primary ACPs. Flow cytometry was performed to evaluate the exhaustion of tumour-infiltrating lymphocytes (TILs) in primary and recurrent ACP tissue samples. Immunohistochemical staining for CD3 and PD-L1 was conducted to determine differences in T-cell infiltration and the expression of immunosuppressive molecules between paired primary and recurrent ACP samples.

RESULTS

The bioinformatics analysis showed that proteins differentially expressed between recurrent and primary ACPs were significantly associated with extracellular matrix organisation and interleukin signalling. Cathepsin K, which was upregulated in recurrent ACP compared with that in primary ACP, may play a role in ACP recurrence. High infiltration of T cells and exhaustion of TILs were revealed by the flow cytometry analysis of ACP.

CONCLUSIONS

This study provides a preliminary description of the proteomic differences between primary ACP, recurrent ACP, and RCC. Our findings serve as a resource for craniopharyngioma researchers and may ultimately expand existing knowledge of recurrent ACP and benefit clinical practice.

Accurate preoperative diagnosis of a Rathke cleft cyst with the aid of a novel classification for sellar cystic lesions and a diagnostic algorithm decision: Tools for differentiating cystic sellar lesions with a representative case

Background

Rathke's cleft cyst (RCC) is a benign lesion in the sellar and suprasellar compartments. Similarly, pituitary adenomas can present with cystic morphology, making it a differential diagnosis when evaluating a patient with a cystic lesion in the sellar region. Surgical goals differ between RCCs and pituitary adenomas as the first can achieve remission of symptoms with cyst decompression in contrast to pituitary adenomas where complete resection would be the main goal. Imaging analysis alone may not be sufficient to define a preoperative surgical plan. The combination of imaging and conjoined use of validated tools may provide valuable insights to the clinician when defining a surgical approach.

Case Description

We present a case of a 27-year-old male with a 3-month history of visual disturbances and headaches. Magnetic resonance imaging showed a cystic lesion in the sellar compartment with compression of nearby structures. The authors were able to accurately diagnose this sellar lesion as an RCC with the conjoined aid of two classifications proposed in the literature. Cyst evacuation was performed with relief of symptoms and improved visual outcomes at follow-up.

Conclusion

While cystic adenomas can require total resection for cure, RCCs can show marked improvement with partial resection and evacuation of its contents. An accurate preoperative diagnosis can lead the surgeon to opt for the best surgical approach.

Pediatric sellar teratoma - Case report and review of the literature

BACKGROUND

Intracranial teratoma represents a rare neoplasm, occurring predominantly during childhood. Characteristic symptoms depend on the location but are mainly hydrocephalus, visual disturbances, hypopituitarism, and diabetes insipidus. Initial diagnosis can be challenging due to similar radiological features in both teratomas and other lesions such as craniopharyngiomas. Gross total resection is recommended if feasible and associated with a good prognosis.

CASE DESCRIPTION

A 10-year-old girl presented with newly diagnosed growth retardation, fatigue, cephalgia and bilateral hemianopia. Further laboratory analysis confirmed central hypothyroidism and hypercortisolism. Cranial magnetic resonance imaging showed a cystic space-occupying lesion in the sellar and suprasellar compartment with compression of the optic chiasm without hydrocephalus present, suspicious of craniopharyngioma. Subsequently, an endonasal endoscopic transsphenoidal near-total tumor resection with decompression of the optic chiasm was performed. During postoperative recovery the patient developed transient diabetes insipidus, the bilateral hemianopia remained unchanged. The patient could be discharged in a stable condition, while hormone replacement for multiple pituitary hormone deficiency was required. Surprisingly, histopathology revealed conspicuous areas of skin with formation of hairs and squamous epithelia, compatible with a mature teratoma.

CONCLUSIONS

We present an extremely rare case of pediatric sellar teratoma originating from the pituitary gland and a review of literature focusing on the variation in presentation and treatment. Sellar teratomas are often mistaken for craniopharyngioma due to their similar radiographic appearances. However, the primary goal of treatment for both pathologies is to decompress eloquent surrounding structures such as the optic tract, and if applicable, resolution of hydrocephalus while avoiding damage to the pituitary stalk and especially the hypothalamic structures. If feasible, the aim of surgery should be gross total resection.

Sex classification from functional brain connectivity: Generalization to multiple datasets Generalizability of sex classifiers

Machine learning (ML) approaches are increasingly being applied to neuroimaging data. Studies in neuroscience typically have to rely on a limited set of training data which may impair the generalizability of ML models. However, it is still unclear which kind of training sample is best suited to optimize generalization performance. In the present study, we systematically investigated the generalization performance of sex classification models trained on the parcelwise connectivity profile of either single samples or a compound sample containing data from four different datasets. Generalization performance was quantified in terms of mean across-sample classification accuracy and spatial consistency of accurately classifying parcels. Our results indicate that generalization performance of pwCs trained on single dataset samples is dependent on the specific test samples. Certain datasets seem to "match" in the sense that classifiers trained on a sample from one dataset achieved a high accuracy when tested on the respected other one and vice versa. The pwC trained on the compound sample demonstrated overall highest generalization performance for all test samples, including one derived from a dataset not included in building the training samples. Thus, our results indicate that a big and heterogenous training sample comprising data of multiple datasets is best suited to achieve generalizable results.

Rathke's Cleft Cyst and Craniopharyngioma: A Continuum of the Same Spectrum? Insights from an Interesting Case and Previous Literature

Rathke's Cleft Cysts (RCCs) and Craniopharyngiomas (CPs) may represent disease entities on the same etio-pathological spectrum. We report the case of a 36-year-old female presenting with vision loss and menstrual irregularities, imaging shows a predominantly cystic lesion in the sellar region with suprasellar extension. She underwent a microscopic transnasal resection of the lesion. She later presented with recurrent symptoms and increased residual lesion size on imaging, a transcranial excision of the lesion was performed. Histopathology from the initial operative specimen revealed RCC with squamous metaplasia which was BRAF negative, while the specimen from the second surgery revealed BRAF positive papillary stratified squamous architecture suggestive of Papillary CP. This case adds to the evidence that both RCCs and papillary CPs may be the spectrum of the same disease. Further, papillary CPs may be an evolution from the RCCs.

Intrasellar Dermoid Cyst: Case Report of a Rare Lesion and Systematic Literature Review Comparing Intrasellar, Suprasellar, and Parasellar Locations

OBJECTIVE

Intracranial dermoid cyst (DC) is a rare benign, slow-growing lesion, most commonly arising along the midline. They can occur in the supratentorial compartment, very rarely involve the sellar region and only exceptionally are intrasellar. The aim of our study is to address the challenges in the diagnosis and management of sellar DCs.

METHODS

We performed a systematic review of sellar DCs, in keeping with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and described an intrasellar DC in a 32-year-old female who presented with bilateral blurring vision.

RESULTS

The review identified 4 intrasellar, 29 suprasellar, and 28 parasellar cases. Intrasellar DCs more likely present with progressive visual impairment and pituitary hormone dysfunctions during the fifth decade of life. Suprasellar and parasellar DCs are typically diagnosed during the third decade of life because of diplopia, ptosis, trigeminal hypoaesthesia/para-esthesia or cyst's rupture. Sellar DCs are typically hypodense on computed tomography scans and contain calcifications. Magnetic resonance imaging features include T1 hyperintensity, T2 heterogeneous intensity, no restriction on diffusion-weighted images, and no contrast enhancement. Surgery is the treatment of choice. Gross total resection is achieved in 60% of intrasellar and 61.9% of suprasellar and parasellar DCs. Early postoperative complications are reported in 40.0%, 16.7%, and 23.8% of intrasellar, suprasellar, and parasellar DCs, respectively.

CONCLUSIONS

Intrasellar DCs are rare lesions typically diagnosed later than suprasellar and parasellar DCs due to their different clinical presentations. However, they should be considered in the differential diagnosis of cystic lesions of the sella, including epidermoid cysts, craniopharyngiomas, Rathke's cleft cysts, and teratomas.

Machine Learning Approaches to Differentiate Sellar-Suprasellar Cystic Lesions on Magnetic Resonance Imaging

Cystic lesions are common lesions of the sellar region with various pathological types, including pituitary apoplexy, Rathke's cleft cyst, cystic craniopharyngioma, etc. Suggested surgical approaches are not unique when dealing with different cystic lesions. However, cystic lesions with different pathological types were hard to differentiate on MRI with the naked eye by doctors. This study aimed to distinguish different pathological types of cystic lesions in the sellar region using preoperative magnetic resonance imaging (MRI). Radiomics and deep learning approaches were used to extract features from gadolinium-enhanced MRIs of 399 patients enrolled at Peking Union Medical College Hospital over the past 15 years. Paired imaging differentiations were performed on four subtypes, including pituitary apoplexy, cystic pituitary adenoma (cysticA), Rathke's cleft cyst, and cystic craniopharyngioma. Results showed that the model achieved an average AUC value of 0.7685. The model based on a support vector machine could distinguish cystic craniopharyngioma from Rathke's cleft cyst with the highest AUC value of 0.8584. However, distinguishing cystic apoplexy from pituitary apoplexy was difficult and almost unclassifiable with any algorithms on any feature set, with the AUC value being only 0.6641. Finally, the proposed methods achieved an average Accuracy of 0.7532, which outperformed the traditional clinical knowledge-based method by about 8%. Therefore, in this study, we first fill the gap in the existing literature and provide a non-invasive method for accurately differentiating between these lesions, which could improve preoperative diagnosis accuracy and help to make surgery plans in clinical work.

Uncommon Presentation of Craniopharyngioma: A Case Report of Post-traumatic Intratumoral Hemorrhage Leading to Cerebral Infarct

Craniopharyngiomas emanate from squamous cell remnants in the hypophyseal/pharyngeal duct region. This report details the unprecedented case of a 29-year-old male with adamantinomatous craniopharyngioma, who, following a motor vehicle collision (MVC), presented with post-traumatic intratumoral hemorrhage leading to acute basal ganglia infarct. The patient, previously subjected to subtotal resection, exhibited focal neurological deficits attributed to compression of lenticulostriate arteries due to the sudden increase in tumor volume. The patient, ineligible for thrombolysis or thrombectomy, was conservatively managed post-MVC. Subtotal resection occurred four months later. After one year, persistent right-sided weakness (2/5 motor power) remained, and the recommended stereotactic radiotherapy was declined by the patient. Notably, this instance represents the first documented case of post-traumatic intratumoral hemorrhage in adamantinomatous craniopharyngioma. This report distinguishes between adamantinomatous and papillary subtypes, noting their prevalence in different age groups. While these tumors commonly present with gradual vision changes, fatigue, and endocrine dysfunction, complications such as intra-tumoral hemorrhage remain rare. This report serves as an educational tool, shedding light on potential complications and urging increased vigilance in managing craniopharyngiomas.

Recurrence of Rathke's Cleft Cyst Following Surgery and Histopathological Considerations for Recurrence: A Case Presentation

Recurrence of Rathke's cleft cysts (RCC) following surgery is not uncommon. We present a 33-year-old male patient with chronic headache and visual disturbances whose MRI showed mostly cystic, suprasellar mass with peripheral enhancement. Endoscopic extended transsphenoidal approach and tumor resection was performed and RCC was pathologically confirmed postoperatively. Early recurrence was first suspected at 3 months following surgery, and his serial MRIs showed a recurred mass without associated clinical symptoms. Upon further histopathological study, extensive squamous metaplasia and high Ki-67 were seen. Also, in this study, we discuss important factors associated with cyst recurrence following surgery.

Transcription Factor GLI1 Induces IL-6-Mediated Inflammatory Response and Facilitates the Progression of Adamantinomatous Craniopharyngioma

Adamantinomatous craniopharyngioma (ACP) is a neuroendocrine tumor whose pathogenesis remains unclear. This study investigated the role of glioma-associated oncogene family zinc finger 1 (GLI1), a transcription factor in the sonic hedgehog (SHH) signaling pathway, in ACP. We discovered that GLI1 regulates the expression of IL-6, thereby triggering inflammatory responses in ACP and influencing the tumor's progression. Analyzing the Gene Expression Omnibus (GEO) database chip GSE68015, we found that GLI1 is overexpressed in ACP, correlating positively with the spite of ACP and inflammation markers. Knockdown of GLI1 significantly inhibited the levels of tumor necrosis factor α, interleukin-6 (IL-6), and IL-1β in ACP cells, as well as cell proliferation and migration. We further identified a binding site between GLI1 and the promoter region of IL-6, demonstrating that GLI1 can enhance the expression of IL-6. These findings were verified in vivo, where activation of the SHH pathway significantly promoted GLI1 and IL-6 expressions in nude mice, inducing inflammation and tumor growth. Conversely, GLI1 knockdown markedly suppressed these processes. Our study uncovers a potential molecular mechanism for the occurrence of inflammatory responses and tumor progression in ACP.

Clinical features and surgical outcomes of Rathke cleft cysts with suprasellar components: a single-center experience of 157 cases

BACKGROUND

Both intrasuprasellar and suprasellar Rathke cleft cysts (RCCs) have suprasellar components, and we aimed to explore their clinical features and surgical outcomes.

METHOD

Patients with surgically treated intrasuprasellar or suprasellar RCCs were retrospectively analyzed. All patients with intrasuprasellar RCCs were treated with the standard endoscopic endonasal approach (EEA, group I); the patients with suprasellar RCCs received the extended EEA (group II) or supraorbital keyhole approach (SKA, group III) according to the relevant indications. A surgical strategy of maximal safe resection aiming to protect neuroendocrine function was adopted. In addition, patients (distinguished from the above 3 groups) who had aggressive resection of suprasellar RCC were also enrolled for comparison of different surgical strategies.

RESULTS

A total of 157 patients were eligible, including 121 patients with intrasuprasellar RCCs in group I, 19 patients with suprasellar RCCs in group II, and 17 patients with suprasellar RCCs in group III. Preoperatively, the patients with suprasellar RCC (groups II and III) more commonly presented with visual dysfunction, diabetes insipidus (DI), and hyperprolactinemia than the patients with intrasuprasellar RCCs (all p<0.05). A higher incidence of hypopituitarism and a larger diameter were observed for intrasuprasellar RCCs (both p<0.05). Postoperatively, group II had a higher rate of new-onset DI, hyponatremia, and recurrence than group I (all p<0.025) and similar outcomes to group III. For suprasellar RCCs, comparison of the maximal safe resection vs. aggressive resection (supplementary patients: 14 with extended EEA, 12 with SKA) showed similar improvement and recurrence, with higher rates of DI and hyponatremia with the latter strategy (all p<0.05).

CONCLUSIONS

Suprasellar RCC is associated with more complicated preoperative presentations, intricate postoperative complications, and frequent recurrence compared with intrasuprasellar RCC. Under rational indications, both extended EEA and SKA achieve satisfactory outcomes. The strategy of maximal safe resection is recommended for greatest functional preservation.

Neuroimaging of pediatric tumors of the sellar region-A review in light of the 2021 WHO classification of tumors of the central nervous system

Sellar/suprasellar tumors comprise about 10% of all pediatric Central Nervous System (CNS) tumors and include a wide variety of entities, with different cellular origins and distinctive histological and radiological findings, demanding customized neuroimaging protocols for appropriate diagnosis and management. The 5th edition of the World Health Organization (WHO) classification of CNS tumors unprecedently incorporated both histologic and molecular alterations into a common diagnostic framework, with a great impact in tumor classification and grading. Based on the current understanding of the clinical, molecular, and morphological features of CNS neoplasms, there have been additions of new tumor types and modifications of existing ones in the latest WHO tumor classification. In the specific case of sellar/suprasellar tumors, changes include for example separation of adamantinomatous and papillary craniopharyngiomas, now classified as distinct tumor types. Nevertheless, although the current molecular landscape is the fundamental driving force to the new WHO CNS tumor classification, the imaging profile of sellar/suprasellar tumors remains largely unexplored, particularly in the pediatric population. In this review, we aim to provide an essential pathological update to better understand the way sellar/suprasellar tumors are currently classified, with a focus on the pediatric population. Furthermore, we intend to present the neuroimaging features that may assist in the differential diagnosis, surgical planning, adjuvant/neoadjuvant therapy, and follow-up of this group of tumors in children.

Association between birth characteristics and incidence of pituitary adenoma and craniopharyngioma: a registry-based study in California, 2001-2015

PURPOSE

To evaluate the association between birth characteristics, including parental sociodemographic characteristics, and early-onset pituitary adenoma (PA) and craniopharyngioma.

METHODS

Leveraging the population-based California Linkage Study of Early-onset Cancers, we identified the birth characteristics of incident cases with PA (n = 1,749) or craniopharyngioma (n = 227) who were born from 1978 to 2015 and diagnosed 1988-2015, as well as controls in a 50:1 ratio matched on birth year. Adjusted odds ratios (OR) and 95% confidence interval (CI) estimates were computed using unconditional multivariable logistic regression.

RESULTS

Males had a lower risk of PA than females (OR = 0.37, 95%CI: 0.34-0.41), and Black (OR = 1.55, 95%CI: 1.30-1.84) or Hispanic (OR = 1.53, 95%CI: 1.34-1.74) individuals had a higher risk compared to non-Hispanic Whites. Older maternal age was positively associated with PA (OR = 1.09, 95%CI: 1.04-1.15 per 5 years, p < 0.01), as was higher maternal education (OR = 1.12, 95%CI: 1.04-1.20 per year, p < 0.01). There were no statistically significant associations between birthweight (OR = 1.04, 95%CI: 0.99-1.09 per 500 g, p = 0.12), birth plurality, or birth order and PA. When stratified by race and ethnicity, the significant association with maternal education was identified only for non-Hispanic White individuals. On multivariable logistic regression, no statistically significant associations were identified between birth characteristics and incidence of craniopharyngioma, except that risk was higher among Hispanic (OR = 1.45, 95%CI: 1.01-2.08) compared to non-Hispanic White individuals.

CONCLUSION

In this large, population-based study, female sex, older maternal age, higher maternal education, and Hispanic ethnicity and Black race compared to non-Hispanic White race, were associated with an increased risk of PA in children and young adults.

Endoscopically operated 15 ventral skull-base dermoid and epidermoid cysts: Outcomes of a case series and technical note

BACKGROUND

Epidermoid and dermoid tumors in the sellar region are rare. These cystic lesions are a surgical challenge, as the thin capsule adheres firmly to nearby structures. A case series of 15 patients is presented.

METHODS

The patients were operated on in our clinic between April 2009 and November 2021. The endoscopic transnasal approach (ETA) was used. Lesions were located in the ventral skull base. In addition, the literature was reviewed to compare clinical features and outcomes of ventral skull-base epidermoid/dermoid tumors operated on via ETA.

RESULTS

In our series, removal of cystic contents and tumor capsule (gross total resection: GTR) was achieved in 3 patients (20%). GTR was not possible for the others, because of adhesions to vital structures. Near total resection (NTR) was achieved in 11 patients (73.4%), and subtotal resection (STR) in 1 (6.6%). At a mean follow-up of 55±26.27 months, there were no cases of recurrence requiring surgery.

CONCLUSION

Our series demonstrates that ETA is suitable for resection of epidermoid and dermoid cysts in the ventral skull base. GTR cannot always be the absolute clinical aim, because of inherent risks. In patients with expected long-term survival, the aggressiveness of surgery should be weighed on an individual risk/benefit basis.

Expanded Endonasal Endoscopic Approach for Suprasellar Rathke Cleft Cyst: Treatment Outcome and Surgical Nuances

OBJECTIVE

Rathke cleft cysts (RCCs) are benign lesions originating from remnants of the Rathke pouch. RCCs have been classified into the intrasellar-based or purely suprasellar types. This research aims to study the optimal treatment nuances and evaluate the surgical outcomes of this distinct type of RCCs.

METHODS

This study retrospectively reviewed 36 patients with purely suprasellar RCCs who were treated by expanded endonasal endoscopic approach (EEA) from September 2018 to January 2021. The demographic data, presenting symptoms, endocrine status, imaging findings, operative details, and surgical outcomes were analyzed.

RESULTS

According to the relationship with pituitary stalk, the suprasellar RCCs can be divided into 2 different growth patterns: intrastalk cyst (ISC, 52.8%) and extrastalk cyst (ESC, 47.2%). Preoperative endocrine dysfunctions occurred more in patients with ISC than ESC (P = 0.007), which are characterized by hypoadrenalism (P = 0.004) and hypogonadism (P = 0.008). Operation exerted different impacts on endocrine functions between ISC and ESC (P = 0.012). When identifying by single hypothalamic-pituitary axis, 4 patients with normal endocrine function developed a new hormonal deficit, 14 patients with preoperative endocrine dysfunctions benefited from our expanded EEA surgical treatment, and 3 of them completely recovered from the endocrinopathy after surgery. The postoperative endocrinopathy was positively associated with the numbers of preoperative abnormal endocrinal axes. Thirty-four (94.4%) patients had achieved gross total resection. Pituitary stalk was intactly preserved in 23 of 36 patients (63.9%), partly preserved in 10 patients, and not preserved in 3 patients.

CONCLUSIONS

Purely suprasellar RCCs are a distinct type of RCCs, which originate from the pituitary stalk above the diaphragmatic sellae, and the treatment strategy via expanded EEA is a rational choice. Classification based on growth patterns would be beneficial to reduce endocrine disorders after surgery.

Endoscopic Treatment of Rathke’s Cleft Cysts: The Case for Simple Fenestration

Background: Rathke’s cleft cysts (RCC) arise from the pars intermedia because of incomplete regression of the embryologic Rathke pouch. A subset of RCC becomes symptomatic causing headaches, visual and endocrinological disturbances such that surgical intervention is indicated. Several points in surgical management remain controversial including operative strategy (simple fenestration (SF) vs complete cyst wall resection (CWR)) as well as reconstructive techniques. Methods: A retrospective analysis was conducted of pathologically confirmed RCC operated on by endoscopic endonasal approach from 2006 to 2019. Pre-operative symptoms, imaging characteristics, operative strategy, symptom response, complications and recurrences were recorded. Results: Thirty-nine patients were identified. Thirty-three underwent SF and six underwent CWR. Worsening pituitary function was significantly increased with CWR (50%) compared to SF (3%) (p = 0.008). All patients underwent “closed” reconstruction with a post-operative CSF leak rate of 5% (3% SF vs 16% CWR, p = 0.287). Six (15%) recurrences necessitating surgery were reported. Recurrence rates stratified by surgical technique (18% SF vs 0% CWR, p = 0.564) were not found to be significantly different. Conclusions: The current series illustrates variability in the surgical management of RCCs. SF with closed reconstruction is a reasonable operative strategy for most symptomatic RCCs cases while CWR can be reserved for selected cases.

Endoscopic Extended Transsphenoidal Approach for Sellar and Suprasellar Xanthogranuloma: Potential Implications for Surgical Strategies in Adult Craniopharyngioma

OBJECTIVE

Differentiation of suprasellar xanthogranuloma (XG) from adult craniopharyngioma (CP) can be problematic in endoscopic extended transsphenoidal surgery.

METHODS

We reviewed the clinical data, preoperative imaging, intraoperative endoscopic findings, and intraoperative frozen section pathology in newly diagnosed adult CPs (19 patients) and XGs (6 patients).

RESULTS

Intracystic signal intensity was often high on T1-weighted magnetic resonance images in the XGs but low in the CPs (P = 0.015). Capsular intensity was low on T2-weighted imaging in XGs but iso to high in CPs (P < 0.001). Capsular gadolinium enhancement was often seen in CPs and not in XGs (P < 0.001). CPs often had a solid component with contrast enhancement but none in XGs (P < 0.001). Intraoperative endoscopic observations frequently found a whitish solid component in the CPs but yellow to brown fibrous granulomatous lesions in XGs (P < 0.001). The tumor capsule was dark grayish and soft in CPs, whereas it was fibrously hard in XGs (P = 0.002). Yellowish hemosiderin deposits were seen in all XGs (P = 0.003). Intraoperative pathologic diagnosis of CP was all verified whereas no evidence of tumor was found in XGs (P < 0.001). Partial removal was performed in 4 patients with XGs. No recurrence was observed in these patients during the follow-up period (1.5-8 years).

CONCLUSIONS

Careful interpretation of preoperative magnetic resonance imaging, intraoperative endoscopic findings, and intraoperative frozen section diagnosis may be important for the differential diagnosis between XG and CP. In endoscopic-extended transsphenoidal surgery, intentional partial removal can be effective for XG after careful diagnosis.

Diagnosis and Management of Pediatric Papillary Craniopharyngiomas

OBJECTIVE

Papillary craniopharyngioma (PCP) was previously believed to occur only in adults. Sporadic pediatric PCP (PPCP) confirmed by detection of BRAF V600E mutation has been reported since 2018, but is often misdiagnosed before being diagnosed definitively. We aimed to evaluate PPCP characteristics and propose diagnostic criteria for prompt diagnosis, seeking to reduce patient morbidity and mortality and reduce costs linked to misdiagnosis.

METHODS

This study included 5 patients with PPCPs whose data were retrieved retrospectively from among 1032 patients with craniopharyngiomas admitted to Sanbo Brain Hospital Management Group from March 2017 to May 2021. Patients' demographics, clinical presentation, tumor imaging characteristics, histopathologic results, surgical approaches, and postoperative outcomes were analyzed.

RESULTS

PPCP was misdiagnosed intraoperatively as sellar abscess (n = 4) or Rathke cleft cyst (n = 1). Preoperative magnetic resonance imaging showed that all tumors were under the saddle diaphragm, and the cyst wall was enhanced (n = 5). Computed tomography scans showed scattered high-density signs (n = 4). No recurrence was noted after complete resection. Postoperative hypothalamic dysfunction was mild. BRAF V600E mutation was confirmed in all cases by sequencing and immunohistochemistry. Immunohistochemistry showed granulation and inflammation and MPO, CD3, CD20, CD38, CD68, and CD163 were positively expressed.

CONCLUSIONS

Misdiagnosis of PPCP is responsible for failed surgical treatment. We propose that prompt diagnosis of PPCP can be achieved if preoperative magnetic resonance images show the tumor under saddle diaphragm with tumor wall enhancement and computed tomography scans show high-density signs scattered in the tumor, which leads to safe, effective tumor resection. Our proposed diagnosis and treatment strategy for PPCP reduces morbidity and mortality.

Rathke’s cleft cysts: A single-center case series

Background:

Rathke’s cleft cysts (RCCs) are common benign sellar or suprasellar lesions. The aim of this study is to report our experience on the management of 27 RCC cases.

Methods:

We retrospectively analyzed a series of 27 patients with symptomatic RCC who were referred to our department between January 2016 and January 2020. Data regarding patients’ demographics, clinical evaluations, laboratory and neuroimaging findings, pathologic records, surgical treatment, and complications were extracted from our electronic database. All patients underwent RCC removal through a direct endoscopic endonasal transsphenoidal (EETS) approach, except for two cases.

Results:

Data of 27 patients (3 men and 24 women; mean age: 38 years) with symptomatic RCC were reviewed. The most common presenting symptom was headache, occurring in 20 (74.0%) patients. In 16 (59.2%) cases, the tumor was primarily located in the sella turcica. Nine (33.3%) cases exhibited a secondary suprasellar extension.

Conclusion:

Our experience with RCC patients showed that EETS is a safe method of treatment, with minimal recurrence.

Xanthogranuloma of the Sellar Region: A Comprehensive Review of Neuroimaging in a Rare Inflammatory Entity

Xanthogranuloma of the sellar region is a rare chronic inflammatory lesion resulting from secondary hemorrhage, inflammation, infarction, and necrosis of an existing Rathke’s cleft cyst, craniopharyngioma, or pituitary adenoma. Sellar xanthogranulomas are challenging to differentiate from other cystic lesions preoperatively due to the lack of characteristic imaging features. We performed a literature overview of the clinical and paraclinical features, treatment options, and long-term outcomes of patients with sellar xanthogranuloma, focusing on the preoperative radiological diagnosis. The hyperintense signal in both T1- and T2-weighted sequences, cystic or partially cystic morphology, ovoid shape, sellar epicenter, intra- and suprasellar location, intratumoral calcifications, linear rim contrast enhancement, and the absence of cavernous sinus invasion suggest xanthogranuloma in the preoperative differential diagnosis. An endoscopic endonasal gross total resection without radiotherapy is the preferred first-line treatment. Given the low rate of recurrence rate and low chance of endocrinological recovery, a mass reduction with decompression of the optic apparatus may represent an appropriate surgical goal. Identifying the xanthogranulomas’ mutational profile could complement histopathological diagnosis and give insight into their histo-pathogenesis. A better preoperative neuroimagistic diagnosis of sellar xanthogranulomas and differentiation from lesions with a poorer prognosis, such as craniopharyngioma, would result in an optimal personalized surgical approach.

Approach to the Patient: Differential Diagnosis of Cystic Sellar Lesions

Cystic lesions arising in the sellar region are not uncommon and encompass cystic pituitary adenomas, Rathke cleft cysts, craniopharyngiomas, and arachnoid cysts. Their clinical presentation may be similar, including headache, visual field defects, and anterior pituitary hormone deficits, which makes differential diagnosis challenging. On the other hand, imaging features may indicate certain pathologies. In this approach to the patient, we describe the case of a patient who presented with right temporal hemianopsia and a sellar/suprasellar cystic lesion, which was determined to be Rathke cleft cyst. We discuss the imaging characteristics that may suggest a particular diagnosis between Rathke cleft cyst, cystic pituitary adenoma, craniopharyngioma, and arachnoid cyst and propose a flowchart for aiding in the imaging differential diagnosis.

Coexistence of craniopharyngioma and cranial fibrous dysplasia: a case series of clinicopathological study

Background

Craniopharyngioma (CP) and cranial fibrous dysplasia (CFD) are rare embryonic benign cranial diseases that most commonly present during childhood or adolescence. The coexistence of CP and CFD is extremely rare and has not yet been reported.

Methods

We retrospectively reviewed the data of five patients with concomitant CP and CFD treated at Beijing Tiantan Hospital from January 2003 to January 2021 and summarized their clinicopathological features, treatment modalities, and outcomes. We also performed a comprehensive literature review, tested the patients for characteristic GNAS gene mutations related to CFD, and tested the CP specimens for corresponding Gsα protein to explore the potential connection leading to the coexistence of CP and CFD.

Results

The cohort comprised four men and one woman (median age, 39 years). The symptoms mainly included headache, dizziness, fatigue, polyuria/polydipsia, hypogonadism, and blurred vision. CFD most commonly involved the sphenoid bone (n = 4). Four patients underwent surgery to remove the CP (one trans-sphenoidal and three transcranial resections); complete and subtotal resection were achieved in two patients, respectively. The tumor subtype was adamantinomatous in three patients and unknown in one. The common postoperative complications were panhypopituitarism, diabetes insipidus, and hypothyroidism. The mean follow-up duration was 57.2 months. Two patients required postoperative hormone replacement therapy. Three patients underwent genetic study of the tumor specimens; GNAS mutations were not detected, but these patients were positive for Gsα protein.

Conclusions

Although a definite causative relationship has not been proved, the coexistence of CP and CFD means that potential interplay or an atypical fibrous dysplasia course as uncommon manifestations of CP cannot be excluded. It is more challenging to initiate prompt diagnosis and appropriate treatment for concomitant CP and CFD than for solitary CP because of skull base deformations. Current management strategies are aimed at surgical treating the CP and regularly monitoring the CFD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02281-1.

Aneurysmal Bone Cyst of the Sphenoid Body Mimicking Craniopharyngioma: A Case Report

An aneurysmal bone cyst is a locally destructive benign lesion that predominately affects the long bones. Sphenoid body involvement is rare. To date, only 19 primary aneurysmal bone cysts of the sphenoid body have been reported. We describe the case of an 18-year-old male with a one-week history of severe right eye pain and lacrimation, right-sided diplopia, right-sided headache, photophobia, nausea, and vomiting. Magnetic resonance imaging (MRI) demonstrated a lobulated lesion centered in the sphenoid body with expansion into the cavernous sinus, sellar region, and clivus. The lesion had a homogenous hyperintense T2 signal with enhancing sidewalls and minimal septations. Computed tomography (CT) angiography revealed a hypoattenuating lesion containing a substance of nine Hounsfield units, compatible with water density. The clinicoradiologic findings were consistent with a craniopharyngioma. Intraoperatively, the lesion was confirmed to contain clear fluid and have prominent arterial feeding vessels. The extradural tumor was then excised with intralesional curettage. The histopathologic analysis resulted in a diagnosis of an aneurysmal bone cyst. This case highlights the potentially non-specific and variable appearance of aneurysmal bone cysts and the need to consider it in the differential diagnosis of sphenoid bone lesions.

The Role of Surgical Approaches in the Multi-Modal Management of Adult Craniopharyngiomas

Craniopharyngiomas are rare, benign primary brain tumors that arise from remnants of the craniopharyngeal duct epithelium within the sellar and suprasellar region. Despite their benign biology, they may cause significant morbidity, secondary to involvement of nearby eloquent neural structures, such as the pituitary gland, hypothalamus, and optic apparatus. Historically, aggressive surgical resection was the treatment goal to minimize risk of tumor recurrence via open transcranial midline, anterolateral, and lateral approaches, but could lead to clinical sequela of visual, endocrine, and hypothalamic dysfunction. However, recent advances in the endoscopic endonasal approach over the last decade have mostly supplanted transcranial surgery as the optimal surgical approach for these tumors. With viable options for adjuvant radiation therapy, targeted medical treatment, and alternative minimally invasive surgical approaches, the management paradigm for craniopharyngiomas has shifted from aggressive open resection to more minimally invasive but maximally safe resection, emphasizing quality of life issues, particularly in regards to visual, endocrine, and hypothalamic function. This review provides an update on current multi-modal approaches for craniopharyngiomas, highlighting the modern surgical treatment paradigm for this disease entity.

Papillary Craniopharyngioma: A Type of Tumor Primarily Impairing the Hypothalamus - A Comprehensive Anatomo-Clinical Characterization of 350 Well-Described Cases

OBJECTIVE

Papillary craniopharyngiomas (PCPs) represent a rare histological type of craniopharyngiomas (CPs) usually involving the hypothalamus. This study systematically analyzes the clinical-anatomical correlation between tumor topography and symptoms related to hypothalamic dysfunction in the largest series of PCPs ever gathered.

METHODS

From 5,346 CP reports published from 1856 to 2021, we selected 350 well-described cases of the squamous-papillary type. Clinical presentation, tumor topography, severity of hypothalamic adhesion, patient outcome, and tumor recurrence were thoroughly analyzed.

RESULTS

PCPs predominantly occur in adult (96.3%), male (61.7%) patients presenting with headache (63.4%), visual alterations (56.2%), and psychiatric disturbances (50.4%). Most PCPs are solid (50%), round (72%) lesions that occupy the third ventricle (3V, 94.8%) and show low-risk severity adhesions to the hypothalamus (66.8%). Two major topographical categories can be found: strictly 3V (57.5%), growing above an intact 3V floor, and not-strictly or infundibulo-tuberal (32.9%), expanding at the infundibulum and/or tuber cinereum. The hypothalamic syndrome predominated among strictly 3V PCPs (p < 0.001). Psychiatric symptoms (p < 0.001) and high-risk hypothalamic attachments (p = 0.031) related to unfavorable postoperative outcomes among patients treated from 2006 onwards. The not-strictly 3V topography was identified as the major predictor of high-risk hypothalamic attachments (71.2% correctly predicted), which, along with incomplete tumor removal (p = 0.018), underlies the higher tumor recurrence of this topography (p = 0.001).

CONCLUSIONS

This systematic review evidences that PCP topography is a major determinant of hypothalamic-related symptoms, type of hypothalamic attachments, and tumor recurrence rate. Accurate preoperative definition of PCP-hypothalamus relationships is essential for the judicious, safe management of these complex lesions.

Reinvestigating Tumor-Ventricle Relationship of Craniopharyngiomas With Predominantly Ventricular Involvement: An Endoscopic Endonasal Series Based on Histopathological Assessment

Objective

Craniopharyngiomas (CPs) predominantly involving the third ventricle were commonly termed “intraventricular” lesions. The aim of this study was to clarify the anatomical relationship between the tumor and the third ventricle by both surgical and histological investigation.

Methods

A retrospective review of primarily resected CPs by endoscopic endonasal surgery was performed. CPs with predominantly ventricular involvement were selected for study inclusion by preoperative imaging. The surgical procedure of each case was reviewed. The wholly removed tumor specimens were histologically analyzed, in all cases, to investigate the tumor–third ventricle relationship using hematoxylin and eosin, immunochemical, and immunofluorescence staining.

Results

Twenty-six primary CPs predominantly involving the third ventricle were selected from our series of 223 CPs treated by endoscopic endonasal surgery between January 2017 and March 2021. Gross-total resection was achieved in 24 (92.3%) of 26 patients, with achievement of near-total resection in the remaining patients. A circumferential layer of stretched third ventricle floor was identified surrounding the tumor capsule, which could be peeled off easily from the ventricle floor remnants at most areas of the plane of tumor attachment. Some portions of the tumor capsule tightly adhered to the third ventricle floor were removed together with the floor. A breach of various size was observed at the third ventricle floor after tumor removal in most cases, the floor remaining intact in only two cases (7.7%). Histological examination on marked portions of tumor capsule showed that the pia mater was frequently detected at most of the tumor–brain interface, except at the antero-frontal border of tumor contacting with the third ventricle floor. At this point, a layer of gliosis with various thickness was observed between the tumor and the neural tissue of the third ventricle floor.

Conclusion

CPs with predominantly ventricular involvement should be considered as lesions with an extraventricular, epi-pia topography rather than “intraventricular” or “subpial” topography. Accurate understanding of the relationship between the third ventricle and such tumors would predict the circumferential cleavage plane of dissection, and remind neurosurgeons of performing dissection along the safe surgical plane to achieve total tumoral resection with minimizing hypothalamic damage.

Cyst Type Differentiates Rathke Cleft Cysts From Cystic Pituitary Adenomas

Purpose

A classification system for cystic sellar lesions does not exist. We propose a novel classification scheme for these lesions based on the heterogeneity of the cyst wall/contents and the presence of a solid component on imaging.

Methods

We retrospectively reviewed 205 patients’ medical records (2008–2020) who underwent primary surgery for a cystic sellar lesion. Cysts were classified a priori into 1 of 4 cyst types based on the heterogeneity of the cyst wall/contents and the presence of a solid component imaging. There was high interrater reliability. Univariable and multivariable models were used to estimate the ability of cyst type to predict the two most common diagnoses: Rathke cleft cyst (RCC) and cystic pituitary adenoma.

Results

The frequencies of RCC and cystic pituitary adenoma in our cohort were 45.4% and 36.4%, respectively. Non-neoplastic lesions (e.g., arachnoid cysts and RCC) were more likely to be Type 1 or 2, whereas cystic neoplasms (e.g., pituitary adenomas and craniopharyngiomas) were more likely to be Type 3 or 4 (p<0.0001). Higher cyst types, compared to Type 1, had higher odds of being cystic pituitary adenomas compared to RCCs (OR: 23.7, p=0.033, and 342.6, p <0.0001, for Types 2 and 4, respectively). Lesions with a fluid-fluid level on preoperative MRI also had higher odds of being pituitary adenomas (OR: 12.7; p=0.023). Cystic pituitary adenomas were more common in patients with obesity (OR: 5.0, p=0.003) or symptomatic hyperprolactinemia (OR: 11.5; p<0.001, respectively). The multivariable model had a positive predictive value of 82.2% and negative predictive value of 86.4%.

Conclusion

When applied to the diagnosis of RCC versus cystic pituitary adenoma, higher cystic lesion types (Type 2 & 4), presence of fluid-fluid level, symptomatic hyperprolactinemia, and obesity were predictors of cystic pituitary adenoma. Further validation is needed, but this classification scheme may prove to be a useful tool for the management of patients with common sellar pathology.

Craniopharyngiomas

Craniopharyngiomas are rare epithelial tumours situated primarily in the sellar/parasellar region, occurring along the path of the craniopharyngeal duct. Whilst classed as histologically benign tumours, their unpredictable growth pattern and proximity to vital structures including the optic chiasm, hypothalamus, and pituitary gland renders them a considerable threat, with significant associated morbidity and increase in mortality. Occurring both in child and adulthood, their clinical manifestations are broad, commonly with symptoms/signs secondary to hypothalamic-pituitary dysfunction, raised intracranial pressure and visual compromise. They have two distinct histological subtypes (adamantinomatous and papillary), with unique patterns of age distribution, and genetic and molecular make-up. With increasing understanding of their genetic pathogenesis including BRAF V600E mutations in the papillary subtype, and β-catenin mutations in the adamantinomatous, further research provides hope for the discovery of targeted medical therapy that can exploit molecular changes occurring as a result of such alterations. Until then, primary treatment consists of surgery with or without radiotherapy, with intracystic aspiration, chemotherapy or irradiation being alternative options in selected patients. Long term management by an experienced multidisciplinary team is essential, given the breadth of complications, including hypothalamic morbidity, visual compromise, cognitive and neuropsychological sequelae and impairment to quality of life.

Suprasellar Mature Cystic Teratoma Mimicking Rathke's Cleft Cyst: A Case Report and Systematic Review of the Literature

In this article, we present a 31-year-old female who presented with intermittent headache and oligomenorrhea of over 10 years' duration. Imaging revealed a large suprasellar mass with sellar extension. The patient underwent an endoscopic endonasal trans-sphenoidal surgery to resection of the mass. Clinical, radiological, and operative findings from this patient were initially considered to be Rathke's cleft cyst (RCC). However, postoperative histological examinations revealed a mature cystic teratoma. No radiotherapy was performed after surgery. At the most recent follow-up, approximately 1 year later, the patient is doing well with no headache and no recurrence of the teratoma.

Development of a Nomogram Based on Preoperative Bi-Parametric MRI and Blood Indices for the Differentiation Between Cystic-Solid Pituitary Adenoma and Craniopharyngioma

Background

Given the similarities in clinical manifestations of cystic-solid pituitary adenomas (CS-PAs) and craniopharyngiomas (CPs), this study aims to establish and validate a nomogram based on preoperative imaging features and blood indices to differentiate between CS-PAs and CPs.

Methods

A departmental database was searched to identify patients who had undergone tumor resection between January 2012 and December 2020, and those diagnosed with CS-PAs or CPs by histopathology were included. Preoperative magnetic resonance imaging (MRI) features as well as blood indices were retrieved and analyzed. Radiological features were extracted from the tumor on contrast-enhanced T1 (CE-T1) weighted and T2 weighted sequences. The two independent samples t-test and principal component analysis (PCA) were used for feature selection, data dimension reduction, and radiomics signature building. Next, the radiomics signature was put in five classification models for exploring the best classifier with superior identification performance. Multivariate logistic regression analysis was then used to establish a radiomic-clinical model containing radiomics and hematological features, and the model was presented as a nomogram. The performance of the radiomics-clinical model was assessed by calibration curve, clinical effectiveness as well as internal validation.

Results

A total of 272 patients were included in this study: 201 with CS-PAs and 71 with CPs. These patients were randomized into training set (n=182) and test set (n=90). The radiomics signature, which consisted of 18 features after dimensionality reduction, showed superior discrimination performance in 5 different classification models. The area under the curve (AUC) values of the training set and the test set obtained by the radiomics signature are 0.92 and 0.88 in the logistic regression model, 0.90 and 0.85 in the Ridge classifier, 0.88 and 0.82 in the stochastic gradient descent (SGD) classifier, 0.78 and 0.85 in the linear support vector classification (Linear SVC), 0.93 and 0.86 in the multilayers perceptron (MLP) classifier, respectively. The predictive factors of the nomogram included radiomic signature, age, WBC count, and FIB. The nomogram showed good discrimination performance (with an AUC of 0.93 in the training set and 0.90 in the test set) and good calibration. Moreover, decision curve analysis (DCA) demonstrated satisfactory clinical effectiveness of the proposed radiomic-clinical nomogram.

Conclusions

A personalized nomogram containing radiomics signature and blood indices was proposed in this study. This nomogram is simple yet effective in differentiating between CS-PAs and CPs and thus can be used in routine clinical practice.

A clinical approach to parasellar lesions in the transition age

Many reviews have summarised the pathology and management of the parasellar region in adult patients, although an analysis of these aspects in the transition years, from puberty onset to the age of peak bone mass, has been lacking. A comprehensive search of English-language original articles, published from 2000 to 2020, was conducted in the MEDLINE database (December 2019 to March 2020). We selected all studies regarding epidemiology, diagnosis and management of the following parasellar lesions: germinoma, craniopharyngioma, Langerhans cell histiocytosis, optic glioma, hypothalamic hamartoma, tuber cinereum hamartoma, cranial chordoma, Rathke cleft cyst, hypophysitis and hypothalamitis during the transition age from childhood to adulthood. In the present review, we provide an overview of the principal parasellar lesions occurring in the transition age. Symptoms are usually a result of the mass effect of the lesions on nearby structures, as well as anterior pituitary deficits. Diabetes insipidus occurs frequently in these patients. In this age group, pubertal developmental disorders may be more evident compared to other stages of life. Parasellar lesions in the transition age mostly include neoplastic lesions such as germinomas, hamartomas, optic gliomas, craniopharyngiomas Langerhans cell histiocytosis and chordomas, and rarely inflammatory lesions (hypophysitis, hypothalamitis). There are limited data on the management of parasellar lesions in the transition age. Endocrine evaluation is crucial for identifying conditions that require hormonal treatment so that they can be treated early to improve the quality of life of the individual patient in this complex age range. The clinical approach to parasellar lesions involves a multidisciplinary effort.

[The 2017 WHO classification of pituitary tumors]

The 2017 WHO classification of pituitary tumors is still based on structural analyses and expression of various pituitary hormones. Three innovations have to be considered: (1) The expression of pituitary transcription factors Pit‑1, T‑Pit and SF‑1. (2) The term "atypical adenoma" was replaced by "aggressive adenoma". (3) The three tumor types of the neurohypophysis (pituicytoma, spindle cell oncocytoma, granular cell tumor) are defined by their common expression of TTF‑1. Craniophyryngiomas are identified as adamantinomatous type by focal nuclear expression of β‑catenin or as papillary type by demonstration of BRAF V600E mutation. Further primary tumors of the pituitary are extremely rare. These and also the other tumors of the sellar region can be structurally very similar to pituitary adenomas but can be-nearly without exception-differentiated by immunocytochemistry.

Up-To-Date Magnetic Resonance Imaging Findings for the Diagnosis of Hypothalamic and Pituitary Tumors

Magnetic resonance imaging (MRI) is the preferred imaging technique for the sellar and parasellar regions. In this review article, we report our clinical experience with MRI for hypothalamic and pituitary lesions, such as pituitary adenomas, craniopharyngiomas, Rathke cleft cysts, germinoma, and hypophysitis with reference to the histopathological findings through a review of the literature. Our previous study indicated that three dimensional-spoiled gradient echo sequence is a more suitable sequence for evaluating sellar lesions on postcontrast T1 weighted image (WI). This image demonstrates the defined relationship between the tumor and its surroundings, such as the normal pituitary gland, cavernous sinus, and optic pathway. We demonstrated the characteristic MRI findings of functioning pituitary adenoma. In growth hormone-producing adenoma, signal intensity on T2WI is important to differentiate densely from sparsely granulated somatotroph adenomas. In prolactin-producing pituitary adenomas, distinct hypointense areas in early phase on T2WI, possibly owning to diffuse hemorrhage, indicate pronounced regressions of invasive macroprolactinomas during cabergoline therapy. The two histopathological subtypes, adamantinomatous and squamous papillary craniopharyngioma, differ in genesis. Calcified tumors are mostly adamantinomatous type. On MRI, these lesions have a heterogenous appearance with a solid portion and cystic components. The solid portions and cyst wall enhance heterogeneously. Although cyst fluid of Rathke cleft cysts show variable intensities on MRI, intracystic waxy nodule can be hypointense on T2WI. The enhancing cyst wall may contain the squamous metaplasia. Cystic lesions of the sellar and parasellar areas may be difficult to differentiate on a clinical, imaging, or even histopathological basis.

Diabetes Insipidus After Endoscopic Transsphenoidal Surgery

BACKGROUND

Diabetes insipidus (DI) is a recognized transient or permanent complication following transsphenoidal surgery (TSS) for pituitary tumors.

OBJECTIVE

To describe significant experience with the incidence of DI after TSS, identifying predictive characteristics and describing our diagnosis and management of postoperative DI.

METHODS

A retrospective analysis was performed of 700 patients who underwent endoscopic TSS for resection of pituitary adenoma (PA), Rathke cleft cyst (RCC), or craniopharyngioma. Inclusion criteria included at least 1 wk of follow-up for diagnosis of postoperative DI. Permanent DI was defined as DI symptoms and/or need for desmopressin more than 1 yr postoperatively. All patients with at least 1 yr of follow-up (n = 345) were included in analyses of permanent DI. Multivariable logistic regression models were constructed to identify predictors of transient or permanent postoperative DI.

RESULTS

The overall rate of any postoperative DI was 14.7% (103/700). Permanent DI developed in 4.6% (16/345). The median follow-up was 10.7 mo (range: 0.2-136.6). Compared to patients with PA, patients with RCC (odds ratio [OR] = 2.2, 95% CI: 1.2-3.9; P = .009) and craniopharyngioma (OR = 7.0, 95% CI: 2.9-16.9; P ≤ .001) were more likely to develop postoperative DI. Furthermore, patients with RCC (OR = 6.1, 95% CI: 1.8-20.6; P = .004) or craniopharyngioma (OR = 18.8, 95% CI: 4.9-72.6; P ≤ .001) were more likely to develop permanent DI compared to those with PA.

CONCLUSION

Although transient DI is a relatively common complication of endoscopic and microscopic TSS, permanent DI is much less frequent. The underlying pathology is an important predictor of both occurrence and permanency of postoperative DI.

Rathke's cleft-like cysts arise from Isl1 deletion in murine pituitary progenitors

The transcription factor ISL1 is expressed in pituitary gland stem cells and the thyrotrope and gonadotrope lineages. Pituitary-specific Isl1 deletion causes hypopituitarism with increased stem cell apoptosis, reduced differentiation of thyrotropes and gonadotropes, and reduced body size. Conditional Isl1 deletion causes development of multiple Rathke's cleft-like cysts, with 100% penetrance. Foxa1 and Foxj1 are abnormally expressed in the pituitary gland and associated with a ciliogenic gene-expression program in the cysts. We confirmed expression of FOXA1, FOXJ1, and stem cell markers in human Rathke's cleft cyst tissue, but not craniopharyngiomas, which suggests these transcription factors are useful, pathological markers for diagnosis of Rathke's cleft cysts. These studies support a model whereby expression of ISL1 in pituitary progenitors drives differentiation into thyrotropes and gonadotropes and without it, activation of FOXA1 and FOXJ1 permits development of an oral epithelial cell fate with mucinous cysts. This pituitary-specific Isl1 mouse knockout sheds light on the etiology of Rathke's cleft cysts and the role of ISL1 in normal pituitary development.

Magnetic resonance imaging of the hypothalamo-pituitary region

The diagnosis and management of mass lesions in the sellar and parasellar areas remain challenging. When approaching patients with possible sellar or hypothalamic masses, it is important not only to focus on imaging but also detect possible pituitary hormone deficits or excess, in order to establish an appropriate diagnosis and initiate treatment. The imaging modalities used to characterize hypothalamic and pituitary lesions have significantly evolved over the course of the past several years. Computed tomography (CT) and CT angiography play a major role in detecting various sellar lesions, especially in patients who have contraindications to magnetic resonance imaging (MRI) and can also yield important information for surgical planning. However, MRI has become the gold standard for the detection and characterization of hypothalamic and pituitary tumors, infections, cystic, or vascular lesions. Indeed, the imaging characteristics of hypothalamic and sellar lesions can help narrow down the differential diagnosis preoperatively. In addition, MRI can help establish the relationship of mass lesions to surrounding structures. A pituitary MRI examination should be obtained if there is concern for mass effect (including visual loss, ophthalmoplegia, headache) or if there is clinical suspicion and laboratory evidence of either hypopituitarism or pituitary hormone excess. The information obtained from MRI images also provides us with assistance in planning surgery. Using intraoperative MRI can be very helpful in assessing the adequacy of tumor resection. In addition, MRI images yield reliable data that allow for noninvasive monitoring of patients postoperatively.

Craniopharyngiomas primarily affecting the hypothalamus

The concept of craniopharyngiomas (CPs) primarily affecting the hypothalamus, or "hypothalamic CPs" (Hy-CPs), refers, in a restrictive sense, to the subgroup of CPs originally developing within the neural tissue of the infundibulum and tuber cinereum, the components of the third ventricle floor. This subgroup, also known as infundibulo-tuberal CPs, largely occupies the third ventricle and comprises up to 40% of this pathological entity. The small subgroup of strictly intraventricular CPs (5%), lesions wholly developed within the third ventricle above an anatomically intact third ventricle floor, can also be included within the Hy-CP category. The remaining types of sellar and/or suprasellar CPs may compress or invade the hypothalamic region during their growth but will not be considered in this review. Hy-CPs predominantly affect adults, causing a wide range of symptoms derived from hypothalamic dysfunction, such as adiposogenital dystrophy (Babinski-Fröhlich's syndrome), diabetes insipidus (DI), abnormal diurnal somnolence, and a complex set of cognitive (dementia-like, Korsakoff-like), emotional (rage, apathy, depression), and behavioral (autism-like, psychotic-like) disturbances. Accordingly, Hy-CPs represent a neurobiological model of psychiatric disorders caused by a lesion restricted to the hypothalamus. The vast majority (90%) of squamous-papillary CPs belong to the Hy-CP category. Pathologically, most Hy-CPs present extensive and strong adhesions to the surrounding hypothalamus, usually formed of a thick band of gliotic tissue encircling the central portion of the tumor ("ring-like" attachment) or its entire boundary ("circumferential" attachment). CPs with these severe adhesion types associate high surgical risk, with morbidity and mortality rates three times higher than those for sellar/suprasellar CPs. Consequently, radical surgical removal of Hy-CPs cannot be generally recommended. Rather, Hy-CPs should be accurately classified according to an individualized surgery-risk stratification scheme considering patient age, CP topography, presence of hypothalamic symptoms, tumor size, and, most importantly, the CP-hypothalamus adhesion pattern.

Endoscopic endonasal cyst fenestration into the sphenoid sinus using the mucosa coupling method for symptomatic Rathke's cleft cyst: a novel method for maintaining cyst drainage to prevent recurrence

OBJECTIVE

Rathke's cleft cyst (RCC) is a benign cystic lesion with a relatively high incidence of local recurrence that occasionally requires repeat surgery. To prevent recurrence, simple cyst fenestration and drainage of the cyst contents to the sphenoid sinus is recommended, but it occasionally recurs. The authors postulated that obstruction of fenestration is a main cause of recurrence, and they developed a method, named the "mucosa coupling method (MC method)," that maintains persistent drainage. In this method, the RCC epithelium and the mucosa of the sphenoid sinus are connected, which promotes re-epithelialization between the two epithelia, maintaining persistent drainage. The outcome of this method was compared with that of conventional cyst fenestration.

METHODS

In a consecutive series of 40 patients with RCC, the surgical strategy was changed during the study period: from December 2009 to September 2014 (the conventional period), 24 patients were scheduled to be treated using the conventional fenestration method, whereas from September 2014 to September 2017 (the MC period), 16 patients were scheduled to be treated using the MC method. However, because of an intraoperative CSF leak, the fenestration was closed during surgery in 3 patients in the conventional period and 2 in the MC period; therefore, these 5 patients were excluded from the analysis. Twenty-one patients treated with the conventional fenestration method (conventional group) and 14 patients treated with the MC method (MC group) were analyzed. All patients regularly underwent MRI after surgery to detect reaccumulation of cyst contents. The rate of reaccumulation with and without reoperation, visual outcomes, endocrinological outcomes, and postoperative complications were compared between these two groups.

RESULTS

The median follow-up period in all 35 patients was 48.0 months (range 1-96 months), 54.0 months (range 1-96 months) in the conventional group and 35.5 months (range 12-51 months) in the MC group. No reaccumulation was detected on MRI in the 14 patients in the MC group, whereas it was noted in 9 (42.9%) of 21 patients in the conventional group, and 2 of these 9 patients required repeat surgery. There were no significant differences in visual and endocrinological outcomes and complications between these two groups.

CONCLUSIONS

The MC method for RCC is effective for preventing obstruction of cyst fenestration, which contributes to preventing cyst reaccumulation. Furthermore, this method is equivalent to the conventional fenestration method in terms of visual and endocrinological outcomes and the complication rate.

Prediction of CTNNB1 Mutation Status in Pediatric Cystic Adamantinomatous Craniopharyngioma by Using Preoperative Magnetic Resonance Imaging Manifestation

OBJECTIVE

CTNNB1-targeted inhibitor is demonstrated to be an effective neoadjuvant therapy in adamantinomatous craniopharyngioma (ACP) patients and cystic degeneration is a canonical sign of pediatric ACP. This study aimed to investigate the relationship between the cystic performances and CTNNB1 mutation (CTNNB1 MUT) status so as to analyze the possible diagnostic criteria of CTNNB1 MUT in pediatric cystic ACP (PCACP).

METHODS

Patient's population, clinical characteristics, tissue samples and MRI data were collected and summarized in PCACP patients. The results were compared between CTNNB1 MUT and CTNNB1 wild-type (WT) groups according to the Sanger sequencing. MRI features of the cyst were also recorded. The receiving operating characteristic (ROC) curve analysis was applied to evaluate the differential diagnostic value.

RESULTS

19 of the 61 patients manifested CTNNB1 MUT PCACP and 42 patients were CTNNB1 WT PCACP. Multiple cysts, irregular shape of cyst, hypo-intense interior signal of cyst on non-contrast T1W1, compression with optic chiasm and pituitary stalk and enhancement signal of cystic wall have been demonstrated in CTNNB1 MUT PCACP patients on MRI. Only the Area under the curve (AUC) values of quantity of cyst, shape of cyst and interior signal of cyst on non-contrast T1W1 were over 0.7. For criteria based on the combination of the 6 characteristic features, the AUC value was 0.928.

CONCLUSION

Preoperative MRI may provide an effective value in predicting PCACP patients with CTNNB1 MUT and offer potential evidence for preoperative management with molecular targeted agents.

Outcome of nonneoplastic pituitary cysts during conservative monitoring and after surgery-a SwissPit study

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.

Neuroimaging of the Pituitary Gland: Practical Anatomy and Pathology

The pituitary gland is a small endocrine organ located within the sella turcica. Various pathologic conditions affect the pituitary gland and produce endocrinologic and neurologic abnormalities. The most common lesion of the pituitary gland is the adenoma, a benign neoplasm. Dedicated MR imaging of the pituitary is radiologic study of choice for evaluating pituitary gland and central skull region. Computed tomography is complimentary and allows for identification of calcification and adjacent abnormalities of the osseous skull base. This review emphasizes basic anatomy, current imaging techniques, and highlights the spectrum of pathologic conditions that affect the pituitary gland and sellar region.

A craniopharyngioma in a Wistar rat most likely originated in a Rathke's cleft cyst

We examined a 110-week-old RccHan^TM: WIST Wistar male rat from a carcinogenicity study. No clinical signs were observed, and the rat was sacrificed at the end of the study. Macroscopically, within the midline of the sphenoid bone, was a 10 mm, non-infiltrative, soft, heterogeneous mass. Microscopic evaluation showed an expansile, cystic proliferation, consisting of two patterns of epithelial lining: well-differentiated areas lined by a single layer to a pseudostratified, ciliated-cuboidal epithelia with Goblet cells compatible with Rathke’s cleft cyst; and poorly differentiated ones that formed irregular papillary projections, covered by atypical epithelia with squamous differentiation and hyperkeratosis compatible with areas of craniopharyngioma. Pleomorphisms were high in atypical areas with up to 2–3 mitotic figures per high power field. Within the cystic cavities, there was abrupt keratinization, mucus, cholesterol clefts, and foci of foamy macrophages. Immunohistochemistry revealed strong pancytokeratin immunolabelling of neoplastic cells confirming the epithelial origin. Well-differentiated epithelial lining showed cytokeratin-20 and cytokeratin-8 immunoreactivity, whereas the atypical squamous epithelium presented with a loss of cytokeratin-20 positive signal and weak to moderate positivity with cytokeratin-8. Areas compatible with a Rathke’s cleft cyst and craniopharyngioma were considered to co-exist in the same mass.

Sellar Cholesterol Granuloma Mimicking Cystic Sellar Lesions: A Report of Three Cases and Literature Review

BACKGROUND

Cystic lesions in the sellar region include a variety of entities, such as craniopharyngioma, Rathke cleft cyst (RCC), intrasellar arachnoid cyst, cystic pituitary adenomas, cholesterol granulomas (CGs), and xanthogranulomas (XGs). The distinction among them remains a preoperative challenge due to similarities in their clinical and radiologic findings.

CASE DESCRIPTION

We describe 3 cases with cystic sellar lesions. The first patient is a woman who presented with headache and hormonal disturbances, including high levels of prolactin, with a sellar and suprasellar cystic lesion discovered on magnetic resonance imaging. She was initially treated with dopamine agonists with normalization of prolactin levels but no changes on the size of the lesion. She underwent an endoscopic endonasal resection and the histology resulted in a CG/XG. The second patient is a woman who consulted for an incidentally discovered sellar cyst. During the follow-up, the lesion demonstrated enlargement with compression of the optic chiasm. With a preoperative diagnosis of RCC, the lesion was removed through an endoscopic endonasal transsellar approach. Final pathologic diagnosis was consistent with CG/XG. The third case was that of a man who presented with refractory headaches and vision loss, with a sellar/suprasellar cystic lesion on magnetic resonance imaging. He underwent endoscopic endonasal transsellar surgery for resection of what preoperatively was thought to be a giant RCC; final pathology again was consistent with CG/XG.

CONCLUSIONS

CG/XG is an uncommon pathology with unspecific clinical and radiologic features. However, this pathology should be considered in the differential diagnosis of mixed cystic/solid lesions in the sellar region.

Atypical sellar cyst: A rare case

Background

Sellar cysts are common in neurosurgery. Around 90% of these are diagnosed as pituitary adenomas. The other 10% are nonadenomatous, inflammatory, infective, metastatic, or cystic in nature. Some rare cysts include dermoid, epidermoid, colloid, and arachnoid. They all have different histological features. The case we present demonstrates a unique cyst with features that are not previously documented.

Case Description

A 60-year-old female presented to the neurosurgical department complaining of blurring of vision and severe headache for more than ½ year. Imaging was done which revealed a bony erosive lesion in the region of sella. Magnetic resonance imaging with contrast showed high signals with no contrast enhancement. A clear diagnosis could not be made based on radiology. Surgery was done and sample was sent for histopathology. Based on histopathological report findings, a diagnosis of benign atypical sellar cyst was made. Post procedure, the patient recovered and was discharged.

Conclusion

Sellar cysts present similarly. They are differentiated based on their histological features. The sellar cyst we encountered had features different from the ones already described in the literature.

Craniopharyngioma treatment: an updated summary of important clinicopathological concepts

INTRODUCTION

Craniopharyngiomas (CPs) are benign histological tumors that may develop at different positions along the hypothalamic-pituitary axis. Their close, heterogenous relationship to the hypothalamus makes surgical removal challenging even though this remains the primary treatment strategy.

AREAS COVERED

This article presents a critical overview of the pathological and clinical concepts regarding CPs that should be considered when planning treatment. Thus, we have performed a comprehensive review of detailed CP reports published between 1839 and 2020.

EXPERT OPINION

CP surgery should pursue maximal tumor resection while minimizing the risk of injuring the hypothalamus. Therefore, surgical strategies should be individualized for each patient. Accurate assessment of presenting symptoms and preoperative MRI has proven useful to predict the type of CP-hypothalamus relationship that will be found during surgery. CPs with dense and extensive adhesions to the hypothalamus should be highly suspected when MRI shows the hypothalamus positioned around the mid-third of the tumor and an amputated upper portion of the pituitary stalk. Symptoms related to functional impairment of the infundibulo-tuberal area of the third ventricle floor, such as obesity/hyperphagia, Fröhlich's syndrome, diabetes insipidus, and/or somnolence, also indicate risky CP-hypothalamic adhesions. In these cases, limited tumor removal is strongly advocated followed by radiation therapy.

Hemorrhagic Presentation of Rathke Cleft Cysts: A Surgical Case Series

BACKGROUND

Rathke cleft cysts (RCCs) are benign sellar and suprasellar lesions commonly presenting as asymptomatic incidental findings. Rarely, RCCs hemorrhage and mimic pituitary apoplexy on presentation.

OBJECTIVE

To review a series of hemorrhagic RCCs for physicians encountering this rare presentation.

METHODS

A database review of >1700 transsphenoidal pituitary operations was performed at the USC Pituitary Center to identify patients with pathologically confirmed RCCs presenting with acute symptoms and evidence of hemorrhage at the time of surgery. Surgical treatment involved transsphenoidal RCC fenestration and drainage. Clinical, endocrine, and imaging outcomes were reviewed.

RESULTS

A total of 119 RCCs were identified, and 6 (5.0%) presented with hemorrhage mimicking pituitary apoplexy. Presenting symptoms included acute onset headaches (5/6), vision loss (2/6), and oculomotor nerve palsy (n = 1). Endocrine disturbances at presentation included pre-existing amenorrhea in all female patients (3/3), hypothyroidism (n = 2), panhypopituitarism (n = 2), and one with profound hyponatremia (Na 116 meq/L). All patients underwent endonasal transsphenoidal fenestration and drainage with no major complications. Over mean follow-up of 38.4 mo, 2/2 patients with vision loss reported improvement, and 2/5 patients with headaches reported improvement. Although all women resumed menses, patients with preoperative hypopituitarism did not experience pituitary axis improvement. Follow-up magnetic resonance imaging showed no instances of RCC recurrence with a mean imaging follow-up of 38.6 mo.

CONCLUSION

RCCs occasionally present with hemorrhage and clinical symptoms that may be confused with apoplexy. Outcomes following hemorrhagic RCC treatment are excellent when treated at tertiary pituitary centers. Although hyperprolactinemia often improves following surgery, other pituitary axis deficits typically do not.

Adamantinomatous Craniopharyngioma in an Adult: A Case Report with NGS Analysis

PURPOSE

Several recent studies have documented CTNNB1 and BRAF mutations which are mutually exclusive for adamantinomatous craniopharyngioma (ACP) and papillary craniopharyngioma (PCP) tumors. This discovery is helpful in the development of novel targeted therapies in successful clinical trials with BRAF mutations in PCP cases. However, no such targeted therapy is available yet for ACP. Here, we report novel mutations, which are not previously reported, in a case of an adult ACP using NGS analysis.

RESULTS

Patient DNA was sequenced using Ion PI v3 chip on Ion Proton. A total of 16 variants were identified in this tumor by NGS analysis, out of which four were missense mutations, seven were synonymous mutations, and five were intronic variants. In CTNNB1 gene a known missense mutation in c.101G>T; in TP53 a known missense mutation in c.215C>G; and two known missense variants in PIK3CA, viz., in c.1173A>G; in exon 7, and in c.3128T>C; in exon 21, were found, respectively. Seven synonymous mutations were detected in this tumor, viz., in IDH1 (rs11554137), in FGFR3 (rs7688609), in PDGFRA (rs1873778), in APC (COSM3760869), in EGFR (rs1050171), in MET (rs35775721), and in RET (rs1800861), respectively. Three known, intronic variants were found in genes, such as PIK3CA, KDR, and JAK3, respectively. Also, a 3'-UTR and a splice site acceptor site variant in CSF1R and FLT3 genes were found in this tumor. We have shown allele coverage, allele ratio, and p-value, for all these mutations. The p-values and Phred quality score were significantly high for these variants.

CONCLUSION

As reported in previous studies, in ACP tumors we found a CTNNB1 mutation by NGS analysis. The PIK3CA variants we detected were not known previously in ACP tumors. Finding the PIK3CA mutations in the ACP tumors may help develop targeted therapy for a subset of craniopharyngiomas with PIK3CA activating mutations. Clinical trials are in progress with specific PIK3CA inhibitors in advanced stages of many cancers.

Intratumoral Rathke's Cleft Cyst Remnants Within Craniopharyngioma, Pituitary Adenoma, Suprasellar Dermoid, and Epidermoid Cysts: A Ubiquitous Signature of Ectodermal Lineage or a Transitional Entity?

BACKGROUND

The authors present cystic epithelial masses in the suprasellar region which on histopathology revealed 4 mixed tumors having simple cuboidal epithelium of Rathke's Cleft Cyst (RCC) elements trapped within pituitary adenoma, epidermoid cyst, dermoid cyst, and papillary craniopharyngioma respectively.

OBJECTIVE

To highlight the developmental theory of ectodermal continuum in the realm of suprasellar epithelial cystic lesions and examines the cardinal aspects that distinguish RCC from its confounder, ciliary craniopharyngioma.

METHODS

The authors performed a medical chart review on 4 patients who had coexisting RCC with craniopharyngioma, pituitary adenoma, suprasellar dermoid, and epidermoid cysts.

RESULTS

This series of unique suprasellar lesions elucidate the spectrum of cases from Rathke's cyst to other suprasellar epithelial cysts including a recently identified clinical entity called ciliary craniopharyngioma, which authors feel is a misnomer. The authors also report the first case of ruptured dermoid cyst admixed with elements of Rathke's cyst elements and xanthogranuloma in neurosurgical literature.

CONCLUSION

We propose that the new entity of ciliary craniopharyngioma could be just another variant of RCC elements nested within a typical papillary or adamantinomatous lesion. Further study is warranted to understand the implications of natural history with tumors containing RCC elements.