Long-term surgical outcomes following transsphenoidal surgery in patients with Rathke’s cleft cysts

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OBJECTIVE

Rathke’s cleft cysts (RCCs) are benign epithelial lesions of the sellar region typically treated via a transsphenoidal approach with cyst fenestration and drainage. At present, there is limited evidence to guide patient selection for operative treatment. Furthermore, there is minimal literature describing factors contributing to cyst recurrence.

METHODS

The authors conducted a retrospective analysis of 109 consecutive cases of pathology-confirmed RCCs treated via a transsphenoidal approach at a single center from 1995 to 2016. The majority of cases (86.2%) involved cyst fenestration, drainage, and partial wall resection. Long-term outcomes were analyzed.

RESULTS

A total of 109 surgeries in 100 patients were included, with a mean follow-up duration of 67 months (range 3–220 months). The mean patient age was 44.6 years (range 12–82 years), and 73% were women. The mean maximal cyst diameter was 14.7 mm. Eighty-eight cases (80.7%) were primary operations, and 21 (19.3%) were reoperations. Intraoperative CSF leak repair was performed in 53% of cases and was more common in reoperation cases (71% vs 48%, p < 0.001). There were no new neurological deficits or perioperative deaths. Two patients (1.8%) developed postoperative CSF leaks. Transient diabetes insipidus (DI) developed in 24 cases (22%) and permanent DI developed in 6 (5.5%). Seven cases (6.4%) developed delayed postoperative hyponatremia. Of the 66 patients with preoperative headache, 27 (44.3%) of 61 reported postoperative improvement and 31 (50.8%) reported no change. Of 31 patients with preoperative vision loss, 13 (48.1%) reported subjective improvement and 12 (44.4%) reported unchanged vision. Initial postoperative MRI showed a residual cyst in 25% of cases and no evidence of RCC in 75% of cases. Imaging revealed evidence of RCC recurrence or progression in 29 cases (26.6%), with an average latency of 28.8 months. Of these, only 10 (9.2% of the total 109 cases) were symptomatic and underwent reoperation.

CONCLUSIONS

Transsphenoidal fenestration and drainage of RCCs is a safe and effective intervention for symptomatic lesions, with many patients experiencing improvement of headaches and vision. RCCs show an appreciable (although usually asymptomatic) recurrence rate, thereby mandating serial follow-up. Despite this, full RCC excision is typically not recommended due to risk of hypopituitarism, DI, and CSF leaks.

ABBREVIATIONS dDAVP = desmopressin acetate; DI = diabetes insipidus; RCC = Rathke’s cleft cyst; SIADH = syndrome of inappropriate antidiuretic hormone; USC = University of Southern California.

Article Information

Correspondence Gabriel Zada: University of Southern California Keck School of Medicine, Los Angeles, CA. gabriel.zada@med.usc.edu.

INCLUDE WHEN CITING Published online May 18, 2018; DOI: 10.3171/2017.11.JNS171498.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Kaplan-Meier plot of recurrence- and reoperation-free survival over 120 months. Figure is available in color online only.

References

1

Aho CJLiu CZelman VCouldwell WTWeiss MH: Surgical outcomes in 118 patients with Rathke cleft cysts. J Neurosurg 102:1891932005

2

Benveniste RJKing WAWalsh JLee JSNaidich TPPost KD: Surgery for Rathke cleft cysts: technical considerations and outcomes. J Neurosurg 101:5775842004

3

Blumenberg CBarros AJ: Electronic data collection in epidemiological research. The use of REDCap in the Pelotas birth cohorts. Appl Clin Inform 7:6726812016

4

Cavallo LMPrevedello DEsposito FLaws ER JrDusick JRMessina A: The role of the endoscope in the transsphenoidal management of cystic lesions of the sellar region. Neurosurg Rev 31:55642008

5

Choi SHKwon BJNa DGKim JHHan MHChang KH: Pituitary adenoma, craniopharyngioma, and Rathke cleft cyst involving both intrasellar and suprasellar regions: differentiation using MRI. Clin Radiol 62:4534622007

6

Conger ARLucas JZada GSchwartz THCohen-Gadol AA: Endoscopic extended transsphenoidal resection of craniopharyngiomas: nuances of neurosurgical technique. Neurosurg Focus 37(4):E102014

7

Dusick JREsposito FKelly DFCohan PDeSalles ABecker DP: The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:8328412005

8

Esposito FDusick JRFatemi NKelly DF: Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 60 (4 Suppl 2):2953042007

9

Fager CACarter H: Intrasellar epithelial cysts. J Neurosurg 24:77811966

10

Frank GSciarretta VMazzatenta DFarneti GModugno GCPasquini E: Transsphenoidal endoscopic approach in the treatment of Rathke’s cleft cyst. Neurosurgery 56:1241292005

11

Hama SArita KNishisaka TFukuhara TTominaga ASugiyama K: Changes in the epithelium of Rathke cleft cyst associated with inflammation. J Neurosurg 96:2092162002

12

Harrison MJMorgello SPost KD: Epithelial cystic lesions of the sellar and parasellar region: a continuum of ectodermal derivatives? J Neurosurg 80:101810251994

13

Higgins DMVan Gompel JJNippoldt TBMeyer FB: Symptomatic Rathke cleft cysts: extent of resection and surgical complications. Neurosurg Focus 31(1):E22011

14

Isono MKamida TKobayashi HShimomura TMatsuyama J: Clinical features of symptomatic Rathke’s cleft cyst. Clin Neurol Neurosurg 103:961002001

15

Kim E: Symptomatic Rathke cleft cyst: clinical features and surgical outcomes. World Neurosurg 78:5275342012

16

Kim JEKim JHKim OLPaek SHKim DGChi JG: Surgical treatment of symptomatic Rathke cleft cysts: clinical features and results with special attention to recurrence. J Neurosurg 100:33402004

17

Kleinschmidt-DeMasters BKLillehei KOStears JC: The pathologic, surgical, and MR spectrum of Rathke cleft cysts. Surg Neurol 44:19271995

18

Laufer IAnand VKSchwartz TH: Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 106:4004062007

19

Lillehei KOWiddel LAstete CAWierman MEKleinschmidt-DeMasters BKKerr JM: Transsphenoidal resection of 82 Rathke cleft cysts: limited value of alcohol cauterization in reducing recurrence rates. J Neurosurg 114:3103172011

20

Madhok RPrevedello DMGardner PCarrau RLSnyderman CHKassam AB: Endoscopic endonasal resection of Rathke cleft cysts: clinical outcomes and surgical nuances. J Neurosurg 112:133313392010

21

Mukherjee JJIslam NKaltsas GLowe DGCharlesworth MAfshar F: Clinical, radiological and pathological features of patients with Rathke’s cleft cysts: tumors that may recur. J Clin Endocrinol Metab 82:235723621997

22

Nishioka HHaraoka JIzawa HIkeda Y: Magnetic resonance imaging, clinical manifestations, and management of Rathke’s cleft cyst. Clin Endocrinol (Oxf) 64:1841882006

23

Ogawa YTominaga TIkeda H: Clinicopathological and endocrinological study of Rathke’s cleft cyst manifesting as hyponatremia. Neurol Med Chir (Tokyo) 47:58642007

24

Ogawa YWatanabe MTominaga T: Prognostic factors of operated Rathke’s cleft cysts with special reference to re-accumulation and recommended surgical strategy. Acta Neurochir (Wien) 153:242724332011

25

Oyama NTahara SOyama KIshii YTeramoto A: Assessment of pre- and postoperative endocrine function in 94 patients with Rathke’s cleft cyst. Endocr J 60:2072132013

26

Ross DANorman DWilson CB: Radiologic characteristics and results of surgical management of Rathke’s cysts in 43 patients. Neurosurgery 30:1731791992

27

Shin JLAsa SLWoodhouse LJSmyth HSEzzat S: Cystic lesions of the pituitary: clinicopathological features distinguishing craniopharyngioma, Rathke’s cleft cyst, and arachnoid cyst. J Clin Endocrinol Metab 84:397239821999

28

Teramoto AHirakawa KSanno NOsamura Y: Incidental pituitary lesions in 1,000 unselected autopsy specimens. Radiology 193:1611641994

29

Wait SDGarrett MPLittle ASKillory BDWhite WL: Endocrinopathy, vision, headache, and recurrence after transsphenoidal surgery for Rathke cleft cysts. Neurosurgery 67:8378432010

30

Zada G: Rathke cleft cysts: a review of clinical and surgical management. Neurosurg Focus 31(1):E12011

31

Zada GLin NOjerholm ERamkissoon SLaws ER: Craniopharyngioma and other cystic epithelial lesions of the sellar region: a review of clinical, imaging, and histopathological relationships. Neurosurg Focus 28(4):E42010

32

Zada GLiu CYFishback DSinger PAWeiss MH: Recognition and management of delayed hyponatremia following transsphenoidal pituitary surgery. J Neurosurg 106:66712007

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