Individualized surgical strategies for Rathke cleft cyst based on cyst location

Clinical article

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Object

An assessment regarding both surgical approaches and the extent of resection for Rathke cleft cysts (RCCs) based on their locations has not been reported. The aim of this study was to report the results of a large series of surgically treated patients with RCCs and to evaluate the feasibility of individualized surgical strategies for different RCCs.

Methods

We retrospectively reviewed 87 cases involving patients with RCCs (16 intrasellar, 50 intra- and suprasellar, and 21 purely suprasellar lesions). Forty-nine patients were treated via a transsphenoidal (TS) approach, and 38 were treated via a transcranial (TC) approach (traditional craniotomy in 21 cases and supraorbital keyhole craniotomy in 17). The extent of resection was classified as gross-total resection (GTR) or subtotal resection (STR) of the cyst wall. Patients were thus divided into 3 groups according to the approach selected and the extent of resection: TS/STR (n = 49), TC/STR (n = 23), and TC/GTR (n = 15).

Results

Preoperative headaches, visual dysfunction, hypopituitarism, and diabetes insipidus (DI) resolved in 85%, 95%, 55%, and 65% of patients, respectively. These rates did not differ significantly among the 3 groups. Overall, complications occurred in 8% of patients in TS/STR group, 9% in TC/STR group, and 47% in TC/GTR group, respectively (p = 0.002). Cerebrospinal fluid (CSF) leakage (3%), new hypopituitarism (9%), and DI (6%) were observed after surgery. All CSF leaks occurred in the endonasal group, while the TC/GTR group showed a higher rate of postoperative hypopituitarism (p = 0.7 and p < 0.001, respectively). It should be particularly noted that preoperative hypopituitarism and DI returned to normal, respectively, in 100% and 83% of patients who underwent supraorbital surgery, and with the exception of 1 patient who had transient postoperative DI, there were no complications in patients treated with supraorbital surgery. Kaplan-Meier 3-year recurrence-free rates were 84%, 87%, and 86% in the TS/STR, TC/STR, and TC/GTR groups, respectively (p = 0.9).

Conclusions

It is reasonable to adopt individualized surgical strategies for RCCs based on cyst location. Gross-total resection does not appear to reduce the recurrence rate but increase the risk of postoperative complications. The endonasal approach seems more appropriate for primarily intrasellar RCCs, while the craniotomy is recommended for purely or mainly suprasellar cysts. The supraorbital route appears to be preferred over traditional craniotomy for its minimal invasiveness and favorable outcomes. The endoscopic technique is helpful for either endonasal or supraorbital surgery.

Abbreviations used in this paper:DI = diabetes insipidus; GTR = gross-total resection; RCC = Rathke cleft cyst; STR = subtotal resection; TC = transcranial; TS = transsphenoidal.

Article Information

Drs. Fan and Peng contributed equally to this work.

Address correspondence to: Songtao Qi, M.D., Ph.D., Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Dadao Bei St., Guangzhou 510515, P.R. China. email: nfsjwk@gmail.com.

Please include this information when citing this paper: published online September 20, 2013; DOI: 10.3171/2013.8.JNS13777.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A case of an intrasellar RCC treated by an endoscopic endonasal route. A and B: Preoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating a 13-mm cyst with an entirely intrasellar location. The sagittal image (A) shows the cyst arising between the anterior and posterior lobes, with only a small amount of residual gland left overlying the sellar floor (arrow). Therefore, an endonasal approach, which may minimize damage to the gland, was suitable for this case. C and D: Postoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating resection of the cyst. E and F: Intraoperative endoscopic photographs showing incision and evacuation of the cyst (E) and the cyst floor left open after resection (F), with the residual gland remaining intact. CC = cyst contents; DS = diaphragma sellae; PG = pituitary gland.

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    A case of a suprasellar RCC treated by a fully endoscopic supraorbital route. A and B: Preoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating a 15-mm cyst with purely suprasellar location. The sagittal image (A) shows the normal gland (arrow) occupying the entire sellar space, and an endonasal approach could therefore cause a higher risk of gland injury. C and D: Postoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating resection of the cyst. E and F: Intraoperative endoscopic photographs showing identification of the cyst and its adjacent structures (E) and partial removal of the cyst wall (F), performed without damage to the pituitary gland and the infundibulum. The cyst was left open, allowing for its drainage into the suprasellar cistern. ICA = internal carotid artery; OC = optic chiasm; PS = pituitary stalk; RCC = Rathke cleft cyst; TS = tuberculum sellae.

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    A case of an intra- and suprasellar RCC treated by a fully endoscopic supraorbital route. A and B: Preoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating a 17-mm sellar cyst with suprasellar extension. Although the cyst is in both the sellar and suprasellar space, normal gland (arrow) can be seen occupying almost the entire sellar space in the sagittal image (A). An endonasal approach was therefore not recommended for this case. C and D: Postoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating resection of the cyst. E–H: Intraoperative endoscopic photographs showing the cyst and the infundibulum (E); incision of the cyst (where there were no neurovascular structures) and evacuation of the contents (F); partial removal of the cyst wall (G), with the cyst left open; and the intact residual gland (H, view from within cyst via 30° endoscope), which would have been likely to suffer damage in an endonasal approach. BAM = basal arachnoid membrane.

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    Radiological recurrence-free survival rates in different surgical groups. The y-axis denotes the percentage of patients who had no radiological recurrence. The Kaplan-Meier 3-year actuarial recurrence-free survival rate was 84% for the TS/STR group, 87% for the TC/STR group, and 86% for the TC/GTR group. Statistical analysis showed no significant between-groups difference (p = 0.9).

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