Symptomatic Rathke Cleft Cysts
Symptomatic Rathke Cleft Cysts
Object. Rathke cleft cysts (RCCs) are benign masses arising from the embryological Rathke pouch, and are commonly treated by transsphenoidal surgery. The authors retrospectively compared RCC extent of resection—either gross-total resection (GTR) or decompression—to the primary outcome measure, which was recurrences resulting in repeat surgery, and the secondary outcome measure, which was complications.
Methods. Seventy-four patients presenting to the neurosurgical department with RCC were analyzed retrospectively. Sixty-eight patients had a total of 78 surgical procedures, with the diagnosis of RCC confirmed by histological investigation; of these, 61 patients had adequate operative notes for the authors to evaluate extent of resection. Groups were separated into GTR (32 patients) or decompression (subtotal resection or fenestration into the sphenoid sinus; 29 patients) based on operative notes and postoperative imaging. The mean follow-up duration was 60.5 ± 72.1 months (the mean is expressed ± SD throughout).
Results. The average age at the time of the initial surgery was 42.8 ± 17.4 years, and 70% of patients were female. The mean cyst diameter preoperatively was 16.9 ± 17.8 mm. Eight patients had repeat surgery, our primary outcome measure; 3 repeat operations occurred in the GTR group, and 5 in the decompression group. There was no significant difference in recurrence when comparing groups (GTR 9%, decompression 17%; p = 0.36). There were no major complications; however, analysis of postoperative minor complications revealed that 11 (34%) GTRs resulted in surgical complications, whereas the decompression cohort accounted for only 3 complications (10%) (p = 0.03), with diabetes insipidus (6) and CSF leaks (5) being the most common. Gross-total resection also resulted in an increase in postoperative hyperprolactinemia compared with decompression (p = 0.03).
Conclusions. It appears that RCCs require repeat surgery in 13% of cases, and attempted GTR does not appear to reduce the overall rate of recurrence. However, more aggressive resections are associated with more complications in this series.
Rathke cleft cysts (RCCs) are benign sellar cysts, and comprise between 6% and 10% of sellar lesions. They are thought to arise from a remnant of the embryological structure, the Rathke pouch, which is typically positioned between the adenohypophysis and the neurohypophysis. Rathke cleft cysts are found frequently at autopsy, and have been reported to occur in 5%–27% of the population.
Although RCCs are nonfunctioning, they can result in neurological and endocrine deficits via mass effect on the pituitary axis, optic chiasm, and surrounding anatomy. As a result, surgical intervention is recommended in symptomatic and at-risk patients, most commonly via a transsphenoidal approach. The extent of resection that produces maximum benefit is still somewhat controversial. Theoretically, a more aggressive resection such as a gross-total resection (GTR) would lead to a lower rate of recurrence than a subtotal resection (STR) or fenestration. However, this benefit has not been proven, and GTR conceivably leads to more complications. Furthermore, STR or fenestration techniques are believed to have fewer complications than a more aggressive resection. To date, there has been no conclusive evidence to show whether decompression of RCCs by fenestration or STR can achieve the same level of relief of mass effect as more aggressive approaches, such as a GTR. Similarly, it is also not fully known whether the rate of recurrence is directly correlated with the amount of tumor remaining postoperatively; that is, if a more aggressive resection will ensure a longer tumor-free period. In our study, we aim to answer these questions. We present a case series of patients with RCC in which these two valid paradigms are compared: GTR versus decompression with regard to cyst recurrence and complications due to surgery.
Abstract and Introduction
Abstract
Object. Rathke cleft cysts (RCCs) are benign masses arising from the embryological Rathke pouch, and are commonly treated by transsphenoidal surgery. The authors retrospectively compared RCC extent of resection—either gross-total resection (GTR) or decompression—to the primary outcome measure, which was recurrences resulting in repeat surgery, and the secondary outcome measure, which was complications.
Methods. Seventy-four patients presenting to the neurosurgical department with RCC were analyzed retrospectively. Sixty-eight patients had a total of 78 surgical procedures, with the diagnosis of RCC confirmed by histological investigation; of these, 61 patients had adequate operative notes for the authors to evaluate extent of resection. Groups were separated into GTR (32 patients) or decompression (subtotal resection or fenestration into the sphenoid sinus; 29 patients) based on operative notes and postoperative imaging. The mean follow-up duration was 60.5 ± 72.1 months (the mean is expressed ± SD throughout).
Results. The average age at the time of the initial surgery was 42.8 ± 17.4 years, and 70% of patients were female. The mean cyst diameter preoperatively was 16.9 ± 17.8 mm. Eight patients had repeat surgery, our primary outcome measure; 3 repeat operations occurred in the GTR group, and 5 in the decompression group. There was no significant difference in recurrence when comparing groups (GTR 9%, decompression 17%; p = 0.36). There were no major complications; however, analysis of postoperative minor complications revealed that 11 (34%) GTRs resulted in surgical complications, whereas the decompression cohort accounted for only 3 complications (10%) (p = 0.03), with diabetes insipidus (6) and CSF leaks (5) being the most common. Gross-total resection also resulted in an increase in postoperative hyperprolactinemia compared with decompression (p = 0.03).
Conclusions. It appears that RCCs require repeat surgery in 13% of cases, and attempted GTR does not appear to reduce the overall rate of recurrence. However, more aggressive resections are associated with more complications in this series.
Introduction
Rathke cleft cysts (RCCs) are benign sellar cysts, and comprise between 6% and 10% of sellar lesions. They are thought to arise from a remnant of the embryological structure, the Rathke pouch, which is typically positioned between the adenohypophysis and the neurohypophysis. Rathke cleft cysts are found frequently at autopsy, and have been reported to occur in 5%–27% of the population.
Although RCCs are nonfunctioning, they can result in neurological and endocrine deficits via mass effect on the pituitary axis, optic chiasm, and surrounding anatomy. As a result, surgical intervention is recommended in symptomatic and at-risk patients, most commonly via a transsphenoidal approach. The extent of resection that produces maximum benefit is still somewhat controversial. Theoretically, a more aggressive resection such as a gross-total resection (GTR) would lead to a lower rate of recurrence than a subtotal resection (STR) or fenestration. However, this benefit has not been proven, and GTR conceivably leads to more complications. Furthermore, STR or fenestration techniques are believed to have fewer complications than a more aggressive resection. To date, there has been no conclusive evidence to show whether decompression of RCCs by fenestration or STR can achieve the same level of relief of mass effect as more aggressive approaches, such as a GTR. Similarly, it is also not fully known whether the rate of recurrence is directly correlated with the amount of tumor remaining postoperatively; that is, if a more aggressive resection will ensure a longer tumor-free period. In our study, we aim to answer these questions. We present a case series of patients with RCC in which these two valid paradigms are compared: GTR versus decompression with regard to cyst recurrence and complications due to surgery.
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