Transsphenoidal Endoscopic Approach in the Treatment of Rathke's Cleft Cyst

Frank, Giorgio; Sciarretta, Vittorio; Mazzatenta, Diego; Farneti, Giovanni; Modugno, Giovanni Carlo; Pasquini, Ernesto

doi:10.1227/01.neu.0000144824.80046.1f

Cited by 88 publications

(55 citation statements)

References 23 publications

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“…However, the range of recurrence rates in previous reports is quite large (0%-42%). 1,8,11,13,15,[23][24][25]28,[34][35][36]47,53 Several factors, including sample size, surgical modalities, duration of follow-up, and definitions of recurrence, may account for the variation. For example, the radiological recurrence rate in our series was 13%, while the symptomatic recurrence rate was 8%.…”

Section: Outcome Analysismentioning

confidence: 99%

“…5,11,13,15,23,24,28,29,[34][35][36] Potts et al 35 retrospectively reviewed a total of 151 RCCs and reported 19 cases (13%) of suprasellar lesions. They compared the presentations, surgical outcomes, and pathology of lesions with different location, but did not evaluate different surgical approaches according to cyst location and extent of resection.…”

Section: Surgical Considerations Based On Cyst Locationmentioning

confidence: 99%

“…The endonasal approach is typically used for sellar lesions, whereas the craniotomy is indicated for suprasellar lesions. 2,11,38,40 Owing to its reduced invasiveness …”

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Individualized surgical strategies for Rathke cleft cyst based on cyst location

Fan¹,

Peng²,

Qi³

et al. 2013

JNS

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R athke cleft cysts (RCCs) are regarded as benign cystic lesions derived from a remnant of the Rathke pouch. They are common findings at autopsy, with a reported incidence of 5% to 33%, and account for 6%-10% of sellar lesions. 3,9,17,32,39,46,49 Although mostly asymptomatic, some RCCs can become sufficiently large to cause compressive effect on surrounding structures, resulting in neurological and endocrine disturbances. As a result, surgical intervention is recommended for symptomatic or at-risk patients.Traditionally, the 2 most common surgical approaches are the endonasal transsphenoidal route and the standard craniotomy. The endonasal approach is typically used for sellar lesions, whereas the craniotomy is indicated for suprasellar lesions. 2,11,38,40 Owing to its reduced invasiveness Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, ChinaObject. 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....

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Section: Outcome Analysismentioning

confidence: 99%

Section: Surgical Considerations Based On Cyst Locationmentioning

confidence: 99%

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Individualized surgical strategies for Rathke cleft cyst based on cyst location

Fan¹,

Peng²,

Qi³

et al. 2013

JNS

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“…In the last 15 years, endoscopic endonasal approaches have become widely used in the surgical management of these lesions. 8,16,27 Although quite rare, open craniotomy may be required in complex cases of giant or purely suprasellar RCCs or in patients in whom a transsphenoidal approach is contraindicated. For most patients, however, extended endonasal approaches have obviated the requirement for craniotomy in all but the most complex RCCs.…”

Section: Intraoperative Management Of Rccsmentioning

confidence: 99%

Rathke cleft cysts: a review of clinical and surgical management

Zada¹

2011

FOC

112

103

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The aim of this paper is to provide a comprehensive review of clinical, imaging, and histopathological features, as well as operative and nonoperative management strategies in patients with Rathke cleft cysts (RCCs). A literature review was performed to identify previous articles that reported surgical and nonsurgical management of RCCs. Rathke cleft cysts are often incidental lesions found in the sellar and suprasellar regions and do not require surgical intervention in the majority of cases. In symptomatic RCCs, the typical clinical presentation includes headache, visual loss, and/or endocrine dysfunction. Visual field testing and endocrine laboratory studies may reveal more subtle deficiencies associated with RCCs. When indicated, the transsphenoidal approach typically offers the least invasive and safest method for treating these lesions. Various surgical strategies including cyst wall resection, intralesional alcohol injection, and sellar floor reconstruction are discussed. Although headache and visual symptoms frequently improve after surgical drainage of RCCs, hypopituitarism and diabetes insipidus are less likely to do so. A subset of more aggressive, atypical RCCs associated with pronounced clinical symptoms and higher recurrence rates is discussed, as well as the possible relationship of these lesions to craniopharyngiomas. Rathke cleft cysts are typically benign, asymptomatic lesions that can be monitored. In selected patients, transsphenoidal surgery provides excellent rates of improvement in clinical symptoms and long-term cyst resolution. Complete cyst wall resection, intraoperative alcohol cauterization, and sellar floor reconstruction in the absence of a CSF leak are not routinely recommended.

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“…4 Entirely suprasellar RCCs with a normal sella turcica are relatively rare (incidence 0%-20%). 8,12,13,15,20,24,25,31,36,39 Suprasellar, intrasuprasellar, and intrasellar RCCs are distinct entities with respect to their clinical presentation, resectability, postoperative recurrence, and outcomes. Few authors have classified RCCs based on cyst location and have compared the presentations, different surgical approaches, pathological types, and surgical outcomes.…”

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Characteristics of Rathke's cleft cyst based on cyst location with a primary focus on recurrence after resection

Chotai¹,

Liu²,

Qi³

2015

JNS

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Rathke's cleft cysts (RCCs) are nonneoplastic epithelial lesions of the sellar and suprasellar region. They are typically asymptomatic with a slow growth rate. An asymptomatic RCC is most often diagnosed at autopsy with a reported incidence of 5%-33%. 5,[47][48][49] Quite often some RCCs grow over time and can become sufficiently large to cause a compressive effect on surrounding structures, resulting in neurological and endocrine abnormalities. 7,28,37,42 Sixteen patients (18%) had an entirely intrasellar RCC, 21 (24%) had a purely suprasellar cyst, and 50 (58%) had an intrasuprasellar RCC. The mean cyst volume was 2.4 ± 0.9 cm 3 (range 0.36-4.9 cm 3 ). Headache was the most frequent initial symptom (76%) followed by visual disturbance (45%). The transsphenoidal approach was performed for all intrasellar RCCs (16 cysts) and 33 of 50 intrasuprasellar RCCs. The transcranial route was used for all suprasellar cysts (21 cysts) and 17 of 50 intrasuprasellar RCCs. Squamous metaplasia was present in 27 (31%) of 87 RCCs. The occurrence of squamous metaplasia was associated with cyst location (p = 0.027), T1 signal intensity (p = 0.004) and ring enhancement on Gd-enhanced MRI (p = 0.017), and cyst volume (p = 0.045). A suprasellar location (p = 0.048, OR 3.89, 95% CI 1.010-15.020), ring enhancement on Gd-enhanced MRI (p = 0.028, OR 3.922, 95% CI 1.158-13.288), hypointensity on T1-weighted MRI (p = 0.002, OR 6.86, 95% CI 1.972-23.909), and cyst volume (p = 0.01, OR 0.367, 95% CI 0.170-0.789) were independent predictors of squamous metaplasia. The mean time to reaccumulation (11 [12.6%] of 87 cases) and recurrence (7 [8%] of 87 cases) was 14 ± 6 months. Recurrence-free survival was 84.5% at a mean of 98.2 ± 4.6 months after treatment. A suprasellar cyst location (p = 0.007, OR 7.7, 95% CI 1.75-34.54), the occurrence of squamous metaplasia (p = 0.007, OR 19.3,, and isointensity on T2-weighted MRI (p = 0.041, OR 10.29, 95% CI 1.094-96.872) were the independent predictors of RCC recurrence. coNclusioNs A suprasellar cyst location, the occurrence of squamous metaplasia, and isointensity on T2-weighted MRI were independent predictors of RCC recurrence. The extent of resection and type of surgical approach used were not associated with recurrence. A tailored extent of resection based on cyst location and predictive factors is recommended.

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Transsphenoidal Endoscopic Approach in the Treatment of Rathke's Cleft Cyst

Abstract: The transsphenoidal endoscopic approach represents a straightforward and mini-invasive approach for the drainage and biopsy of a Rathke's cleft cyst.

Cited by 88 publications

References 23 publications

Individualized surgical strategies for Rathke cleft cyst based on cyst location

Individualized surgical strategies for Rathke cleft cyst based on cyst location

Rathke cleft cysts: a review of clinical and surgical management

Characteristics of Rathke's cleft cyst based on cyst location with a primary focus on recurrence after resection

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