Clinical Analysis Of 111 Rathke’s Cleft Cysts Patients

Objective:Commonly asymptomatic,Rathke’s cleft cysts could be symptomatic when these lesions cause mass effect on surrounding structures.It is still difficult to make accurate preoperative diagnosis and optimal treatment.For a better understanding,this article focuses on its natural history,clinicopathologic features,radiographic features,surgical outcomes and recurrence rate.Methods:The clinical data of 111 cases from 2006.1 to 2016.12 in second affiliated hospital of Zhejiang University,which diagnosed Rathke’s cleft cysts pathologically after surgery,was retrospectively collected and analyzed.All subjects were examined neurologically,radiologically,pathologically and biochemically to ascertain the clinical significance of surgery on endocrine and visual improvement,as well as its surgery morbidity and recurrence rates.Results:1.In the 111 cases,there are 55 male patients and 56 female patients;the onset age is between 16-78 years,the average onset age is 48.4±13.4 years.The disease course is between 1 week to 10 years with average course 14.0±27.3 months;2.The typical clinical manifestations are headache(62.2%),visual dysfunction(38.3%),pituitary deficiency(23.4%),with 19.8%recognized incidentally like trauma and physical examination.3.Pituitary hormone abnormality varies,hyperprolactinemia(27 patients)and TSH elevation(15 patients)are more common than LH elevation(7 patients),GH deficiency(6 patients)and hypothyroidism(6 patients).And GH elevation,hypercortisolemia and hypocortisolemia have same frequency with 2 patients.4.Rathke’s cleft cysts were mainly confined to the sellar,whereas 40 cases were situated in the sellar,69 cases crossed saddle into suprasellar regions and only 2 cases were purely suprasellar.57 patients’CT scan showed the round or oval,dumbbell-shaped mass was mostly hypodense to the gray matter of the brain.7 of 11 CT enhanced scan showed a patchy or rim enhancement,which others show no contrast enhancement.5.MRI scan shows cysts are usually cystic,round,enhanced with thin wall,homogeneous density,well-defined margin and located in pituitary intermediate lobe,with low T1WI,high T2WI in 62 cases,high T1WI,high T2WI in 18 cases and iso or hypo intensity on T2WI in 31 cases.Specially,the cyst wall shown irregular enhancement:52 cases showed cyst wall complete rim enhancement,16 cases shown discrete rim enhancement.6.According to radiologic classification,it was significant difference between the clinical symptoms,like headache and visual dysfunction and cyst’s size based on Chi-square test(P<0.01),while endocrinologic symptoms didn’t.It was no significant difference between clinical symptoms and MRI imaging features like intensity on T1WI,intensity on T2WI or the enhancement of cyst wall.7.Pre-operational diagnosis shown that only 25 cases were correctly diagnosed.Those misdiagnosis were pituitary adenomas for 42 cases,sella neoplasm in dispute for 26 cases,the rest are craniopharyngiomas,cystic change of pituitary adenomas and pituitary apoplexy.Specially,between the two 5.5 years6 period,the accuracy and the relative accuracy of diagnosis were obviously improved from 15.4%to 32.6%and 21.5%to 52.2%respectively.8.Among the 111 patients,95 cases were treated by transnasal-sphenoidal microsurgery,which 7 cases using the assistance of neuroendoscopy,9 cases through craniotomy.During the surgery,the content of cyst ranged from clear materials to purulent or colorful contents.In our series,40%were yellow mucoid,23.4%are white caseous and 23.4%were brown gel-like.9.The most common pathological description of cyst content was homogeneous pink stained with non-structure fluid.What’s more,one case reported blood clot and necrotic tissue,one case reported hyperplasia of fibrous tissue with a few atypical cells in degeneration necrosis tissue and one case shown obvious infiltration of neutrophils.The pathological test of cyst wall mostly reported ciliated columnar epithelium or cuboidal cover with 7 cases had squamous metaplasia,4 cases reported calcification and 4 cases reported infiltration of neutrophils.10.The morbidity of surgical treatment include postoperative diabetes insipidus(31/111),cerebrospinal fluid leks(26/111),aseptic meningitis(1/111),nasopharyngeal bleeding(1/111)and whole pituitary hormone deficiency(1/111).All were improved after symptomatic treatment.11.Improved rates of symptom are headache(100%),visual dysfunction(83.7%),pituitary deficiency(84.6%).Improved rates of hormone abnormality varies,hypercortisolemia and hypocortisolemia(100%),hyperprolactinemia(74.1%)and TSH elevation(40%),GH deficiency and hypothyroidism(33.3%),LH elevation and GH elevation showed no improvement.12.Iso or hypo intensity on T2WI,squamous metaplasia and infiltration of neutrophils show significant difference with the recurrence of RCCs.And squamous metaplasia combined with infiltration of neutrophils show the strongest correlation.Result:Rathke cleft cysts grew over time slowly and can become sufficiently large to cause a compressive effect on surrounding structures,resulting in neurologic and endocrine abnormalities.Through the retrospective analysis of 111 RCCs’ clinical data in the last 11 years,we found the benign lesion in sellar region have multiple clinical and radiographic inspection.The indication of relatively higher possibility of RCCs were:the chief complain about headache,visual and pituitary endocrine dysfunction,the round or oval,dumbbell-shaped,iso-hypodense,rim enhancement mass on CT and cystic,round,enhanced with thin wall,homogeneous density,well-defined margin and located in pituitary intermediate lobe,most low T1WI,high T2WI description on MRI indicated the.Transnasal-sphenoidal microsurgical procedure was the primary therapy with clear vision,less damage and quick recovery.