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Clinical, Radiological and Pathological Features of Patients with Rathke’s Cleft Cysts: Tumors That May Recur

Departments of Endocrinology (J.J.M., N.I., G.K., P.J.T., J.P.M., G.M.B., A.B.G.), Pathology (D.G.L.), Radiology (M.C.), and Neurosurgery (F.A.), St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom

Address all correspondence and requests for reprints to: Professor A. B. Grossman, Department of Endocrinology, St. Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, United Kingdom.

	Abstract

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Rathke’s cleft cysts are cystic sellar and suprasellar lesions, characteristically lined by a single layer of ciliated cuboidal or columnar epithelium. In contrast, craniopharyngiomas, which are also cystic sellar and suprasellar lesions, are characteristically lined by stratified squamous epithelium with keratinization on a layer of connective tissue. The usual management recommended for Rathke’s cleft cysts is simple surgical drainage with partial excision of the cyst wall. Recurrences of these cysts reportedly have been very rare. This retrospective study presents the details of 12 patients (6 females; median age 30 yr, range 21–58 yr) with Rathke’s cleft cyst, referred to our department over a 15-yr period (1981–1996), an unusual feature being the recurrence of 4 (33%) of these lesions. Clinical, endocrine, radiological, surgical (10 transsphenoidal; 2 transcranial), and pathological details were recorded. Nine out of 12 patients (75%) were symptomatic; visual symptoms were the commonest, and 8 had visual field defects. The median duration of symptoms was 12 months (range 3–24 months). Three patients (25%) had panhypopituitarism, 2 of whom also had diabetes insipidus (17%). The cysts varied in size from 6 mm to 50 mm, 1 being entirely suprasellar. There were no pathognomonic clinical or radiological features to differentiate them from other pituitary lesions, although the presence of diabetes insipidus in 2 patients suggested that the lesion was not a pituitary adenoma. A definite histological diagnosis was possible in 8 patients; in 4, the diagnosis was presumptive. The median duration of follow-up was 30 months (1–168 months). Four patients (33%) showed reexpansion at 3, 6, 48, and 48 months after initial surgery, 3 of whom were symptomatic and required repeat surgery. Two of these patients were given postoperative external beam pituitary radiotherapy.

Apparent recurrence of Rathke’s cleft cysts after initially successful surgery in our series was higher than suggested by previous reports, and thus, long-term follow-up with pituitary imaging and neuroophthalmological assessment is essential. There are no specific characteristics of the cyst that predict recurrence. Ideal management of these cysts is unclear, but aspiration, followed by extensive excision of the cyst wall when possible, seems to be the best initial option. For recurrent symptomatic tumors, surgical resection is the treatment of choice. Considering the high recurrence rate with residual structural and functional dysfunction, the role of radiotherapy in preventing recurrence of these cysts needs careful evaluation with a larger study with a longer follow-up period.

	Introduction

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RATHKE’S CLEFT cysts are cystic sellar and suprasellar lesions, which are thought to originate from the remnants of Rathke’s pouch and are characteristically lined by a single layer of ciliated cuboidal or columnar epithelium with goblet cells (1, 2). Rathke’s cleft cysts with foci of squamous epithelium also have been reported (3, 4, 5). Craniopharyngiomas also are cystic sellar and suprasellar lesions that are characteristically lined by stratified squamous epithelium with keratinization and additionally may possess either a basal layer of small cells and an intermediate layer of stellate cells, or papillary projections of epithelial cords into the surrounding tissues (6). Although small asymptomatic Rathke’s cleft cysts have been recorded at autopsy in 13–22% of normal pituitary glands (7, 8, 9), symptomatic cysts are rare, and only approximately 150 cases have been reported in the literature (10). The usual management of symptomatic Rathke’s cleft cysts has been simple surgical drainage with partial excision of the cyst wall (11). Because recurrence of these cysts is reputedly rare, with only a few isolated case reports in the literature (3, 11, 12, 13, 14, 15, 16), postsurgical radiotherapy usually has not been recommended. However, we have recently noted a number of patients treated in the conventional manner who showed a reaccumulation of the cyst, and therefore, we have reviewed our total experience over the last 15 yr on the clinical, radiological, surgical, and histopathological features of all patients with Rathke’s cleft cysts seen in our department, with special reference to their recurrence rate.

	Subjects and Methods

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We reviewed the case notes of all 12 patients with the diagnosis of Rathke’s cleft cyst (6 females; median age 30 yr, range 21–58 yr), referred to our department over a 15-yr period (1981–1996). These were accessed from a central database on which all departmental patients are classified according to diagnosis. One patient (no. 1) has been presented earlier as a single case report (17); a further 2 patients (nos. 2 and 11) were initially treated at another institution and were subsequently referred to our hospital for further assessment and treatment.

Pituitary imaging was available for review in 8 out of 12 patients; in 2 patients (nos. 1 and 12), the original computed tomography (CT) and magnetic resonance imaging (MRI) films could not be obtained, and in a further 2 patients (nos. 2 and 11), the preoperative films were not available for review. We relied on the original radiologist’s report in these 4 patients. Pituitary imaging included contrast-enhanced CT scans in 5 patients, gadolinium-enhanced MR scans in 3 patients, and both types of scan in 4. Four patients (nos. 4, 7, 10, and 11) were noted to have a reaccumulation of the cyst, 3 of whom were reoperated. Of these 3 patients, 2 had a preoperative gadolinium-enhanced MR scan and 1 a contrast-enhanced CT scan. All MR scans were T1-weighted sequences, except in 2 patients (nos. 3 and 12), who also had T2-weighted sequences.

Endocrine evaluation was carried out using standardized basal and dynamic stimulation tests, as previously published (18).

Ten patients underwent transsphenoidal surgery and 2 had transfrontal craniotomy at first presentation. Of the 3 patients reoperated for recurrence, 2 had transsphenoidal and 1 had transcranial surgery. The histology from 10 patients was available for review, including all 3 patients with a recurrence who were reoperated; in the remaining 2 patients (nos. 2 and 11), we had to rely on the original report of the histopathologist from the referring institution.

	Results

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Clinical details (Table 1)

Nine patients presented with relevant symptoms, whereas in 3 (nos. 5, 6, and 7), the lesions were found coincidentally during a CT scan of the brain for other disorders. Of the 9 symptomatic patients, 4 presented with visual symptoms and 4 with headaches; another patient presented with visual symptoms plus nausea and vomiting. Seven patients had bitemporal hemianopias, and 1 had a bitemporal upper quadrantinopia. The median duration of symptoms at presentation was 12 months (range 3–24 months). The median duration of follow-up was 30 months (range 1–168 months).

Endocrine function (Table 2)

One patient (no. 11) had high serum PRL levels and complained of galactorrhea and amenorrhea. Three patients (nos. 2, 9, and 12) were panhypopituitary, and two (nos. 2 and 9) had diabetes insipidus at presentation. Patient no. 6 had pituitary-dependent Cushing’s syndrome, which was subsequently confirmed histologically. In the four patients with recurrent disease, only one (no. 4) had developed a further hormonal defect, that of gonadotropin deficiency.

The cysts varied in size from 6 mm to 50 mm. One was located entirely in the suprasellar region, two were entirely intrasellar, and nine were intrasellar with suprasellar extensions. Of the eight CT scans reviewed, the cyst was isodense to the grey matter of the brain in three, of low density in two, of high density in one, and of mixed density (low and isodense) in one. One of the lesions showed patchy calcification. Postcontrast CT scans showed rim enhancement with a small superior nodule in two lesions, two showed peripheral enhancement, in two there was patchy enhancement, and in one there was no enhancement.

Of the five MR scans (T1-weighted) reviewed, the lesion was of low signal intensity in two patients, isointense in two, and of high signal intensity in one. In four patients, there was rim enhancement noted post-gadolinium, whereas there was no enhancement in patient no. 12. Two scans were T2-weighted, and the cyst was recorded to be of high intensity on both these studies.

In the four recurrent tumors, the cyst size varied at representation from 11 to 28 mm. Two of the cysts were intrasellar, and the other two both were intra- and suprasellar. One patient had a CT scan of the pituitary fossa, whereas the other three had an MRI. The lesion was of mixed density with patchy calcification and enhancement on the CT study. Two of the three T1-weighted MRI studies were available for review; in one the lesion was of low signal intensity, and in the other it was isointense. Both had peripheral enhancement post gadolinium.

Operative findings (Table 3)

Ten patients underwent transsphenoidal surgery, whereas two had transfrontal craniotomy at first presentation. Three of the four patients with a recurrence were reoperated; one patient with a previous transcranial approach had transsphenoidal surgery, the second had a repeat transcranial approach, whereas the third patient had a repeat transsphenoidal approach. The cyst contents were drained, and a biopsy of a portion of the cyst wall was obtained, where possible without causing destruction of surrounding structures.

Cyst fluid ß-hCG measurements were performed in three patients, two with a recurrence. Patient no. 12 had undetectable levels (<50 IU/L). Patient no. 4, on first presentation, had a cyst fluid ß-hCG of 187 IU/L; but on recurrence, this was undetectable. Patient no. 10 had detectable cyst fluid ß-hCG at first presentation and, on recurrence, had levels of more than 100 IU/L (no further dilutions were done). Patient no. 1 had undetectable CSF ß-hCG.

There were no perioperative complications. Post operatively, transient diabetes insipidus was noted following 9 of the 12 transsphenoidal approaches and 1 out of 3 transcranial approaches.

Histopathology (Table 3)

A definite diagnosis of Rathke’s cleft cyst was possible in eight patients (Table 3). In the remaining four patients (nos. 2, 6, 7, and 9), the diagnosis of Rathke’s cleft cyst is presumptive. In two patients (nos. 2 and 6), the original pathology report identified a Rathke’s cleft cyst, although the actual histology was not available to us for review. In patient no. 7, no epithelial lining could be detected, and the diagnosis of Rathke’s cleft cyst was made on the basis of the radiological findings and the peroperative appearance of a soft structureless lesion. In patient no. 9, a small amount of epithelial lining was included in the biopsy specimen that was cuboidal, thereby suggesting a Rathke’s cleft cyst.

Details of patients with recurrent cysts

Patient no. 4. The patient presented with blurred vision and bitemporal hemianopia. Pituitary imaging revealed a 35-mm cystic lesion. At surgery, 8 mL clear fluid was aspirated, followed by partial excision of the cyst wall, and histology showed cuboidal epithelium. The patient presented 4 yr later with headaches and deterioration of visual fields. A 22-mm cystic mass was seen; and at surgery, 15 mL clear fluid was aspirated, followed by resection of the cyst wall. Pituitary radiotherapy (4500 cGy in 25 fractions over 35 days) was given. There has been no change in the size of the cyst on follow-up MR scans over 1 yr. This patient also had a cystic pineal lesion that measured 12–20 mm over 5 yr.

Patient no. 7. This patient was found to have a 13-mm cystic lesion, which was removed, but no epithelial lining was detected on histology, whereas a postoperative MR scan showed resolution of the lesion; a further scan, 4 yr later, showed an 11-mm intrasellar lesion. Because she was asymptomatic and the recurrence was intrasellar, it was followed with yearly MR scans; there has been no change in size over 2 yr.

Patient no. 10. This patient presented with blurred vision and bitemporal hemianopia. On imaging, a 40-mm cyst with patchy calcification was seen, which was evacuated and its wall partially excised. Histology showed ciliated columnar and stratified squamous epithelium. A postoperative scan showed considerable reduction in the size of the cyst, but she represented, 3 months later, with decreased acuity and optic atrophy in the right eye. On imaging, a 28-mm cystic lesion was seen, from which clear CSF-like fluid was aspirated after partial excision of its wall. Pituitary radiotherapy was given, and MR scanning, a year later, showed no change in the size of the cyst.

Patient 11. This patient presented with headache, galactorrhea, and oligomenorrhea. Serum PRL was elevated, and an MR scan revealed a 25-mm cystic lesion; at surgery, chocolate-colored fluid was aspirated, and the semisolid components were evacuated. Histology showed flattened cuboidal cells. She represented, 5 months later, with headaches and an elevated serum PRL. MR scan of the pituitary showed a 12.5-mm cystic lesion. At surgery, the cyst was aspirated again and its wall partially excised. Histology showed ciliated columnar epithelium, and a postoperative MR scan confirmed the complete removal of the cyst. Follow-up CT scans, over 2 yr, have not shown any further reaccumulation of cyst fluid.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Rathke’s cleft cysts are believed to be derived from the remnants of Rathke’s pouch (8, 9, 11). Some authors, however, believe that these cysts are derived directly from the neuroepithelium (19, 20), some consider them to arise as a result of metaplasia of the anterior pituitary cells (21), whereas still others propose an endodermal origin (22). Symptomatic Rathke’s cleft cysts are rare, usually presenting as intrasellar lesions with approximately one third having a significant suprasellar extension (23, 24). Our experience would suggest a prevalence of approximately 1% of patients with pituitary and hypothalamic tumors, based on our patient referral to a tertiary centre. The common presentations include headache, pituitary dysfunction, and in the event of suprasellar extension, visual loss caused by compression of the optic chiasm. Diabetes insipidus was a presenting feature in 17% of the patients in our series. Various atypical clinical appearances of Rathke’s cleft cysts also have been described in the literature: an entirely suprasellar location (25), as in one patient in our series; hemorrhage into a Rathke’s cleft cyst (26), as in one patient of our series; abscess within the Rathke’s cleft cyst (27, 28, 29, 30), as in one patient in our series; and cysts associated with pituitary adenomas (31), as in one of our patients. Although there are isolated reports of craniopharyngiomas associated with a pineal cyst (32), to our knowledge there has been no previously documented case of a Rathke’s cleft cyst associated with a pineal cyst.

There have been numerous attempts to define the features of a Rathke’s cleft cyst on pituitary imaging. The cyst density on CT scanning and cyst intensity on MRI imaging have been variably reported to range from hypo- to iso- to mixed intensity (5, 33). Calcification, said to be characteristically absent from Rathke’s cleft cysts, also has been seen in isolated cases (4, 34). Lack of postcontrast enhancement on MRI has been suggested by some to be the hallmark of these cysts (5), but patchy or ring enhancement post-gadolinium injection also has been reported (16). We were unable to identify any characteristic features, on imaging with either CT or MRI, which distinguished a Rathke’s cleft cyst from either a pituitary adenoma or a craniopharyngioma. At surgery, these lesions have been variably noted to have a cystic to semisolid consistency, and the cyst contents have been described from clear CSF-like to milky-white, brown, machine oil-like, and engine oil-like (5, 35). Cholesterol crystals within the cyst fluid has been documented (36), as are cysts with solid components (3, 5, 19, 33, 37).

Recurrence of Rathke’s cleft cysts is said to be very rare. A review of the literature revealed only 7 well-documented recurrences of Rathke’s cleft cysts (34, 11, 12, 13, 14, 15, 16). In contrast, the recurrence rate in our group of patients is much higher: 4 out of 12 patients had a recurrence, 3 of whom were symptomatic and required reexploration. It has been suggested that the presence of a solid lesion within the cyst, consisting of stratified squamous epithelium, increases the risk of a recurrence (3, 13, 14). However, recurrence of cysts lined by a single layer of cuboidal or columnar epithelium also has been reported (12, 15, 16). Of the 4 recurrences in our series, 2 were lined by a single layer of cuboidal epithelium, and 1 had a focus of stratified squamous epithelium. One of our recurrences had clear cyst fluid, whereas 1 had a solid component. Thus, we could not identify any definite cyst fluid or histopathological characteristic that might predict an increased risk of recurrence. However, because complete surgical removal was not attempted in many cases, it may be more appropriate to consider such recurrences as cyst fluid reaccumulation, at least in some instances.

The reason for a higher recurrence rate in our series is unclear. It is possible that the true incidence of recurrence in Rathke’s cleft cysts is higher than previously reported. As suggested by Fager and Carter (38), there has always been a confusion in the diagnosis between Rathke’s cleft cysts and craniopharyngiomas, which may contain overlapping histological features, and it is possible that many Rathke’s cleft cysts are misdiagnosed as craniopharyngiomas, more so in the case of a recurrence (39). An elevated level of immunoreactive ß-HCG in the cyst fluid of patients of craniopharyngioma has been reported (40, 41). One of our patients (no. 12) had undetectable ß-HCG levels in the cyst fluid. However, of the two recurrences, in the one lined by pure cuboidal epithelium, cyst fluid ß-HCG was detectable at first presentation but undetectable at recurrence; whereas in the second, with a focus of squamous epithelium, cyst fluid ß-HCG seemed to increase. Thus, it would seem that cyst fluid ß-HCG was also not discriminatory between the simple single-layered Rathke’s cyst and the one with a focus of squamous epithelium, and also between Rathke’s cysts and craniopharyngiomas.

In summary, we present the clinical, radiological, surgical, and histopathological features of eight definite and four probable cases of Rathke’s cleft cysts. Clinical, endocrine and radiological characteristics were highly variable and were rarely helpful in identifying such lesions. We believe that long-term follow-up with periodic MRI and neuroophthalmological assessment is hence necessary in all cases. We recommend that a postoperative MR scan should be performed to assess the extent of removal of the cyst, with further scans at 6 and 12 months and then at intervals for at least 5 yr. The optimal therapy for a recurrent symptomatic cyst is unclear, but transsphenoidal aspiration and, where possible, extensive removal of the cyst wall are most appropriate; we have adopted a regimen whereby repeat surgery is followed by external beam pituitary radiotherapy, although the role of radiotherapy in preventing further recurrence at present is unclear. Rathke’s cleft cysts seem to be more prone to cyst fluid reaccumulation and recurrence than previously recognized.

Received December 16, 1996.

Accepted March 19, 1997.

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This Article Abstract Full Text (PDF) Submit a related Letter to the Editor Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Copyright Permission Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mukherjee, J. J. Articles by Grossman, A. B. Search for Related Content PubMed PubMed Citation Articles by Mukherjee, J. J. Articles by Grossman, A. B.