Early Morning Cortisol Levels as Predictors of Short-Term and Long-Term Adrenal Function After Endonasal Transsphenoidal Surgery for Pituitary Adenomas and Rathke’s Cleft Cysts

Object While transsphenoidal surgery is associated with low morbidity, the degree to which morbidity increases after reoperation remains unclear. The authors determined the morbidity associated with repeat versus initial transsphenoidal surgery after 1015 consecutive operations. Methods The authors conducted a 5-year retrospective review of the first 916 patients undergoing transsphenoidal surgery at their institution after a pituitary center of expertise was established, and they analyzed morbidities. Results The authors analyzed 907 initial and 108 repeat transsphenoidal surgeries performed in 916 patients (9 initial surgeries performed outside the authors' center were excluded). The most common diagnoses were endocrine inactive (30%) or active (36%) adenomas, Rathke's cleft cysts (10%), and craniopharyngioma (3%). Morbidity of initial surgery versus reoperation included diabetes insipidus ([DI] 16% vs 26%; p = 0.03), postoperative hyponatremia (20% vs 16%; p = 0.3), new postoperative hypopituitarism (5% vs 8%; p = 0.3), CSF leak requiring repair (1% vs 4%; p = 0.04), meningitis (0.4% vs 3%; p = 0.02), and length of stay ([LOS] 2.8 vs 4.5 days; p = 0.006). Of intraoperative parameters and postoperative morbidities, 1) some (use of lumbar drain and new postoperative hypopituitarism) did not increase with second or subsequent reoperations (p = 0.3–0.9); 2) some (DI and meningitis) increased upon second surgery (p = 0.02–0.04) but did not continue to increase for subsequent reoperations (p = 0.3–0.9); 3) some (LOS) increased upon second surgery and increased again for subsequent reoperations (p < 0.001); and 4) some (postoperative hyponatremia and CSF leak requiring repair) did not increase upon second surgery (p = 0.3) but went on to increase upon subsequent reoperations (p = 0.001–0.02). Multivariate analysis revealed that operation number, but not sex, age, pathology, radiation therapy, or lesion size, increased the risk of CSF leak, meningitis, and increased LOS. Separate analysis of initial versus repeat transsphenoidal surgery on the 2 most common benign pituitary lesions, pituitary adenomas and Rathke's cleft cysts, revealed that the increased incidence of DI and CSF leak requiring repair seen when all pathologies were combined remained significant when analyzing only pituitary adenomas and Rathke's cleft cysts (DI, 13% vs 35% [p = 0.001]; and CSF leak, 0.3% vs 9% [p = 0.0009]). Conclusions Repeat transsphenoidal surgery was associated with somewhat more frequent postoperative DI, meningitis, CSF leak requiring repair, and greater LOS than the low morbidity characterizing initial transsphenoidal surgery. These results provide a framework for neurosurgeons in discussing reoperation for pituitary disease with their patients.

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Rathke’s cleft cysts following transsphenoidal surgery: long-term outcomes and development of an optimal follow-up strategy

Acta Neurochirurgica ◽

10.1007/s00701-020-04237-5 ◽

2020 ◽

Vol 162 (4) ◽

pp. 853-861 ◽

Cited By ~ 1

Author(s):

Hani J. Marcus ◽

Anouk Borg ◽

Ziad Hussein ◽

Zane Jaunmuktane ◽

Stephanie E. Baldeweg ◽

...

Keyword(s):

Transsphenoidal Surgery ◽

Long Term Outcomes ◽

Rathke's Cleft Cysts ◽

Rathke's Cleft

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Early Morning Cortisol Levels as a Predictor of Remission After Transsphenoidal Surgery for Cushing’s Disease

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2005-1204 ◽

2006 ◽

Vol 91 (1) ◽

pp. 7-13 ◽

Cited By ~ 129

Author(s):

Felice Esposito ◽

Joshua R. Dusick ◽

Pejman Cohan ◽

Parham Moftakhar ◽

David McArthur ◽

...

Keyword(s):

Cushing’S Disease ◽

Transsphenoidal Surgery ◽

Early Morning ◽

Cushing's Disease ◽

Morning Cortisol ◽

Cortisol Levels

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Outcome in surgically treated Rathke's cleft cysts: long-term monitoring needed

Acta Endocrinologica ◽

10.1530/eje-11-0142 ◽

2011 ◽

Vol 165 (1) ◽

pp. 33-37 ◽

Cited By ~ 18

Author(s):

R Trifanescu ◽

V Stavrinides ◽

P Plaha ◽

S Cudlip ◽

J V Byrne ◽

...

Keyword(s):

Visual Field ◽

Visual Field Defects ◽

Rathke's Cleft Cysts ◽

Long Term Monitoring ◽

Rathke's Cleft ◽

Term Monitoring ◽

Field Defects ◽

Tsh Deficiency

ObjectiveTo clarify the outcome of all cases of Rathke's cleft cysts (RCC) treated surgically and followed up in Oxford during a long-term period.Subjects and methodsThe records of all patients with RCC seen in the Department of Endocrinology between January 1978 and June 2009 were reviewed.ResultsA total of 33 patients (20 females, median age 43 years) were identified. At presentation, major visual field defects were detected in 58% of patients and gonadotrophin, ACTH and TSH deficiency in 60, 36 and 36% of patients respectively. Desmopressin treatment was required in 18% of patients. Treatment consisted of cyst evacuation combined with or without biopsy/removal of the wall. Post-operatively, visual fields improved in 83% of patients with impairment, whereas there was no reversal of ACTH or TSH deficiency or of diabetes insipidus. All but one subject had imaging follow-up during a mean period of 48 months (range 2–267). Cyst relapse was detected in 22% of patients at a mean interval of 29 months (range 3–48 months); in 57% of them, the recurrence was symptomatic. Relapse-free rates were 88% at 24-months and 52% at 48-months follow-up. At last assessment, at least quadrantanopia was reported in 19% of patients, gonadotrophin, ACTH and TSH deficiency in 50, 42 and 47% of patients respectively. Desmopressin treatment was required in 39% of patients.ConclusionsIn this study of patients with RCC and long-term follow-up, we showed a considerable relapse rate necessitating long-term monitoring. Surgical intervention is of major importance for the restoration of visual field defects, but it does not improve endocrine morbidity, which in the long-term affects a substantial number of patients.

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Long-term surgical outcomes following transsphenoidal surgery in patients with Rathke’s cleft cysts

Journal of Neurosurgery ◽

10.3171/2017.11.jns171498 ◽

2019 ◽

Vol 130 (3) ◽

pp. 831-837 ◽

Cited By ~ 7

Author(s):

Michelle Lin ◽

Michelle A. Wedemeyer ◽

Daniel Bradley ◽

Daniel A. Donoho ◽

Vance L. Fredrickson ◽

...

Keyword(s):

Transsphenoidal Approach ◽

Neurological Deficits ◽

Csf Leak ◽

Rathke's Cleft Cysts ◽

The Mean ◽

Rathke's Cleft ◽

Cyst Fenestration ◽

Csf Leaks

OBJECTIVERathke’s cleft cysts (RCCs) are benign epithelial lesions of the sellar region typically treated via a transsphenoidal approach with cyst fenestration and drainage. At present, there is limited evidence to guide patient selection for operative treatment. Furthermore, there is minimal literature describing factors contributing to cyst recurrence.METHODSThe authors conducted a retrospective analysis of 109 consecutive cases of pathology-confirmed RCCs treated via a transsphenoidal approach at a single center from 1995 to 2016. The majority of cases (86.2%) involved cyst fenestration, drainage, and partial wall resection. Long-term outcomes were analyzed.RESULTSA total of 109 surgeries in 100 patients were included, with a mean follow-up duration of 67 months (range 3–220 months). The mean patient age was 44.6 years (range 12–82 years), and 73% were women. The mean maximal cyst diameter was 14.7 mm. Eighty-eight cases (80.7%) were primary operations, and 21 (19.3%) were reoperations. Intraoperative CSF leak repair was performed in 53% of cases and was more common in reoperation cases (71% vs 48%, p < 0.001). There were no new neurological deficits or perioperative deaths. Two patients (1.8%) developed postoperative CSF leaks. Transient diabetes insipidus (DI) developed in 24 cases (22%) and permanent DI developed in 6 (5.5%). Seven cases (6.4%) developed delayed postoperative hyponatremia. Of the 66 patients with preoperative headache, 27 (44.3%) of 61 reported postoperative improvement and 31 (50.8%) reported no change. Of 31 patients with preoperative vision loss, 13 (48.1%) reported subjective improvement and 12 (44.4%) reported unchanged vision. Initial postoperative MRI showed a residual cyst in 25% of cases and no evidence of RCC in 75% of cases. Imaging revealed evidence of RCC recurrence or progression in 29 cases (26.6%), with an average latency of 28.8 months. Of these, only 10 (9.2% of the total 109 cases) were symptomatic and underwent reoperation.CONCLUSIONSTranssphenoidal fenestration and drainage of RCCs is a safe and effective intervention for symptomatic lesions, with many patients experiencing improvement of headaches and vision. RCCs show an appreciable (although usually asymptomatic) recurrence rate, thereby mandating serial follow-up. Despite this, full RCC excision is typically not recommended due to risk of hypopituitarism, DI, and CSF leaks.

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Proton Magnetic Resonance Spectroscopy Characterization of Rathke’s Cleft Cysts (RCCs): Relevance to the Differential Diagnosis of Pituitary Adenomas and RCCs

Cancers ◽

10.3390/cancers12020360 ◽

2020 ◽

Vol 12 (2) ◽

pp. 360

Author(s):

Omkar B. Ijare ◽

Martyn A. Sharpe ◽

David S. Baskin ◽

Kumar Pichumani

Keyword(s):

Differential Diagnosis ◽

Magnetic Resonance ◽

Magnetic Resonance Spectroscopy ◽

Pituitary Adenomas ◽

Ex Vivo ◽

Medical Professionals ◽

Resonance Spectroscopy ◽

Rathke's Cleft Cysts ◽

Rathke's Cleft

Background: Rathke’s Cleft Cysts (RCCs) are rare epithelial cysts arising from remnants of the Rathke pouch in the pituitary gland. A subset of these lesions enlarge and produce a mass effect with consequent hypopituitarism, and may result in visual loss. Moreover, some RCCs with a high intra-cystic protein content may mimic cystic pituitary adenoma, which makes their differential diagnosis ambiguous. Currently, medical professionals have no definitive way to distinguish RCCs from pituitary adenomas. Therefore, preoperative confirmation of RCCs would be of help to medical professionals for the management and proper surgical decision making. The goal of this study is to identify molecular markers in RCCs. Methods: We characterized aqueous and chloroform extracts of surgically resected RCCs and pituitary adenomas using ex vivo 1H NMR spectroscopy. Results: All RCCs exclusively showed the presence of mucopolysaccharides which are glycosaminoglycans (GAGs) made up of disaccharides of aminosugars and uronic sugars. Conclusion: GAGs can be used as metabolite marker for the detection of RCCs and this knowledge will lay the groundwork for the development of a non-invasive, in vivo magnetic resonance spectroscopy methodology for the differential diagnosis of RCCs and pituitary adenomas using clinical MRI scanners.

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Long-term surgical outcome in 16 patients with thyrotropin pituitary adenoma

Journal of Neurosurgery ◽

10.3171/jns.2000.93.2.0194 ◽

2000 ◽

Vol 93 (2) ◽

pp. 194-200 ◽

Cited By ~ 81

Author(s):

Naoko Sanno ◽

Akira Teramoto ◽

R. Yoshiyuki Osamura

Keyword(s):

Cavernous Sinus ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Term Outcome ◽

Long Term Outcome ◽

Content Type ◽

Primary Hyperthyroidism ◽

Fine Print

Object. Thyrotropin-secreting pituitary adenomas are rare lesions of the endocrinological system. Although introduction of a hypersensitive radioimmunoassay for thyrotropin enables the recognition of inappropriate secretion of this hormone, the aforementioned lesions remain uncommon and unfamiliar to most neurosurgeons. It has been reported previously that surgical cure of thyrotropin-secreting adenomas is more difficult than in other functional adenomas because of the large size and invasive features of the former. However, the long-term outcome after surgery has not been well documented. The authors report on a surgical series of 16 patients with thyrotropin adenoma and the results of long-term follow up.Methods. Sixteen patients ages 23 to 62 years (12 women and four men) underwent transsphenoidal removal of thyrotropin adenomas between 1983 and 1999. These patients had the syndrome of inappropriate thyrotropin secretion (SITS) with pituitary mass lesions. Four of the patients had undergone previous subtotal thyroidectomy and/or radioiodine thyroid ablation, and 11 had been treated with antithyroid medication. Radiological investigations demonstrated macroadenomas in 14 patients, and 10 of those had cavernous sinus invasion. Surgical findings showed unusually fibrous and firm tumors in 13 (81.2%) of 16 patients. Preoperative octreotide administration was revealed to be effective for serum thyrotropin reduction as well as tumor shrinkage. Transsphenoidal surgery was performed with no morbidity resulting. Surgical remission was achieved in 10 (62.5%) of 16 patients, and total remission was achieved in 14 patients (87.5%) with a combination of additional radiation or medical therapy. In the other two patients, SITS persisted because of tumor rests in the cavernous sinus. Therefore, radiation and/or antithyroid therapy was administered. In the mean follow-up period of 7.5 years (range 11 months–15.8 years), no recurrence of tumor was observed on magnetic resonance images, whereas recurrence of SITS was found in two patients with no tumor regrowth. In addition, coexistent primary hyperthyroidism was found in two other patients despite remission of SITS after surgery.Conclusions. Transsphenoidal surgery can achieve a good long-term outcome in patients with thyrotropin-secreting pituitary adenomas if surgery is performed before these become larger, invasive tumors. In the authors' experience, thyrotropin-secreting adenomas are fibrous and firm, which makes it difficult to achieve surgical remission. In addition, even satisfactory resection of the tumor sometimes results in recurrence of SITS or hyperthyroid symptoms due to coexistent primary hyperthyroidism. It is emphasized that a careful follow-up review is necessary after surgery, especially in patients with a long preoperative history of hyperthyroidism.

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