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TOPIC OF THE ISSUE: LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 3  |  Page : 310-311

Growth hormone secreting pituitary adenoma associated with Rathke's cleft cyst


Department of Neurosurgery, West China Hospital of SiChuan University, Chengdu, China

Date of Submission30-Nov-2011
Date of Decision01-Dec-2011
Date of Acceptance04-Mar-2012
Date of Web Publication14-Jul-2012

Correspondence Address:
Chao You
Department of Neurosurgery, West China Hospital of SiChuan University, Chengdu
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.98521

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How to cite this article:
You C, Qiao F, Jiang S, Xiao A. Growth hormone secreting pituitary adenoma associated with Rathke's cleft cyst. Neurol India 2012;60:310-1

How to cite this URL:
You C, Qiao F, Jiang S, Xiao A. Growth hormone secreting pituitary adenoma associated with Rathke's cleft cyst. Neurol India [serial online] 2012 [cited 2019 Aug 18];60:310-1. Available from: http://www.neurologyindia.com/text.asp?2012/60/3/310/98521


Sir,

A-46-year-old female presented with decreased visual acuity of 9 months duration. She had acromegalic features. She had coarse facies, and thickened lips, upper eye lids, and oral mucosa. Her toes and fingers were longer and larger than normal people. She had decreased visual acuity with visual field defects. Hormonal profile showed elevated levels of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Magnetic resonance imaging (MRI), T-weighted sequence revealed sellar mass with differential intensities, the upper portion being brilliantly hyperintense and the lower portion being slightly hyperintense when compared to the brain. Contrast MRI showed inhomogeneous enhancement of the lower portion of the sellar mass [Figure 1]. Preoperatively, our radiologist interpreted these features consistent with pituitary apoplexy. She had transsphenoid surgery. Intraoperatively, the sellar base bone was thickened. On opening the dura, in addition to gray pituitary tumor, there was a cyst between the diaphragma sellae and the hypophysis, which is called Rathke's cleft cyst (RCC). The cyst was white in color and oval shaped and its contents looked like cheese. We biopsied the cyst and histology showed ciliated columnar cell [Figure 1] consistent with RCC. The patient was discharged 1 week later after the surgery. Postoperatively there was dramatic improvement in the visual acuity and visual field. She also felt much more agility in her fingers and toes.
Figure 1: From left to right, top to bottom. (a) Preoperative MR T1- weighted coronal images show the same two different densities in the sellar. (b) Preoperative enhancing MRI test shows high density in the sellar lesion (with high density of both lesions, the upper one is much more obvious). (c) The biopsied cyst, Cytokeratin immunohistochemical staining (×200), there were ciliated columnar cells, which mostly implied the Rathke's cleft cyst. d: the biopsied adenoma, H and E staining (×100), there were densely granulated GH adenoma cells

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The first report of RCC associated with GH secreting pituitary adenoma was reported by Bader and colleagues. [1] RCC, first described by Luschka in 1860, is thought to arise from incomplete obliteration of the lumen of Rathke's pouch. [2] Symptomatic RCC is rare. [3] The cells of the anterior pituitary lobe, from which pituitary adenomas develop, are also derived from the cells of Rathke's pouch. Although RCC and pituitary adenoma have a shared ancestry, they rarely occur together. Common symptoms of RCC are headache, visual disturbance, hypopituitarism, and hypothalamic dysfunction. Other rare symptoms include decreased libido, impotence, and diabetes insipidus. [3] When RCC and pituitary adenoma are found together, symptoms of mass effect may be accompanied by hormonal changes caused by the functioning tumor as in this patient. MRI is the modality of choice in detecting RCC. MRI also helps to diagnose the coexisting RCC and pituitary adenoma. RCCs almost always are homogeneous in signal intensity, whereas other lesions, such as cystic craniopharyngiomas and hemorrhagic adenomas, more frequently have heterogeneous signal intensity. Kunii et al. [4] concluded that single-shot fast spin-echo (SSFSE), diffusion-weighted MR imaging (DWI) with apparent diffusion coefficient (ADC) can be employed in the differentiation of RCCs from craniopharyngiomas and hemorrhagic pituitary adenomas. Some cases may be mistakenly diagnosed as arachnoid cyst, craniopharyngioma, and pituitary apoplexy. A combination of clinical, biochemical, and radiographic findings must be used to establish a diagnosis of RCC and the histologic examination seems to be much more important. Pituitary adenoma can be easily diagnosed by histologic examination of the resected mass. Most RCC have cuboidal or columnar epithelium and ciliated epithelium. But some researchers note that 12% of RCC displayed stratified squamous epithelium, a characteristic feature commonly associated with craniopharyngioma. [5] Decompression and biopsy may represent the optimal surgical management of RCC, with low morbidity rates; this patient underwent a transsphenoidal approach, where we excised not only the adenoma but also the Rathke's cleft cyst at one go. The recurrence rate during postoperative follow-up can be up to 19%. [5] This patient had coexisting lesion, and the lesion was below the sellae diaphragma. Because of this, we could excise the two lesions as much as possible without causing damage to the pituitary stalk. This resulted in a good outcome for the patient.

 
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1.Bader LJ, Carter KD, Latchaw RE, Ellis WG, Wexler JA, Watson JC. Simultaneous symptomatic Rathke's cleft cyst and GH secreting pituitary adenoma: A case report. Pituitary 2004;7:9-44.  Back to cited text no. 1
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2.Kim JE, Kim JH, Kim OL, Paek SH, Kim DG, Chi JG, et al. Surgical treatment of symptomatic Rathke cleft cysts: Clinical features and results with special attention to recurrence. J Neurosurg 2004;100:33-40.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.El-Mahdy W, Powell M. Transsphenoidal management of 28 symptomatic Rathke's cleft cysts, with special reference to visual and hormonal recovery. Neurosurgery 1998:42:7-17.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Johnsen DE, Woodruff WW, Allen IS, Cera PJ, Funkhouser GR, Coleman LL. MR imaging of the sellar and juxtasellar regions. Radiographics 1991;11:727-58.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Shin JL, Asa SL, Woodhouse LJ, Smyth HS, Ezzat S. Cystic lesions of the pituitary: Clinicopathological features distinguishing craniopharyngioma, Rathke's cleft cyst, and arachnoid cyst. J Clin Endocrinol Metab 1999;84:3972-82.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  


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