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Year : 2011  |  Volume : 54  |  Issue : 3  |  Page : 649-651
Non-functioning pituitary adenoma and concomitant Rathke's cleft cyst


1 Department of Pathology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
2 Department of Neurosurgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
3 Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India

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Date of Web Publication20-Sep-2011
 

How to cite this article:
Radhakrishnan N, Menon G, Hingwala DR, Radhakrishnan V V. Non-functioning pituitary adenoma and concomitant Rathke's cleft cyst. Indian J Pathol Microbiol 2011;54:649-51

How to cite this URL:
Radhakrishnan N, Menon G, Hingwala DR, Radhakrishnan V V. Non-functioning pituitary adenoma and concomitant Rathke's cleft cyst. Indian J Pathol Microbiol [serial online] 2011 [cited 2020 Nov 29];54:649-51. Available from: https://www.ijpmonline.org/text.asp?2011/54/3/649/85135


Sir,

Concomitant occurrence of Rathke's cleft cyst (RCC) and pituitary adenoma is extremely uncommon and hitherto 32 cases been documented in the literature. [1]

We report here a case of a pituitary adenoma associated with a RCC in a 16-year-old female patient. She presented with complaints of progressive visual diminution of 3-year duration. She had attained menarche at 12 years of age, but had irregular cycles thereafter progressing on to amenorrhea. On neurological examination, the patient had bitemporal field defects as well as features of bilateral early primary optic atrophy. A computed tomography (CT) scan showed a hyperdense lesion in the sellar-suprasellar region with evidence of minimal widening of the sella. Magnetic resonance imaging (MRI) scans showed a well-defined lesion in the pituitary gland measuring 1.6 × 1.8 × 1.4 cm. The lesion was seen compressing and lifting the optic chiasma superiorly [Figure 1]a. The lesion was cystic with fluid-fluid levels having hyperdense and iso- to hyperintense contents on both T1 and T2W images [Figure 1]b, c, and d. These MRI findings were interpreted as a pituitary adenoma with hemorrhage. The pituitary hormonal profile of this patient was within normal limits. The patient underwent transnasal transsphenoidal decompression of the tumor. At surgery, a cystic tumor was seen containing xanthochromic fluid and altered blood. A thin rim of solid tumor was seen lining the cyst, which was yellow in color. Normal pituitary tissue could be visualized superomedially.
Figure 1: (a) Precontrast T1-weighted coronal image shows a cystic lesion in the sella and suprasellar cistern with thick walls and hyperintense central contents, (b) T2-weighted sagitial image shows a fluid-fluid level in the cyst, The anterior component is more hyperintense than the posterior component, (c) Precontrast T1-weighted sagitial image also shows a fluid-fluid level in the cyst with the anterior component appearing more hyperintense than the posterior component, (d) Postcontrast T1-weighted sagittal image shows no significant contrast enhancement

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The entire surgical specimen was subjected to routine histopathological studies. Hematoxylin and eosin (H and E)-stained sections showed two distinct components [Figure 2]a. The first and predominant component was fragments of a neoplasm composed of a monomorphic population of cells in sheets and lobules. These cells had moderate eosinophilic cytoplasm with oval bland nuclei and were characteristic of a pituitary adenoma [Figure 2]b. Reticulin staining was done to differentiate the compressed normal pituitary gland from the adenomatous tissue. The second component in the sections showed fragments of a cyst wall lined by ciliated and pseudostratified cuboidal epithelium [Figure 2]c. Immunohistochemistry using antibodies to growth hormone, prolactin, adrenocorticotrophic hormone, thyroid-stimulating hormone, and follicle stimulating hormone were performed and all were negative. Based on the salient histomorphological findings, this was regarded as a nonfunctioning pituitary adenoma associated with RCC.
Figure 2: (a) Photomicrograph showing fragments of a cyst wall and a neoplasm (hematoxylin and eosin, ×200), (b) Photomicrograph showing features of a pituitary adenoma composed of monomorphic population of polygonal cells in sheets separated by thin-walled vascular channels(hematoxylin and eosin, ×400), (c) Photomicrograph showing fragments of a cyst lined by pseudostratified ciliated columnar epithelium (hematoxylin and eosin, ×400)

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   Discussion Top


RCCs are uncommon benign cystic lesions usually occurring in the sellar region. The pathogenesis of RCCs still remains a subject of conjecture and speculation. However it is being regarded that RCCs are remnants of embryonic pharyngeal stomodeum. [1],[2] During the third or fourth week of intrauterine life, Rathke's pouch is formed by the infolding of ciliated columnar epithelial cells lining the roof of the stomodeum. The anterior and posterior walls of the stomodeum give rise to the anterior and intermediate lobes of the adenohypophysis. [2] Neoplastic transformation of cells of the adenohypophysis occurs under the influence of hormonal and growth factors or clonal expansion. [1],[3] The residual caudal lumen between the anterior and intermediate lobes of adenohypophysis is designated as Rathke's cleft. It has been proposed that epithelial cells lining the intermediate lobe secrete products that accumulate and dilate Rathke's cleft to form a cyst. Hence pituitary adenomas and RCCs are thought to have a common embryonic ancestry. [1]

At most instances, a preoperative diagnosis of a pituitary adenoma and concomitant RCC is seldom made with any degree of certainty. In the conventional MRI scans, RCCs appear as nonenhancing cystic lesions. It is difficult to distinguish RCCs from other intrasellar cystic lesions such as cystic craniopharyngioma, cystic or hemorrhagic pituitary adenoma, and arachnoid cysts. [1] However, with the advent of high-resolution MRI, it is now possible to distinguish the RCC from other cystic lesions of the sella. These include (a) the intracystic (waxy) nodules with a characteristic intensity on T2W images and (b) a high T1W image indicates a high content of protein and mucopolysaccharide. [1],[4]

In our case, the pituitary adenoma and RCC were unevenly distributed in the sections. By and large, the pituitary adenoma component was more dominant than the RCC component. The RCC component was seen close to the normal pituitary tissue. In order to distinguish neoplastic from nonneoplastic pituitary tissue, a reticulin stain was done which revealed a typical sinusoidal pattern of the normal pituitary tissue whereas this reticulin pattern was disrupted in the adenomatous tissue.

Among the various surgical approaches, transsphenoidal microsurgery remains the treatment of choice. Surgery provides a prompt relief from symptoms due to the mass effect produced by the tumor. However, recurrence rates are largely dependent on the size of the tumor as well as extension into suprasellar and parasellar regions. In cases of recurrence, adjuvant therapy is indicated in the postoperative period. [5] In some cases, an intraoperative MRI could benefit complete resection. Also an intraoperative MRI provides excellent information on these two different disease entities. [1]


   Acknowledgment Top


The authors express their sincere gratitude to the Director of the institute for the permission to publish this article.

 
   References Top

1.Noh SJ, Ahn JY, Lee KS, Kim SH. Pituitary adenoma and concomitant Rathke's cleft cyst. Short Illustrated Review. Acta Neurochir (Wien) 2007;149:1223-8.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Oka H, Kawano N, Suwa T, Yada K, Kan S, Kameya T. Radiological study of symptomatic Rathke's cleft cyst. Neurosurgery 1994;35:632-7.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.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;7:39-44.  Back to cited text no. 3
    
4.Binning MJ, Gottfried ON, Osborn AG, Couldwell WT. Rathke cleft cyst intracystic nodule: A characteristic magnetic resonance imaging finding. J Neurosurg 2005;103:837-40.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Kreutzer J, Vance ML, Lopes MB, Laws ER. Surgical management of GH-secreting pituitary adenomas: An outcome study using modern remission criteria. J Clin Endocrinol Metab 2001;86:4072-7.  Back to cited text no. 5
    

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Correspondence Address:
V V Radhakrishnan
Department of Pathology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.85135

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