Introduction: Rathke’s cleft cyst (RCC) are benign lesions located entirely intrasellar (IS), IS with suprasellar extension (IS+SS) and purely suprasellar (SS) location. The recurrence in RCC is relatively uncommon. The present study was conducted with primary focus on the analyzing the predictors of squamous metaplasia and recurrence in these three types of RCC

Methods: A retrospective review of the medical records was conducted for 87 patients with symptomatic RCCs, who underwent surgical resection. The effect of squamous metaplasia on recurrence in each location was analyzed.

Results: The mean age of 64 female and 23 male patients was 41±14 years. Sixteen patients (18%) had an entirely IS RCC, 21 (24%) had a purely SS, and 50 (58%) had an IS+SS RCC. The transsphenoidal approach was employed for all IS and (33/50) IS+SS RCCs and transcranial route for all SS, (17/50) IS+SS RCCs. Squamous metaplasia was present in 31% RCCs. The squamous metaplasia was associated with SS location (P=0.003), size (P=0.023), hypointensity on T1-weighted (16/27, P=0.005), isointensity on T2-weighted (19/27, P=0.002), and ring enhancement on gadolinium enhanced MRI (P=0.001). The SS location (P=0.018, OR-3.4, CI=1.2-9.5), size > 3.5 cm (P=0.03, OR=0.4, CI=0.2-0.93) and the ring enhancement on the preoperative MRI (P=0.002, OR=5.2, CI=1.8-14.9) were predictors of squamous metaplasia. The mean time to re-accumulation (11/87,12.6%) and recurrence (7/87, 8%) was 14±6 months. The RFS was 84.5% at mean 98.2 ±4.6 months. The age group (<18 years) (P=0.02, OR=3.8, CI-1.1-12.2) and isointensity on T2-weighted MRI (P= 0.031, OR=0.097, CI-0.012-0.8), squamous metaplasia (P=0.001, OR=34.7, CI-4.1-290.6), SS RCC (P=0.018, OR=4.8, CI=1.3-18.1), SS with squamous metaplasia (P=0.003, OR=16.1, CI=2.5-101.3) and IS+SS RCC with squamous metaplasia (P=0.02, OR=4.9, CI=1.2-18.9) were predictors of recurrence.

Conclusions: The age group (<18 years), isointensity on T2-weighted MRI, the squamous metaplasia, SS RCC with and without squamous metaplasia, IS+SS RCC with squamous metaplasia were predictors of recurrence.

Patient Care: This study emphasize that aggressive and total resection of the RCC might not be required and the patient specific resection strategies should be used.

Learning Objectives: Tailored extent of resection based on the location and predictive factors is recommended. Aggressive resection might be reasonable in recurrent cases.

References: Aho CJ, Liu C, Zelman V, Couldwell WT, Weiss MH: Surgical outcomes in 118 patients with Rathke cleft cysts. J Neurosurg 102:189-193, 2005 Ogawa Y, Watanabe M, Tominaga T: Rathke's cleft cysts with significant squamous metaplasia--high risk of postoperative deterioration and close origins to craniopharyngioma. Acta Neurochir (Wien) 155:1069-1075, 2013 Potts MB, Jahangiri A, Lamborn KR, Blevins LS, Kunwar S, Aghi MK: Suprasellar Rathke cleft cysts: clinical presentation and treatment outcomes. Neurosurgery 69:1058-1068; discussion 1068-1057, 2011