Introduction: Rathke’s cleft cysts (RCCs) are common benign skull-base lesions arising from embryologic remnants of Rathke’s pouch. Though frequently asymptomatic, RCCs can become symptomatic due to compression of adjacent neural structures. Both transcranial and neuroendoscopic surgical treatments have been described for symptomatic RCCs but recurrence rates remain as high as 30%. Bioabsorbable steroid-eluting (BASE) stents significantly decrease adhesions and recurrent ostia obstruction following endoscopic sinus surgery for chronic sinusitis. We present our initial experience with endoscopic-endonasal fenestration and placement of BASE-stents for RCCs.
Methods: Patients undergoing neuroendoscopic transsphenoidal fenestration of RCCs with BASE-stent placement were identified and their medical records retrospectively reviewed.
Results: Two patients underwent neuroendoscopic transsphenoidal RCC fenestration and BASE-stent placement from 3/2016 to 3/2018. A 79-year old woman presented 31-years status-post transcranial RCC resection and was diagnosed with a symptomatic 5x6cm RCC recurrence. She was initially managed with stereotactic cyst aspiration and subsequently underwent Ommaya reservoir placement. After repeated admissions for symptom recurrence, a 3 x 3cm cyst persisted despite repeated reservoir aspirations. A 24-year old woman presented with subacute left monocular vision loss and was subsequently diagnosed with a 1.9 x 2cm RCC. Both patients underwent neuroendoscopic transsphenoidal cyst fenestration. After the cyst contents were evacuated, a BASE stent was deployed in the sella opening to prevent cyst wall regrowth or closure. No perioperative complications were encountered. Both patients had symptomatic resolution by 4-weeks postoperatively. Postoperative endoscopic evaluation at 3- and 2-months, respectively, demonstrated epithelization of the cyst wall opening and marsupialization into the sphenoid sinus. After 24- and 2- months of follow-up, respectively, both patients remain asymptomatic with return of baseline visual function and without radiographic evidence of RCC recurrence.
Conclusions: Bioabsorbable steroid-eluting stent placement is a safe, viable, less-invasive augmentation of neuroendoscopic technique for symptomatic and surgically-recalcitrant Rathke’s cleft cysts with the potential to reduce recurrence rates.
Patient Care: This technical case series describes the novel application of bioabsorbable steroid-eluting stents in the treatment of both symptomatic and surgically refractory Rathke’s cleft cysts. This is the second case series, to our knowledge, and first to be presented in the US demonstrating the safety and feasibility of bioabsorbable steroid-eluting stent placement after endoscopic fenestration with long-term follow up. We document durable symptomatic and radiographic resolution, even in a surgically refractory recurrent Rathke’s cleft cyst. This case series highlights the off-label application of FDA-approved technology pioneered in functional endoscopic sinus surgery for the treatment of refractory Rathke’s cleft cysts and demonstrates the potential for this technique to improve recurrence rates.
Learning Objectives: By the conclusion of this session, participants should be able to:
(1) Describe bioabsorbable steroid-eluting stents, their development, and the trials demonstrating their efficacy in functional endoscopic sinus surgery.
(2) Discuss, in small groups, surgical treatment options for symptomatic and surgically-refractory Rathke’s cleft cysts.
(3) Discuss the technical steps to augment neuroendoscopic transsphenoidal cyst fenestration with bioabsorbable steroid-eluting stent placement for symptomatic and surgically-refractory Rathke’s cleft cysts from a series of illustrative cases.
References: 1: Ference EH, Badran KW, Kuan EC, Bergsneider M, Wang MB. P099: Steroid-eluting stents in the treatment of recurrent Rathke’s cleft cyst. J Neurol Surg B Skull Base. 2018 Feb; 79(S1): S1-S188.
2: Adriaensen GFJPM, Lim KH, Fokkens WJ. Safety and efficacy of a bioabsorbable fluticasone propionate-eluting sinus dressing in postoperative management of endoscopic sinus surgery: a randomized clinical trial. Int Forum Allergy Rhinol. 2017 Aug;7(8):813-820.
3: Hauser LJ, Turner JH, Chandra RK. Trends in the Use of Stents and Drug-Eluting Stents in Sinus Surgery. Otolaryngol Clin North Am. 2017 Jun;50(3):565-571.
4: Bangiyev JN, Govil N, Sheyn A, Haupert M, Thottam PJ. Novel Application of Steroid Eluting Stents in Choanal Atresia Repair: A Case Series. Ann Otol Rhinol Laryngol. 2017 Jan;126(1):79-82.
5: Santarelli GD, Han JK. Evaluation of the PROPEL(®) mini sinus implant for the treatment of frontal sinus disease. Expert Opin Drug Deliv. 2016 Dec;13(12):1789-1793.
6: Forwith KD, Han JK, Stolovitzky JP, Yen DM, Chandra RK, Karanfilov B, Matheny KE, Stambaugh JW, Gawlicka AK. RESOLVE: bioabsorbable steroid-eluting sinus implants for in-office treatment of recurrent sinonasal polyposis after sinus
surgery: 6-month outcomes from a randomized, controlled, blinded study. Int Forum Allergy Rhinol. 2016 Jun;6(6):573-81.
7: Businco LD, Mattei A, Laurino S, Angelone AM, Lauriello M, Crescenzi D, Alessia DM, Radici M, Businco AD. Steroid-Eluting Ethmoidal Stent Versus Antero-Posterior Ethmoidectomy: Comparison Of Efficacy And Safety In Allergic Patients. Otolaryngol Pol. 2016 Apr 30;70(2):6-12.
8: Solari D, Cavallo LM, Somma T, Chiaramonte C, Esposito F, Del Basso De Caro M, Cappabianca P. Endoscopic Endonasal Approach in the Management of Rathke's Cleft Cysts. PLoS One. 2015 Oct 16;10(10):e0139609.
9: Huang Z, Hwang P, Sun Y, Zhou B. Steroid-eluting sinus stents for improving symptoms in chronic rhinosinusitis patients undergoing functional endoscopic sinus surgery. Cochrane Database Syst Rev. 2015 Jun 10;(6):CD010436.
10: Mendelson ZS, Husain Q, Elmoursi S, Svider PF, Eloy JA, Liu JK. Rathke's cleft cyst recurrence after transsphenoidal surgery: a meta-analysis of 1151 cases. J Clin Neurosci. 2014 Mar;21(3):378-85.
11: Forwith KD, Chandra RK, Yun PT, Miller SK, Jampel HD. ADVANCE: a multisite trial of bioabsorbable steroid-eluting sinus implants. Laryngoscope. 2011 Nov;121(11):2473-80.
12: Murr AH, Smith TL, Hwang PH, Bhattacharyya N, Lanier BJ, Stambaugh JW, Mugglin AS. Safety and efficacy of a novel bioabsorbable, steroid-eluting sinus stent. Int Forum Allergy Rhinol. 2011 Jan-Feb;1(1):23-32.
13: Li PM, Downie D, Hwang PH. Controlled steroid delivery via bioabsorbable stent: safety and performance in a rabbit model. Am J Rhinol Allergy. 2009 Nov-Dec;23(6):591-6. doi: 10.2500/ajra.2009.23.3391. Erratum in: Am J Rhinol Allergy. 2010 Mar;24(2):165.
14: el-Mahdy W, Powell M. Transsphenoidal management of 28 symptomatic Rathke's cleft cysts, with special reference to visual and hormonal recovery. Neurosurgery. 1998 Jan;42(1):7-16.