Factors Predictive of Radiologic Recurrence in a Large Cohort of 133 Rathke’s Cleft Cysts Receiving Transsphenoidal Surgery

Introduction: Rathke’s cleft cysts (RCC) are benign sellar lesions with high rates of recurrence. Transsphenoidal surgery (TSS) remains the first-line treatment for large and symptomatic lesions. However, the clinical and endocrinological characteristics of lesions exhibiting recurrence post TSS, as well as the risk factors for developing radiological recurrence remain poorly described.

Objectives: This article aims to characterize the clinical characteristics and factors predictive of lesion recurrence in RCC patients receiving transsphenoidal surgery.

Methods: In this single-institution retrospective study, a large cohort of 133 RCCs which had received TSS between 2008 and 2024 were examined. Radiological, surgical, clinical, and endocrinological characteristics at baseline and postoperatively were tracked. Hormone values were determined at baseline and up to 3 years postoperatively. RCC recurrence, size, location, and dimensions were determined using magnetic resonance imaging (MRI) and computed tomography (CT) imaging. T-tests and chi-square tests were not performed due to the high type-1 error rate. A multivariate logistic regression model was created to determine factors predictive of postoperative radiological recurrence.

Results: Among the 133 lesions with data available, 39 (29.3%) had exhibited radiological recurrence during follow-up. The rates of common preoperative symptoms were largely similar in recurrent versus nonrecurrent cysts, such as headache (84.6 vs. 78.7%) and visual loss (43.6 vs. 37.2%). Interestingly, male gender was observed in a higher proportion of nonrecurrent RCCs compared to recurrent lesions (34 vs. 17.9%). Although the rates of preoperative comorbidities were largely similar, patients with lesions exhibiting recurrence experienced higher rates of statin (28.2 vs. 11.8%) and levothyroxine (43.6 vs. 24.5%) prescription.

Preoperatively, lesions exhibiting recurrence experienced higher rates of hyperprolactinemia (40.5 vs. 32.2%) and hypothyroidism (50 vs. 26.7%). Postoperatively, rates of hypoadrenalism and hypothyroidism were higher in lesions exhibiting recurrence (37.8 vs. 28.4%, and 45.9 vs. 27.1%, respectively). The majority of lesions included were intrasellar, with suprasellar extension being more common in lesions exhibiting recurrence (66.7 vs. 48.4%). The maximum diameter (1.47 ± 0.7 cm vs. 1.35 ± 0.6) and lesion volume (1.74 ± 3.2 cm² vs. 1.48 ± 4.1 cm²) were similar between groups. There were no significant differences in the usage of TSS technique (microscopic vs. endoscopic) or sellar reconstruction method, with nearly all patients received endoscopic TSS (95.5% overall). Intraoperative leaks were more common in RCCs exhibiting recurrence (61.5 vs. 34%), and the most common sellar reconstruction method used was fat grafting.

Rates of common postoperative complication incidence, such as SIADH (7.7 vs. 6.4% in recurrent vs. nonrecurrent RCCS) and transient diabetes insipidus (20.5 vs. 20.2%) were largely similar between groups. Interestingly, the rate of gross total resection (of both the cyst contents and wall) was higher in nonrecurrent lesions (54.3 vs. 28.2%). Multivariate logistic regression demonstrated that gross total resection was the only factor which impacted radiological recurrence (OR: 0.32; 95% CI: 0.13–0.79).

Conclusion: Overall, gross total resection was the only factor predictive of postoperative radiological RCC recurrence. Lesion size, location, and preoperative hormone dysfunction were not associated with a greater risk of developing postoperative recurrence.