Differential reversibility of anterior and posterior pituitary dysfunction in delayed recurrent pediatric Rathke’s cleft cyst

Summary: Rathke's cleft cyst (RCC) is a benign sellar or suprasellar lesion increasingly detected by magnetic resonance imaging (MRI). Although surgery is indicated for symptomatic or enlarging RCCs, recurrence may occur and reoperation may be required, particularly in pediatric patients, for whom long-term postoperative data remain limited. We report a pediatric case with RCC associated with growth hormone (GH) deficiency. GH replacement therapy was started at 5 years of age. At 8 years of age, MRI revealed a sellar and suprasellar cystic lesion diagnosed as RCC, and endoscopic transsphenoidal surgery was performed. Following the initial surgery, GH secretion showed no improvement, and desmopressin therapy was initiated due to postoperative arginine vasopressin (AVP) deficiency. Gradual cyst recurrence became evident, necessitating reoperation seven years after the initial surgery. After the second surgery, GH secretion improved, whereas postoperative AVP deficiency persisted. This case demonstrates delayed recurrence of pediatric RCC and dynamic changes in anterior and posterior pituitary function, highlighting axis-specific reversibility of pituitary dysfunction and the need for long-term follow-up. Learning points: Pediatric RCC may demonstrate delayed recurrence many years after initial surgery, requiring long-term endocrine follow-up. Anterior pituitary dysfunction, including GH deficiency, may be reversible following adequate decompression. Persistent postoperative arginine vasopressin deficiency may reflect irreversible posterior pituitary or stalk injury and may not recover after reoperation. Pituitary function in RCC can evolve over time and should be reassessed even after apparent surgical success.