Natural course of Rathke’s cleft cysts and risk factors for progression

Yasuyuki Kinoshita Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima;

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Akira Taguchi Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima;

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Fumiyuki Yamasaki Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima;

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Atsushi Tominaga Department of Neurosurgery and Neuro-Endovascular Therapy, Hiroshima Prefectural Hospital, Hiroshima; and

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Kazunori Arita Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan

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Nobutaka Horie Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima;

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OBJECTIVE

Rathke’s cleft cysts (RCCs) are relatively common and often detected incidentally. They are usually asymptomatic and managed conservatively. However, little is known about their natural history. Thus, the authors aimed to examine the natural course of RCCs and identify the risk factors for their progression.

METHODS

This retrospective study examined 229 patients (median age 43.0 years) diagnosed with RCCs by MRI and followed up without surgery (median period 36.6 months). The median cyst height on the initial MRI was 10 mm. Progression or regression of RCC was defined as cyst height changes of ≥ 1 mm.

RESULTS

In total, 23 (10.0%) RCCs progressed, whereas 73 (31.9%) RCCs spontaneously regressed. The remaining 133 were noted to be stable throughout the follow-up period. Patients with progressed RCCs were significantly older than those with stable RCCs. In patients with acute headache as an initial symptom, RCCs were significantly more likely to spontaneously regress. New symptoms occurred in 6 patients, 5 of whom underwent surgery for RCC progression. Of these 6 patients, 1 patient had persistent adrenocorticotropic hormone deficiency and 1 patient developed diabetes insipidus. Kaplan-Meier analysis results showed RCC progression and new symptom development rates to be 12.0% and 4.1% at 5 years and 13.7% and 5.7% at 10 years, respectively.

CONCLUSIONS

RCCs rarely progress or cause new symptoms in the long term. Patients with asymptomatic RCC should be followed up for at least 5 years to ensure RCC inactivity. RCCs in older adults may require greater surveillance.

ABBREVIATIONS

DI = diabetes insipidus; RCC = Rathke’s cleft cyst; ROC = receiver operating characteristic.

OBJECTIVE

Rathke’s cleft cysts (RCCs) are relatively common and often detected incidentally. They are usually asymptomatic and managed conservatively. However, little is known about their natural history. Thus, the authors aimed to examine the natural course of RCCs and identify the risk factors for their progression.

METHODS

This retrospective study examined 229 patients (median age 43.0 years) diagnosed with RCCs by MRI and followed up without surgery (median period 36.6 months). The median cyst height on the initial MRI was 10 mm. Progression or regression of RCC was defined as cyst height changes of ≥ 1 mm.

RESULTS

In total, 23 (10.0%) RCCs progressed, whereas 73 (31.9%) RCCs spontaneously regressed. The remaining 133 were noted to be stable throughout the follow-up period. Patients with progressed RCCs were significantly older than those with stable RCCs. In patients with acute headache as an initial symptom, RCCs were significantly more likely to spontaneously regress. New symptoms occurred in 6 patients, 5 of whom underwent surgery for RCC progression. Of these 6 patients, 1 patient had persistent adrenocorticotropic hormone deficiency and 1 patient developed diabetes insipidus. Kaplan-Meier analysis results showed RCC progression and new symptom development rates to be 12.0% and 4.1% at 5 years and 13.7% and 5.7% at 10 years, respectively.

CONCLUSIONS

RCCs rarely progress or cause new symptoms in the long term. Patients with asymptomatic RCC should be followed up for at least 5 years to ensure RCC inactivity. RCCs in older adults may require greater surveillance.

In Brief

In this study, the authors aimed to clarify the natural course of Rathk's cleft cysts (RCCs) and identify the risk factors for their progression. Patients with progression of RCCs were significantly older than those with stable RCCs. The progression rate of RCC was 12.0% at 5 years and presumably plateaued at 5 years. Patients with RCC should be followed up for at least 5 years to ensure RCC inactivity. RCCs in older adults may require greater surveillance.

Rathke's cleft cysts (RCCs) are relatively common. In 1000 autopsies, RCCs were found in 3.7% of cases.1 Symptomatic RCC is surgically treated to resolve headaches, visual disturbance, and hormone deficiencies. The surgical procedure is simple, involving only cyst puncture and irrigation of the cyst cavity, with or without partial removal of the cyst wall. However, this procedure can result in morbidities, including diabetes insipidus (DI) (4.8%), anterior pituitary gland dysfunction (6.9%), and postoperative CSF leakage (4.9%), based on a systemic review of the literature.2 Furthermore, the rate of recurrence in RCC treated by surgery is relatively high (39.6%).3 Hence, the standard procedure is not to operate on asymptomatic RCCs but to monitor these cysts with regular MRI.

The advent of high-resolution radiological imaging has led to increased incidental detection of RCCs, and the number of patients who require follow-up MRI for asymptomatic RCCs has increased. However, the natural course of RCC has not been well elucidated, and little is known regarding the rates of RCC progression, regression, and new symptom development; the follow-up period needed; and the factors that predict RCC progression, regression, or the likelihood that a patient with RCC will require future surgery. Therefore, in the present study, we retrospectively surveyed patients with RCC from a single medical institution who did not undergo surgery at initial diagnosis but were followed up to monitor for progression. The purpose of this study was to clarify the natural course of RCC.

Methods

This retrospective cohort study was approved by the Ethics Committee for Epidemiology of Hiroshima University.

A search of the medical records of Hiroshima University Hospital found that 355 patients were diagnosed with RCC by MRI between January 2000 and December 2021. Of these, 89 underwent surgery as an initial RCC treatment and 37 were not followed up after the initial MRI. These 126 patients were excluded from our study, leaving a sample size of 229 patients under the initial policy of follow-up for whatever reasons (74 male, 155 female; median age at diagnosis 43.0 years; age range 0–86 years). The median follow-up period was 36.6 months (range 1.3–219.3 months). The median cyst height on the initial MRI was 10 mm (range 4–38 mm). The patients were categorized into three groups according to their final MRI results: 1) a progression group, in whom the cyst height increased ≥ 1 mm between the initial and final MRI; 2) a regression group, in whom the cyst height decreased ≥ 1 mm between the initial and final MRI; and 3) a stable group, in whom there was < 1 mm difference in the cyst height on the initial and final MRI. We examined the cyst height to detect the change of cyst size because extended cyst height can cause visual disturbance; moreover, the cyst height on the midline sagittal plane had only relatively small errors for use in comparing cyst size on repeated MRI examinations.

The following data were collected from patient medical records: age, sex, initial symptoms, whether hormonal replacement treatment was given, cyst height on the sagittal plane, the intensity of cyst content, and detection of attachment or compression of the optic chiasm on the initial MRI.

Statistical Analyses

All statistical analyses were performed using JMP Pro version 15.0 software (SAS Institute Inc.). Values are expressed as medians and interquartile ranges. The median values were compared using the Mann-Whitney U-test, Fisher exact test, or chi-square test. Time-to-event calculation was performed from the initial diagnosis to the date of the following events: identification of RCC progression by MRI, identification of RCC regression by MRI, manifestation of new symptoms, and final follow-up. The cumulative incidences of RCC progression, regression, and new symptom development were estimated using the Kaplan-Meier method. A p value < 0.05 was considered statistically significant. A receiver operating characteristic (ROC) curve was plotted to identify the age cutoff value for RCC progression.

Results

On the final MRI, RCCs had progressed in 23 (10.0%) patients and spontaneously regressed in 73 (31.9%) patients. In the patients whose RCCs had regressed, the RCCs had disappeared completely at the final MRI in 11 (4.8%) patients. The remaining 133 RCCs remained stable throughout the follow-up period. Figure 1A shows the changes in cyst height of the progression and regression groups. Although cyst height increased in the progression group, the increase was very small. The median height change was 3 mm (range 1–12 mm) in the progression group. Only 4 (1.7%) patients showed an RCC height increase > 5 mm. In contrast, the cyst height dramatically decreased in the patients in the regression group compared with those in the progression group (p = 0.0009). The median height change was 6 mm (range 1–16 mm) in the progression group. Figure 1B shows the changes in the cyst height according to the follow-up period. The range of height change did not relate to the follow-up duration. Representative MR images of RCCs with progression and regression are shown in Fig. 2.

FIG. 1.
FIG. 1.

Changes in cyst heights in patients whose RCCs progressed or regressed during the follow-up period after diagnosis. A: Graph showing that cyst heights increased in patients with cyst progression, but the enlargements were small. In patients whose cysts regressed, changes in cyst heights were significantly greater than those in patients whose cysts progressed (p = 0.0009). B: Graph showing that the range of height change did not relate to the length of follow-up periods.

FIG. 2.
FIG. 2.

Sagittal T1-weighted MR images of RCCs in a patient with regression (A and B) and a patient with progression (C and D). A: MR image obtained in a 36-year-old male patient with acute headache showed a cyst with a height of 15 mm. His headache improved 2 weeks after onset. B: MR image repeated in the same patient 2 months later showed cyst regression of height to 4 mm. C: MR image obtained in a 38-year-old male patient with chronic headache showed a cyst with a height of 11 mm. The height of the cyst was stable on the MR image 6 months later. D: MR image obtained 12 months later than the image in panel C because a new development of DI showed cyst progression of height to 18 mm. The patient’s DI improved 2 years after a surgical procedure involving simple drainage of the RCC.

Characteristics of Patients in the Progression, Regression, and Stable Groups

Table 1 shows patient characteristics for the three groups. It can be noted that patients in the progression group were significantly older than those in the stable group (p = 0.0412). An ROC curve analysis showed that the cutoff age for progression was 57.0 years (sensitivity 60.9%, specificity 70.4%, area under the curve 0.6529). Cyst height and intensity of cyst content were unrelated to RCC progression. Acute headache as an initial symptom, larger cysts, and the presence of nodules within the cyst were significant predictors of RCC regression, with a significantly greater incidence of these clinical characteristics in the regression group than in the stable group. Patients with longer-term follow-up showed a higher incidence of both progression and regression of RCCs than the stable group (p < 0.0001).

TABLE 1.

Characteristics of RCC patients in the progression, regression, and stable groups in this study

Progression Groupp Value (progression vs regression)p Value (progression vs stable)Regression Groupp Value (regression vs stable)Stable Group
No. of pts2373133
Age, yrs59.0 (34.0–67.0)0.00600.041239.0 (25.5–55.0)0.214344.0 (27.0–63.0)
Sex, male12 (52.2%)0.08600.051823 (31.5%)0.753039 (29.3%)
Initial Sx
 Acute headache2 (8.7%)0.0546>0.921 (28.8%)0.000713 (9.8%)
 Chronic headache3 (13.0%)>0.90.57239 (12.3%)0.244926 (19.5%)
 VFD1 (4.3%)0.23960.475200.55373 (2.3%)
Hormone replacement4 (17.4%)0.09060.10324 (5.5%)>0.99 (6.8%)
Hydrocortisone241
Levothyroxine222
DDAVP216
MRI findings
 Cyst attached to/compressed chiasm on 1st MRI9 (39.1%)>0.90.640327 (37.0%)0.650445 (33.8%)
 Cyst attached to/compressed chiasm on final MRI or at op14 (60.9%)*4 (5.5%)45 (33.8%)
 Cyst height, mm9.0 (8.0–15.0)0.33390.100211.0 (9.0–14.0)<0.00018.0 (7.0–12.0)
 Intensity of cyst content
   T1WI
   High13 (56.5%)0.96210.777139 (53.4%)0.612174 (55.6%)
   Iso6 (26.1%)21 (28.8%)42 (31.6%)
   Low4 (17.4%)13 (17.8%)17 (12.8%)
  T2W1
   High14 (60.9%)0.37370.306142 (57.5%)0.669968 (51.1%)
   Iso1 (4.3%)11 (15.1%)22 (16.5%)
   Low8 (34.8%)20 (27.4%)43 (32.3%)
 Nodule in cyst3 (13.0%)0.17140.768022 (30.1%)0.036223 (17.3%)
 Change in cyst height on final MRI, mm3.0 (2.0–4.0)0.00096.0 (3.0–9.0)0
 Alternate cyst progression & regression5 (21.7%)0.757319 (26.0%)0
Time to progression or regression, mos21.7 (6.4–57.2)0.062511.4 (3.2–38.9)
FU, mos75.8 (28.8–142.8)0.2273<0.000158.7 (23.7–119.5)<0.000125.4 (11.0–46.4)

DDAVP = 1-desamino-8-d-arginine vasopressin; FU = follow-up; Iso = isointense; pt = patient; Sx = symptom; T1WI = T1-weighted imaging; T2WI = T2-weighted imaging; VFD = visual field disturbance.

Data are expressed as number (%) of patients or median (IQR) unless otherwise indicated.

Five patients underwent a surgery because of new visual disturbances (n = 2), DI (n = 1), hyperprolactinemia and headache (n = 1), and hypocortisolism (n = 1).

Throughout the follow-up period, 24 (10.5%) RCCs alternately progressed and regressed—4 RCCs initially progressed and the remaining 20 RCCs initially regressed. Of these, 19 (including the 4 RCCs that initially progressed) had regressed at the final follow-up and, therefore, were included in the regression group. The remaining 5 fluctuating RCCs (all initially regressed) were found to have progressed on the final MRI and were included in the progression group.

Development of New Symptoms During the Follow-Up Period

Table 2 shows the details of patients who developed new symptoms. Among the 229 patients, only 6 (2.6%) developed new symptoms during the follow-up period. Five of these patients underwent surgery for progressed RCCs. In these 5 patients, the new symptoms were visual disturbances (n = 2), DI (n = 1), hyperprolactinemia and headache (n = 1), and hypocortisolism (n = 1). In the patient who developed hypocortisolism, the symptom persisted even after surgery. The other 4 patients recovered from their new symptoms postoperatively. The sixth patient with a new symptom along with spontaneous regression of her RCC, who did not undergo surgery because of the collapse of her cyst, had permanent DI.

TABLE 2.

Characteristics of RCC patients who developed new symptoms during the follow-up periods

Age (yrs)*SexInitial Cyst Height (mm)*Final Cyst Height (mm)T1WI*T2WI*Time to New Sx (mos)New SxOpOutcome
78M1221HighLow15VFDYRecovery
64M1317HighIso74ACTH deficiencyYPersistent
59F916HighLow47HyperPRL, headacheYRecovery
71M1921LowHigh38VFDYRecovery
40M1220HighHigh14DIYRecovery
24F1910HighLow33DINPersistent

ACTH = adrenocorticotropic hormone; HyperPRL = hyperprolactinemia.

Data obtained at initial diagnosis.

Rates of Progression-Free Survival, Symptom-Free Survival, and Regression

Figure 3A shows the progression-free survival rates over the 10 years after the initial MRI. These were 88.0% at 5 years and 86.3% at 10 years. Figure 3B shows the symptom-free survival rates. These were 95.9% at 5 years and 94.3% at 10 years after the initial MRI. Figure 3C shows the regression rates over the 10 years. These were 41.6% at 5 years and 51.4% at 10 years. In patients with acute headache as an initial symptom, RCCs significantly regressed and did so over a shorter period than in patients without initial acute headache (p < 0.0001). The regression rates in patients with initial acute headaches were 47.1% at 6 months and 66.4% at 3 years.

FIG. 3.
FIG. 3.

Graphs showing 5- and 10-year rates of progression-free survival, symptom-free survival, and cyst regression in patients with RCCs. A: Graph showing the progression-free survival rates of our patient sample (n = 229) over a 10-year period. These rates were 88.0% at 5 years and 86.3% at 10 years. Twenty-three data points fell outside the axis limits. B: Graph showing the symptom-free survival rates for all patients. These rates were 95.9% at 5 years and 94.3% at 10 years. Twenty-seven data points fell outside the axis limits. C: Graph showing the regression rates for all patients over a 10-year period, indicated by the thick line. These rates were 58.4% at 5 years and 48.6% at 10 years. RCCs in patients who presented with acute headaches at initial diagnosis (n = 36) showed significant regression over shorter periods than those in patients without acute headaches (n = 193) (p < 0.0001). Twenty-six data points were outside the axis limits. AHA = acute headache; Pts = patients.

Discussion

In this study, we found that many RCCs change in size over prolonged periods. RCC regression was found to occur more often than progression, and only a small number of patients required surgery for RCC because of progression.

In the existing literature, the reported rates of RCC progression vary widely, ranging from 3.3% to 32.9% between studies (Table 3).412 This inconsistency might be caused by small sample sizes and short follow-up periods. Factors predicting cyst progression have received little research attention. Petersson et al. found that RCCs with diameters ≥ 10 mm were more likely to progress.12 In contrast, the only factor we found to predict RCC progression was older age, with no relationship evident between RCC size and progression.

TABLE 3.

Rates of RCC progression and regression found in various studies

Authors & YearNo. of PtsFU Period (mos)Progression (%)Regression (%)
Sanno et al., 2003494Mean 38.95.315.9
Aho et al., 2005561*>6031.1
Culver et al., 2015675Median 242814.7
Sala et al., 2018762Mean 416.43.2
Shepard et al., 2018817Median 502935
Barkhoudarian et al., 2019930Mean 133.310
Truong et al., 20211035Mean 68.65.720.0
Chong et al., 20221179Median 7232.9
Petersson et al., 202212102§601548
Present study229Median 36.61031.9

Cyst diameter < 10 mm.

Patients aged < 18 years.

Patients aged ≥ 18 years.

Cyst diameter ≥ 10 mm.

RCCs are congenital and originate from the remnants of the embryonic Rathke’s pouch and can be diagnosed at any point in adult life, with a median age at diagnosis of 40–50 years.12,13 Diagnosis is also common in the pediatric population.14 Our results suggest that RCCs diagnosed in young and middle-aged adults are likely to either remain stable or regress in the long term. RCCs existing and diagnosed in older adults may remain stable, but progression is more likely than it is in younger adults. Truong et al. found that patients with RCC who developed new symptoms during the follow-up period were significantly older than those who did not.10 Hence, RCCs diagnosed in older adults require more careful monitoring and, possibly, a longer follow-up period.

The mechanism responsible for spontaneous regression of RCCs remains unclear.1518 Igarashi et al. have hypothesized that RCC regression is caused by an imbalance between fluid secreted from the cyst and either fluid absorbed through the cyst wall or recurrent hemorrhage into the cyst cavity.18 Simmons and Simmons suggested that the fluid in the cyst is resorbed or drained.17 In the patients in our study, RCC regression was frequently preceded by an acute headache. This finding implies that some event occurs within the cyst prior to regression that causes headache, such as intracystic hemorrhage or rupture leading to leakage of cyst content.

It was reported that headaches were more common in patients with RCC than in patients with other sellar lesions19 and could improve after surgery with a high probability of 74%–91%.2022 However, in the recent literature, there was no reported difference in the rates of headache improvement between patients who underwent surgery and those managed conservatively.8,10 We recommend close observation of patients complaining of headaches, particularly those with acute headaches, at the time of RCC diagnosis for at least a few months but without surgical intervention when visual and endocrinological functions are well preserved.

As our study showed that most RCCs remain stable or regress, surgical indications of RCCs should be strictly assessed. RCC progression does not always necessitate surgery. We found that progression can sometimes alternate with regression. When RCCs attach to or compress the optic chiasm without causing visual dysfunction, surgery remains contraindicated. In our sample, 80 (35%) of the RCCs attached to or compressed the optic chiasm; however, deterioration of visual function was only seen in 2 (0.9%) patients. Even if visual function deteriorates, RCC-induced visual dysfunction can usually be improved by surgery.2 Considering the high rate of spontaneous RCC regression, surgery should not be performed on an asymptomatic RCC even if the RCC attaches to the optic chiasm.

In our study, 2 (0.9%) of the 229 patients developed permanent pituitary deficits. The risk of pituitary dysfunction development cannot be excluded in patients with initially asymptomatic RCC; however, the incidence of this is very low. Conversely, the development of pituitary deficiency due to RCC surgery is not infrequent.2 Sala et al. reported new pituitary deficits following surgery in 12 (16.6%) of 72 patients with RCC.7 Castle-Kirszbaum et al. reported that 6.9% of patients had hypopituitarism following RCC surgery based on a systematic review of the literature.2 Permanent DI due to surgery has also been reported (5.5%–18.9% of patients).23,24 The risk of pituitary dysfunction development in patients with RCC who do not receive surgery is of an acceptable level in comparison to the risk of its induction by surgery.

The optimum follow-up period for RCCs is still unclear. Chong et al. have proposed around 3 years based on their finding that the median time of progression was 14 months after initial diagnosis.11 Petersson et al. suggest that follow-up can be restricted to 5 years in patients with cysts < 10 mm, as these rarely progress.12 In our sample, the rate of cyst progression (unrelated to cyst size) was 12.0% at 5 years and 13.7% at 10 years. The potential risk of RCC progression presumably decreased after approximately 5 years. Moreover, only 1.7% of our patients developed new symptoms later than 5 years after initial diagnosis. Thus, we recommend a 5-year minimum follow-up period to verify RCC inactivity.

Study Limitations

The current study has some limitations. First, indications for surgery were not based on established guidelines. Therefore, the selection of patients who met our inclusion criteria was not free from bias. Second, patients with RCC who were followed up for only a short period were included. As longer-term follow-up will inevitably increase the rate of RCC events, the inclusion of these patients may have led to an underestimation of the risks of cyst progression and new symptom development. Third, patients in the progression and regression groups did not receive visual examinations from an ophthalmologist and endocrinological evaluations at every follow-up appointment. This may have resulted in underestimation of the rates of endocrinological and visual deterioration. Fourth, the evaluation of cyst progression or regression might have some errors and bias because the cyst height was strictly not a surrogate for cyst size and a height change of 1 mm could have included examination errors. Despite these disadvantages, our study has revealed important information about the natural course of RCCs that can usefully contribute to the management of the condition.

Conclusions

While RCCs rarely progress and cause new symptoms over time, it is important to monitor asymptomatic RCCs to ensure their ongoing latency. We recommend a minimum follow-up period of 5 years to confirm the inactivity of RCCs. It may be necessary to increase the frequency of checks and/or follow-up duration in older adults due to their higher risk of RCC progression.

Acknowledgments

We thank the Alumni Association Group of the Department of Neurosurgery at Hiroshima University and Dr. H. Yoshioka for their contributions and Enago for the English-language review.

This study was partially supported by JSPS KAKENHI (grant no. JP19K17987).

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Kinoshita, Tominaga. Acquisition of data: Kinoshita, Taguchi, Tominaga. Analysis and interpretation of data: Kinoshita. Drafting the article: Kinoshita. Critically revising the article: Yamasaki, Tominaga, Arita. Reviewed submitted version of manuscript: Kinoshita, Taguchi, Yamasaki, Arita. Approved the final version of the manuscript on behalf of all authors: Kinoshita. Statistical analysis: Kinoshita. Administrative/technical/material support: Yamasaki, Tominaga. Study supervision: Horie.

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  • 24

    Lin M, Wedemeyer MA, Bradley D, et al. Long-term surgical outcomes following transsphenoidal surgery in patients with Rathke’s cleft cysts. J Neurosurg. 2018;130(3):831837.

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Illustrations from Esen Aydin et al. (pp 1443–1456). © Gökhan Canaz, published with permission.

  • FIG. 1.

    Changes in cyst heights in patients whose RCCs progressed or regressed during the follow-up period after diagnosis. A: Graph showing that cyst heights increased in patients with cyst progression, but the enlargements were small. In patients whose cysts regressed, changes in cyst heights were significantly greater than those in patients whose cysts progressed (p = 0.0009). B: Graph showing that the range of height change did not relate to the length of follow-up periods.

  • FIG. 2.

    Sagittal T1-weighted MR images of RCCs in a patient with regression (A and B) and a patient with progression (C and D). A: MR image obtained in a 36-year-old male patient with acute headache showed a cyst with a height of 15 mm. His headache improved 2 weeks after onset. B: MR image repeated in the same patient 2 months later showed cyst regression of height to 4 mm. C: MR image obtained in a 38-year-old male patient with chronic headache showed a cyst with a height of 11 mm. The height of the cyst was stable on the MR image 6 months later. D: MR image obtained 12 months later than the image in panel C because a new development of DI showed cyst progression of height to 18 mm. The patient’s DI improved 2 years after a surgical procedure involving simple drainage of the RCC.

  • FIG. 3.

    Graphs showing 5- and 10-year rates of progression-free survival, symptom-free survival, and cyst regression in patients with RCCs. A: Graph showing the progression-free survival rates of our patient sample (n = 229) over a 10-year period. These rates were 88.0% at 5 years and 86.3% at 10 years. Twenty-three data points fell outside the axis limits. B: Graph showing the symptom-free survival rates for all patients. These rates were 95.9% at 5 years and 94.3% at 10 years. Twenty-seven data points fell outside the axis limits. C: Graph showing the regression rates for all patients over a 10-year period, indicated by the thick line. These rates were 58.4% at 5 years and 48.6% at 10 years. RCCs in patients who presented with acute headaches at initial diagnosis (n = 36) showed significant regression over shorter periods than those in patients without acute headaches (n = 193) (p < 0.0001). Twenty-six data points were outside the axis limits. AHA = acute headache; Pts = patients.

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