Natural history and radiological features of Rathke's cleft cysts diagnosed on MRI: Analysis of 410 patients...

Rathke's cleft cysts (RCCs) are common sellar lesions with a heterogeneous natural history. Unlike most sellar tumors, RCCs may remain stable, regress, or progress, making decisions regarding surgery and follow-up challenging. This study aimed to identify radiological features associated with the natural course of RCCs in a large single-center cohort. We hypothesized that specific MRI features would be associated with progression, stability, regression, and the likelihood of surgical intervention.

We retrospectively reviewed 410 patients with RCCs diagnosed on MRI between 2008 and 2021. Of these, 131 underwent primary surgery and 279 were initially managed conservatively. Radiological characteristics and interval changes during follow-up were analyzed.

Among 279 conservatively managed patients (median follow-up, 124 months), 16.1% showed progression, 63.1% remained stable, and 20.8% regressed. Larger cysts (>10 mm) and cysts of the entirely suprasellar type showed higher progression rates (24.8% and 30.1%, respectively), whereas cysts ≤ 10 mm without suprasellar extension had a low progression rate (8.5%). Imaging features associated with surgical treatment included larger size, dumbbell morphology, rim enhancement, waxy nodules, and T2-mixed signal patterns. During follow-up, 21 patients (7.5%) required surgery.

RCCs show a heterogeneous natural history, with most cases remaining stable or regressing. Larger cyst size, suprasellar extension, and T2-mixed signal patterns are associated with progression. These findings support initial conservative management in most asymptomatic patients and emphasize risk-stratified follow-up.