Xanthogranuloma of the Sellar Region: A Comprehensive Review of Neuroimaging in a Rare Inflammatory Entity

Abstract

Xanthogranuloma of the sellar region is a rare chronic inflammatory lesion resulting from secondary hemorrhage, inflammation, infarction, and necrosis of an existing Rathke’s cleft cyst, craniopharyngioma, or pituitary adenoma. Sellar xanthogranulomas are challenging to differentiate from other cystic lesions preoperatively due to the lack of characteristic imaging features. We performed a literature overview of the clinical and paraclinical features, treatment options, and long-term outcomes of patients with sellar xanthogranuloma, focusing on the preoperative radiological diagnosis. The hyperintense signal in both T1- and T2-weighted sequences, cystic or partially cystic morphology, ovoid shape, sellar epicenter, intra- and suprasellar location, intratumoral calcifications, linear rim contrast enhancement, and the absence of cavernous sinus invasion suggest xanthogranuloma in the preoperative differential diagnosis. An endoscopic endonasal gross total resection without radiotherapy is the preferred first-line treatment. Given the low rate of recurrence rate and low chance of endocrinological recovery, a mass reduction with decompression of the optic apparatus may represent an appropriate surgical goal. Identifying the xanthogranulomas’ mutational profile could complement histopathological diagnosis and give insight into their histo-pathogenesis. A better preoperative neuroimagistic diagnosis of sellar xanthogranulomas and differentiation from lesions with a poorer prognosis, such as craniopharyngioma, would result in an optimal personalized surgical approach.

Calcified Pituitary Adenoma Mimicking Craniopharyngioma: A Case Report

“…Radiological evidence can help distinguish between sellar and suprasellar lesions based on various calcification patterns, such as curvilinear, nodular, or mixed. This helps identify the type of lesion [ 7 ]. Common masses originating from the suprasellar region include pituitary adenomas and craniopharyngiomas.…”

Intrasellar xanthogranuloma mimicking macroadenoma

“…Thus, the final diagnosis is made histologically, showing a granulomatous reaction characterized by cholesterol clefts, hemosiderin deposits, accumulation of multinucleated foreign body giant cells and foamy macrophages, necrotic debris, and fibrous proliferation. 6,7 The first-line treatment is surgical resection. The endoscopic endonasal approach is the preferred technique for surgery of the sellar region in most centers, and gross total resection typically provides good prognosis with low relapse rates.…”

“…Subtotal resection may also be considered, depending on tumor dimensions and adhesions to the normal gland. 7 The preoperative suspicion of XG might facilitate the surgical approach strategy. Although no radical changes to the approach strategy would come about, since the endoscopic endonasal approach with eventual variations would be the best suited for almost all sellar and suprasellar lesions, independent of the pathology.…”

“…Thus, the final diagnosis is made histologically, showing a granulomatous reaction characterized by cholesterol clefts, hemosiderin deposits, accumulation of multinucleated foreign body giant cells and foamy macrophages, necrotic debris, and fibrous proliferation. 6,7…”

“…Subtotal resection may also be considered, depending on tumor dimensions and adhesions to the normal gland. 7…”