Xanthogranulomas Presenting as Sellar Masses: Case Series and Review of the Literature

Object: Cholesterol granulomas are granulomatous lesions containing cholesterol clefts and occurring secondary to hemorrhage, infarction, inflammation and/or necrosis. The occurrence of cholesterol granulomas within the sellar region is rare. However, their appearance can mimic that of craniopharyngioma or Rathke’s cleft cysts. Differentiation of cystic lesions of the sellar and parasellar region therefore may pose a dilemma. Information regarding the clinical presentation, imaging characteristics, and clinical course of sellar cholesterol granulomas can help clinicians to differentiate these lesions from other cystic lesions occurring in the sellar region.

Methods: We present three cases of cholesterol granulomas presenting as sellar masses. A literature review was performed for all cases of cholesterol granulomas in the sellar region with sufficient individual patient data that would allow us to generate summary statistics on the clinical presentation, imaging characteristics, and outcome of the entire patient cohort.

Results: We identified 24 previously reported cases in addition to our three presented cases. Mean age was 36.6 years (range: 5–68). There were 16 (59%) females and 11 (41%) males. The most common (74%) presenting symptom was endocrinological deficits, with either isolated DI or panhypopituitarism being the most frequent presentation. Seventeen (63%) patients also had visual deficits on initial presentation. Location was purely intrasellar in 3 (11%), suprasellar in 6 (22%), and both intrasellar and suprasellar in 18 (67%) patients. On T1, lesions were hyperintense in 19 (83%), heterogenous in 4 (17%) and hypointense in no cases. On T2, lesions were hyperintense in 4 (17%), heterogenous in 10 (43%), and hypointense in 9 (39%) patients. Of the 25 cases reporting extent of resection, gross total resection was achieved in 16 (64%) and subtotal resection in 9 (36%) patients. Of the 17 patients presenting with varying degrees of bitemporal hemianopsia, all had improvement in vision postoperatively. It is worth noting that no cases of preoperative hypopituitarism or DI improved postoperatively. Even though gross total resection was only achieved in 64%, there was only one recurrence reported.

Conclusion: Although rare, cholesterol granulomas may present in the sellar region. These lesions are characterized by T1 hyperintensity, occurrence in younger patients, and increased frequency of more severe endocrinological deficits on presentation. The endoscopic endonasal approach for surgical resection is a good treatment option. Our review demonstrates high rates of improvement of visual deficits, but poor rates of endocrine function recovery. Recurrence appears to be rare even in cases of subtotal resection. Cholesterol granulomas should be considered in the differential of mixed cystic/solid lesions in the sellar region.