Sellar cholesterol granuloma mimicking cystic sellar lesions: A report of three cases and literature review

Background: Cystic lesions in the sellar region include a variety of entities as craniopharyngioma, Rathke's cleft cyst, intrasellar arachnoid cyst, cystic pituitary adenomas, cholesterol granulomas and xanthogranulomas The distinction among them remains a preoperative challenge due to similarities in their clinical and radiological findings.

Case description: We describe three cases with cystic sellar lesions. The first patient is a woman who presented with headache and hormonal disturbances including high levels of prolactin, with a sellar and suprasellar cystic lesion discovered on the MRI. She was initially treated with dopamine agonists with normalization of prolactin levels but no changes on the size of the lesion. She underwent an endoscopic endonasal resection and the histology resulted in a cholesterol granuloma/xanthogranuloma (CG/XG). The second patient is a woman who consulted for an incidentally discovered sellar cyst. During the follow up, the lesion demonstrated enlargement with compression of the optic chiasm. With a preoperative diagnosis of Rathke's cleft cyst, the lesion was removed through an endoscopic endonasal transsellar approach. Final pathologic diagnosis was consistent with CG/XG. The third case was that of a man who presented with refractory headaches and vision loss, with a sellar/suprasellar cystic lesion on MRI. He underwent endoscopic endonasal transsellar surgery for resection of what preoperatively was thought to be a giant Rathke's cleft cyst; final pathology again was consistent with CG/XG.

Conclusions: CG/XG is an uncommon pathology with unspecific clinical and radiological features. However, this pathology should be considered in the differential diagnosis of mixed cystic/solid lesions in the sellar region.

Keywords: Cholesterol granuloma; cystic pituitary lesions; hyperprolactinemia; sellar.; xanthogranuloma.