Endoscopic Endonasal Management of Sellar Xanthogranuloma: A Three-Case Experience and Review of the Literature

Introduction: Xanthogranuloma can occur in many anatomical sites; however, its presence in the sellar region is rare among intracranial lesions. It is a benign entity described mainly in case reports and case series. We present three cases of sellar xanthogranulomas diagnosed and treated in Brazil, along with a literature review. Methods: This study comprises a case series of sellar xanthogranulomas and a literature review conducted through PubMed over the last 10 years. Only articles in English were included, using the search terms: “pituitary xanthogranuloma” OR “sellar xanthogranuloma” OR “suprasellar xanthogranuloma” OR “parasellar xanthogranuloma.” Results: We report three cases—one male and two females, aged 17–37 years—treated at two Brazilian centers. Two patients were symptomatic at diagnosis with hypopituitarism, requiring levothyroxine and glucocorticoids; one also had diabetes insipidus. The third was incidental and later developed hyperprolactinemia. All lesions involved the sellar and suprasellar regions, with cystic or mixed solid-cystic components; optic chiasm compression was seen in two cases. MRI revealed hyperintense signals on T1- and STIR-weighted images, with hypo- and isointensity on T2, and no contrast enhancement. All patients underwent endoscopic endonasal surgery with gross total resection and no recurrence. Preoperative endocrinological disturbances persisted postoperatively in all, except one who presented with hypopituitarism in the postoperative period, requiring lifelong replacement therapy. Mean follow-up was 3 years (range 1–5). Discussion: Sellar xanthogranuloma (SXG) is a rare, benign inflammatory lesion of the sellar/suprasellar region, histologically defined by cholesterol clefts, foamy macrophages, multinucleated giant cells, hemosiderin, fibrous tissue, and chronic inflammatory infiltrates, all observed in our cases. Unlike craniopharyngiomas or Rathke’s cleft cysts, SXG lacks epithelial components. Etiology involves secondary inflammation, often from Rathke’s cleft cysts and less frequently from craniopharyngiomas, triggered by cyst rupture, leakage, or hemorrhage, leading to granulomatous reaction and xanthomatous transformation. Clinically, SXG causes headaches, visual disturbances from chiasm compression, and anterior/posterior pituitary dysfunction such as hypopituitarism or diabetes insipidus, consistent with our cases. Imaging typically shows a cystic or mixed sellar mass: cystic components hyperintense on T1WI/T2WI, solid components hyperintense on T1WI and hypointense on T2WI, sometimes with fluid-fluid levels. Definitive diagnosis requires histopathology, distinguishing SXG from other sellar lesions by absence of epithelial lining and presence of xanthogranulomatous features, observed in our cases: granulomatous inflammation, foreign-body giant cells, cholesterol clefts, necrosis, and fibrosis. Surgical resection, usually endoscopic endonasally, is the treatment of choice and generally curative, though pituitary dysfunction often persists. The rarity and heterogeneity of SXG remain a clinical challenge. Conclusion: SXG is a rare but important differential diagnosis for sellar masses, often mimicking other lesions radiologically. Diagnosis relies on histopathology after surgical resection, typically curative. However, pituitary dysfunction may persist, underscoring the need for careful endocrine management. Awareness of SXG’s varied presentation is essential for accurate diagnosis. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany