Abstract
PurposeA classification system for cystic sellar lesions does not exist. We propose a novel classification scheme for these lesions based on the heterogeneity of the cyst wall/contents and the presence of a solid component on imaging.MethodsWe retrospectively reviewed 205 patients’ medical records (2008–2020) who underwent primary surgery for a cystic sellar lesion. Cysts were classified a priori into 1 of 4 cyst types based on the heterogeneity of the cyst wall/contents and the presence of a solid component imaging. There was high interrater reliability. Univariable and multivariable models were used to estimate the ability of cyst type to predict the two most common diagnoses: Rathke cleft cyst (RCC) and cystic pituitary adenoma.ResultsThe frequencies of RCC and cystic pituitary adenoma in our cohort were 45.4% and 36.4%, respectively. Non-neoplastic lesions (e.g., arachnoid cysts and RCC) were more likely to be Type 1 or 2, whereas cystic neoplasms (e.g., pituitary adenomas and craniopharyngiomas) were more likely to be Type 3 or 4 (p<0.0001). Higher cyst types, compared to Type 1, had higher odds of being cystic pituitary adenomas compared to RCCs (OR: 23.7, p=0.033, and 342.6, p <0.0001, for Types 2 and 4, respectively). Lesions with a fluid-fluid level on preoperative MRI also had higher odds of being pituitary adenomas (OR: 12.7; p=0.023). Cystic pituitary adenomas were more common in patients with obesity (OR: 5.0, p=0.003) or symptomatic hyperprolactinemia (OR: 11.5; p<0.001, respectively). The multivariable model had a positive predictive value of 82.2% and negative predictive value of 86.4%.ConclusionWhen applied to the diagnosis of RCC versus cystic pituitary adenoma, higher cystic lesion types (Type 2 & 4), presence of fluid-fluid level, symptomatic hyperprolactinemia, and obesity were predictors of cystic pituitary adenoma. Further validation is needed, but this classification scheme may prove to be a useful tool for the management of patients with common sellar pathology.
Highlights
Cystic lesions in the sellar region encompass a broad gamut of pathologies, which can be challenging to distinguish on imaging, given their variability in clinical presentation and heterogeneity of cyst appearance
We originally queried an institutional database of 1083 transsphenoidal operations in 982 patients for sellar pathology (757 operations for pituitary adenoma) performed by one of the senior authors (ERL) from April 2008 to January 2020
Rathke cleft cysts (RCC) and cystic pituitary adenomas comprised the vast majority of cystic lesions (36% and 45%, respectively)
Summary
Cystic lesions in the sellar region encompass a broad gamut of pathologies, which can be challenging to distinguish on imaging, given their variability in clinical presentation and heterogeneity of cyst appearance. Some cystic lesions are benign, incidentally found lesions, others can lead to significant morbidity through disruption of hormonal axes or associated mass effect Found lesions such as small pituitary adenoma or RCC may be observed, while surgical resection is indicated for symptomatic lesions or those requiring tissue diagnosis. Clinical and imaging factors are often used to generate a preliminary diagnosis and guide management This variation in treatment pathways necessitates further study into the features that distinguish these various cystic pathologies, especially the two most common pathologies: RCC and cystic pituitary adenoma. The classification scheme can be applied to every lesion, regardless of size using the heterogeneity of the cyst wall/ contents and presence of a solid component on preoperative magnetic resonance imaging (MRI). We used this a priori classification scheme and applied it to a retrospective cohort of patients
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