Are Sellar Xanthogranulomas the Climax of a Spectrum of Secondary Inflammatory Reactions to Various Sellar Lesions?

Since 1999, sellar xanthogranulomas (XGs) have been recognized as a distinct pathological entity characterized by cholesterol clefts, macrophages, chronic inflammatory infiltrates with multinucleated giant cells, necrotic debris, and hemosiderin, suggesting a chronic inflammatory process with repetitive intralesional bleeding. This study aims to characterize the clinical phenomenology of the rare XG entity and to explore its correlation with other lesions. A retrospective screening was conducted of 628 sellar surgeries performed during the 2007–2024 period at a major communal hospital in Berlin and 529 surgeries between 2015 and 2024 at Ulm University. Eight XGs were analyzed. Eight XGs (0.6% of 1157 surgeries) showed mixed intra- and suprasellar localization. Visual deficits and endocrinological insufficiencies were the most common symptoms (four out of eight each). Visual recovery was favorable (three out of four complete, one out of four marked improvement), whereas endocrinological recovery was limited (one out of four). One patient experienced recurrence. Intraoperatively, seven out of eight lesions contained characteristic fluid described as ‘golden water of Gdansk.’ Postoperatively, transient arginine vasopressin deficiency occurred in four out of eight patients. The illustrative case demonstrated transformation of a Rathke’s cleft cyst, while two cases were associated with pituitary adenomas. Sellar XGs are benign, chronic inflammatory and hemorrhagic lesions with low recurrence risk. Their frequent association with other sellar pathologies supports a secondary reactive origin.