Case Report: Differential diagnosis of Rathke’s cleft cyst and sellar xanthogranuloma by 1H magnetic resonance spectroscopy
8 affiliations
- 1Kenneth R. Peak Brain and Pituitary Tumor Treatment Center, Houston Methodist Hospital
- 2Department of Neurosurgery, Houston Methodist Hospital
- 3Houston Methodist Academic Institute
- 4Houston Methodist Research Institute
- 5Houston Methodist Neurological Institute
- 6Weill Cornell Medical College
- 7Texas A&M University Naresh K. Vashisht College of Medicine
- 8Department of Pathology and Genomic Medicine, Houston Methodist Hospital
Abstract
Background: Sellar xanthogranulomas closely resemble Rathke’s cleft cysts (RCCs) and present a diagnostic challenge. It is difficult to differentiate xanthogranulomas preoperatively from other sellar masses, such as RCCs. The objective of this study is to differentiate the biochemical profiles of xanthogranulomas and RCCs using ex vivo ¹ H magnetic resonance spectroscopy (MRS), which may serve as a valuable future tool for the non-invasive diagnosis of sellar lesions.
Case presentation: A 48-year-old man presented with an episode of numbness and tingling in the legs, followed by severe malaise and weakness (September 2021). The initial blood work revealed hyponatremia (serum sodium, 127 mmol/L). A detailed blood hormone panel revealed hypocortisolism (blood cortisol, <1.0 µg/dL). Magnetic resonance imaging (MRI) examination of the brain and pituitary region detected 2.0 cm × 1.7 cm × 1.7 cm sellar/suprasellar mass that was predominantly hyperintense on pre-contrast T1- and T2-weighted images, and a diagnosis of subacute pituitary apoplexy or complex RCC was made. Prior to presentation to our center, the patient was diagnosed with hypothyroidism. To treat the above conditions, the patient was placed on hydrocortisone (30 mg/day) fludrocortisone (0.1 mg/day) and levothyroxine (88 µg/day) replacement therapy (October 2021) before transfer to our care. The patient underwent endoscopic transsphenoidal exploration and selective removal of the sellar mass (November 2021). Biochemical analysis of the resected specimen by ex vivo ¹ H magnetic resonance spectroscopy ( ¹ H MRS) revealed the absence of glycosaminoglycans (GAGs) and showed the elevated levels of lactate (9.0 mM), when compared to biochemical profile of RCC specimen. The increased lactate levels in xanthogranuloma indicate ongoing inflammatory processes within the sellar lesion. Additionally, lipid profiling of xanthogranuloma showed elevated levels of cholesterol and cholesteryl esters. Surgical pathology of the sellar lesion demonstrated xanthogranulomatous reactions with chronic inflammation, the presence of cholesterol clefts and necrosis, findings that are consistent with ¹ H MRS findings.
Conclusion: Although sellar xanthogranulomas may resemble RCCs histologically, they exhibit distinct biochemical and lipidomic profiles characterized by the absence of GAGs and elevated levels of lactate, cholesterol and cholesteryl esters. ¹ H MRS has potential to differentiate the biochemical profiles of xanthogranulomas and RCCs. Furthermore, the findings from this study may be translated into non-invasive diagnostic methods using clinical MRI scanners, enabling improved preoperative differentiation of sellar lesions.
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BibTeX
@article{ijare2026case,
title = {{Case Report: Differential diagnosis of Rathke’s cleft cyst and sellar xanthogranuloma by 1H magnetic resonance spectroscopy}},
author = {Omkar B. Ijare and David S. Baskin and Suzanne Z. Powell and Kumar Pichumani},
journal = {Frontiers in Endocrinology},
year = {2026},
month = nov,
doi = {10.3389/fendo.2026.1913986},
url = {https://www.frontiersin.org/articles/10.3389/fendo.2026.1913986/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Case Report: Differential diagnosis of Rathke’s cleft cyst and sellar xanthogranuloma by 1H magnetic resonance spectroscopy
AU - Omkar B. Ijare
AU - David S. Baskin
AU - Suzanne Z. Powell
AU - Kumar Pichumani
PY - 2026
DA - 2026/11/09
JO - Frontiers in Endocrinology
DO - 10.3389/fendo.2026.1913986
UR - https://www.frontiersin.org/articles/10.3389/fendo.2026.1913986/full
AB - Background: Sellar xanthogranulomas closely resemble Rathke’s cleft cysts (RCCs) and present a diagnostic challenge. It is difficult to differentiate xanthogranulomas preoperatively from other sellar masses, such as RCCs. The objective of this study is to differentiate the biochemical profiles of xanthogranulomas and RCCs using ex vivo ¹ H magnetic resonance spectroscopy (MRS), which may serve as a valuable future tool for the non-invasive diagnosis of sellar lesions. Case presentation: A 48-year-old man presented with an episode of numbness and tingling in the legs, followed by severe malaise and weakness (September 2021). The initial blood work revealed hyponatremia (serum sodium, 127 mmol/L). A detailed blood hormone panel revealed hypocortisolism (blood cortisol, <1.0 µg/dL). Magnetic resonance imaging (MRI) examination of the brain and pituitary region detected 2.0 cm × 1.7 cm × 1.7 cm sellar/suprasellar mass that was predominantly hyperintense on pre-contrast T1- and T2-weighted images, and a diagnosis of subacute pituitary apoplexy or complex RCC was made. Prior to presentation to our center, the patient was diagnosed with hypothyroidism. To treat the above conditions, the patient was placed on hydrocortisone (30 mg/day) fludrocortisone (0.1 mg/day) and levothyroxine (88 µg/day) replacement therapy (October 2021) before transfer to our care. The patient underwent endoscopic transsphenoidal exploration and selective removal of the sellar mass (November 2021). Biochemical analysis of the resected specimen by ex vivo ¹ H magnetic resonance spectroscopy ( ¹ H MRS) revealed the absence of glycosaminoglycans (GAGs) and showed the elevated levels of lactate (9.0 mM), when compared to biochemical profile of RCC specimen. The increased lactate levels in xanthogranuloma indicate ongoing inflammatory processes within the sellar lesion. Additionally, lipid profiling of xanthogranuloma showed elevated levels of cholesterol and cholesteryl esters. Surgical pathology of the sellar lesion demonstrated xanthogranulomatous reactions with chronic inflammation, the presence of cholesterol clefts and necrosis, findings that are consistent with ¹ H MRS findings. Conclusion: Although sellar xanthogranulomas may resemble RCCs histologically, they exhibit distinct biochemical and lipidomic profiles characterized by the absence of GAGs and elevated levels of lactate, cholesterol and cholesteryl esters. ¹ H MRS has potential to differentiate the biochemical profiles of xanthogranulomas and RCCs. Furthermore, the findings from this study may be translated into non-invasive diagnostic methods using clinical MRI scanners, enabling improved preoperative differentiation of sellar lesions.
SN - 1664-2392
ER -