Differential Clinical Presentation, Intraoperative Management Strategies and Surgical Outcomes Following Endoscopic Endonasal Treatment of Cystic Sellar Masses

Abstract Background Cystic sellar masses (CSMs) pose diagnostic and therapeutic challenges associated with subtotal cyst wall resection, cerebrospinal fluid (CSF) leak repair, and disease recurrence. Current MRI interpretation often cannot reliably differentiate CSMs, mandating adaptable intraoperative strategies. Objective We reviewed our diagnostic and therapeutic experience following endoscopic endonasal approaches (EEA) for CSMs. Methods A retrospective record review of CSM patients managed via EEA at USC from 2011-2018 was conducted. Patient demographics, preoperative characteristics, surgical details, pathological findings, and postoperative outcomes were assessed. Results Analysis included 47 patients (mean age 43.2 years), of which 78.7% were women. Preoperative symptoms included headache (76.6%) and vision loss (42.6%). Histologically-verified sellar pathology included 27 Rathke’s cleft cysts (RCCs, 57.4%), 17 cystic pituitary adenomas (CPA, 36.2%), 2 arachnoid cysts (4.3%), and 1 xanthogranuloma (2.1%). Twelve patients (70.6%) with CPAs underwent complete resection and 5 (29.4%) subtotal resection. All 27 RCC patients and 2 with arachnoid cysts underwent complete fenestration and drainage. One xanthogranuloma was completely resected. There were 14 intraoperative (29.8%) and 4 postoperative CSF leaks (8.5%). Headaches, vision, and endocrinopathy improved in 69.2%, 80.0%, and 33.3% of CPA patients and 73.9%, 71.4%, and 40.9% of RCC patients, respectively. There were 2 RCC recurrences and 1 CPA recurrence over the follow-up period. Conclusion Surgeons must prepare for versatile management strategies of CSMs based on pre-test probability associated with MRI and intraoperative findings. Outcomes following EEA for CSMs show low complication profiles and excellent rates of headache and visual improvement, albeit lower rates of endocrine normalization.