Radiological Differentiation of Pituitary Adenomas From Other Sellar Masses: A Systematic Review

Sellar masses frequently share overlapping magnetic resonance imaging (MRI) appearances, yet management and prognosis vary across entities such as pituitary adenoma, Rathke cleft cyst (RCC), and craniopharyngioma. Improving preoperative discrimination would support surgical planning and endocrine outcomes. This review synthesizes comparative radiologic features and adjunct sequences that differentiate sellar masses and appraises the methodological quality of recent studies. We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. We collected data from these databases: PubMed, Cochrane Library, ScienceDirect, Oxford Academic, American Journal of Neuroradiology (AJNR), and MDPI. We extracted relevant data from screening and quality appraisal with quality appraisal tools according to the respective study. Fifteen studies met criteria after full-text assessment. Two higher-quality diagnostic studies showed that combining structured semantic MRI features with radiomics or simple clinical indices improved discrimination in common differentials (cystic pituitary adenoma vs. RCC; cystic-solid adenoma vs. craniopharyngioma). Diffusion-weighted imaging and high-resolution 3D T2 sequences provided supportive gains in confidence and detection, although thresholds and verification strategies varied. Across JBI and QUADAS-2, the most frequent limitations were retrospective design, unclear index-test blinding/pre-specification, and partial verification in sequence-evaluation cohorts. Structured semantic MRI remains foundational for sellar mass work-up; thoughtfully integrated radiomics and selective adjunct sequences can increase diagnostic confidence. Standardized acquisition, prespecified thresholds, and external validation are needed before universal protocol adoption.