TUMORS VENTRAL TO THE SACRUM

Laparoscopic approach in the surgical treatment of large retrorectal tumors: a short-term experience at a single tertiary center case series in Korea

Retrorectal tumors, although rare, pose diagnostic and treatment challenges due to their nonspecific symptoms and complex anatomical location. This single-center case series reports short-term outcomes of laparoscopic transabdominal resection as a surgical approach for large retrorectal tumors. Between 2017 and 2020, five patients underwent this procedure. The median patient age was 53.2 years (range, 34-60 years), and the median operating time was 130 minutes (range, 95-205 minutes). All tumors were located in the retrorectal space. The median tumor size was 5.8 × 4.3 cm (range, 3.5-7.5 cm). Biopsy results included epidermoid cysts, tailgut cyst, lipoma, and keratinous cyst. The median hospital stay was 7.8 days (range, 5-11 days), and the median follow-up duration was 78.0 days (range, 14-219 days). One patient developed a postoperative surgical site infection. Overall, laparoscopic transabdominal resection appears to be a minimally invasive and effective treatment option for retrorectal tumors.

Risk factors for perioperative complications in laparoscopic surgeries of retrorectal cystic lesions

BACKGROUND

The incidence of retrorectal lesions is low, and no consensus has been reached regarding the most optimal surgical approach. Laparoscopic approach has the advantage of minimally invasive. The risk factors influencing perioperative complications of laparoscopic surgery are rarely discussed.

AIM

To investigate the risk factors for perioperative complications in laparoscopic surgeries of retrorectal cystic lesions.

METHODS

We retrospectively reviewed the medical records of patients who underwent laparoscopic excision of retrorectal cystic lesions between August 2012 and May 2020 at our hospital. All surgeries were performed in the general surgery department. Patients were divided into groups based on the lesion location and diameter. We analysed the risk factors like type 2 diabetes mellitus, hypertension, the history of abdominal surgery, previous treatment, clinical manifestation, operation duration, blood loss, perioperative complications, and readmission rate within 90 d retrospectively.

RESULTS

Severe perioperative complications occurred in seven patients. Prophylactic transverse colostomy was performed in four patients with suspected rectal injury. Two patients underwent puncture drainage due to postoperative pelvic infection. One patient underwent debridement in the operating room due to incision infection. The massive-lesion group had a significantly longer surgery duration, higher blood loss, higher incidence of perioperative complications, and higher readmission rate within 90 d (P < 0.05). Univariate analysis, multivariate analysis, and logistic regression showed that lesion diameter was an independent risk factor for the development of perioperative complications in patients who underwent laparoscopic excision of retrorectal cystic lesions.

CONCLUSION

The diameter of the lesion is an independent risk factor for perioperative complications in patients who undergo laparoscopic excision of retrorectal cystic lesions. The location of the lesion was not a determining factor of the surgical approach. Laparoscopic surgery is minimally invasive, high-resolution, and flexible, and its use in retrorectal cystic lesions is safe and feasible, also for lesions below the S3 level.

Management of giant presacral schwannoma. Clinical series and literature review

PURPOSE

Presacral schwannomas are rare tumors. Due to their benign nature and slow growth, these tumors are often giant and become difficult to treat. Their removal is a surgical challenge with different strategies reported in the literature. This study presents the consecutives cases of presacral schwannomas operated on in our institution, our surgical strategy and literature review.

METHODS

This retrospective study includes all consecutive patients operated on for a pre-sacral schwannoma in our department between 2006 and 2019, i.e. 6 patients. We report clinical features, pre and post-operative imaging, surgical data and post-operative outcomes.

RESULTS

All patients had symptoms before surgery (constipation, dysuria, radicular or lower back pain) with an average duration of 7.4 months. All patients underwent an MRI and a CT scan before the surgery. Five patients had type III schwannoma according to Klimo classification and one patient had a type II. The average size was 504,9 cm³ (range 53,1-1495,4). All the patients were operated on by an anterior approach in a double team with an mean duration of 246 min. Intraoperative bleeding was less than 500 ml for 4 patients, 2 patients had significant bleeding (2700 and 2900 mL). Excision was total or subtotal in all cases. One patient had an intraoperative complication (air embolism). Follow up at 3 months was excellent with a disappearance of symptoms for all patients except one patient who retained constipation. One patient had a late complication (bowel obstruction due to tissue adhesions). At last follow-up after phone interview, no patient had clinical symptoms that could suggest a recurrence.

CONCLUSION

The anterior approach with a double surgical team is a great option for the treatment of presacral schwannoma. Combined with adequate preoperative imaging and intraoperative stimulation, it reduces the risk of intra and postoperative complications.

Giant Invasive Sacral Schwannoma with Aortic Bifurcation Compression and Hydronephrosis

BACKGROUND

Sacral schwannomas are rare tumors arising from nerve sheath Schwann cells. They are classified into 3 types: first type schwannoma arising from the sacrum, second type schwannoma eroding the sacrum, and third type schwannoma extending extensively, involving anterior, posterior, and retroperitoneal space. Among these type 2 sacral tumors, according to Klimo's classification, an eroding sacrum extending all over posteriorly, anteriorly, and laterally is still rarer. Only 38 cases have been reported in literature reviews. Only 6 cases of giant tumors of >10 cm in any 1 dimension have been reported.

CASE DESCRIPTION

We present such a giant sacral schwannoma, with invasiveness eroding the sacrum; compressing the ureters, aortic bifurcation, bladder, and bowel; and presenting as lower abdominal pain, hydronephrosis, dysuria, and constipation. This is the first case reported in the literature that has described a large retroperitoneal tumor compressing retroperitoneal structures-aortic bifurcation vascular compression and ureter compression causing hydronephrosis.

CONCLUSIONS

Though complete resection, which caused various severe postoperative complications in the reported cases, is the best option, a less morbid procedure would be appropriate; hence we underwent subtotal excision of the tumor, with complete recovery of our patient's symptoms without neurologic deficit.

[Resection of a giant sacral schwannoma: case report and literature review]

Neurogenic sacral tumors are extremely rare. In most reported cases, this pathology was associated with neurofibromatosis. Sacral tumors manifest themselves at the stage when the neoplasm volume becomes giant, but these manifestations usually go unnoticed for the patient. Surgical approach to the sacral region is extremely challenging; intimate proximity of tumor capsule to vital organs, vessels, and nerves makes radical surgical treatment of these neoplasms rather difficult. A case report of radical resection of a schwannoma that was destroying the sacrum and continued to grow after radiotherapy is presented in this article.

Sacral intraosseous lipoma: a case report

Sacral tumors are one of the most challenging lesions of the spine to study and manage. Surgical resection techniques are often difficult due to the regional anatomy, in addition to tumor involvement of neural and structural elements. The surgical goals are influenced by tumor pathology but this can be made more complicated by a difficult diagnostic process. The authors present the rare entity of a sacral lipoma and the radiological and histological features which highlight this condition.

Case report: Laparoscopic approach in the treatment of presacral lipoma

Retrorectal lipoma, as well as other retrorectal tumours, is a relatively rare disorder. Retrorectal tumours accounted for 1 in 40,000 hospital admissions. We present a case of retrorectal lipoma, 15 cm × 10 cm × 8 cm in size, treated by the laparoscopic approach. The preoperative magnetic resonance imaging visualised a mass, 12 cm × 6.7 cm × 8.6 cm in diameter, in the retrorectal space, spreading toward the left obturator foramen. Surgery was indicated due to exclude malignant process certainly, because it is difficult to differentiate lipoma from low-grade liposarcoma on non invasive imaging. Laparoscopic extirpation of the tumour was performed. The overall operative time was 80 min. The diagnosis of lipoma was established on histological examination. The patient was discharged from hospital on the 2nd day after the surgery. We have found this minimally invasive operation to be an effective and well-tolerated treatment option, determined by the experience of the surgeon.

A systematic review of minimally invasive surgery for retrorectal tumors

Retrorectal tumors are rare tumors that require resection for symptoms, malignancy and potential malignant transformation. Traditional approaches have included laparotomy, perineal excision or a combination. Multiple minimally invasive techniques are available which have the potential to minimize morbidity and enhance recovery. We performed a systematic review of the literature to determine the feasibility and surgical outcomes of retrorectal tumors approached using minimally invasive surgical techniques. Publications in which adult patients (≥ 18 years) had a minimally invasive approach (laparoscopic or robotic) for resection of a primary retrorectal tumor were included. Data were collected on approach, preoperative investigation, size and sacral level of the tumor, operating time, length of stay, perioperative complications, margins and recurrence. Thirty-five articles which included a total of 82 patients met the inclusion criteria. The majority of patients were female (n = 65; 79.2%), with a mean age of 41.7 years (range 18-89 years). Seventy-three patients (89.0%) underwent laparoscopic or combined laparoscopic-perineal resection, and 9 (10.8%) had a robotic approach. The conversion rate was 5.5%. The overall 30-day morbidity rate was 15.7%, including 1 intraoperative rectal injury (1.2%). Ninety-five percent (n = 78) of the retrorectal tumors were benign. Median length of stay was 4 days for both laparoscopic and robotic groups, with ranges of 1-8 and 2-10 days, respectively. No tumor recurrence was noted during follow-up [median 28 months (range 5-71 months)]. A minimally invasive approach for the resection of retrorectal tumors is feasible in selected patients. Careful patient selection is necessary to avoid incomplete resection and higher morbidity than traditional approaches.

Retrorectal Tumors: A Comprehensive Literature Review

IMPORTANCE

Retrorectal tumors are rare lesions that comprise a multitude of histologic types. Reports are limited to small single-institution case series, and recommendations on the ideal surgical approaches are lacking.

OBJECTIVE

The purpose of the study was to provide a comprehensive review of the epidemiology, pathologic subtypes, surgical approaches, and clinical outcomes of retrorectal tumors.

EVIDENCE REVIEW

We conducted a review of the literature using PubMed and searched the reference lists of published studies.

RESULTS

A total of 341 studies comprising 1708 patients were included. Overall, 68 % of patients were female. The mean age was 44.6 ± 13.7 years. Of all patients, 1194 (70 %) had benign lesions, and 514 patients (30 %) had malignant tumors. Congenital tumors (60.5 %) were the most frequent histologic type. Other pathologic types were neurogenic tumors (14.8 %), osseous tumors (3.1 %), inflammatory tumors (2.6 %), and miscellaneous tumors (19.1 %). Biopsy was performed in 27 % of the patients. Of these patients, incorrect diagnoses occurred in 44 %. An anterior surgical approach (AA) was performed in 299 patients (35 %); a posterior approach (PA) was performed in 443 (52 %), and a combined approach (CA) was performed in 119 patients (14 %). The mean length of stay (LOS) of PA was 7 ± 5 days compared to 8 ± 7 days for AA and 11 ± 7 days for CA (p < 0.05). The overall morbidity rate was 13.2 %: 19.3 % associated with anterior approach, 7.2 % associated with posterior approach, and 24.7 % after a combined approach (p < 0.05). Overall postoperative recurrence rate was 21.6 %; 6.7 % after an anterior approach, 26.6 % after a posterior approach, and 28.6 % after a combined approach (p < 0.05). A minimally invasive approach (MIS) was employed in 83 patients. MIS provided shorter hospital stays than open surgery (4 ± 2 vs. 9 ± 7 days; p < 0.05). Differences in complication rate were 19.8 % in MIS and 12.2 % in open surgery and not statistically significant.

CONCLUSIONS AND RELEVANCE

Retrorectal tumors are most commonly benign in etiology, of a congenital nature, and have a female predominance. Complete surgical resection is the cornerstone of retrorectal tumor management. A minimal access surgery approach, when feasible, appears to be a safe option for the management of retrorectal tumors, with shorter operative time and length of stay.

Incidence and Operative Excision of Presacral Masses: An Institutional Analysis

Presacral masses are rare lesions that encompass a broad range of pathologic findings. Most presacral masses are benign. The aim of this study was to analyze the clinical presentation, pathology, and surgical treatment of presacral masses at a single academic institution over a decade. In this retrospective study, we reviewed all surgically excised presacral tumors between 2003 and 2013. Clinical and pathologic data were recorded. Thirteen patients had surgical excision of a presacral mass. The median age was 42 years (standard deviation ± 19.7) and average follow-up was 11.9 months (standard deviation ± 17.5). The majority of patients were symptomatic. Forty-six per cent (6/13) had sacral or rectal pain. Thirty-eight per cent (5/13) of patients had a palpable mass on digital rectal examination. Sixty-nine per cent of patients had an MRI, 84.6 per cent a CT, and 61.5 per cent multimodality imaging. Most presacral masses were benign (10/13,77%). Twenty-three per cent (3/13) were malignant. A majority were excised via posterior approach (9/13, 69%), but 31 per cent (4/13) required an anterior or combined approach. Presacral masses are rare, even at a high-volume tertiary care center. They are commonly evaluated with a multiple imaging modalities, are most likely benign, and can be excised via posterior approach.

Magnetic resonance imaging evaluation of non ovarian adnexal lesions

Differentiation of nonovarian from ovarian lesions is a diagnostic challenge. MRI (Magnetic Resonance Imaging) of the pelvis provides excellent tissue characterization and high contrast resolution, allowing for detailed evaluation of adnexal lesions. Salient MRI characteristics of predominantly cystic lesions and predominantly solid adnexal lesions are presented along with epidemiology and clinical presentation. Due to its excellent soft tissue resolution, MRI may be able to characterize indeterminate adnexal masses and aid the radiologist to arrive at the correct diagnosis, thus positively affect patient management.

Management of presacral tumors: Our experience with posterior approach

INTRODUCTION

Presacral tumors are a rare variety of space occupying lesions arising in the presacral space. Most of the tumors are congenital in origin. Due to obscure anatomic location, difficult surgical approach and etiological heterogeneity, tumors arising here pose a diagnostic and therapeutic challenge. We report our experience of 10 cases of presacral tumors with posterior approach being used in 6.

MATERIALS AND METHODS

A retrospective analysis was conducted on 10 cases of presacral tumors managed at our hospital during a period of 14 months (May 2013-July 2014). 9 cases were operated while one had advanced disease and was referred for palliative care. Complete en bloc excision of the mass was possible in 8 cases. Finally, presenting complaints, clinical diagnosis, surgical procedure and histopahological findings of the cases were studied.

RESULTS

All of our patients were females in the age group of 18-50 (mean 28.4) years. The pathological findings included schwannoma, leiomyosarcoma, hemangiopericytoma, neurofibroma, paraganglioma and rest were developmental cysts. 6 cases were managed using the posterior approach and rest by anterior approach. There was no major complication or mortality in the follow up.

CONCLUSION

Complete surgical excision remains the mainstay of therapy. Surgical approach depends upon the location, size, local invasion and surgical expertise of the surgeon. Benign tumors have a good prognosis while the prognosis in malignant tumors remains guarded due to difficulty in obtaining safe resection margins. Posterior approach is an attractive option for low lying, benign tumors that is more direct, with better exposure and quicker recovery.

Retrorectal/Presacral epidermoid cyst: report of a case

Although epidermal cysts are frequently observed throughout the body, they are rarely found in the retrorectal/presacral regions. Retrorectal epidermal cysts are congenital lesions of ectodermal origin and generally occur in women during the reproductive period. In this case report, a 47 year old female patient with 25 years of complaint of a mass extending from the perianal region to the retro-coccygeal region is discussed. A total mass excision with paracoccygeal incision was performed under spinal anesthesia. The histopathologic examination demonstrated an epidermal cyst. Correct diagnosis and appropriate treatment when first detected significantly decrease the recurrence and complication risks in all retrorectal tumors. Any mass should be completely removed in the treatment.

Pandora's box and retrorectal tumors in laparoscopy: A case report and review of the literature

INTRODUCTION

Retrorectal tumors are uncommon and the etiology diverse. Literature to define the preoperative diagnosis and plan the intraoperative management are uncommon.

PRESENTATION OF CASE

We describe a case of a 44 year old patient with a laparoscopic approach for the removal of a retrorectal tumor and emphasize on the preoperative diagnostics and the intraoperative, minimal invasive approach.

DISCUSSION

Especially because these tumors are rare and often an incidental finding in gynecologic surgery, it is important to know the various differential diagnoses and its consequences with the laparoscopic approach.

CONCLUSION

We suggest the laparoscopic approach in cases of retroperitoneal cysts of unknown origin is ideal also because anatomic structures, mostly nerves, can be easily spared.

Sacrococcygeal chordoma presenting as a retro rectal tumour

INTRODUCTION

Chordomas are rare, slow growing, locally destructive bone tumours arising from the notochord.

PRESENTATION OF CASE

Presenting a case of a 65 year old man, who presented with complaints of swelling on the right lower back for 1 year associated with pain. On, physical examination, a swelling measuring 5cm×4cm was noted in the lower back with posterior wall indentation on per rectal examination. MRI revealed a mass lesion involving the sacrum (s3-s4) and coccyx. FNAC showed features of a chroma. At surgery, we excised a mass from the retrorectal space and biopsy proved it to be a chondroid chordoma, a variant of chordoma.

DISCUSSION

Chordomas are solid malignant tumours that arise from vestiges of the foetal notochord. Common locations are the clivus and the sacrococcygeus region. Annual incidence of these tumours is 1 in one million. MRI is the imaging modality of choice. Prognosis improves based on the age, resected margins and postoperative treatment.

CONCLUSION

Here, we shall discuss the literature, variants, treatment and prognosis of this rare tumour.

The value of preoperative biopsy in the management of solid presacral tumors

BACKGROUND

Surgical decision making and the use of neoadjuvant therapy in the management of solid presacral tumors rely greatly on an accurate preoperative diagnosis. The utility of preoperative biopsy has been questioned because of potential complications and the increasing accuracy of modern imaging.

OBJECTIVE

The aim of this study was to analyze biopsy-related morbidity and to compare the accuracy of imaging versus biopsy in making a preoperative diagnosis.

DESIGN

This study is a retrospective review of all patients who underwent biopsy of presacral tumors at Mayo Clinic Rochester between 1990 and 2010. The demographics, pathology, complications of biopsy, and imaging were reviewed. Biopsy results and radiologic findings were matched with the final pathology and analyzed.

SETTINGS

This study was conducted at a tertiary care center.

PATIENTS

Adult patients with solid presacral tumors who underwent preoperative biopsy were evaluated.

MAIN OUTCOME MEASURES

The primary outcomes measured were the biopsy-related complications and the accuracy of preoperative imaging and biopsy in comparison with final pathology.

RESULTS

Seventy-six biopsies were performed in 73 patients. Fifty-six patients underwent percutaneous biopsies, 14 underwent open biopsies, and 3 underwent both. Biopsy-specific complications included 2 hematomas (1 open, 1 percutaneous). Preoperative biopsy correlated with the postoperative pathologic diagnosis in 63 patients (91%). Of the 6 solid presacral tumors diagnosed incorrectly on biopsy, 1 was falsely reported as benign. Sensitivity, specificity, and positive and negative predictive values of biopsy to detect malignant disease was 96%, 100%, 100%, and 98%. Ten of 35 patients (29%) with a definitive imaging diagnosis were given incorrect diagnoses. Sensitivity, specificity, and positive and negative predictive values of imaging to diagnose malignant disease was 83%, 81%, 83%, and 81%.

LIMITATIONS

This investigation was designed as a retrospective study.

CONCLUSION

Preoperative biopsy of presacral tumors is safe and highly concordant with postoperative pathology in comparison with imaging. Given the significant differences in therapeutic approach for benign versus malignant solid presacral tumors, as well as the current limitations of imaging, a percutaneous preoperative biopsy should be obtained to guide management decisions.

Local recurrence after intended curative excision of presacral lesions: causes and preventions

OBJECTIVE

This study was designed to explore causes for local recurrence of presacral lesions after intended curative surgery and discuss prevention strategies.

METHODS

Medical data of presacral lesions in our hospital from January 2001 to September 2009 were retrospectively studied, including preoperative examinations, intraoperative findings, and postoperative histopathologies.

RESULTS

Of 39 patients (29 women and 10 men) with presacral lesions, who ranged in age from 14 to 71 (mean, 39.56) years, 7 patients were diagnosed with recurrent presacral lesions on admission. Preoperative pelvic MRI, pelvic CT, and endorectal ultrasonography (ERUS) were performed in 23, 22, and 8 cases, respectively. MRI/CT showed that five cases had two coexisting lesions and three cases had lobulated or dumbbell shaped lesions, all of which were confirmed by intraoperative findings. ERUS suspected involvement of the rectal wall in three cases: adhesion to the rectal wall in two cases, and tumor invasion in the remaining case. During the operation, 26, 8, and 2 cases were resected by the transsacral, transabdominal, and combined abdominosacral approach, respectively. Four patients underwent simultaneous coccygectomy, and three patients received simultaneous resection of the sacrum and coccyx. Simultaneous partial resection of the invaded sigmoid colon or rectum was performed in two patients, respectively. By postoperative pathological examination, three cases were found to have ruptured cystic lesions, three had previous cyst rupture history, and five had infected lesions.

CONCLUSIONS

Presacral lesions are likely to be multiple, lobulated, infected, ruptured, and adhesive to the sacrococcyx and rectum, which contribute to the high local recurrence rate. Preoperative CT/MRI/ERUS and careful intraoperative exploration are required to direct surgical treatment and to reduce local recurrence. Optimal selection of surgical approach also is very important to reduce local recurrence. Presacral lesions attached to the sacrococcyx or rectum require simultaneous partial resection of the sacrococcyx or rectum to reduce local recurrence.

Long-term outcomes following en bloc resection for sacral tumor: a retrospective analysis of 93 cases

Sacral tumors are rare. Appropriate surgical resection is crucial to treat the disease while minimizing disease recurrence. We present the results of 93 patients with sacral tumors to analyze the long-term functional and oncological results of patients undergoing en bloc resection. The medical data between January 2003 and July 2010 was retrospectively reviewed. None of the 93 patients died intra- or postoperatively. Patients undergoing intralesional curettage (range, 6500-25,000 mL; mean, 13,500 mL) lost more blood than those patients with wide excision (range, 1000-8100 mL; mean, 3590 mL). Mean follow-up duration from the time of surgery until most recent clinic visit or death was 44.5 months (range, 6-105 months). This study is an educational tool regarding primary sacral tumors and provides evidence on the treatment. It presents results from a large group of patients with sacral tumor. After follow-up, we did not find that sacrificed nerve roots and surgical margins have an impact on the recurrence of the tumor. Patients undergoing intralesional curettage lost more blood than those patients with wide excision. Postoperative bladder/bowel dysfunction was more severe for patients with removal of S1 and S2.

Retrorectal tumors in adults: magnetic resonance imaging findings

AIM

To retrospectively evaluate the magnetic resonance imaging (MRI) features of adult retrorectal tumors and compare with histopathologic findings.

METHODS

MRI features of 21 patients with preoperative suspicion of retrorectal tumors were analyzed based on the histopathological and clinical data.

RESULTS

Fourteen benign cystic lesions appeared hypointense on T1-weighted images, and hyperintense on T2-weighted images with regular peripheral rim. Epidermoid or dermoid cysts were unilocular, and tailgut cysts were multilocular. Presence of intracystic intermediate signal intensity was observed in one case of tailgut cyst with a component of adenocarcinoma. Six solid tumors were malignant lesions and showed heterogeneous intensity on MRI. Mucinous adenocarcinomas showed high signal intensity on T2-weighted and mesh-like enhancing areas on fat-suppressed T2-weighted images. There was a fistula between the mass and anus with an internal opening in mucinous adenocarcinomas arising from anal fistula. Gastrointestinal stromal tumors displayed low signal intensity on T1-weighted images, and intermediate to high signal intensity on T2-weighted images. Central necrosis could be seen as a high signal on T2-weighted images.

CONCLUSION

MRI is a helpful technique to define the extent of the retrorectal tumor and its relationship to the surrounding structures, and also to demonstrate possible complications so as to choose the best surgical approach.

Presacral epidermoid cyst in a male: a case report and literature review

Presacral cysts are an uncommon entity most often found incidentally in women. These tumors can arise from any of the 1 or more cell lines present in the presacral space during embryogenesis. We present a case of a 46-year-old male patient who was found to have a well-circumscribed presacral mass on computed tomography (CT) scan, which was obtained for his complaint of vague lower back pain. He underwent transabdominal excision, and pathology revealed a presacral epidermoid cyst filled with keratinaceous material. Presacral cysts are rare, especially in male patients. These tumors originate from an embryologic error during development. Because of the risk of infection and malignant transformation, they should be excised. Surgical options include a posterior approach, transabdominal approach, combined approach, or transrectal approach. The approach is dictated by the tumor size, location, presence of malignancy, and bony invasion.

Giant sacral schwannoma: a report of six cases

Sacral and presacral schwannomas are often found incidentally, because they present with vague symptoms or symptomless. Schwannoma occurring in this area occasionally presents with enormous dimensions, known as a giant schwannoma. The tumor removal is a surgical challenge due to the difficult approach and abundant vascularity. The aim of this study is to review cases of giant sacral schwannomas focusing the surgical management and outcome. Six patients with sacral and presacral schwannoma were treated surgically. The patients included two males and four females, and the mean age was 47.8 years. All patients experienced pain at the time of presentation. The tumors were classified as intraosseous type in one case, dumb-bell type in four cases, and retroperitoneal type in one case. The tumors were removed with a piecemeal subtotal excision in three patients, a partial excision in two patients, and enucleation in one patient. The surgeries were performed by the combination of an anterior and posterior approach in three patients, a posterior approach in two patients, and an anterior approach in one patient. The mean surgical time was 7.8 hrs, and the mean blood loss was 2572 g. The tumor recurred in one patient after the partial excision and was removed completely in a second surgery. No patient, including the patient who underwent the second surgery, presented with pain and obvious neurological deficit at the final follow-up. The surgical treatment of the giant sacral schwannoma with a piecemeal subtotal excision can achieve a good outcome, avoiding unnecessary neurological deficit.

A case report of a giant presacral cystic schwannoma with sigmoid megacolon

Schwannomas are peripheral nerve sheath tumours with a slow growth rate. Giant sacral schwannoma with anterior cortex erosion and associated intrapelvic extension are uncommon. Though they tend to be large when initially found, most Giant schwannomas are clinically asymptomatic. The tumour appears heterogenous due to long standing degeneration. Herein, we present a case of a large purely cystic presacral schwannoma in a patient with poliomyelitis, which has displaced adjacent organs including urinary bladder and sigmoid colon, with an initial presentation of constipation. The tumour was partially excised and diagnosis was confirmed by histo-pathology and immunohistochemistry.

Polyaxial screws for lumbo-iliac fixation after sacral tumor resection: experience with a new technique for an old surgical problem

BACKGROUND

Although numerous reports have been published about various methods for reconstruction after sacrectomies, there are still biomechanical and technical dilemmas that are unaddressed. This report describes the experience at authors' institution of five cases in which polyaxial pedicle screws construct has been successfully used for lumbo-iliac fixation after sacral tumor resection.

METHODS

Five cases of sacral tumors, two of Ewing's sarcoma and three of giant cell tumor (GCT) underwent surgical resection and then reconstruction was done with hardware using vertical rods placed alongside the spine bilaterally, transfixing monoaxial and polyaxial pedicle screws in lower lumbar levels and polyaxial screws into the ilium bilaterally. Cross links were also used to connect the two vertical members, thus enhancing biomechanical stability of the construct. Use of autologous bone grafts was relied upon to fill the gap created by sacral resection.

RESULTS

No instrumentation failure was noted and the continuity of the spine and pelvis was well established with the instrumentation and auto grafts. In follow up of these patients (1-3 years), no complications were seen.

CONCLUSION

Polyaxial pedicle screws fixation is an effective technique to transmit axial load from spine to the appendicular bone and can be used safely in patients in whom sacral integrity is compromised after surgical resection. However, the long term benefits of this technique need to be evaluated.

Retrorectal epidermoid cyst--a rare entity: the effectiveness of a transperineal posterior approach

BACKGROUND

Presacral cysts are rare presacral tumours. The ideal treatment is a matter of debate.

METHODS

We report the case of a 39-year-old woman referred to our institution for a presacral mass, casually diagnosed during a pelvic ultrasound examination. Ano-rectal examination and MRI revealed the presence of a mass (53 x 52 x 54 mm) in the retrorectal space, located between the right pyriform muscle and the lateral rectal wall, without signs of invasion of the surrounding structures. We performed the intervention with a transperineal approach in the jack-knife position.

RESULTS

Operating time was 20 minutes. During the postoperative period no complication was observed. The patient was discharged in good general condition. No complication occurred during 48 months follow-up.

CONCLUSION

We chose this approach, because, although alternative approaches are described in the literature, they are based on a small number of patients, even if showing encouraging results. We found the posterior procedure safe, feasible and effective.

Algorithms for the surgical management of retrorectal tumours

BACKGROUND

Retrorectal tumours are uncommon and may present a surgical challenge. The aim of this study was to identify a surgical strategy based on information gained from the multidisciplinary management of retrorectal tumours.

METHODS

This was a retrospective review of 27 patients who had resection of retrorectal tumours between 1998 and 2006.

RESULTS

The tumours included ten cystic lesions, two mature teratomas, four chordomas, seven neurogenic tumours, two sarcomas, one angiomyxoma and one gastrointestinal stromal tumour. The diagnosis was suggested initially by non-specific clinical presentation and palpation of a retrorectal mass on examination (16 patients), pelvic imaging (six), obstructed labour (one), recurrent pilonidal sinus (one), recurrent perianal sepsis (one) and return of symptoms after resection (two). Magnetic resonance imaging (MRI) confirmed the diagnosis and enabled surgical planning. The operative approach was perineal (12 patients), abdominal (11) or combined (four). Factors that influenced the operative approach were tumour position, its neoplastic nature, involvement of the pelvic sidewall or pelvic viscera, and size. The retrorectal tumour recurred in three patients.

CONCLUSION

A successful multidisciplinary surgical strategy, based on preoperative localization by MRI, has been developed for the treatment of retrorectal tumours.

Neurological manifestation of sacral tumors

An extensive analysis of the existing literature concerning sacral tumors was conducted to characterize their clinical manifestations. Although certain specific manifestations can be attributed to some of the tumor types, a more general pattern of clinical presentation of an expansive sacral lesion can be elaborated. Local pain with or without pseudoradicular or radicular radiation is the most frequent initial symptom and is usually followed by the manifestation of a lumbosacral sensorimotor deficit; bladder/bowel and/or sexual dysfunction appear throughout the natural course of disease.

Nerve sheath tumors involving the sacrum. Case report and classification scheme

Nerve sheath tumors that involve the sacrum are rare. Delayed presentation is common because of their slow-growing nature, the permissive surrounding anatomical environment, and nonspecific symptoms. Consequently, these tumors are usually of considerable size at the time of diagnosis. The authors discuss a case of a sacral nerve sheath tumor. They also propose a classification scheme for these tumors based on their location with respect to the sacrum into three types (Types I-III). Type I tumors are confined to the sacrum; Type II originate within the sacrum but then locally metastasize through the anterior and posterior sacral walls into the presacral and subcutaneous spaces, respectively; and Type III are located primarily in the presacral/retroperitoneal area. The overwhelming majority of sacral nerve sheath tumors are schwannomas. Neurofibromas and malignant nerve sheath tumors are exceedingly rare. Regardless of their histological features, the goal of treatment is complete excision. Adjuvant radiotherapy may be used in patients in whom resection was subtotal. Approaches to the sacrum can generally be classified as anterior or posterior. Type I tumors may be resected via a posterior approach alone, Type III may require an anterior approach, and Type II tumors usually require combined anterior-posterior surgery.

Presacral tumors: a practical classification and treatment of a unique and heterogeneous group of diseases

BACKGROUND

Presacral tumors are a rare and diverse group of diseases that originate from the different tissues that comprise the potential presacral space. Because of their relative rarity, confusion exists regarding their clinical presentation, natural history, and treatment. The aim of this study is to describe a single institution's experience with the management of presacral tumors and to suggest a practical method of classification.

METHODS

Records of all patients who underwent operation for presacral tumors from the years 1991 to 2001 were reviewed. Clinical, pathologic, treatment, and outcome variables were evaluated.

RESULTS

Forty-two patients were included in the study and were divided into 4 groups according to lesion pathology: benign congenital (n = 12), malignant congenital (n = 9), benign acquired (n = 9), and malignant acquired (n = 12). Symptoms were nonspecific, and 26% of the cases were completely asymptomatic. Diagnosis was made with rectal examination and confirmed with pelvic computerized tomographic scan. Surgical approach varied among the different groups, with the posterior approach used mainly for congenital tumors and the anterior approach for acquired. Complete surgical resection of the tumor was obtained in all cases of benign tumors and in 76% of malignant tumors. No postoperative mortality was seen, and complications occurred in 36% (15/42); most were reversible. None of the patients with benign tumors had recurrences, and all are alive at this time. The survival rate of patients with malignant tumors was significantly improved when complete resection was possible.

CONCLUSION

Classification of presacral tumors into congenital versus acquired and benign versus malignant is simple and efficient. Treatment is complete surgical resection, which can be performed safely with low morbidity and no mortality.

[Developmental cysts in the presacral space in adults]

Localization of primitive neoplasms the retrorectal or presacral space is rare in adults as most of these tumors are congenital. Developmental cysts are included within the group of retrorectal congenital cystic neoplasms and are slowly-progressive cystic neoplasms. Because of their localization, their manifestation is delayed, despite their congenital nature. Their form of presentation is varied and is caused by compression of the surrounding organs or infectious complications of the cyst.We describe two cases of presacral developmental cysts (one epidermoid cyst and one dermoid cyst) that presented in adulthood. Special attention is paid to the classification, and diagnostic and therapeutic problems of these tumors.

Tailgut cyst associated with a pilonidal sinus: an unusual case and a review

Tailgut cysts are rare congenital abnormalities in the retrocaecal/presacral region. Clinical diagnosis is difficult and delayed and they can present in childhood and adult life with a variety of clinical symptoms and complications. Differential diagnoses include, rectal duplication cysts, cystic teratoma, epidermal cyst, anal gland cyst and anal gland carcinoma. Magnetic resonance imaging has recently become the modality of choice to image these cysts. Although Tailgut cysts rarely undergo malignant transformation, early surgical resection is presently considered the treatment of choice. Here we report the case of a 34 year old gentleman with a Tailgut cyst associated with a Pilonidal sinus, and review of the literature. We believe that the high incidence of complications associated with operations in the presacral region should be weighed against the generally benign course of these lesions, especially with the quality of modern imaging technology.

Presacral Cysts: Transrectal Excision in Select Patients

Fourteen patients presenting with presacral cystic lesions were managed over a 20-year period. Retrospective review identified 12 females and 2 males. Fifty-seven per cent were symptomatic at diagnosis. Forty-three per cent presented with pain; half of these patients had infected cysts. All lesions were palpable on digital rectal exam. Computed tomography identified the cyst in all seven patients in which it was performed. The transrectal approach was used for cyst excision in ten patients. One patient had transrectal drainage and wall biopsy only. Three patients underwent posterior parasacral excision. Pathologic review demonstrated four dermoid cysts, four epidermoid cysts, four cyst hamartomas, and two benign teratomas. One cyst hamartoma had a focus of invasive adenocarcinoma. Two complications occurred. There were no deaths. Follow-up averaged 39 months, at which time there were no recurrences. Developmental cysts are the most common presacral tumors. Excision is recommended, and the transrectal approach may be used in select patients with low morbidity and minimal recurrence.

Anal duct/gland cyst: report of a case and review of the literature

PURPOSE

The purpose of this communication is to report a case of anal duct/gland cyst and review cases of perianal and presacrococcygeal mucus-secreting cysts reported in the literature with emphasis on their histopathologic features.

METHOD

Our patient presented with coccydynia. An extraluminal retrorectal tumor was felt on rectal examination. A computerized tomographic scan demonstrated a presacrococcygeal mass closely related to the anorectal junction. The tumor and the coccyx were excised using a posterior approach. Cases of perianal and presacrococcygeal mucus-secreting cysts reported in the literature were reviewed.

RESULTS

In our case, the tumor proved to be an anal duct/gland cyst. Some of the reported cases of presacrococcygeal glandular cysts had histopathologic features suggestive of anal duct/gland origin.

CONCLUSION

Diagnosis of anal duct/gland cyst is based on routine histologic features, histochemical characteristics of mucus, and/or the presence of a communication with an anal duct or crypt. Based on these criteria, some of the reported cases of mucus-secreting cysts occurring around the anorectum may prove to be anal duct/gland in origin.

Tailgut cysts: CT and MR findings

Two cases of tailgut cysts are reported. These lesions are rare and congenital, lying anterior to the sacrum and posterior to the rectum. CT findings are described. For one patient MR evidence is also presented. In a second case, the mass showed malignant behavior with local recurrence.

Presacral tumors: case report, review of the literature

A case report involving a 42-year-old female is presented. The symptoms and objective physical findings manifest a diagnostic problem. The anatomical site of the tumor depends on the consideration of the numerous possible etiological factors, and one of which is the embryologic knowledge of the region involved. The clinical, pathological, and embryologic features of a case of presacral tumor is presented.

Presacral epidermal cyst found in an adult male with a high CEA content: report of an unusual case

A 63-year-old Japanese man presented with constipation, having noticed flat stools for several years. Digital examination of the rectum, followed by barium enema, colono-fiberscopy, computed tomography (CT), and magnetic resonance imaging (MRI) revealed an oval mass located between the retrorectal and presacral space without any mucosal lesion. This mass had narrowed the rectal lumen by compressing the rectum anteriorly. Although the plasma levels of the tumor markers were within the normal range, those of the tumor contents were elevated with a carcinoembryonic antigen (CEA) of 118 ng/mL, while the alpha-fetoprotein (AFP) value was 1 ng/mL. The tumor was completely extirpated through an abdominal incision, and there has been no evidence of recurrence thus far. Histological examination showed that the tumor wall was made of keratinized stratified squamous epithelium without any cutaneous adnexal structure, and hence it was diagnosed as an epidermal cyst. CEA was identified in these benign epithelial cells by immunoperoxidase staining using a monoclonal antibody. To the best of our knowledge, there have been only four other cases with a presacral epidermal cyst documented in the Japanese literature, all of whom were female. Our patient is the first reported case of an adult male with a presacral epidermal cyst.

Our approach to the management of congenital presacral tumors in adults

This study reviews the recent overall experience in one colorectal surgery department with congenital presacral tumors in adults. 24 patients greater than 21 years of age, who underwent curative resection between January 1980 and August 1992, were analyzed retrospectively. The growths were divided into two broad categories: developmental cysts and chordomas. The most common presenting symptom was pain (19/24). A preoperative evaluation regimen is outlined in the study and includes use of CT scanning, MRI imaging, and possibly the use of endoluminal ultrasound to document the relationship of presacral tumors to pelvic viscera. There were 20 developmental cysts and 4 chordomas treated in this series. 15 of 19 developmental cysts were excised by a posterior approach alone, 2 were excised by an anterior approach alone, and 3 were treated by a combined approach. Trans-sacral excision was carried out in 4 patients with developmental cysts. One chordoma was resected posteriorly and the other 3 through a combined anterior and posterior approach. Three recurrences were diagnosed after excision of developmental cysts at 8, 18, and 41 months postoperatively. Recurrence occurred in 3 of 4 chordoma patients after 25, 32, and 55 months. Reexcision was carried out in all patients. None of the developmental cyst cases developed a second recurrence but 2 of the 3 chordoma patients have recurred, but have undergone local irradiation, which has controlled their disease.(ABSTRACT TRUNCATED AT 250 WORDS)