Retrorectal tumours: optimization of surgical approach and outcome

The management of retrorectal tumors - a single-center analysis of 21 cases and overview of the literature

AIM

Retrorectal tumors are rare and heterogeneous. They are often asymptomatic or present with nonspecific symptoms, making management challenging. This study examines the diagnosis and treatment of retrorectal tumors.

METHODS

Between 2002 and 2022, 21 patients with retrorectal tumors were treated in our department. We analyzed patient characteristics, diagnosis and treatment modalities retrospectively. Additionally, a literature review (2002-2023, "retrorectal tumors" and "presacral tumors", 20 or more cases included) was performed.

RESULTS

Of the 21 patients (median age 54 years, 62% female), 17 patients (81%) suffered from benign lesions and 4 (19%) from malignant lesions. Symptoms were mostly nonspecific, with pain being the most common (11/21 (52%)). Diagnosis was incidental in eight cases. Magnetic resonance imaging was performed in 20 (95%) and biopsy was obtained in 10 (48%). Twenty patients underwent surgery, mostly via a posterior approach (14/20 (70%)). At a mean follow-up of 42 months (median 10 months, range 1-166 months), the local recurrence rate was 19%. There was no mortality. Our Pubmed search identified 39 publications.

CONCLUSION

Our data confirms the significant heterogeneity of retrorectal tumors, which poses a challenge to management, especially considering the often nonspecific symptoms. Regarding diagnosis and treatment, our data highlights the importance of MRI and surgical resection. In particular a malignancy rate of almost 20% warrants a surgical resection in case of the findings of a retrorectal tumour. A local recurrence rate of 19% supports the need for follow up.

Robotic resection of presacral tumors

BACKGROUND

Presacral tumors are a rare entity typically treated with an open surgical approach. A limited number of minimally invasive resections have been described. The aim of the study is to evaluate the safety and efficacy of roboticresection of presacral tumors.

METHODS

This is a retrospective single system analysis, conducted at a quaternary referral academic healthcare system, and included all patients who underwent a robotic excision of a presacral tumor between 2015 and 2023. Outcomes of interest were operative time, estimated blood loss, complications, length of stay, margin status, and recurrence rates.

RESULTS

Sixteen patients (11 females and 5 males) were included. The median age of the cohort was 51 years (range 25-69 years). The median operative time was 197 min (range 98-802 min). The median estimated blood loss was 40 ml, ranging from 0 to 1800 ml, with one patient experiencing conversion to open surgery after uncontrolled hemorrhage. Urinary retention was the only postoperative complication that occurred in three patients (19%) and was solved within 30 days in all cases. The median length of stay was one day (range 1-6 days). The median follow-up was 6.7 months (range 1-110 months). All tumors were excised with appropriate margins, but one benign and one malignant tumor recurred (12.5%). Ten tumors were classified as congenital (one was malignant), two were mesenchymal (both malignant), and five were miscellaneous (one malignant).

CONCLUSIONS

Robotic resection of select presacral pathology is feasible and safe. Further studies must be conducted to determine complication rates, outcomes, and long-term safety profiles.

Factors affecting operative morbidity and long-term outcomes in patients undergoing surgery for presacral tumours: a multicentric cohort study from the Turkish Collaborative Group for Quality Improvement in Colorectal and Pelvic Surgery

AIM

Data regarding the operative management of presacral tumours present various dilemmas due to their rarity and heterogeneous nature. The aim of this study was to evaluate the management strategy, factors associated with operative morbidity and long-term postoperative outcomes in a large group of patients undergoing surgery for presacral tumours.

METHOD

This study was designed as a multicentre retrospective cohort study. Records of patients who underwent surgery for presacral tumours at 10 tertiary colorectal centres between 1996 and 2017 were evaluated.

RESULTS

One hundred and twenty seven patients (44 men) with a mean age of 46 years and body mass index of 27 kg/m2 were included. Fifty eight per cent of the patients had low sacral lesions (below S3). The operative approaches were transabdominal (17%), transsacral (65%) and abdominosacral (17%). The postoperative morbidity was 19%. Thirty per cent of the patients had a malignant tumour. Longer duration of symptoms (p = 0.001), higher American Society of Anesthesiologists score (p = 0.01), abdominosacral operations (p = 0.0001) and presacral tumours located above S3 (p = 0.004) were associated with an increased risk of postoperative morbidity. Overall long-term postoperative recurrence and mortality were 6% and 5%, respectively, within a 3-year mean follow-up period in patients with presacral malignant tumours.

CONCLUSION

Reduced physical condition, omission of symptoms prior to surgery, combined resections and high sacral tumours are the risk factors associated with postoperative complications in patients undergoing surgery for presacral tumours. Meticulous planning of the operation and intensified perioperative care may improve the outcomes in high-risk patients.

Surgical Management of Presacral Tumors: Report of 5 Cases With Video Vignette of Laparoscopic Removal

BACKGROUND

Cystic tumors in the presacral space represent a rare pathology. In case of symptoms, but particularly due to the danger of malignant degeneration, surgical removal is indicated. Due to the complex position in the pelvis with its proximity to important anatomic structures, the choice of the surgical approach is decisive.

METHODS

To present an overview of the recent knowledge of presacral tumors, a PubMed-based literature review was performed. Subsequently, we present 5 cases where different surgical strategies were evaluated including a video of a laparoscopic removal.

RESULTS

Presacral tumors can be of different histopathologic origins. Complete surgical excision is the treatment of choice, with open abdominal, open abdominoperineal, and posterior accesses available, as well as minimally invasive techniques.

CONCLUSION

Laparoscopic resection of presacral tumors is a well-suitable option, but the decision must always be made individually.

Primary malignant tumours and malignant transformation of cysts in the retrorectal space: MRI diagnosis and treatment outcomes

BACKGROUND

There are no clear guidelines for the diagnosis and treatment of malignant retrorectal tumours. The purpose of this study was to increase preoperative diagnostic knowledge and to describe the outcomes of treatment for these patients.

METHODS

This retrospective study was conducted on patients who underwent complete retrorectal tumour resection between May 2006 and July 2018, and had confirmed post-operative pathology reports. Demographic and clinical data (including imaging, perioperative, pathological, and prognostic data) were collected and analysed.

RESULTS

Malignant lesions were identified in 15 (9 [60%], female) patients. The median age of the patients was 59 years (range, 34-72 years). Primary malignant tumours were identified in seven patients with solid tumours, in which gastrointestinal stromal tumours accounted for 71.4% (five of seven) and the remainder were chordoma or mucinous adenocarcinoma. Malignant transformation of cysts occurred in another eight patients with heterogeneous tumours, while histopathological features were present in 75% (six of eight) of patients with mucinous adenocarcinoma, and the remainder were squamous-cell carcinoma or neuroendocrine tumour (Grade 2). The malignant characteristics of the solid portions observed using magnetic resonance imaging (MRI) were as follows: the cyst wall of the tumour was irregularly thickened; the surface was convex or lobed; the solid tumour had no capsule, or the capsule was destroyed; and the surface had a gyrus-like morphology. At a median follow-up time of 52 months (range, 13-100 months), the overall recurrence-free survival rate was 40.0% and the survival rate was 46.7%.

CONCLUSION

Some MRI features can be used to distinguish malignant retrorectal tumours from benign retrorectal tumours. The survival rate of patients with malignant retrorectal tumours is poor.

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.

Long-term surgical outcomes after resection of presacral tumours and risk factors associated with recurrence

AIM

The incidence of presacral tumours is low and pertinent data on the management and outcomes after surgery are sparse. The aim of this study was to identify the risk factors for recurrence in patients with presacral tumours undergoing surgery at our institution.

METHOD

Patients undergoing resection of a presacral tumour between 2009 and 2019 were identified from a prospectively maintained database. Demographics, clinicopathological features, preoperative imaging, operative details, morbidity, mortality, recurrence and survival were investigated.

RESULTS

A total of 122 patients were identified. There were 95 women (77.9%) and the median age was 34 years. The most common presenting symptoms included pelvic pain (n = 60, 49.2%) and recurrent abscesses or fistulas (n = 40, 32.8%). The accuracy of preoperative magnetic resonance imaging (MRI) in distinguishing malignant from benign tumours was 93.9%. Six patients underwent three-dimensional computed tomography angiography (3D-CTA) and preoperative interventional embolization. Procedures were performed using transabdominal (n = 9), posterior (n = 99) and combined abdominal and posterior (n = 14) approaches. There were 21 (17.2%) malignant and 101 (82.8%) benign tumours. The local recurrence rate was 33.3% for malignant tumours and 9.9% for benign tumours. Multivariate analysis revealed that recurrence of malignant tumours was associated with R1 resection while recurrence of benign tumours was associated with secondary resections and intraoperative lesion rupture.

CONCLUSION

Presacral tumours continue to be a diagnostic and therapeutic challenge. A multidisciplinary team, informed by modern imaging modalities, is essential for the management of presacral tumours.

Surgical Management of Retrorectal Tumors: A French Multicentric Experience of 270 Consecutives Cases

OBJECTIVE

To report the largest multicentric experience on surgical management of retrorectal tumors (RRT).

SUMMARY BACKGROUND DATA

Literature data on RRT is limited. There is no consensus concerning the best surgical approach for the management of RRT.

METHODS

Patients operated for RRT in 18 academic French centers were retrospectively included (2000-2019).

RESULTS

270 patients were included. Surgery was performed through abdominal (n=72, 27%), bottom (n=190, 70%) or combined approach (n=8, 3%). Abdominal approach was laparoscopic in 53/72 (74%) and bottom approach was a Kraske modified procedures in 169/190 (89%) patients. In laparoscopic abdominal group, tumors were more frequently symptomatic (37/53, 70% vs 88/169, 52%, p=0.02), larger (mean diameter = 60.5 ± 24 (range, 13-107) vs 51 ± 26 (20-105) mm, p=0.02) and located above S3 vertebra (n=3/42, 7% vs 0, p=0.001) than those from Kraske modified group. Laparoscopy was associated with a higher risk of postoperative ileus (n=4/53, 7.5% vs 0%, p=0.002) and rectal fistula (n=3/53, 6% vs 0%, p=0.01) but less wound abscess (n=1/53, 2% vs 24/169, 14%, p=0.02) than Kraske modified procedures. RRT was malignant in 8%. After a mean follow up of 27 ±39 (1-221) months, local recurrence was noted in 8% of the patients. After surgery, chronic pain was observed in 17% of the patients without significant difference between the 2 groups (15/74, 20% vs 3/30, 10%; p=0.3).

CONCLUSIONS

Both laparoscopic and Kraske modified approaches can be used for surgical treatment of RRT (according to their location and their size), with similar long-term results.

Retrorectal tumors: Case report and review of literature

BACKGROUND

Retrorectal tumors are rare diseases and they can be challenging to diagnose and to manage. Usually they have a slow growth and they are asymptomatic. When present, symptoms depends on the dimensions of the tumor and their position. Inside the retrorectal space may develope a wide variety of benign and malignant masses.

CASE REPORT

A 70-years-old, obese, female patient was admitted to our hospital referring pelvic and lower-back pain for six months. The retrorectal mass was incidentally detected on imaging, and treated with a modified Kraske procedure.
Pathological examination revealed a rare retrorectal epidermoid cyst. We also reviewed the informations present in the scientific literature about the incidence, diagnosis and treatment options of retrorectal tumors.

CONCLUSIONS

Even though the rarity and heterogeneity of these tumors, we agree with literature that their surgical management is mandatory in order to achieve a definitive diagnosis and to avoid complications including malignant transformation. The surgical approach should be tailored for each patient and according to tumor's features.

Clinical management of 52 consecutive retro-rectal tumours treated at a tertiary referral centre

AIM

The aim of this single-institution study was to analyse the diagnostic methods, preoperative work-up and outcomes of 52 retro-rectal tumours.

METHOD

All patients treated for retro-rectal tumours from 2012 to 2017 were included.

RESULTS

Out of 52 patients, 40 (77%) were women. The median age of patients at the time of surgery was 43 (19-76) years, and 30 (58%) were asymptomatic at the time of diagnosis. All tumours were visible on magnetic resonance imaging (MRI) prior to surgery. The sensitivity and specificity for predicting malignancy on preoperative imaging for retro-rectal tumours were 25% and 98%, respectively. Forty-four procedures (85%) were performed using the perineal approach. The median hospital stay was 3 (1-18) days. There was no 30-day postoperative mortality. Eleven (21%) patients developed postoperative complications, mostly surgical site infections. Twenty-nine tumours (56%) were benign tailgut cysts. Four (8%) tumours were malignant and were considered to be removed with a tumour-free resection margin. Local recurrent disease was detected on MRI in 14 (27%) patients at a median of 1.05 (range 0.78-1.77) years after primary surgery. Only the multi-lobular shape of the tumour was found to be an independent risk factor for recurrence (P = 0.030).

CONCLUSION

A preoperative MRI is mandatory in order to plan the surgical strategy for retro-rectal tumours. Symptomatic, solid, large tumours should be removed because of the risk of malignancy. Minor cystic lesions with thin walls as well as asymptomatic recurrences of benign tumours are suitable to be followed conservatively.

Retrorectal tumor: a single-center 10-years' experience

Purpose

Retrorectal tumors (RTs) are a rare incidence and recommendations on the ideal surgical approaches are lacking. This study aimed to evaluate outcomes and follow-up results of patients undergoing excision of RTs at our institution.

Methods

A retrospective review was conducted for undergoing surgery for RT between January 2009 and January 2019. Demographic characteristics, presenting symptoms, preoperative diagnostic tests, surgical procedures, histopathological results, intraoperative and postoperative complications, postoperative hospital stay, postoperative 30-day mortality, 90-day unplanned readmission rate, and long-term outcomes were evaluated.

Results

Twenty patients with a mean age of 48.3 ± 14.2 were analyzed. The most common presenting complaint was perineal pain (35.0%). Magnetic resonance imaging and computed tomography was preferred in 18 and 2 patients, respectively. Tumor localization was below the level of the third sacral vertebrae in 14 patients for whom the posterior surgical approach was used. No postoperative mortality was recorded at the end of follow-up of 53.8 ± 40 months. Mean length of postoperative hospital stay was 8.6 ± 9.4 days. Ten percent of the patients had unplanned hospital readmission within 90 days after discharge. Recurrence developed in 1 patient, for whom pathology were reported as chordoma.

Conclusion

RT should be managed by a multidisciplinary team given the complexity and heterogeneity of these tumors despite the fact that the majority are benign. A good understanding of pelvic anatomy and characterization of lesions through detailed radiological imaging is crucial to optimize surgical planning. Complete surgical resection is key for prolonged disease-free and overall survival of patients diagnosed with RTs.

Retrorectal Tumors in Adults: A 10-Year Retrospective Study

Due to the rarity and large diversity of the primary retrorectal tumors (RTs), the diagnoses are often difficult and they can be misdiagnosed. We present our experience in light of scarce information available on the clinical manifestations of RTs. The retrospective study included 17 patients diagnosed as RTs between January 2004 and January 2014. Demographic characteristics, length of symptoms, clinical findings, diagnostic methods, evaluations on the treatment procedures and postoperative periods, pathology, complications, and length of hospital stay were recorded. A mean of 1.7 of patients were diagnosed with RTs annually in our hospital. Patients comprised 12 females and 5 males. Pain and discomfort were the most common symptoms at presentation. All the lesions were evaluated by using magnetic resonance imaging (MRI) and computed tomography (CT), and all the patients were treated operatively. Based on the preoperative MRI or CT findings, an anterior approach was performed in 7 patients, a posterior approach in 6 patients, and combined approach in 4 patients. Mean size of tumors was 9.2 ± 4.3 cm. Epidermoid cyst (n = 8) was the most common tumor. Except for 1 case of liposarcoma, 16 tumors were confirmed to be of benign nature in histologic examination. Mean length of hospital stay 12.4 ± 6.8 days. Retrorectal tumors are heterogeneous and lead to diagnostic difficulties. A high index of clinical suspicion is needed for diagnosis. Preoperative imaging may be helpful in determining the course of treatment. Total excision of a retrorectal tumor may alleviate pressure symptoms and confirm the diagnosis.

Tumors of the Ischiorectal Fossa: A Single-Institution Experience

BACKGROUND

Ischiorectal fossa tumors are rare.

OBJECTIVE

This study reviews a single institution's series of ischiorectal tumors with comparison against presacral tumors and assesses the utility of preoperative biopsy and angioembolization.

DESIGN

This is a retrospective study.

SETTINGS

This study was conducted at a quaternary referral center.

PATIENTS

All patients with ischiorectal tumor treated between February 1995 and April 2017 were retrospectively reviewed. Tumors extending secondarily into the ischiorectal fossa and inflammatory pathologies were excluded.

INTERVENTIONS

Preoperative biopsy, neoadjuvant therapy, angioembolization, and surgical excision of these tumors were reviewed.

MAIN OUTCOME MEASURES

Demographic, perioperative, pathological, and oncologic outcomes were evaluated.

RESULTS

Twenty-four patients (15 female; median age 54) were identified. Two-thirds were symptomatic. Forty-six percent had a palpable mass. All patients had CT and/or MRI. Fifty percent had a preoperative biopsy, of which 83% were diagnostic, and management was altered in 50%. All patients underwent surgical excision. Fifty-five percent had local excision, 38% had radical pelvic excision, and 8% had total mesorectal excision. Two patients had preoperative angioembolization. Both had successful R0 local excision. Morbidity occurred in 25%, with 1 major complication. There was no 30-day mortality. Histopathology demonstrated 17 soft tissue tumors (3 malignant), 2 GI stromal tumors, 1 neuroendocrine tumor, 1 Merkel cell carcinoma, 1 basaloid carcinoma, 1 epidermal cyst, and 1 lipoma. R0 resection was achieved in 75%. All patients were alive after a median follow-up of 33 months. Four patients developed recurrence at a median 10 months postoperatively. All recurrences were malignant, and 75% had had a R1 resection.

LIMITATIONS

This study is limited by its small numbers. The quaternary institution source may introduce bias.

CONCLUSIONS

Ischiorectal fossa tumors are heterogeneous and more likely to be malignant than presacral tumors. Biopsy can be useful if a malignant diagnosis is suspected and changes management in 50% of cases. Preoperative embolization may be useful for large vascular tumors. R0 resection is important to minimize recurrence. See Video Abstract at http://links.lww.com/DCR/A779.

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.

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.

Colorectal Stenting for Obstruction due to Retrorectal Tumor in a Patient Unsuitable for Surgery

Fund of knowledge on palliative treatment of unresectable retrorectal tumors is scare. Here, we reported a non-surgical treatment of a huge retrorectal malignant tumor in an aged and debilitated patient complicated with colorectal obstruction. An 86-year-old male with severe comorbidities was admitted with acute colorectal obstruction owing to an untreated retrorectal malign epithelial tumor. There was a lobulated retrorectal mass, 20 cm × 15 cm at largest size, extending to the superior iliac bifurcation level, caused an obstruction of the rectal lumen. He was not suitable for surgical excision because of the severe comorbidities. Rectal obstruction was palliated by two self-expandable metallic stents. He tolerated the procedures well and post-procedural course was uneventful. After four months, stents were patent and the patient was continent. Stenting for colorectal obstruction owing to a retrorectal tumor can be feasible in patients who are not suitable for surgery (aged, debilitated, advanced tumor). It avoided the surgical trauma to a high-risk patient and ensured the continuity of continence. As far as we know, this was the first report on colorectal stenting for a retrorectal tumor.

Magnetic Resonance Imaging of Pelvic Masses: A Compartmental Approach

Magnetic resonance imaging (MRI) is often "one stop shop" for evaluating female pelvic masses that helps in diagnosis, staging, and restaging of these tumors. A pelvic mass can arise from any tissue present within the pelvis. Although most masses in the female pelvis arise from the reproductive organs, masses may also arise from the gastrointestinal tract, urinary system, adjacent soft tissues, peritoneum, etc. It may not always be possible to determine the site of origin or distinguish these masses based on imaging characteristics. However, familiarity with the clinicopathologic and MRI features of most common pelvic masses helps in narrowing the differential diagnosis. Diagnosis of these masses needs a holistic approach as required for any tumor including clinical history, laboratory data, and imaging characteristics. We focus on MRI characteristics of commonly encountered pelvic masses. A compartmental imaging approach is discussed in this article that helps in identifying and characterizing these masses.

Treatment of tailgut cysts by extended distal rectal segmental resection with rectoanal anastomosis

PURPOSE

Complete surgical resection is the treatment of choice for tailgut cysts, because of their malignant potential and tendency to regrow if incompletely resected. We report our experience of treating patients with tailgut cysts, and discuss diagnostics, surgical approaches, and follow-up.

METHODS

We performed extended distal rectal segmental resection of the tailgut cyst, with rectoanal anastomosis. We report the clinical, radiological, pathological, and surgical findings, describe the procedures performed, and summarize follow-up data.

RESULTS

Two patients underwent en-bloc resection of a tailgut cyst, the adjacent part of the levator muscle, and the distal rectal segment, followed by an end-to-end rectoanal anastomosis. There was no evidence of anastomotic leakage postoperatively. At the time of writing, our patients were relapse-free with no, or non-limiting, symptoms of anal incontinence, respectively.

CONCLUSIONS

This surgical approach appears to have a low complication rate and good recovery outcomes. Moreover, as the sphincter is preserved, so is the postoperative anorectal function. This approach could result in a low recurrence rate.

Surgical Management of Tailgut Cysts: A Report of Two Cases

A tailgut cyst is an uncommon congenital developmental cyst that arises from the postnatal remnants of the primitive gut. These cysts are generally located in the retrorectal space. The rarity of this lesion and its anatomical position frequently lead to difficulties in its diagnosis and surgical management. Complete surgical resection remains the cornerstone of treatment, and numerous surgical approaches to achieve this objective have been described in the literature. We present 2 cases of tailgut cysts that were resected using a trans-sacral approach. We discuss the surgical management of these cases, including the operative approach that was adopted. Two cases of tailgut cysts that presented as incidentally detected retrorectal tumors are described here. A pelvic magnetic resonance imaging scan revealed a retrorectal multicystic tumor consistent with a tailgut cyst. The patients underwent surgery via a trans-sacral approach with coccygectomy. The histopathologic diagnosis for each patient was a tailgut cyst with no evidence of malignancy. Surgical approaches for tailgut cysts depend on the exact locations of the cysts and suspicions regarding the malignancies of the cysts. En bloc organ resection, including coccygectomy, is required if malignancy is suspected. We endorse the trans-sacral approach as a feasible, easy to perform, minimally invasive, and safe option for treating relatively low-lying tailgut cysts.

Progress in the management of retrorectal tumours

AIM

Tumours in the retrorectal space are rare and pathologically heterogeneous. The roles of imaging and preoperative biopsy, nonoperative management and the indications for surgical resection are controversial. This study investigated a series of retrorectal tumours treated in a single institution with the aim of producing a modern improved management algorithm.

METHOD

A retrospective analysis was conducted of the management of all retrorectal lesions identified between 1998 and 2013 from a radiology database search. Patient demographics, presenting symptoms, imaging, biopsy, management and the results were recorded. Descriptive statistics were used and Kaplan-Meier survival analysis was performed.

RESULTS

Sixty-nine patients with a confirmed retrorectal tumour were identified. The median age was 50 (36-67 interquartile range) and 42 (56%) were female. Twenty (29%) of the tumours were malignant: 4 of 41 cystic lesions were malignant (12.9%) vs. 16 of 28 solid (or heterogeneous) lesions (57.1%) (P < 0.0001). Imaging demonstrated a 95% sensitivity and 64% specificity for differentiating benign from malignant tumours. Magnetic resonance imaging (MRI) was significantly better at distinguishing between benign and malignant tumours than computed tomography (94% vs. 64%, P = 0.03). Percutaneous biopsy was performed in 16 patients and only 27 underwent resection. There was no evidence of local recurrence associated with biopsy. Solid lesions were associated with a nonsignificant decreased overall survival (P = 0.348).

CONCLUSION

This study demonstrated that MRI should be the investigation of choice for retrorectal lesions. Biopsy of solid lesions is safe and useful for guiding neoadjuvant and surgical therapy. Cystic lesions without suspicious radiological features can be followed by serial imaging without resection.

Management approach and surgical strategies for retrorectal tumours: a systematic review

AIM

The management strategy for retrorectal tumours is complex. Due to their rarity, few surgeons have expertise in management.

METHOD

A systematic literature review was conducted using the PubMed database. English language publications in the years 2011-2015 that assessed preoperative management, surgical strategies and chemoradiotherapy for presacral tumours were included. Two hundred and fifty-one abstracts were screened of which 88 met the inclusion criteria. After review of the full text, this resulted in a final list of 42 studies eligible for review.

RESULTS

In all, 932 patients (63.2% female, 36.8% male; P < 0.01) with a retrorectal tumour were identified. Most were benign (65.9% vs. 33.7%, P < 0.01). Imaging distinguished benign from malignant lesions in 88.1% of cases; preoperative biopsy was superior to imaging in providing an accurate definitive diagnosis (91.3% vs. 61.4%, P < 0.05) with negligible seeding risk. Biopsy should be performed in solid tumours. It is useful in guiding neoadjuvant therapy for gastrointestinal stromal tumours, sarcomas and desmoid type fibromatosis and may alter the management strategy in cases of diffuse large B-cell lymphoma and metastases. Biopsies for cystic lesions are not recommended. The gold standard in imaging is MRI. The posterior Kraske procedure is the most common surgical approach. Overall, the reported recurrence rate was 19.7%.

CONCLUSION

This review evaluated the management strategies for retrorectal tumours. A preoperative biopsy should be performed for solid tumours. MRI is the most useful imaging modality. Surgery is the mainstay of treatment. There is limited information on robotic surgery, single-port surgery, transanal endoscopic microsurgery, chemoradiotherapy and reconstruction.

Benign and malignant tumors of the rectum and perirectal region

Although most rectal masses are histologically characterized as adenocarcinomas, the rectum and perirectal region can be affected by a wide variety of tumors and tumor-like conditions that can mimic the symptoms caused by rectal adenocarcinoma, including mucosal or submucosal rectal tumors such as lymphoma, gastrointestinal stromal tumor, leiomyosarcoma, neuroendocrine tumor, hemangioma, and melanoma, as well as tumors of the perirectal region such as developmental cyst, neurogenic tumor, osseous tumor, and other miscellaneous conditions. As a group, tumors of the rectum are considerably different from the group of tumors that arise in the perirectal region: they are most often neoplastic, symptomatic, and malignant, whereas tumors arising in the perirectal region are most commonly congenital, asymptomatic, and benign. Proctoscopy with biopsy is the most important method for the diagnosis of rectal tumors, but this procedure cannot determine the precise intramural extension of a rectal tumor and cannot accurately distinguish submucosal and intramural tumors from extramural tumors. Cross-sectional imaging, especially transrectal ultrasound and magnetic resonance imaging, allows evaluation of the entire bowel wall thickness and the perirectal tissues, helping further characterize these tumors. Recognition of the existence of these masses and their key clinical and imaging features is crucial for clinicians to accurately diagnose and appropriately manage these conditions.

Management of tailgut cysts in a tertiary referral centre: a 10-year experience

AIM

Tailgut cysts are rare congenital lesions typically presenting as presacral masses. A variable clinical presentation often leads to misdiagnosis and unsuccessful operations.

METHOD

A retrospective analysis was performed of tailgut cysts presenting to one surgeon at St Mark's hospital between 2003 and 2013. The patient demographic data and clinicopathological and radiological features, together with perioperative details and recurrence, were reviewed.

RESULTS

A total of 17 patients (15 women) with a median age of 35 (21-64) years were included in the study. The mean duration of symptoms before referral was 40 months, with sepsis predominating in 12 cases. Fifteen of the patients had previously undergone surgery (mean 2.9 procedures). A posterior surgical approach was adopted in all patients with a coccygectomy performed in 13. A loop colostomy was formed in three patients. Two of them went on to have a secondary pull-through operation after an initial failed local repair of rectal injury. One case was reported to show malignant degeneration on histological examination. There was one recurrence during a median follow-up period of 13 (3-36) months.

CONCLUSION

Tailgut cysts are an uncommon yet important cause of chronic perianal sepsis. Suspicion should be raised in a patient, usually female, presenting with a history of unsuccessful procedures. Diagnosis can be made by clinical assessment and MRI. Complete excision usually resolves the problem.

Transsacrococcygeal Approach for Resection of Retrorectal Tumors

Retrorectal tumors, are a rare and interesting entity, traditionally managed with surgery. The surgical approach is a key to get an easy and safe access. The purpose of this study was to evaluate the results of resection by a transsacrococcygeal approach. Thirty-six patients had retrorectal tumors resected by a transsacrococcygeal approach in our department. All the tumors were en bloc resected, irrespective of size and anatomical depth. The clinic data were retrospectively reviewed. Tumor mean size was 10 ± 4.4 cm. In 16 cases, tumors were 10 cm or more in size. The largest tumor measured 20 cm. The estimated mean blood loss was 130 ml. No mortality and severe postoperative complications were observed. The most significant issues were wound infection and delayed healing. Pathology showed 15 cases of epidermal cysts, two cases of enterogenous cyst, one case of bronchogenic cyst, 12cases of teratoma, two cases of schwannoma, two cases of low-grade malignant fibrous myxoma, one case of aggressive angiomyxoma, one case of desmoid tumor. The trans-sacrococcygeal approach gives an easy access and good visualization with fewer complications. This surgical approach shows to be safe and effective for resection of retrorectal tumors.

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.

Surgical outcomes in adults with benign and malignant sacrococcygeal teratoma: a single-institution experience of 26 cases

BACKGROUND

Adult sacrococcygeal teratomas are rare, and limited data exist on their management and outcomes following surgery.

OBJECTIVE

The aim of this study was to review the outcomes in adult patients undergoing surgery for sacrococcygeal teratomas.

DESIGN

A retrospective review of our prospectively maintained surgical pathology and tumor registries was conducted.

SETTING

This study was conducted at the Mayo Clinic in Rochester. Information was collected on patients treated between 1980 and 2013.

PATIENTS

A total of 26 patients with sacrococcygeal teratoma were identified (19 female), with a median age of 37.5 years. Malignancy was seen in 5 patients.

MAIN OUTCOME MEASURES

Data on demographics, clinical presentation, tumor pathology, adjuvant therapy, surgical approach, surgical margins, use of preoperative biopsy, radiological investigations, morbidity, mortality, and local recurrence was collected. Complications were assessed by using the Clavien-Dindo system of classification.

RESULTS

Patients most commonly presented with pelvic pain (n = 16) and/or a palpable mass (n = 15). On radiology, 8 lesions were purely cystic, 14 were mixed, and 4 were solid; teratoma was suspected as a diagnosis in 8 patients. Preoperative biopsy (13 patients) had 100% concordance with final pathology. Median tumor size was 6 cm, and the surgical approach was posterior only (n = 15), anterior only (n = 5), and combined anterior-posterior (n = 6). Of 5 patients with malignancy, 3 died of recurrent disease.

LIMITATIONS

Limitations of this study include the small number of patients, the long study period, and the heterogeneous nature of these tumors.

CONCLUSION

Presacral teratomas require multidisciplinary management and have a risk of malignant transformation. They are more common in females, and the majority are intrapelvic in location in adults. We recommend clinical evaluation, radiological investigation, and image-guided biopsy in all suspicious presacral lesions. A treatment algorithm has been designed to improve the management of these rare tumors.

A laparoscopic approach to benign retrorectal tumors

BACKGROUND

Retrorectal tumors (RTs) are rare in adults. Their surgical excision is often difficult because of their anatomic location. The aim of this study was to evaluate the results of straight laparoscopic resection of RTs in our institution.

METHODS

Eight patients (six women and two men) with benign RTs were treated by laparoscopic resection in our tertiary care center between September 2012 and June 2013. Exclusion criteria included malignant tumors, lesions with fistula formation, and anterior sacral meningoceles. Clinical data, imaging features, operative details, pathological results, and treatment outcomes were reviewed and analyzed.

RESULTS

Eight cases of benign RT with an average diameter of 8.9 ± 1.7 cm were treated by a straight laparoscopic procedure. The mean operative time was 122 ± 36 min, and the average intraoperative blood loss was 46 ± 33 ml. The median postoperative stay was 5 days (range 3-8 days), and all patients were discharged without serious complications. During a median follow-up of 11 months, no tumor recurrence was observed.

CONCLUSIONS

In our experience, a laparoscopic approach is safe for removing benign tumors in the retrorectal space. This approach may provide access to this difficult-to-reach space and has the advantages of allowing excellent visualization, meticulous dissection, less morbidities, and fast recuperation.

Preoperative assessment of retrorectal tumours

Background

Retrorectal tumours present diagnostic and surgical challenges. This study aimed to identify whether preoperative imaging and/or biopsy provide diagnostic accuracy.

Methods

A consecutive series of patients who had undergone excision of a retrorectal tumour were identified from a database (2002–2013). Details of patient demographics, preoperative presentation, imaging, biopsy, surgical procedure, and gross and microscopic pathology were reviewed. Preoperative imaging and/or biopsies were compared with eventual pathology findings.

Results

In total, 76 patients were identified, all of whom had undergone preoperative cross-sectional imaging whereas only 22 had preoperative biopsy. Imaging correctly discriminated benign from malignant tumours in 72 of the 76 patients (specificity 97 per cent, sensitivity 88 per cent, positive predictive value 88 per cent and negative predictive value 97 per cent). The corresponding values for preoperative biopsy (benign versus malignant) were 100, 83, 100 and 93 per cent. None of the four patients who were assessed incorrectly as having benign or malignant disease on imaging would have undergone an alternative procedure had this been known before surgery. Preoperative biopsy did not significantly influence patient management, and the absence of preoperative biopsy had no detrimental effect; a definitive preoperative histological diagnosis would not have influenced subsequent management.

Conclusion

Preoperative imaging was accurate in the assessment of retrorectal tumours, whereas biopsy did not add to the surgical strategy.

Surgical management of a retro-rectal cystic hamartoma (tailgut cyst) using a trans-rectal approach: a case report and review of the literature

Introduction

Retro-rectal cystic hamartoma (tailgut cyst) is a rare congenital developmental lesion arising from post-natal primitive gut remnants in the retro-rectal space. The rarity of the lesion and its anatomical position usually leads to difficulty in diagnosis and surgical management. Complete surgical resection remains the cornerstone of treatment. A dozen or so surgical approaches have been described in the literature to date to make the operation as simple as possible, but the trans-rectal access route is extremely rarely reported and not well described. Here, we present a case that demonstrates the trans-rectal approach to a retro-rectal tumor is a feasible option in terms of surgical radicality, minimal invasiveness and safety for carefully selected patients with this rare type of retro-rectal cystic lesion.

Case presentation

A 29-year-old Caucasian woman was referred to our institution due to perineal pain extending to the right inguinal region. Her symptoms had been present for the last two months. She was first examined at her regional hospital for a suspected ruptured ovarian cyst; however, after consultation with a gynecologist and a computed tomography scan of her pelvis, a tumor in the retro-rectal space was discovered. Our patient was admitted to our hospital and when a pelvic magnetic resonance imaging study confirmed the diagnosis of the retro-rectal cystic formation, a complete extirpation of retro-rectal tumor fixed to the coccyx using trans-rectal approach was performed. The final pathological diagnosis was retro-rectal cystic hamartoma (tailgut cyst) with no evidence of malignancy. Her post-operative course was uneventful, and at four months after surgery our patient is symptom free with no evidence of recurrent or residual disease.

Conclusions

Trans-rectal excision is feasible in terms of surgical radicality and is a simple to perform, minimally invasive and safe option, providing complete recovery for carefully selected patients with retro-rectal cystic hamartoma treated operatively.

Laparoscopic resection of retrorectal tumors: a feasibility study in 12 consecutive patients

BACKGROUND

Surgical approaches for retrorectal tumors (RRT) are either abdominal, dorsal trans-sacrococcygeal, or perineal. Very few cases have been reported so far concerning a laparoscopic approach. The aim of this study was to assess the results of laparoscopy for the treatment of RRT.

METHODS

All patients who underwent laparoscopy for RRT between 2003 and 2012 were reviewed. Data included patient and tumor characteristics, surgical morbidity, and mortality.

RESULTS

A total of 12 consecutive women with a median age of 55 years underwent laparoscopy for RRT. Median operative time was 145 min (range 70-215). Two conversions in laparotomy occurred, and one patient needed a temporary diverting ileostomy for rectal injury. Postoperatively, two patients presented urinary tract infections. Median length of stay was 8 days (range 4-16). Pathological examinations showed complete resections (R0) for ten benign tumors and one malignant tumor (Ewing sarcoma). One lesion was incompletely resected, a colloid sarcoma (R1 status), and was re-operated on by laparotomy after neoadjuvant chemoradiation. No local recurrence was observed after a median follow-up of 34 months (range 12-79) for benign lesions, and 28 and 71 months for the two patients who underwent resection of Ewing and colloid sarcoma, respectively.

CONCLUSIONS

Laparoscopic resection for RRT seems feasible and safe. It allows complete excision of tumors located in the retrorectal space with low morbidity. Thus, this approach can be a valid alternative to standard Kraske or open abdominal approaches for the treatment of RRT.

Presacral ganglioneuroma: diagnostic considerations and therapeutic strategy

Presacral ganglioneuroma is an extremely rare tumor of neural crest origin. To the best of our knowledge, less than 20 cases have been reported previously. The present study reports on a presacral ganglioneuroma, 10.5 × 8 × 4 cm in size, that was found incidentally in a 35-year-old man with prior history of diverticulitis. He was admitted to our hospital due to lower left abdominal pain. Abdominal computed tomography and magnetic resonance imaging confirmed the extension of the lesion from the S2 level to the coccyx. The mass had low signal intensity on T1-weighted images and heterogeneous high signal intensity on T2-weighted images with no intraspinal or rectal extension. T2-weighted images demonstrated a compartmentalized solid tumor with cystic components. Complete tumor resection with free surgical margins was achieved using an abdominal approach. The patient remains asymptomatic 2 years after surgery. We emphasize on clinical features, radiologic appearance and surgical treatment of this rare entity. The clinical and pathologic features of previously reported studies are also briefly reviewed.

Neurological outcome following resection of benign presacral neurogenic tumors using a nerve-sparing technique

BACKGROUND

Benign presacral nerve sheath tumors represent up to 10% of all presacral tumors. Limited data exist regarding the impact of the surgical technique on neurological outcomes following resection.

OBJECTIVE

The aim of this study was to test our hypothesis that a nerve-sparing resection technique results in the improvement of preoperative neurological dysfunction and minimal postoperative neurological morbidity.

DESIGN

This study is a case series of all patients with benign neurogenic presacral tumors operated on by the same 2 surgeons between 2004 and 2010 at our institution.

SETTINGS

This study was performed at a tertiary care center.

PATIENTS

Adult patients with benign presacral neurogenic tumors who underwent a nerve-sparing resection were included.

MAIN OUTCOME MEASURES

Postoperative urogenital, anorectal, and lower-extremity neurological functions were analyzed.

RESULTS

Seventeen patients were identified with a mean age of 40 years; 14 were women. Preoperatively, 13 patients had symptoms from neurological dysfunction or presumed mass effect of the tumor. The mean tumor size was 7.4 cm. The pathology was a schwannoma in 12 patients and neurofibroma in 5 patients. Mortality was nil, and 30-day morbidity was noted in 3 patients (hemorrhage, ileus, acute respiratory distress syndrome, deep vein thrombosis, and transient foot drop). Mean follow-up was 36 months. Of the 13 symptomatic patients, 7 achieved complete resolution of symptoms and 5 had improved, but persistent symptoms. None of the 4 asymptomatic patients developed postoperative neurological dysfunction.

LIMITATIONS

Small sample size was a limitation of this study.

CONCLUSIONS

With the use of a nerve-sparing technique, function-preserving resection can be safely completed with an overall improvement in symptoms.

Surgical resection of retrorectal tumours in adults: long-term results in 47 patients

AIM

Retrorectal tumours (RT) are uncommon, and diagnosis and management remain difficult. The aim of this study was to evaluate the results of the surgical management of RT in our institution.

METHOD

Medical notes of all patients operated on for RT were reviewed. Clinical, radiological, surgical, histological data as well as morbidity and long-term results were noted.

RESULTS

Forty-seven patients [34 women (72%), mean age 45.8 (range 17-85) years] underwent surgery for RT between 1997 and 2011. The commonest symptoms were pain (n = 31) and suppuration (n = 10). Thirty-nine (83%) patients underwent preoperative magnetic resonance imaging (MRI). Malignant lesions exhibited typical characteristics on MRI including heterogeneity (n = 5, 83%), solid appearance (n = 4, 67%), a low-T1 signal and high-T2 intensity (n = 5, 83%), enhancement after gadolinium injection (n = 5, 83%), irregular margin (n = 4, 67%) and extension above S3 (i = 5, 83%). A Kraske approach was used in 42 (89%) patients with resection of the coccyx in 25 (60%) and an abdominal or combined approach for the remaining five. Four patients developed complications (two haematoma, two abscess), but only one (haematoma) required reoperation. Histological examination showed 38 (80.9%) benign lesions. After a median follow-up of 71 (2-168) months, 5-year disease-free survival was 75% for malignant lesions and 93.1% for benign lesions (P = 0.023). Four (4/42; 9.5%) patients had moderate perineal pain after a Kraske approach, while no anal dysfunction was seen.

CONCLUSION

Magnetic resonance imaging was the most helpful investigation for retrorectal tumours. The posterior trans-sacrococcygeal approach is the procedure of choice for complete resection for most, especially for benign and cystic lesions without extension above S2.

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.