Surgical Treatment of Sacral Neurogenic Tumor: A 10-year Experience with 64 Cases

Exploring the mechanisms and current status of acupuncture in alleviating tumor metabolism and associated diseases: Insights from the central nervous system and immune microenvironment

Acupuncture, as a traditional Chinese medical treatment, has garnered increasing attention in recent years in fields such as tumor metabolism, the central nervous system, and the immune microenvironment. This paper aims to explore the fundamental principles, mechanisms, and research status of acupuncture therapy for tumor-related diseases. Firstly, we introduce the basic principles of acupuncture therapy, including the theories of meridians and its theoretical basis in tumor treatment. Secondly, we systematically review the mechanisms of acupuncture therapy for tumor-related diseases, discussing how acupuncture alleviates side effects such as pain, depression, fatigue, and gastrointestinal discomfort caused by conventional treatments through modulation of the immune microenvironment, central nervous system, and endocrine system. Subsequently, we discuss the current research status of acupuncture therapy for tumor-related diseases, as well as the application of current research methods and technologies in elucidating acupuncture mechanisms. Additionally, by combining clinical practice with different types of tumor-related diseases as experimental subjects, we demonstrate the application effectiveness and clinical practice experience of acupuncture in tumor treatment. Finally, a comprehensive assessment of acupuncture therapy for tumor-related diseases is provided, summarizing its limitations and prospecting future directions, including interdisciplinary collaboration and personalized treatment. In conclusion, acupuncture, as a feasible adjunctive therapy, is closely related to the central nervous system and the immune microenvironment, holding potential significant value in tumor treatment.

Development of Pseudosacral Cyst Following Surgery for Primary Presacral Neuroendocrine Tumors With Liver Metastasis: A Case Report

Presacral neuroendocrine tumor (PSNET) is a rare disease that currently lacks a standardized treatment approach. In this report, we present a unique case of PSNET with liver metastasis that progressed into a pseudosacral cyst following complete surgical resection and sulfatinib treatment with radiofrequency ablation. Before undergoing surgical treatment for presacral neuroendocrinology, it is important to consider the potential risks of poor healing of the presacral incision and formation of pseudocysts. These complications may be caused by various factors, including the procedure itself and the use of targeted drugs.

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.

Minimally Invasive Dorsal Approach for the Treatment of Giant Presacral Schwannomas

BACKGROUND

The treatment of giant presacral schwannomas is currently a grand challenge for neurosurgeons. Although these tumors are benign and do not infiltrate the surrounding tissues, it is difficult to choose the best surgical approach because they are surrounded by the pelvic organs and great vessels. There is no universally accepted approach to the surgical treatment because giant presacral schwannomas are rare in the population. The anterior approach through laparotomy is more often recommended in the literature. A dorsal approach that involves laminotomy and stabilization is also described in the literature. However, these approaches are rather traumatic for the patient and have both intraoperative and postoperative risks.

OBJECTIVE

To report a minimally invasive dorsal approach for the treatment of giant presacral schwannomas.

METHODS

We present a fundamentally new approach to the treatment of these tumors using a minimally invasive dorsal approach, based on the specific anatomy and growth of giant presacral schwannomas. This approach is using the potential of modern neurosurgery.

RESULTS

We describe 2 cases of successful total tumor resection using this novel surgical approach. No complications have been registered after the surgery.

CONCLUSION

A minimally invasive dorsal approach for the treatment of giant presacral schwannomas is sufficient for complete tumor removal, minimizes intraoperative and postoperative risks, is associated with good cosmetic effect, and can be successfully applied in surgical practice.

Surgical Strategy and Application of Robotic-Assisted Benign Sacral Neurogenic Tumor Resection

BACKGROUND

Robotic surgery may be advantageous in neurogenic sacral tumor resection but only a few studies reported robotic-assisted neurogenic sacral tumor resection.

OBJECTIVE

To propose a new surgical strategy for robotic-assisted benign sacral neurogenic tumor resection and introduce the ultrasonic osteotomy surgical system in robotic surgery.

METHODS

Twelve patients who had robotic-assisted primary benign sacral neurogenic tumor resection between May 2015 and March 2021 were included. Our surgical strategy divides tumors into 4 types. Type I: Presacral tumors with diameter <10 cm. Type II: Narrow-base tumors involving the sacrum with diameter <10 cm. Type III: Broad-base tumors involving the sacrum with diameter <10 cm. Type IV: Tumors involving sacral nerve roots ≥2 levels and/or with diameter ≥10 cm.

RESULTS

Five type I, 5 type II, and 1 type III patients underwent tumor resection via an anterior approach, and 1 type IV patient via a combined approach. The median operation time, blood loss, and postoperative hospital stay of type I and II were much less than those of type IV. The ultrasonic osteotomy surgical system facilitated osteotomy in 2 type II and 1 type III patients. Eleven patients had total resections, and 1 type III patient had a partial resection. During the follow-up period of 7.9 to 70.9 months (median: 28.5 months), no local recurrences or deaths were noted.

CONCLUSION

With the largest single-center series to our knowledge, this surgical strategy helped to guide robotic-assisted benign sacral neurogenic tumor resection. The ultrasonic osteotomy surgical system was effective for type II and III.

Is There Another Posterior Approach for Presacral Tumors Besides the Kraske Procedure? — A Study on the Feasibility and Safety of Surgical Resection of Primary Presacral Tumors via Transsacrococcygeal Transverse Incision

Background

The aim of the present study was to explore the feasibility and safety of the surgical resection of presacral tumors via a transsacrococcygeal transverse incision.

Methods

The clinical data and prognoses of patients with presacral tumors who underwent surgery at the Chinese People’s Liberation Army (PLA) General Hospital between January 2009 and December 2018 were retrospectively reviewed and analyzed.

Results

A total of 110 patients with presacral tumors were included in this study, including 82 female patients and 28 male patients, with a female-to-male ratio of 2.9:1. A posterior approach (transsacrococcygeal transverse incision) was utilized in 105 patients, an anterior approach (transabdominal excision) was utilized in 1 patient, and a combined (posterior plus anterior) approach was utilized in 4 patients. The mean tumor size was 8.72 ± 4.28 cm. More than half of the patients (n=59/110) with presacral tumors were asymptomatic. Twenty-six pathological types were observed in our study, including 97 benign lesions and 13 malignant lesions. The intraoperative complication rate was 42.7% (n=47/110), whereas the postoperative morbidity rate was 3.6% (n=4/110). The length of hospital stay for patients treated with the posterior approach was shorter than that of patients treated with the anterior and combined approaches. After a mean follow-up of 90.13 ± 31.22 months, 11 patients had local presacral tumor recurrence, and 1 patient had distant metastasis, with a combined recurrence rate of 10.9% (n=12/110).

Conclusions

The surgical resection of primary presacral tumors via a transsacrococcygeal transverse incision is feasible and safe, with acceptable oncological therapeutic outcomes and a low postoperative morbidity rate, making it worth popularizing in clinical practice.

Total resection of presacral giant schwannoma via minimally invasive dorsal approach: illustrative case

BACKGROUND

Giant presacral schwannomas are extremely rare in neurosurgery. There are various approaches to the surgical treatment of symptomatic giant presacral schwannomas. The least traumatic is the one-stage surgery with a dorsal approach.

OBSERVATIONS

The authors describe a case of a 52-year-old male with pain in the sacral region and partial urinary dysfunction. A total tumor resection through a minimally invasive dorsal approach was performed, and anatomical and functional preservation of all sacral nerves with no postoperative complications was achieved.

LESSONS

The authors have shown the possibility of total tumor resection with a minimally invasive dorsal approach without the development of intra- and postoperative complications. Operative corridors that have been created by a tumor can be used and expanded for a minimally invasive dorsal approach to facilitate resection and minimize tissue disruption.

Presacral Tumor: Insights From a Decade's Experience of This Rare and Diverse Disease

Background

Presacral tumors are a group of rare and heterogeneous tumors that arise from the potential presacral space between the rectum and sacrum. The low occurrence and diverse origins make the diagnosis and treatment of these tumors a challenge. The aim of the study was to retrospectively review patient demographics and to identify advantages and disadvantages in the diagnosis and treatment of these tumors.

Methods

Retrospectively collected and reviewed data from patients who received treatment of presacral tumors at the First Affiliated Hospital of China Medical University between August 2009 and June 2019.

Results

The data from forty-four patients (33 females) with a median age of 50 years who were diagnosed with a presacral/retrorectal tumor were analyzed. The majority of tumors were congenital (61.4%) and benign tumors are more common (59.1%). The median age of patients with benign tumor was significantly higher than that of malignant tumor. The most common symptoms were sacrococcygeal/perianal pain (56.8%) and mass (36.4%), and 8 out of 9 patients having lower limb symptoms diagnosed with malignant tumor. The tumor detection rate of digital rectal examination was 75% and more than 90% of all patients underwent one or more radiology imaging exams for tumor diagnosis. Every patient had a biopsy result. The most common type of tumor was presacral cyst (40.9%) with overall tumor median size of 5.6 cm. Thirty-one (70.5%) patients underwent surgery, most often via the posterior route (83.9%). Posterior route surgery had significantly shorter operation time and tumors operated via posterior route were significantly smaller. The survival rate after surgery was 100%. The median course of disease was 6 months and median follow-up was 25 months.

Conclusions

Presacral tumors have low occurrence and are more frequently observed in females in their 30s and 50s indicating a possible link between tumor occurrence and hormonal changes. Patients with lower limb symptoms were more likely to have a malignant presacral tumor. Posterior route was the most commonly utilized surgical approach. Supplementary iodine tincture treatment of cysts ruptured in operation could potentially be helpful in reducing the chance of recurrence.

Deciphering the antitumoral potential of the bioactive metabolites from medicinal mushroom Inonotus obliquus

ETHNOPHARMACOLOGICAL RELEVANCE

The crude extracts of the medicinal mushroom Inonotus obliquus have been used as an effective traditional medicine to treat malicious tumors, gastritis, gastric ulcers, and other inflammatory conditions in Russia and most Baltic countries.

AIM OF THIS REVIEW

Deciphering the antitumoral potential of the bioactive metabolites from I. obliquus and addressing its possibility to be used as effective agents for tumor treatment, restoration of compromised immunity and protection of gastrointestinal damage caused by chemotherapy.

MATERIALS AND METHODS

We analysed the current achievements and dilemma in tumor chemo- or immunotherapy. In this context, we searched the published literatures on I. obliquus covering from 1990 to 2020, and summarized the activities of antitumor, antioxidation, and immunomodulation by the polysaccharides, triterpenoids, small phenolic compounds, and hispidin polyphenols. By comparing the merits and shortcomings of current and traditional methodology for tumor treatment, we further addressed feasibility for the use of I. obliquus as an effective natural drug for tumor treatment and prevention.

RESULTS

The diverse bioactive metabolites confer I. obliquus great potential to inhibit tumor growth and metastasis. Its antitumor activities are achieved either through suppressing multiple oncogenic signals including but not limited to the activation of NF-κB and FAK, and the expression of RhoA/MMP-9 via ERK1/2 and PI3K/Akt signaling pathway. The antitumor activities can also be achieved by inhibiting tyrosinase activity via PAK1-dependent signaling pathway or altering lysosomal membrane permeabilization through blocking tubulin polymerization and/or disturbing energy metabolism through LKB1/AMPK pathway. In addition, the metabolites from I. obliquus also harbour the potentials to reverse MDR either through selective inhibition on P-gp/ABCB1 or MRP1/ABCC1 proteins or the induction of G2/M checkpoint arrest in tumor cells of chemoresistant phenotypes mediated by Nox/ROS/NF-kB/STAT3 signaling pathway. In addition to the eminent effects in tumor inhibition, the metabolites in I. obliquus also exhibit immunomodulatory potential to restore the compromised immunity and protect against ulcerative damage of GI tract caused by chemotherapy.

CONCLUSIONS

I. obliquus possesses the potential to reduce incidence of tumorigenesis in healthy people. For those whose complete remission has been achieved by chemotherapy, administration of the fungus will inhibit the activation of upstream oncogenic signals and thereby prevent metastasis; for those who are in the process of chemotherapy administration of the fungus will not only chemosensitize the tumor cells and thereby increasing the chemotherapeutic effects, but also help to restore the compromised immunity and protect against ulcerative GI tract damage and other side-effects induced by chemotherapy.

Surgical Strategy for Sacral Tumor Resection

PURPOSE

This study aimed to present our experiences with a precise surgical strategy for sacrectomy.

MATERIALS AND METHODS

This study comprised a retrospective review of 16 patients (6 males and 10 females) who underwent sacrectomy from 2011 to 2019. The average age was 42.4 years old, and the mean follow-up period was 40.8 months. Clinical data, including age, sex, history, pathology, radiographs, surgical approaches, onset of recurrence, and prognosis, were analyzed.

RESULTS

The main preoperative symptom was non-specific local pain. Nine patients (56%) complained of bladder and bowel symptoms. All patients required spinopelvic reconstruction after sacrectomy. Three patients, one high, one middle, and one hemi-sacrectomy, underwent spinopelvic reconstruction. The pathology findings of tumors varied (chordoma, n=7; nerve sheath tumor, n=4; giant cell tumor, n=3, etc.). Adjuvant radiotherapy was performed for 5 patients, chemotherapy for three, and combined chemoradiotherapy for another three. Six patients (38%) reported postoperative motor weakness, and newly postoperative bladder and bowel symptoms occurred in 5 patients. Three patients (12%) experienced recurrence and expired.

CONCLUSION

In surgical resection of sacral tumors, the surgical approach depends on the size, location, extension, and pathology of the tumors. The recommended treatment option for sacral tumors is to remove as much of the tumor as possible. The level of root sacrifice is a predicting factor for postoperative neurologic functional impairment and the potential for morbidity. Pre-operative angiography and embolization are recommended to prevent excessive bleeding during surgery. Spinopelvic reconstruction must be considered following a total or high sacrectomy or sacroiliac joint removal.

Hip disarticulation with pedicled total leg fillet flap for recurrent fungating sarcoma

Soft tissue sarcomas may be treated with limb-sparing procedures in the majority of cases; however, certain cases involving significant tumor spread and fungation may call for amputation. In the thigh, hip disarticulation typically involves a pedicled gluteus maximus flap or a pedicled anterior quadriceps flap. In this case report, we describe a rare situation in which the anterior flap, posterior flap, and adductor flap musculature were contaminated with tumor; therefore, a hip disarticulation was performed applying a pedicled total leg fillet flap for closure. Eighteen months after treatment, the patient continues to have no local recurrence of disease, a stable flap site, and ambulates with a walker. We present this amputation and closure method as a potentially effective modality in treating extensive oncologic disease of the proximal lower extremity.

Preliminary investigation of bilateral internal iliac artery ligation and anterior tumor separation through laparoscopy before posterior resection of a giant sacral tumor

BACKGROUND

Surgical is the optimal therapeutic strategy for sacral tumors, and complete resection can effectively improve the recurrence and survival rates. However, the specialized anatomy, massive bleeding and adhesion to the anterior tissue, especially that caused by giant sacral tumors, makes complete resection difficult. The laparoscopic technique provides a new method to resect sacral tumors.

METHODS

34 patients with primary giant sacral tumors who underwent surgical resection were enrolled. After bilateral internal iliac artery ligation and anterior laparoscopic tumor separation, the sacral tumors were successfully resected posteriorly. The clinical, radiological and follow-up data were collected and analyzed.

RESULTS

The average operative time was 276.47 min and that for laparoscopy was 76.24 min. The average intraoperative blood loss was 1757.64 ml. No complications associated with laparoscopic surgery, such as intestinal, urinary tract, or vascular injuries, occurred. Ten patients (29.41%) had perioperative complications, including infection, unhealed wounds, and cerebrospinal fluid leaks in 10, 5 and 2 patients, respectively. Patients with complications had significantly longer total (55.00 ± 34.53 vs 25.13 ± 14.60, P = 0.001) and postoperative (39.10 ± 30.61 vs 14.83 ± 10.00, P = 0.002) hospitalization stays than patients without complications. Postoperatively, bowel and bladder dysfunction, intestinal obstruction, pain, and perianal numbness occurred in 21, 5, 8, and 2 patients, respectively. The recurrence rate was 11.76%.

CONCLUSIONS

Laparoscopically assisted sacral tumor resection is a technically feasible and effective surgical method to resect giant sacral tumors, with the advantages of reduced operative blood loss during internal iliac artery ligation and anterior tumor separation.

Perineal and Radicular Pain Caused by Contralateral Sacral Nerve Root Schwannoma: Case Report and Review of Literature

BACKGROUND

Sacral schwannomas are very rare nerve sheath tumors. Patients usually present with a variety of nonspecific symptoms, which often lead to a delay in diagnosis. Although most schwannomas are benign, they present surgical challenges owing to their proximity to neurologic and other anatomic structures.

CASE DESCRIPTION

This 58-year-old female presented with a 2-month old history of left-sided perineal and radicular pain secondary to a right S2 sacral nerve root schwannoma. The sacral mass demonstrated homogenous enhancement with cystic changes in a T2-weighted magnetic resonance imaging sequence. The patient underwent S1-S3 laminectomy and tumor excision through a posterior surgical approach. Intraoperative monitoring was used to distinguish nonfunctional tissue during tumor resection. The patient had an unremarkable postoperative course.

CONCLUSIONS

Sacral schwannomas can present with a variety of nonspecific symptoms. They pose unique challenges given their location, size, and involvement of surrounding structures. Complete surgical resection is the main goal of sacral schwannoma treatment. A combined anterior-posterior surgical approach and a multidisciplinary surgical team are associated with improved outcomes.

Computed Tomography-Guided Posterolateral Transsacral Ala Approach to Presacral L5 Schwannoma: Technical Note

BACKGROUND

Presacral schwannomas are rare benign tumors that may reach large size before becoming symptomatic. Total surgical removal has been considered the best treatment option. Tumors arising from the presacral area are commonly managed through anterior approaches, whereas posterior approaches are used for pure intrasacral tumors or large lesions with both intrasacral and presacral extension, alone or in combination with anterior approaches.

METHODS

We describe a quick and minimally invasive navigation-guided posterolateral approach to a right presacral L5 schwannoma. The lesion was microsurgically removed through high-speed drilling of the upper portion of the right sacral ala, under intraoperative neurophysiologic monitoring.

RESULTS

The postoperative course was unremarkable, and the patient experienced improvement in his sensory disturbance. Postoperative magnetic resonance imaging and computed tomography scan showed the complete excision of the lesion and the removal of the upper sacral ala with preservation of the right L5-S1 articular complex. The histologic examination confirmed a schwannoma (World Health Organization grade I).

CONCLUSIONS

The posterolateral transsacral ala approach may represent a minimally invasive option in the surgical management of presacral well-circumscribed benign tumors. Spinal navigation could be properly used to facilitate lesion exposure and to minimize the bone removal. The intraoperative neurophysiologic monitoring is an essential tool for the preservation of the lumbosacral nerve roots.

Single Stage Posterior Approach for Total Resection of Presacral Giant Schwannoma: A Technical Case Report

The neurogenic tumor of frequent occurrence in the presacral area is a schwannoma. Giant presacral schwannoma has a risk for anterior surgical approach because of its massive size and proximity to abundant vascularity of presacral region. We report a single stage posterior approach for total resection of a giant presacral schwannoma. A 40-year-old female patient experienced left buttock pain and tingling sensation at left S1 dermatome. Magnetic resonance imaging showed that the presacral huge mass at S1–3 level with osseous extension and structural remodeling in left sacral ala. The presacral mass was ranging in maximum diameter from 8.0 to 8.6 cm. S2 foramen laminectomy was performed to expose the mass. The tumor capsule and the root were carefully dissected away. The tumor was removed while preserving the capsule by dissecting the plane between the inner wall of the capsule and the tumor. The single stage posterior approach for presacral giant schwannoma is feasible, and it can be a good surgical alternative to prevent pelvic organ or vascular damage and anterior approach related dystocia and infertility.