Presacral tumours in adults

Presacral Neuroendocrine Neoplasms: A Multi-site Review of Surgical Outcomes

INTRODUCTION

Presacral neuroendocrine neoplasms (PNENs) are rare tumors, with limited data on management and outcomes.

METHODS

A retrospective review of institutional medical records was conducted to identify all patients with PNENs between 2008 and 2022. Data collection included demographics, symptoms, imaging, surgical approaches, pathology, complications, and long-term outcomes.

RESULTS

Twelve patients were identified; two-thirds were female, averaging 44.8 years of age, and, for the most part, presenting with back pain, constipation, and abdominal discomfort. Preoperative imaging included computed tomography scans and magnetic resonance images, with somatostatin receptor imaging and biopsies being common. Half of the patients had metastatic disease on presentation. Surgical approach varied, with anterior, posterior, and combined techniques used, often involving muscle transection and coccygectomy. Short-term complications affected one-quarter of patients. Pathologically, PNENs were mainly well-differentiated grade 2 tumors with positive synaptophysin and chromogranin A. Associated anomalies were common, with tail-gut cysts prevalent. Mean tumor diameter was 6.3 cm. Four patients received long-term adjuvant therapy. Disease progression necessitated additional interventions, including surgery and various chemotherapy regimens. Skeletal, liver, thyroid, lung, and pancreatic metastases occurred during follow-up, with no mortality reported. Kaplan-Meier analysis showed a 5-year local recurrence rate of 23.8%, disease progression rate of 14.3%, and de novo metastases rate of 30%.

CONCLUSION

The study underscores the complex management of PNENs and emphasizes the need for multicenter research to better understand and manage these tumors. It provides valuable insights into surgical outcomes, recurrence rates, and overall survival, guiding future treatment strategies for PNEN patients.

OUP accepted manuscript

Aim

Tumours of the retrorectal space are uncommon, pathologically heterogeneous, and difficult to diagnose, with ongoing controversy over their surgical management. The aim of this study was to evaluate the surgical management of a consecutive series of patients who had undergone excision of primary retrorectal tumours (PRRTs) at a tertiary referral centre.

Method

Patients were identified from a prospectively maintained database between 1 March 2001 and 1 August 2021. Electronic patient records were reviewed for demographics, preoperative imaging, operative details, histology, and follow-up. A chi-squared test was used to assess the statistical significance of findings.

Results

A total of 144 patients were included in the study. Of these, 103 patients were female (71.5 per cent), 46 patients (31.9 per cent) presented incidentally, and 99 of the patients had tumours located below S3 (68.7 per cent). Overall, 76 patients underwent a transperineal approach (52.7 per cent) with the most common findings of a benign tailgut cyst occurring in 59 (40.9 per cent) of cases. Preoperative MRI predicted urovascular and pelvic sidewall involvement assessed intraoperatively with a sensitivity of 83.3 and 90 per cent and a specificity of 98.1 and 98 per cent respectively. Risk of malignancy in solid tumours was 31.4 versus 8.8 per cent in cystic tumours (relative risk 3.5, 95 per cent c.i. 1.6 to 7.6, P < 0.001). Major complications (Clavien–Dindo grade III and above) occurred in eight patients (5.6 per cent) and all-cause long-term mortality was 4.8 per cent (seven patients).

Discussion

PRRTs can be safely excised with minimal complications in specialized centres by surgical teams with the relevant expertise. This study questions the conservative management of cystic tumours and given the risk of solid tumour malignancy, supports surgical management.

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.

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.

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 adenocarcinoma arising from tailgut cysts: a rare case report

BACKGROUND

Tailgut cysts arise from the remnants of the tailgut during the embryonic period. Although malignant transition of tailgut cysts is very rarely observed in the clinic, this congenital condition should be carefully monitored for early diagnosis and appropriate treatment, especially when the tailgut cysts are malignant.

CASE PRESENTATION

Here, we report the case of a 33-year-old man with retrorectal adenocarcinoma originating from the tailgut cysts. Magnetic resonance imaging (MRI) showed many cystic masses in the posterior rectal space, the largest of which was approximately 100 mm × 59 mm × 53 mm in size and compressed the rectum. The patient underwent surgical resection of the masses located in the retrorectal and anterior sacral spaces. Histological and immunohistological examinations confirmed adenocarcinoma transition of the tailgut cysts. The patient recovered well and was discharged 10 days after surgery.

CONCLUSIONS

We have reported a rare case of retrorectal adenocarcinoma originating from tailgut cysts. MRI, histological, and immunohistological examinations are vital for the diagnosis of tailgut cysts. Complete surgical resection of the tumor should be better performed.

Primary neuroendocrine tumor in the presacral region: A case report

BACKGROUND

Primary neuroendocrine tumors (NETs) in the presacral region are extremely rare, some of which are caused by other primary tumors or metastatic rectal carcinoids. Nevertheless, cases of NETs have been increasing in recent years. This report describes the first primary neuroendocrine tumor in the presacral region that was found at our hospital within the last five years.

CASE SUMMARY

The patient was identified as a 36-year-old woman with a presacral mass and pelvic floor pain. A digital rectal examination revealed a presacral mass with unclear margins and obvious tenderness. Magnetic resonance imaging (MRI) demonstrated a 57 mm × 29 mm presacral lump. An ultrasound-guided needle biopsy confirmed a well-differentiated neuroendocrine tumor. No other primary or metastatic tumors were found.

CONCLUSION

Comprehensive consideration of our case report and literature reported by others suggests that a conclusive diagnosis of NETs should be based on computed tomography/MRI and pathological examinations. The treatment of primary NETs in the presacral region mainly relies on surgical procedures with follow-up.

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.

Presacral tumors: diagnosis and treatment - a challenge for a surgeon

INTRODUCTION

Presacral tumors are a rare group of heterogeneous lesions located in a potential space referred to as the retrorectal or presacral space. Lack of characteristic symptomatology and difficult anatomical localization make the diagnosis and management challenging for a surgeon. The aim of this study was to analyze cases of presacral tumors that underwent surgical treatment with regard to diagnostics, methods and outcomes.

MATERIAL AND METHODS

The study enrolled patients who underwent surgical treatment at the Department of General and Colorectal Surgery, Medical University of Lodz. The data was analyzed for age, gender, clinical symptoms, type of diagnostic procedures conducted, histopathology results, type of treatment implemented, intra- and perioperative complications as well as early and long-term treatment outcomes.

RESULTS

The study enrolled 29 patients who underwent surgical treatment for presacral tumors. Malignant tumors accounted for 34% of all cases (n = 10), and 80% of them occurred in men. Benign cases accounted for 66% of cases (n = 19), and they occurred predominantly in women (58%). Malignant lesions were more common in men (p < 0.05). The average age of patients with benign tumors was lower than that of patients with malignant tumors (p < 0.05). The transsacral approach was used in 51% of patients, abdominal laparotomy in 41% and a combined approach in 7%. Cure was achieved in 72% of patients, including 67% who were cured after their initial surgery.

CONCLUSIONS

Presacral tumors are more common in men and more commonly are malignant tumors in this group. The success rate of surgical treatment is 72%, and selection of the surgical approach does not affect the final treatment outcome.

Neuroendocrine Tumor Arising in a Tailgut Cyst: A Rare Presacral Tumor

A tailgut cyst (retrorectal cystic hamartoma) is an uncommon lesion that develops in the presacral (retrorectal) space. Malignant change in a tailgut cyst is extremely rare and presents as a soft tissue (presacral) or bone (sacral) neoplasm. We report a case of tailgut cyst in which a neuroendocrine tumor developed in a 25-year-old female. Computed tomography and magnetic resonance imaging scans revealed a sacrococcygeal malformation with absent left S4 and S5 and a partly cystic lesion within the right presacral space. Histologically, the lesion contained cystic and solid elements. The cysts were lined by columnar and stratified squamous epithelial cells with underlying patchy smooth muscle. The solid element was a partly necrotic neuroendocrine tumor composed mainly of ribbons of tumor cells, which showed mitotic activity and expressed cytokeratin, chromogranin, and synaptophysin. Histologically, tailgut cysts are lined by epithelium and contain scattered smooth muscle bundles in the cyst wall. Although rare, the possibility of tailgut cyst with neuroendocrine tumor should be included in the differential diagnosis of an enlarging presacral tumor.

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.

Mucinous tumor arising in a giant sacrococcygeal teratoma: A rare case report

RATIONALE

Teratomas, which most frequently affect adult females, are the most common type of germ cell tumor, it always comprises derivatives of at least 2 germ layers. The most common site of primary teratomas is the ovary. Sacrococcygeal teratomas (SCTs), which are exceedingly rare in adults, are generally found in newborns or children.

PATIENT CONCERNS

A 39-year-old woman presented to our clinic with a 1-year history of gradually aggravated difficulty in micturition and defecation, and a tumor in her right buttock present since birth. Appropriate preoperative examinations showed a large (15.6 cm × 12.2 cm × 30.0 cm) multicystic SCT.

DIAGNOSES

Histologic examination confirmed a mucinous tumor arising in a giant SCT.

INTERVENTIONS

Abdominoperineal rectal resection was performed.

OUTCOMES

The patient recovered well and was discharged on day 33 of admission.

LESSONS

We report the first case of a mucinous tumor arising in an SCT, in which the teratoma presented mature tissue elements derived only from the endodermal germ layer (keratinous debris).

Myelodysplastic Syndrome Developing Presacral Extramedullary Hematopoiesis with Atypical MRI Findings

A 64-year-old woman was diagnosed to have refractory cytopenia with multilineage dysplasia (RCMD) including an increased number of sideroblasts in the bone marrow (BM). Computed tomography (CT) revealed a presacral mass which showed iso- or high-intensity signals according to T1-weighted and hypo-intensity signals on T2-weighted magnetic resonance imaging (MRI). CT-guided biopsy revealed the presence of hematopoietic tissue with features that correlated with the BM findings. While the formation of extramedullary hematopoiesis in the presacral area is rare, it is important to differentiate it from other parasacral tumors even though such differentiation is often difficult. This patient demonstrated atypical MRI signals possibly due to an increase in the cellular iron content of the erythroid precursors.

A systematic review of presacral extramedullary haematopoiesis: a diagnosis to be considered for presacral masses

AIM

Presacral masses are uncommon and have malignant potential; treatment typically includes surgical excision. However, there are conditions such as extramedullary haematopoiesis (EMH) which are benign. The present study aimed to summarize the presentation of presacral EMH in our institution, to review the literature and to offer management strategies for this rare condition.

METHOD

The literature was searched for articles related to presacral EMH, and case reports were collected from articles meeting the inclusion criteria. We collected data on patient demographics, diagnostic investigation, management and the results of treatment.

RESULTS

Thirty-nine patients were included in the systematic review. Initial imaging included computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound (US) suggestive of EMH. Some patients then underwent a technetium scan (n = 7, 18%), biopsy of the presacral lesion (n = 27, 69%) or excision of the entire mass (n = 3, 8%). All patients who underwent technetium scan were confirmed to have EMH, demonstrating enhancement similar to bone marrow. Patients who underwent technetium scan and presacral mass biopsy had concordant results confirming presacral EMH (n = 5, 13%). Data on management were available for 35/39 (90%) with most patients followed by clinical observation (n = 20, 51%). Symptomatic patients were treated with radiotherapy (15%), surgical excision (15%) or hydroxyurea (5%) and blood transfusions (10%). Most (81%, n = 17/21) patients whose outcome was reported remained asymptomatic or experienced pain relief.

CONCLUSION

Although uncommon, EMH should be considered in the differential diagnosis of a presacral mass. Presacral EMH is a benign condition that can be suspected on CT or MRI and confirmed with technetium scan. Patients may not necessarily need to undergo biopsy to confirm haematopoietic elements. Unlike other presacral masses, patients diagnosed with presacral EMH can be managed by observation. If symptomatic, radiotherapy or surgical excision may be offered.

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.

Tailgut cyst accompanied with bony defect

Retro-rectal cystic hamartoma (tailgut cyst), is an uncommon congenital developmental lesion, generally located in the retro-rectal space. Its diagnosis and approach is challenging because the retropelvic space is not familiar. We report a 51-year-old woman who presented with paresthesia and pain in perianal area. The magnetic resonance image showed high signal intensity on the T1-weighted image and iso to high signal intensity on the T2-weighted image of the retropelvic space and CT showed sacral bony defect. We chose the posterior approach for removal of the tailgut cyst. Histopathology exam of the retropelvic cyst revealed a multiloculated cyst containing abundant mucoid material lined by both squamous and glandular mucinous epithelium. The patient has recovered nicely with no recurrence. Tailgut cyst needs complete surgical excision for good prognosis. So, a preoperative high-resolution image and co-operation between neurosurgen and general surgeon would help to make safe and feasible diagnosis and surgical access.

A Rare Presentation of Lower Back Swelling as Tailgut Cyst

Retrorectal cystic hamartoma, also known as tailgut cyst, is a rare congenital developmental lesion arising from postnatal primitive gut remnants in the retrorectal space. The rarity of the lesion and its anatomical position usually leads to difficulty in diagnosis and surgical management. This cyst predominantly occurs in women (female to male ratio, 3:1). Tailgut cysts can present as incidental findings during the routine examination but over half of the patients are thought to present with symptoms. Computed tomography or magnetic resonance imaging has a crucial role in diagnosing these misdiagnosed cysts. Complete surgical excision is the treatment of choice for tailgut cysts as this provides a definitive diagnosis, relieves symptoms, and prevents possible complications such as infection, fistula formation, and malignant degeneration. We present a case of a 40-year-old female, who presented to us with lower back swelling (7 cm × 5 cm) for last 2 years, which had become more prominent to her while sitting. The patient was investigated. Ultrasonography demonstrated ill-defined large cystic lesion (8 cm × 7 cm), posterior to the uterus. Fine needle aspiration cytology suggested sebaceous cyst. A lumbosacral contrast-enhanced computed tomography demonstrated well-defined fluid density mass/collection with enhancing walls in the retrorectal, presacral, precoccygeal area, and suggested tailgut duplication cyst/retrorectal cystic hamartoma. Surgical complete excision of the cystic mass was done with both anterior (transabdominal) and posterior approach. Histopathology confirmed a tailgut cyst.

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.

The Case of an Elderly Male Patient with Unknown Primary Mucinous Adenocarcinoma within Presacral Teratoma (Teratoma with Malignant Transformation)

Teratomas are rarely seen in adults, and presacral region is an area where they rarely settle in. Similarly, only about 1% of teratomas show malignant transformation. Malignant transformation is often associated with the area where teratoma settles in. Malignant transformation of mediastinal teratomas is more frequent than the ones located in retroperitoneal area and gonad. They most commonly show rhabdomyosarcoma, primitive neuroectodermal tumor, enteric adenocarcinoma, and leukemia transformation. In teratomas showing malignant transformation, the clinical course is aggressive; and survival of patients with metastatic disease is very low. The primary treatment of teratomas with malignant transformations is surgical. Effect of radiotherapy and chemotherapy is not clear in patients, to whom surgical operation cannot be applied, or those who are with residual tumor, even if surgical operation can be applied to them, or those who are at metastatic stage. In this paper, we presented a 76-year-old male patient due to the histologic diagnosis of mucinous adenocarcinoma within teratoma, in whom approximately 7 cm presacral mass was found during the radiographic examination made by the reason of low back pain and pelvic pain.

Sacro-coccygeal teratoma in adult: Two rare case reports and review of literature

The sacrococcygeal area is the most common site of extragonadal teratomas in infants, but is a challenge to make clinical as well as radiological diagnosis in adults. We herein describe two cases of sacrococcygeal teratoma (SCT) in adult. The clinical, radiological and histopathological characteristics of both the cases with their outcome are described with review of the literature. The standard care for SCTs is complete surgical resection of the tumor. The presence of malignant transformation is associated with a less favorable outcome.

Lesions originating within the retrorectal space: a diverse group requiring individualized evaluation and surgery

BACKGROUND

Tumors occurring within the retrorectal space are rare and their low incidence has led to a paucity of literature regarding them.

METHODS

Adult patients with retrorectal tumors managed at this institution from 1981-2011 were identified. A retrospective chart review was conducted to obtain relevant data.

RESULTS

Retrorectal tumors were identified in 87 patients (67 female) with median age at diagnosis of 44 years (19-88), and median follow-up 8 months (0.1-225). Of the 25 different histologic tumors diagnosed, hamartomas were most common (32 %; n = 28) followed by epidermal cysts (11 %; n = 10), and teratomas (10 %; n = 9). Twenty-six percent (23/87) of all tumors were malignant. CT scans were obtained in 84 % (73/87) of patients, MRI in 59 % (51/87), and TRUS in 16 % (14/87). While 74 % (64/87) of tumors were at or below the S4 level, operative approach was strictly posterior in 73 % (46/63) of these tumors. Twenty-eight percent (24/87) of patients underwent diagnostic biopsy with no reported biopsy site recurrence. Thirty percent (7/23) of resected malignant (all recurrences: distant) and eleven percent (7/64) of benign tumors (all recurrences: local) recurred. Survival was 70 % (16/23) for malignant tumors and 98 % (63/64) for benign tumors.

CONCLUSIONS

Retrorectal tumors remain heterogeneous and a diagnostic challenge. Pre-operative imaging may help guide surgeons; however, malignancy portends worse outcomes. Despite preoperative biopsy site recurrence concerns, no patient in this study had biopsy site recurrence. As their natural history remains unclear, more studies are necessary to further characterize their behavior.

Posterior approach (Kraske procedure) for surgical treatment of presacral tumors

Presacral tumors are rare, but can comprise a great variety of histological types. Congenital tumors are the most common. Once the diagnosis is established, surgical resection is essential because of the potential for malignancy or infection. Previous biopsy is not necessary or may be even harmful. To decide the best surgical approach (abdominal, sacral or combined) an individual and multidisciplinary analysis must be carried out. We report three cases of cystic presacral masses in which a posterior approach (Kraske procedure) enabled complete resection, the only way to decrease local recurrence. All patients had a satisfactory recovery. A brief overview of retrorectal tumors is presented, focusing on classification, clinical presentation, diagnosis and surgical management.

A rare cause of low back pain: report of a tailgut cyst

Tailgut cysts, also known as retrorectal cystic hamartomas, are rare developmental abnormalities that typically occur in the retrorectal space. They are believed to arise from remnants of the embryonic hindgut (Hjermstad and Helwig, 1988). They can present as incidental findings during routine examination but over half of patients are thought to present with symptoms. MRI has become the modality of choice to image these frequently misdiagnosed cysts. Biopsy is not recommended. Complete intact surgical excision is advised to avoid the potential complications of these cysts which include infection, fistula formation, and the possibility of malignant transformation (Hjermstad and Helwig (1988), Mathis et al. (2010)). We describe the case of a 46-year-old female who presented with a 6-month history of low back pain. CT and MRI imaging demonstrated a complex retrorectal lesion with supralevator and infralevator components. This was removed using a combined transperineal and transabdominal approach. Histology confirmed a tailgut cyst.

Ghrelin-producing well-differentiated neuroendocrine tumor (carcinoid) of tailgut cyst. Morphological, immunohistochemical, ultrastructural, and RT-PCR study of a case and review of the literature

Well-differentiated neuroendocrine tumors (carcinoids) arising in the presacral space are rare neoplasms that can arise in association with either sacrococcygeal teratomas or tailgut cysts. Although tumors arising in tailgut cysts are more frequent than those associated with teratomas, they are still very rare, and only 13 cases have been reported in the literature. We describe the first case of a carcinoid composed of ghrelin-producing cells arising in a tailgut cyst. Ghrelin production was demonstrated using immunohistochemistry, electron microscopy, and reverse transcription-polymerase chain reaction methods. A 73-year-old woman with back and pelvic pain was found to have a presacral mass histologically diagnosed, on needle biopsy, as a well-differentiated neuroendocrine tumor. Workup did not show another primary tumor or metastatic disease. The patient underwent laparoscopic resection of the mass, and the pathological diagnosis of the surgical specimen was of a tailgut cyst-associated carcinoid composed of ghrelin-producing cells. In addition, we have accurately reviewed the literature on presacral carcinoids, associated or unassociated with tailgut cysts, to give the reader a comprehensive overview of these very rare tumor types.

An interesting diagnosis for a presacral mass: case report

A presacral mass can present a diagnostic dilemma for the surgical oncologist. Differential diagnoses include congenital causes such as teratoma or chordoma, neurological causes such as neurilemoma or neurofibroma or other malignancies such as lymphoma or sarcoma. Diagnosis usually requires imaging such as CT and MRI and tissue biopsy. We present an unusual cause of a presacral mass being extramedullary haematopoiesis, found incidentally in a 71 year old female. Extramedullary haematopoiesis is defined as the production of myeloid and erythroid elements outside of the bone-marrow. This diagnosis is extremely rare in the presacral area especially in a patient with no haematological abnormalities. A review of the literature is presented.