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Pre sacral tumor



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  • 1. A Case of Pre-Sacral Tumor
    Surgical Unit-6
    Dr. K. M. Garg
    Nilesh N. Agrawal
    Manoj, a 20 yr. old unmarried hindu female, resident of Nagaur, was admitted on 11.08.’10 with chief complaints of :
    Swelling in sacral region since 10 yrs
    Pain in the swelling since 1 yr.
  • 3. HOPI
    Pt. was asymptomatic 10 yrs. back, when she noticed a globular swelling in her sacral region which was initially around 2X2 cms. in size and has increased in size gradually to around 6X6 cms. at present
    Since last 1 yr. pt. is experiencing dull pain over the swelling especially while sitting and lying down
  • 4.
    • No h/o acute pain or sudden increase in size of the swelling
    • 5. No h/o trauma
    • 6. No h/o fever
    • 7. No h/o constipation or bleeding p/r
    • 8. No h/o urinary complaints
    • 9. No h/o menstrual irregularity
    • 10. No h/o loss of weight or appetite
    • 11. No h/o pain or weakness in limbs
  • Past History
    • No h/o TB, DM, Bronchial Asthma, Congenital deformity
    • 12. No h/o any surgical intervention
    • 13. No h/o drug allergy
    Personal History
    • Vegetarian diet
    • 14. Bladder and bowel habits normal
    • 15. No addiction
    Family History
    • Not significant
    Menstrual History
    • Cycles normal with average flow
    • 16. LMP- 20.07.’10
  • General Examination
    Conscious, oriented, moderately built female pt.
    Vital stable
    No pallor, icterus, cyanosis, clubbing, edema feet, generalized LNP
  • 17. Local EXAMINATION
    Inspection :
    A single globular swelling of approx 6X6 cms. present over the sacral area,
    Smooth surface,
    No impulse on coughing,
    Skin over the swelling shows bluish discoloration
  • 18. Palpation:
    • Temp. over the swelling is normal,
    • 19. Findings of inspection are
    • Non-tender, 6X6 cms., globular swelling with smooth
    surface and cystic consistency.
    • Swelling is fluctuant, non-translucent, irreducible,no
    impulse on coughing, non-pulsatile, fixed to the
    overlying skin.
    • The deeper dimension of the swelling cannot be
    Percussion: Dull note over the swelling
    Auscultation:No bruit or venous hum
    P/R: boggy swelling felt posteriorly, on the rt. side.
  • 20. investigations
    Routine blood investigations, Chest X-ray, ECG – WNL
    MRI L.S. spine- Large multiloculated lobulated thin walled cystic mass is seen overlying lower sacrum and coccyx with larger intrapelvic component causing anterior and left side displacement and compression over rectum, uterus and urinary bladder. No e/o intraspinal extension or bony involvement, visualized spinal cord is normal
  • 21.
  • 22.
  • 23.
  • 25.
  • 26. What we did ?
    Complete excision of cyst en bloc
    with coccyxectomy
    N.B.- Pt. in prone jack-knife position
    Per operative findings:
    A cystic swelling with external component of 6X6 cms., passing from below the coccyx anteriorly into pre sacral space with larger intra pelvic component of about 10X10 cms., pushing the rectum anteriorly and to the left without any local infiltration
    Closed suction drain removed on day 4
    Pt. discharged on day 5
    Skin staplers removed after 2 weeks
  • 28.
  • 29.
  • 30. Histopathology report
    Dermoid cyst
    Anatomy :
    The boundaries include posterior wall of the rectum anteriorly and the sacrum posteriorly
    This space extends superiorly to the peritoneal reflection and inferiorly to the rectosacral fascia and the supralevator space
    Laterally bordered by the ureters, the iliac vessels, and the sacral nerve roots
    Pre sacral space contains multiple embryologic remnants
    derived from variety of tissues and tumors in this space are often heterogeneous
  • 33.
    • Congenital
    Benign: Developmental cysts ( teratoma, epidermoid, dermoid), Duplication of rectum, Anterior sacral meningocele, Adrenal rest tumor
    Malignant: Chordoma, Teratocarcinoma,
    • Neurogenic
    Benign: Neurofibroma, Neurilemoma(schwannoma), Ganglioneuroma
    Malignant:Neuroblastoma, Ganglioneuroblastoma, Ependymoma, Malignant peripheral nerve sheath tumors (malignant schwannoma, neurofibrosarcoma, neurogenic sarcoma)
    • Osseous
    Benign: Giant-cell tumor, Osteoblastoma, Aneurysmal bone cyst
    Malignant: Osteogenic sarcoma, Ewing’s sarcoma, Myeloma Chondrosarcoma
    • Miscellaneous
    Benign:Lipoma, Fibroma, Leiomyoma, Hemangioma, Endothelioma, Desmoid
    Malignant: Liposarcoma, Fibrosarcoma/malignant fibrous histiocytoma, Leiomyosarcoma, Hemangiopericytoma, Metastatic carcinoma
    • Other: Ectopic kidney, Hematoma, Abscess
    • Congenital lesions- Most common (around 2/3)
    • 35. Developmental cysts constitute most of congenital lesions
    • 36. Dermoid and epidermoid are benign and arise from ectoderm
    • 37. Enterogeneous cyst arise from primitive hindgut (endodermal)
    • 38. Anterior meningocele and myelomeningocele arise from herniation of dural sac through a defect in anterior sacrum (scimitar sign)
    • Teratomas are true neoplasms and contain tissue from all germ layers. They have both solid and cystic components and are more common in children, but when found in adults 30% may be malignant (s.c.c- from ectoderm, rhabomyosarcoma- mesenchymal or anaplastic)
    • 39. Chordomas that arise from primitive notochord are the most common malignant tumor in this region. More common in men above 30 yrs of age. They are slow growing, invasive and show characteristics bony destruction
  • Clinical features
    Pain: Lower back, pelvic or lower extremities
    GI symptoms: Constipation
    Urinary tract symptoms
    Most lesions are palpable on digital rectal examination
    Some lesions may have an extra pelvic external component, leading to early diagnosis
    CT scan- Useful to detect bony involvement
    Pelvic MRI- Most sensitive and specific imaging modality
    Endorectal Ultrasound: may deliniate rectal invasion
    Myelogram-If CNS is involved
  • 41. Biopsy- Not required for resectable tumors, but, in case of solid or heterogenously cystic lesions or if suspicion of Ewing’s or large desmoid tumor is present pre treatment biopsy may be required. Transperineal or parasacral approach is used and needle tract has to be excised in future surgical procedure. Transrectal/ vaginal approaches are strictly contraindicated
  • 42. Management
    Almost always surgical.
    Approach: depends upon the location and size of tumor.
    Low lying tumor (below S3): posterior transsacralapproach/ perineal approach.
    Intermediate tumors (between S3 and promontory): combined abdominal and sacral approach.
    High lying tumors (above sacrum): transabdominal approach.
    Neoadjuvant/ adjuvant treatment: indicated in radio/chemo sensitive tumors. Pre op radiotherapy is better than post op.