A Case of Pre-Sacral Tumor Surgical Unit-6 Dr. K. M. Garg Nilesh N. Agrawal
CASE SUMMARY 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.
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
General Examination Conscious, oriented, moderately built female pt. Vital stable No pallor, icterus, cyanosis, clubbing, edema feet, generalized LNP
Local EXAMINATION Inspection : A single globular swelling of approx 6X6 cms. present over the sacral area, Smooth surface, Non-pulsatile, No impulse on coughing, Skin over the swelling shows bluish discoloration
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
assessed Percussion: Dull note over the swelling Auscultation:No bruit or venous hum P/R: boggy swelling felt posteriorly, on the rt. side.
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
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
POST OPERATIVE COURSE Un-eventful Closed suction drain removed on day 4 Pt. discharged on day 5 Skin staplers removed after 2 weeks
PRESACRAL/ RETRORECTAL TUMORS 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
Developmental cysts constitute most of congenital lesions
Dermoid and epidermoid are benign and arise from ectoderm
Enterogeneous cyst arise from primitive hindgut (endodermal)
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)
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
INVESTIGATIONS X-ray 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
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
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.