Squamous cell carcinoma arising from a presacral epidermoid cyst: CT and MR findings

Cystic lesions of the retrorectal space

Cysts of the retrorectal space comprise a heterogeneous group of rare lesions. Most develop from embryological remnants and include tailgut cysts, dermoid cysts, rectal duplication cysts, anal canal duplication cysts, sacrococcygeal teratomas and anterior meningocoele. Tailgut cyst is the most common cyst of developmental origin, usually presenting as a multilocular cystic mass with mucoid content and lined by multiple epithelial types. Compared with tailgut cysts, rectal duplication cysts display all layers of the large bowel wall including a well-defined muscularis propria. Retrorectal cysts of non-developmental origin are far less common and represent lesions that either infrequently involve the retrorectal space or undergo extensive cystic change. This review provides an overview of the various histological types of cystic lesions of the retrorectal space, divided into cysts of developmental origin and those of non-developmental origin. A practical pathological and multidisciplinary approach to diagnosing these lesions is presented.

Establishment and Verification of a Prediction Model for Identifying Pathologic Infections Based on the Clinical Characteristics of Epidermoid Cysts

Background: To construct a prediction model based on the clinical characteristics of epidermoid cysts to identify pathologic infections, evaluate the diagnostic accuracy of the model, and conduct preliminary verification. Patients and Methods: We conducted a retrospective analysis of 314 patients diagnosed with epidermoid cysts that had been removed surgically. The clinical and pathologic data of all patients were collected. The patients were divided randomly into modeling group and verification group in a 75:25 ratio. In the modeling group, the multifactor logistic regression method was used to construct a prediction model for identifying epidermoid cyst pathologic infection, and the receiver operating characteristic (ROC) curve was used to evaluate the diagnostic accuracy of the model, which was then validated in the verification group. Results: All 314 patients with epidermoid cysts were divided into non-infected group (183 cases) and infected group (131 cases) according to the pathologic results. Logistic regression analysis showed that the disease course, growth trend, redness, and texture of epidermoid cysts were independent factors affecting pathologic infection. The above four indicators were selected to construct the prediction model of epidermoid cyst pathologic infection. In the modeling group, the prediction model showed an area under the curve (AUC) of 0.898, with the sensitivity of 0.830, specificity of 0.890, positive likelihood ratio of 7.523, and negative likelihood ratio of 0.191. The AUC of the prediction model in the verification group was 0.919, which was not significantly different from that of the modeling group (p = 0.886). Conclusions: The prediction model based on the clinical characteristics of epidermoid cysts had good diagnostic accuracy and high specificity; it can be used to identify pathologic infections of epidermoid cysts.

Surgical management of large, connected perineal and pelvic epidermal inclusion cysts mimicking a dumbbell-shaped lesion in an adult male

INTRODUCTION AND IMPORTANCE

Epidermal inclusion cysts are a common benign finding, and they are predominantly asymptomatic. They can rarely form in the pelvis or abdomen, however, and may cause symptoms secondary to mass effect. This case highlights management of an anterectal epidermal inclusion cyst connected to the perineal cyst, mimicking a dumbbell-shaped lesion, found in a male.

CASE PRESENTATION

This is a unique case of a 21-year-old Caucasian male with a palpable perineal mass, lower extremity hypoesthesia, and constipation who was found to have a complex-shaped cyst on computed tomography and magnetic resonance imaging. This was ultimately managed with a two-stage perineal and transabdominal resection.

CLINICAL DISCUSSION

This case highlights that perineal epidermal inclusion cysts may have pelvic extension, especially in patients with additional new-onset neurologic, gastrointestinal, or urologic symptoms. These symptoms should completely resolve after resection. Additionally, resection is recommended to prevent complications including malignant degeneration and fistulization.

CONCLUSION

This is the first reported case of an anterectal, epidermal inclusion cyst connected to a perineal cyst found in a male. Perineal and pelvic cysts may be synchronous and may be connected through the pudendal canal. These masses can be safely removed via a combined perineal and transabdominal resection. The connecting portion of lesions that have both pelvic and perineal components should be meticulously identified and dissected because even a thin, patent segment - if left unresected - may result in lesion recurrence.

Cecal epidermoid cyst: a neonatal case with clinicopathological consideration

Background

Only 10 cases of cecal epidermoid cyst (CEC) have been reported in the literature. Furthermore, its pathogenesis remains unclear. We report a rare case of congenital CEC in neonate, and discuss its clinicopathological findings.

Case presentation

A cystic lesion was incidentally identified in the retroperitoneal area of the abdominal right lower quadrant during a routine prenatal ultrasonography (US), prompting an ileocolectomy 3 days after birth. This congenital cyst was composed of mucosal lining cells and submucosal connective tissues, and the inner lining mucosa was composed of stratified squamous epithelium and focally mucin-producing ciliated epithelium. Based on the macroscopic and microscopic findings, the cystic lesion was diagnosed as a congenital cecal epidermoid cyst.

Conclusions

The management of a fetal abdominal mass should be tailored individually, considering that epidermoid cysts can occur in the cecum during the perinatal period. We report the clinicopathological findings in this case, including its possible pathogenesis.

Squamous Cell Carcinoma Malignantly Transformed From Frequent Recurrence of a Presacral Epidermoid Cyst: Report of a Case

Backgroud: Presacral tumors are rare space occupying lesions that arise in the presacral space. The incidence of presacral tumor has been reported to be 1 in 40,000 to 63,000 patients. An even rarer occurrence is the transformation of a presacral tumor into a squamous cell carcinoma (SCC).

Case Summary: A 61 years old man was referred to our hospital for a palpable mass near anus and appeared repeatedly in last 10 years. The patient previously underwent two surgeries at another hospital. A posterior approach was implemented in the first two surgeries, and the diagnosis was benign presacral epidermoid cyst. Two months before his admission to our department in 2017, the patient complained of a mass measuring ~2 cm around his anus. Physical examination revealed a 2 cm mass at the 12 o'clock direction in chest-knee position. A digital rectal examination indicated a rubbery lesion located in the presacral space. The Pre-operative pelvic magnetic resonance imaging (MRI) confirmed the presence of a 6.8 cm * 5.2 cm * 7.3 cm mass located at the presacral space. In contrast phase, the center of the lesion exhibited homogenous density without enhancement. The mass was then excised via posterior para-sacral approach with pathological report showing a benign epidermoid cyst after operation. The patient was discharged with full recovery without fecal incontinence. Fifteen months after being discharged from our hospital, the patient discovered a recurrence at the original site of where the mass previously appeared. Unlike the previous instance, the mass was accompanied with swelling, pain, and localized increased skin temperature. Pelvic MRI showed a 3.2 cm * 7.2 cm * 5.8 cm located at the same place, with no enhance in the core of mass. However, a speckled enhancement was observed on the margin of the lesion. The lesion was completely resected using the same procedure as before with a pathological diagnosis of SCC. The patient underwent chemoradiation therapy and remained disease free for more than 1 year.

Conclusion: Although very rare, benign cyst from presacral space can become malignant transformation. This highlights the importance of pre-operative diagnostic tests and evaluation to correctly identify the source of the primary cancer, which is crucial prior to starting adjuvant therapy.

Rare squamous cell carcinoma arising from a presacral epidermoid cyst: A case report

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Presacral epidermoid cysts are extremely rare and require further study.

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Thorough preoperative imaging evaluation is important for complete resection.

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Multidisciplinary treatments may be effective.

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Presacral epidermoid cysts may be malignant.

Introduction

Presacral epidermoid cysts are uncommon, usually benign cysts caused by developmental abnormalities in the fetal period. We present a rare case of squamous cell carcinoma arising from a presacral epidermoid cyst.

Presentation of case

A 59-year-old woman complained of tenesmus and discomfort in the buttocks. Computed tomography revealed a 50-mm well-defined cystic mass in the presacrum and a 70-mm solid mass extending from the cyst into the rectum, vagina, and left sciatic spine. On T1-weighted magnetic resonance images, the cyst was unilocular and the mass was marginated with low intensity. On T2-weighted images, the mass had high intensity. A malignant presacral developmental cyst was diagnosed, without obvious metastasis. Using abdominal and parasacral approaches, Hartmann’s operation was performed with multiorgan resection, including the sacrum, coccyx, left sciatic spine, internal obturator muscle, rectum, and uterine appendage. Histopathology of the excised specimen revealed a squamous cell carcinoma originating from the presacral epidermoid cyst.

Discussion

Reports of malignant transformation of epidermoid cysts in the presacral space, as in the present case, are extremely rare. Because of their unusual location and slow growth, epidermoid cysts tend to remain asymptomatic. Because the patient had a malignant tumor with suspected invasion of adjacent organs, combination surgery was selected.

Conclusion

Although further research is required, presacral epidermoid cysts are extremely rare and may be malignant. Thorough preoperative image evaluation is crucial for complete resection.

Laparoscopic Resection of Presacral Tumor: A New Approach in the Era of the Minimally Invasive Surgery

Presacral tumors are rare; however, once diagnosed, surgical resection is recommended even in asymptomatic patients as there is potential risk for growth or malignant transformation. Many different types of surgical approaches to resect presacral tumors have been reported including posterior, anterior, and combined abdominosacral approaches. With introduction of the minimally invasive approach, laparoscopic or robotic approaches to resect presacral tumors are reported increasingly. We report a case of successful anterior laparoscopic resection for a presacral mass that was incidentally diagnosed during management of pancreatitis.

Squamous Cell Carcinoma following Epidermoid Cyst in the Buttock

In the field of plastic surgery, subcutaneous masses in the buttocks are frequently observed. However, squamous cell carcinoma (SCC) after epidermoid cyst, which appears in the presacral space, is extremely rare. This report described a case of a 71-year-old woman, who previously received a skin incision by a doctor for treating a cystic lesion in the buttock; she was diagnosed with SCC by preoperative biopsy at the authors' department. In addition, computed tomography suspected that the tumor originated in the presacral space. Under general anesthesia, an extended resection of the malignant tumor with gastrointestinal surgery was performed. After resection, the defect of buttocks region was reconstructed with a V-Y advancement gluteus maximus myocutaneous flap. After pathological examination the tumor was diagnosed as SCC after epidermoid cyst; peplomycin sulfate at 50 mg/d was administered intramuscularly for 2 weeks as chemotherapy. No wound complications were observed after surgery, and no recurrence was noted for 5 years. For managing tumor in the gluteal region, a possibility of malignancy must be considered, and thorough radiographic studies must be pursued before surgery.

A Rare Case of Presacral Epidermoid Cyst in an Adult Male: Emphasis on Diffusion Weighted Magnetic Resonance Sequences in Preoperative Imaging

Epidermoid cyst of the presacral space is a rare congenital lesion of ectodermal origin. Presacral epidermoid cysts have been previously reported in women, however are extremely rare in males. We report a case of presacral epidermoid cyst in a 55-year-old male who presented to our emergency department with acute urinary retention and history of chronic constipation. A non-contrast computed tomography scan was performed with suspicion of urolithiasis, which revealed a well circumscribed low attenuation presacral mass. Magnetic resonance imaging (MRI) of the pelvis was subsequently performed to further characterize the lesion. The mass was returning hypointense T1 and hyperintense T2 signals with few foci of T2 hypointensities. There was no post-contrast enhancement; however the lesion was showing diffusion restriction, appearing hyperintense on diffusion weighted imaging (DWI) and hypointense on the corresponding apparent diffusion coefficient map. These imaging features were consistent with an epidermoid cyst. Laparotomy with complete surgical excision of the cyst and preservation of the adjacent structures was performed. The histopathology confirmed the diagnosis. This case highlights the importance of MRI with additional sequences of diffusion weighted imaging which can be helpful to differentiate, to a good degree of confidence, among different pelvic tumors, therefore obviating the need of biopsy before surgery.

Is Routine Pathologic Evaluation of Sebaceous Cysts Necessary?: A 15-Year Retrospective Review of a Single Institution

A question arose in our practice of whether all cysts considered sebaceous should be sent for pathologic evaluation. To address this controversial topic, we performed a retrospective study of our single institution's histopathology database. A natural language search of the CoPath database across the institution was undertaken using the diagnosis of sebaceous cyst, epidermal cyst, epidermoid cyst, epithelial cyst, infundibular cyst, pilar cyst, trichilemmal cyst, and steatocystoma. A surgical pathologic review of all specimens with one of these preexcision diagnoses was included in the 15-year retrospective study of 1998 to 2013. All slides were confirmed to have undergone histopathologic review, and the preexcision diagnoses were compared with the postexcision diagnoses. Chart review was undertaken in instances of a diagnosis of malignancy. A total of 13,746 samples were identified. Forty-eight specimens had histopathologic diagnosis of malignancy, for an incidence of 0.3% and with the most common malignancy being squamous cell carcinoma. Chart review showed that for all cases, the surgeons reported uncertainty with regard to the diagnosis because of history or physical characteristics, or both. In addition, a comprehensive literature review showed results consistent with our data and illustrated 19 cases during the past 10 years in which most of the findings were squamous cell carcinoma. We propose the recommendation that routine pathologic evaluation of sebaceous cysts is necessary only when clinical suspicion exists.

Bi-lobed Perirectal Epidermoid Cyst: An Unusual Cause of Hematochezia in a Middle-aged Woman

Perirectal epidermoid cysts are congenital cysts originating from the ectodermal germ cell layer of the hind gut. Their presenting symptoms are most often nonspecific and distinguishing them from other presacral developmental cysts often present a diagnostic and therapeutic dilemma. We present a 58-year-old woman who presented with chronic dyschezia and hematochezia of a few days duration and no prior colonoscopies. Initial blood work and tumor markers were unremarkable. Pelvic magnetic resonance imaging (MRI) showed a 7.5 cm × 5 cm × 6 cm homogenous bi-lobed cystic mass in the pelvis adherent to the left lateral wall of the rectum and posteriorly to the sacrum with a displacement of the rectum anteriorly and to the right. There was no pelvic sidewall adenopathy or free fluid in the pelvis. Preoperative colonoscopy showed rectal compression with no rectal involvement of the mass. The cyst was successfully resected posteriorly via the trans-sacrococcygeal approach. An intraoperative proctosigmoidoscopy confirmed an intact rectum. The patient remains recurrence-free 1 year postsurgical resection.

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.

Retrorectal tumors in adults: Magnetic resonance imaging findings

AIM: To retrospectively evaluate the magnetic resonance imaging (MRI) features of adult retrorectal tumors and compare with histopathologic findings.

METHODS: MRI features of 21 patients with preoperative suspicion of retrorectal tumors were analyzed based on the histopathological and clinical data.

RESULTS: Fourteen benign cystic lesions appeared hypointense on T1-weighted images, and hyperintense on T2-weighted images with regular peripheral rim. Epidermoid or dermoid cysts were unilocular, and tailgut cysts were multilocular. Presence of intracystic intermediate signal intensity was observed in one case of tailgut cyst with a component of adenocarcinoma. Six solid tumors were malignant lesions and showed heterogeneous intensity on MRI. Mucinous adenocarcinomas showed high signal intensity on T2-weighted and mesh-like enhancing areas on fat-suppressed T2-weighted images. There was a fistula between the mass and anus with an internal opening in mucinous adenocarcinomas arising from anal fistula. Gastrointestinal stromal tumors displayed low signal intensity on T1-weighted images, and intermediate to high signal intensity on T2-weighted images. Central necrosis could be seen as a high signal on T2-weighted images.

CONCLUSION: MRI is a helpful technique to define the extent of the retrorectal tumor and its relationship to the surrounding structures, and also to demonstrate possible complications so as to choose the best surgical approach.