Tailgut cysts: report of two cases

Chinese expert consensus on standardized treatment for presacral cysts

Presacral cysts are cystic or cyst-solid lesions between the sacrum and rectum, almost involving adjacent pelvic floorstructures including sacrococcygeal fascia, rectum, and anal sphincter. Presacral cysts are usually benign, currently believed to arise from aberrant embryogenesis. Presacral cysts are clinically rare and the true incidence is unknown. Surgical resection remains the major treatment for presacral cysts. Unless the cysts are completely resected, recurrence is unavoidable. Recurrent cysts or hard-to-heal sinuses in the sacrococcyx cause patients extreme pain. However, the current knowledge of presacral cysts is insufficient. They are occasionally confused with other diseases such as ovarian cysts and perianal abscesses. Moreover, lack of the correct surgical concept and skills leads to palliative treatment for complex presacral cysts and serious complications such as impairing the function of the anal sphincter or important blood vessels and nerves. The consensus summarizes the opinions and experiences of multidisciplinary experts in presacral cysts and aims to provide clinicians with a more defined concept of the treatment, standardize the surgical approach, and improve the efficacy of presacral cysts.

Isolated lumbar intradural tailgut cyst: A case report and review of the literature

Tailgut cysts are rare developmental cysts arising from remnants of the embryological postnatal gut. Despite being frequently located in the presacral space, isolated cases of aberrant locations have been reported, including, perirenal, perianal, and subcutaneous sites, with only two cases of subdural tailgut cysts reported to date. The clinical course is often marked by linear growth, causing compression of the adjacent structures, however malignant transformation with carcinomatous features has been previously described. Hereby the authors describe a case of an intradural extramedullary tailgut cyst in a 33-year-old man presenting with progressive low back pain and signs of autonomic dysfunction, including urinary retention and bowel incontinence. Whole-spine MRI revealed an intrathecal cystic lesion located at L2-L3 level exhibiting hyperintensity on T2-weighted images not enhancing when contrast was administered. Laminectomy followed by tumor excision was performed and pathological analysis confirmed the diagnosis of tailgut cyst.

Adenocarcinoma in a Recurrent Retrorectal Cyst: A Case Report

I present a case of an adenocarcinoma in a retrorectal cyst in a 63-year-old female with a prior history of a congenital cyst excised as a newborn. The patient had a resection with positive margins, followed by chemotherapy and radiotherapy at progression. Her disease did not respond to chemotherapy or radiotherapy and she died with systemic manifestations related to her disease 28 months after diagnosis.

Single-center Experience of 24 Cases of Tailgut Cyst

Purpose

Tailgut cysts are rare congenital or developmental lesions that arise from vestiges of the embryological hindgut. They are usually present in the presacral space. We report our single-center experience with managing tailgut cysts.

Methods

We conducted a retrospective analysis of 24 patients with tailgut cyst treated surgically at the Colorectal Surgery Department of Severance Hospital, Yonsei University, Seoul, South Korea, between 2007–2018.

Results

This study included 24 patients (18 females) with a median age of 51.5 years (range, 21–68 years). Ten cases were symptomatic and 14 were asymptomatic. Cysts were retrorectal in 21 patients. Cysts were below the coccyx level in 16 patients, opposite the coccyx in 6, and above the coccyx in 2. Cysts were supralevator in 5 patients, had a supra- and infralevator extension in 18 patients, and were infralevator in 1. Ten patients were managed using an anterior laparoscopic approach, 11 using a posterior approach, and 3 using a combined approach. Mean cyst size was 5.5 ± 2.7 cm. Postoperative complications were Clavien-Dindo (CD) classification grade II in 9 patients (37.5%) and CD grade III in 1 (4.2%). The posterior approach group showed the highest rate of complications (P = 0.021). Patients managed using a combined approach showed a larger cyst size (P < 0.001), longer operation times (P < 0.001), and a greater likelihood of tumor level above the coccyx (P = 0.002) compared to other approaches. The tumors of 2 male patients were malignant: 1 was a neuroendocrine tumor treated with radiotherapy, while the other was a closely followed adenocarcinoma. Median follow-up was 12 months (range, 1–66 months) with no recurrence.

Conclusion

Tailgut cysts are uncommon but can cause perineal or pelvic pain. Complete surgical excision via an appropriate approach according to tumor size, location, and correlation with adjacent pelvic floor muscles is the key treatment.

Malignant transformation of tailgut cysts is significantly higher than previously reported: systematic review of cases in the literature

AIM

The best treatment for tailgut cysts has not been firmly established. We report a systematic review of the cases in the available literature in order to provide an evidence base for treatment.

METHOD

A systematic search of articles wholly or partly in English was made of PubMed, Embase and Google Scholar; additional studies were discovered by searching reference lists and contacting authors directly. Search terms 'tailgut cyst', 'tail gut cyst', 'retrorectal hamartoma' and 'retrorectal tumour' were used for case reports or case series; no publication date restrictions were imposed. Only studies with histological confirmation of diagnosis and reporting the age and gender of patients were included. Papers were excluded by consensus between the first two authors.

RESULTS

A total of 196 individual cases were analysed in detail including 51 cases of neoplasia. The overall rate of neoplastic transformation was 26.6%. Although the male:female cyst incidence ratio was 1:4, men over 18 had a significantly greater relative risk of neoplasm at 1.94 (P = 0.0055). Radiological evidence of nodular thickening of the cyst wall significantly increased the relative risk of the presence of cancer (P = 0.0023).

CONCLUSIONS

Current orthodoxy that these are not dangerous embryological remnants is unfounded and may be false. The available data suggest the risk of malignant transformation is high and will apply to any residual tissue after excision. The same rationale behind total mesorectal excision in rectal cancer applies to tailgut cysts. Consequently they should be resected with similar oncological margins.

Alcohol injection for nonsurgical management of tailgut cyst in a middle-aged woman: A case report

Managing recurrent tailgut cyst in a patient who is refraining from the definitive surgical en bloc resection can be challenging. Therefore, in this case report we outlined a less invasive approach which is computed tomography-guided aspiration with alcohol injection which resulted in prolongation of symptoms free period in our patient.

Tailgut cyst: report of three cases and review of the literature

INTRODUCTION

Tailgut cysts or retrorectal cystic hamartomas are congenital developmental lesions which are often misdiagnosed due to their rare incidence, anatomical position and variable clinical presentation.

CASE REPORT

We report three clinical cases: one of a 67-year old woman with high fever and anal bulging; the second case was a 50-year old woman with diffuse abdominal pain and the third case was a 52-year old woman with high fever and no abdominal or rectal pain. The rectal examination and MRI indicated the presence of a tailgut cyst. In all the cases a complete resection through a posterior perineal route was performed. Histopathological examination confirmed the diagnosis of a tailgut cyst, with a malignant component identified in the third case.

DISCUSSION

The discussion presents a brief review of the relevant information described in the literature to highlight the cornerstones for appropriate diagnosis and treatment of a tailgut cyst. Tailgut cysts are to be considered in the differential diagnosis of retrorectal or presacral masses as malignant transformation can occur.

Neuroendocrine carcinoma arising in a tailgut cyst

INTRODUCTION

A tailgut cyst, also called retrorectal cystic hamartoma, is a rare congenital lesion that forms most commonly in the retrorectal space. It is presumed to arise from remnants of early embryogenesis.

PRESENTATION OF CASE

The following report describes a unique case of a retrorectal cystic hamartoma in a 53 year-old French Canadian man with a history of low back pain. The tumour underwent malignant transformation into a well-differentiated neuroendocrine carcinoma three years after the beginning of symptoms.

DISCUSSION

This condition can be found at any age, but occurs especially among middle-aged women. Not only is it frequently misdiagnosed, but also several complications associated to the cyst have been reported such as infection and malignant transformation. This is why complete surgical excision of the tailgut cyst is currently recommended.

Diagnosis of Tailgut Cyst in Gynecologic Patients: Systematic Review of the Literature

Tailgut cysts, also called retrorectal cystic hamartomas, are rare findings that usually occur in the retrorectal space. The incidence is estimated to be about 1 in 40,000.

The aim of our review is to evaluate the potential pitfalls in the diagnosis of this rare pathologic condition, according to diagnostic procedures for this rare but misleading and subtle entity.

We conducted a Medline literature review of the English literature discussing tailgut cysts in female patients. We concentrated on imaging technology used for diagnosis in gynecologic patients. For our search, we used the key words “tailgut cyst”, “retrorectal cystic hamartoma”, “gynecology”, focusing on clinical presentation, imaging technology used for diagnosis, presence of malignancy, and misdiagnosis with more common gynecologic pathology.

Our search revealed 143 articles during the years 1975–2016 and, of these, 30 articles describing 91 female patients were considered.

We concluded that tailgut cyst should be included in the differential diagnosis of pelvic lesions in gynecologic patients.

A giant pararectal cyst successfully treated by robotic surgery

A 50 year-old patient was referred to our department with severe obstructive lower urinary tract symptoms, suprapubic pain and rectal fullness that started after a perianal fistula operation performed one year ago. Radiologic evaluation showed a large pararectal cystic lesion with septa formation on the right side compressing the bladder and prostate. Aspiration of the cystic fluid attempted initially but was not successful. A robotic transperitoneal approach was applied and the cyst was excised completely. On 1-year follow-up, patient did not have any symptoms and cyst was completely disappeared on radiology.

Treatment of tailgut cysts by extended distal rectal segmental resection with rectoanal anastomosis

PURPOSE

Complete surgical resection is the treatment of choice for tailgut cysts, because of their malignant potential and tendency to regrow if incompletely resected. We report our experience of treating patients with tailgut cysts, and discuss diagnostics, surgical approaches, and follow-up.

METHODS

We performed extended distal rectal segmental resection of the tailgut cyst, with rectoanal anastomosis. We report the clinical, radiological, pathological, and surgical findings, describe the procedures performed, and summarize follow-up data.

RESULTS

Two patients underwent en-bloc resection of a tailgut cyst, the adjacent part of the levator muscle, and the distal rectal segment, followed by an end-to-end rectoanal anastomosis. There was no evidence of anastomotic leakage postoperatively. At the time of writing, our patients were relapse-free with no, or non-limiting, symptoms of anal incontinence, respectively.

CONCLUSIONS

This surgical approach appears to have a low complication rate and good recovery outcomes. Moreover, as the sphincter is preserved, so is the postoperative anorectal function. This approach could result in a low recurrence rate.

A Rare Coexistence of Retrorectal and Ovarian Cysts: A Case Report

Introduction

Retrorectal cysts are rare benign lesions which are frequently diagnosed in middle-aged females. According to their origin and histopathologic features, retrorectal cysts are classified as squamous-lined (dermoid or epidermoid) cysts, postanal gut (tailgut) cysts, and rectal duplications (enteric or enterogenous cysts, enterocystomas). Described in this case report is an extremely unusual patient, a woman who simultaneously had a retrorectal cyst and an ovarian serous cystadenoma in addition to a long history of misdiagnosis and multiple unsuccessful surgeries.

Case Presentation

The patient was a 45-year-old female who presented with back pain, rectal fullness, constipation, and urinary symptoms. Upon her first pregnancy, a cystic pelvic mass had been misdiagnosed as an ovarian cyst. During the following 17 years, she had undergone several ineffective operations. The last CT scan and MRI studies revealed two separate noncalcified, unilocular, cystic lesions with well-defined borders in the retrorectal and retroperitoneal spaces. Two cysts were excised completely by a combined abdominoperineal approach. Pathological assessment revealed a dermoid cyst and an ovarian serous cystadenoma. No complications occurred during the 18 months of follow-up.

Conclusions

Coexistence of a retrorectal cyst and a serous cystadenoma is very unusual. Retrorectal cysts are rare entities that remain a difficult diagnostic and therapeutic challenge. Misdiagnosis and multiple unsuccessful surgeries are common. Complete surgical removal is the treatment of choice and requires a multidisciplinary approach in complicated cases.

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.

A Tailgut Cyst Diagnosed by Endoscopic Ultrasound-Guided Fine-Needle Aspiration

Tailgut cysts are rare developmental cysts. Surgery has been the primary method of diagnosis and treatment of these cysts, but endoscopic ultrasound (EUS) has recently been used to establish diagnosis. Only 2 cases of tailgut cyst diagnosed by EUS-guided FNA have been reported. We present a woman in her fourth decade who presented for evaluation of perirectal mass. EUS-guided fine-needle aspiration (FNA) helped establish the diagnosis of tailgut cyst. The patient opted for observation rather than surgery.

Fine needle aspiration cytology diagnosis of tailgut cyst: a rare entity

BACKGROUND

Tailgut cyst is a rare tumor believed to originate from small portions of the embryonic tailgut, which normally disappear in early fetal development. It is often misdiagnosed due to the general unfamiliarity with this entity and also because of its clinical presentation similar to other more common diseases such as perianal fistulas and abscesses.

CASE

The authors take this opportunity to report a case of tailgut cyst in a 21-year-old Saudi female. The patient had presented with painful low back swelling, which had been gradually increasing in size. The case was diagnosed by fine needle aspiration cytology (FNAC) as tailgut cyst and later confirmed by histopathology.

CONCLUSION

Tailgut cysts are congenital cystic hamartomatous lesions, which are rare in occurrence. They are generally benign, but malignancy has also been reported, which is even rarer in occurrence. FNAC is an effective diagnostic tool, which if applied appropriately can be used for the early detection of rarer lesions such as tailgut cyst.

Transitional cell carcinoma of the retrorectal space arisen in tailgut cyst: a case report and review of the literature

Tailgut cysts, also known as retrorectal cystic hamartomas, are congenital lesions derived by an abnormal remnant of the postanal primitive hindgut, consisting of unilocular or multilocular cysts usually lined by squamous, transitional, or glandular epithelium. Malignant transformation is an uncommon event, and it mainly involves the neuroendocrine or glandular epithelium; other histotypes are sporadic. Here, we report, for the first time, the clinicopathological features of a transitional cell carcinoma that arose in a tailgut cyst.

Adenocarcinoma associated with tail gut cyst

Primary adenocarcinomas of the presacral (retrorectal) space are rare. The diagnosis is usually delayed because of non-specific symptoms, and is made after a biopsy or surgery. These carcinomas arise from cystic lesions developing from remnants of the embryological postanal gut containing mucous-secreting epithelium, known as tail gut cysts. The potential for infection, perianal fistulas and most importantly, malignant change warrants an early complete surgical resection. From an oncologist's perspective, the management of these carcinomas has varied, and has included adjuvant chemotherapy and/or radiation therapy. We describe here a rare case of adenocarcinoma associated with a tail gut cyst that was discovered incidentally and resected by a posterior approach (Kraske procedure). The patient has had clinical and periodic radiologic surveillance without any evidence of cancer recurrence for over a year and a half.

Tailgut cyst: A case report in a 9-month-old infant

INTRODUCTION

Tailgut cysts or retrorectal cystic hamartomas are rare developmental anomalies that are believed to arise from the embryonic hindgut.

PRESENTATION OF CASE

9 months old male infant was presented with swelling in the right gluteal region. MRI lumbo-sacral spine showed well defined round to oval lesion which is brightly hypertense on T2W1 and hypotense on T1W1 posterior to sacrum and coccyx with no evidence of connection to the thecal sac indicating cyst. Complete excision of the cyst was done. Histopathology report shows cyst wall partially lined with stratified squamous epithelium and cyst wall shows spaces lined by cuboidal epithelium and nerve bundles with no evidence of malignancy suggestive of tailgut cyst.

DISCUSSION

Tailgut cysts are rare congenital anomalies. Most commonly located in the retrorectal space. They are thought to be derived from the remnants of the embryonic hindgut. Age ranges from 4 to 73 years but an average presentation is at 35 years. Female to male ratio is 3:1. MRI is a good diagnostic tool for diagnosis of tailgut cyst. Complete surgical excision is the treatment of choice as this provides a definite diagnosis and prevents possible complications such as infection, fistula formation and malignant degeneration.

CONCLUSION

The aim of presenting this case is its rarity. Complete surgical excision is the treatment of choice. Preoperative imaging with MRI is essential to plan the most appropriate surgical approach.

Acute urinary retention and obstipation: a rare cause…

Tailgut cysts are rare congenital anomalies, believed to be remnants of the primitive embryonic hindgut. In addition to causing genitourinary and bowel obstructive symptoms, they have been reported to harbour occult adenocarcinoma. Varying positions of a tailgut cyst with respect to the rectum have also been reported in literature. We present a rare presentation of this disease vis a vis obstipation and acute urinary retention in a 70 year old man.

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.

Laparoscopic management of tailgut cyst: case report and review of literature

Tailgut cyst, also called retrorectal hamartoma, is a rare congenital lesion that arises from the remnants of the postanal primitive gut and is usually located anterior to the sacrum and posterior to the rectum. It is usually asymptomatic or demonstrates mass effects, and preoperatively is frequently misdiagnosed as adnexal tumor. Treatment is complete surgical resection. The English-language literature contains only limited reports of the laparoendoscopic approach to retrorectal cystic tumor and tailgut cyst. Herein, we report our experience with successful laparoscopic management of a tailgut cyst, discuss the laparoscopic resection technique, and present a review of the literature.

Diagnosis and treatment of retrorectal cyst: a report of 23 cases

AIM: To explore the clinical characteristics, diagnosis and therapy of retrorectal cyst.

METHODS: The clinical data for 23 patients with retrorectal cyst treated at our hospital from September 1995 to July 2007 were retrospectively analyzed.

RESULTS: Of all patients, 17 presented varying degrees of symptoms of oppression, and 6 were asymptomatic on routine anal examination or ultrasound examination; 13 were treated via a single abdominal approach, 6 via a single posterior approach, and 4 via a combination of the abdominal and posterior approaches; 19 underwent total cyst resection, and 4 underwent partial resection; 4 had massive bleeding, and 3 had rectal injury during operation. None of them died during operation.

CONCLUSION: Digital rectal examination and imaging examination are important for the diagnosis of retrorectal cyst and the choice of surgical approach. Adequate preoperative preparation and suitable surgical approach is essential for successful surgery.