Strategy of surgical treatment of sacral neurogenic tumors

A rare case of giant pelvic retroperitoneal schwannoma

This report highlights the successful treatment of large pelvic schwannomas and underscores the importance of preoperative embolization. A 40-year-old male presented with a lower abdominal mass and reported pain and numbness in the left lower limb attributed to nerve compression. Preoperative embolization of the main feeding vessels was performed to mitigate intraoperative bleeding. The tumor was completely excised during surgery, with preservation of the hypogastric nerve. Histopathological examination confirmed the diagnosis of schwannoma. We underscore the significant role of preoperative embolization in effectively managing large pelvic tumors, such as schwannomas, by reducing the risk of excessive bleeding.

The management of retrorectal tumors - a single-center analysis of 21 cases and overview of the literature

AIM

Retrorectal tumors are rare and heterogeneous. They are often asymptomatic or present with nonspecific symptoms, making management challenging. This study examines the diagnosis and treatment of retrorectal tumors.

METHODS

Between 2002 and 2022, 21 patients with retrorectal tumors were treated in our department. We analyzed patient characteristics, diagnosis and treatment modalities retrospectively. Additionally, a literature review (2002-2023, "retrorectal tumors" and "presacral tumors", 20 or more cases included) was performed.

RESULTS

Of the 21 patients (median age 54 years, 62% female), 17 patients (81%) suffered from benign lesions and 4 (19%) from malignant lesions. Symptoms were mostly nonspecific, with pain being the most common (11/21 (52%)). Diagnosis was incidental in eight cases. Magnetic resonance imaging was performed in 20 (95%) and biopsy was obtained in 10 (48%). Twenty patients underwent surgery, mostly via a posterior approach (14/20 (70%)). At a mean follow-up of 42 months (median 10 months, range 1-166 months), the local recurrence rate was 19%. There was no mortality. Our Pubmed search identified 39 publications.

CONCLUSION

Our data confirms the significant heterogeneity of retrorectal tumors, which poses a challenge to management, especially considering the often nonspecific symptoms. Regarding diagnosis and treatment, our data highlights the importance of MRI and surgical resection. In particular a malignancy rate of almost 20% warrants a surgical resection in case of the findings of a retrorectal tumour. A local recurrence rate of 19% supports the need for follow up.

Surgical Management of Lumbosacral Plexus Tumors

BACKGROUND

Lumbosacral plexus tumors are uncommon, and because of their deep location and proximity to critical nerves subserving lower extremity function, understanding surgical approaches and short-term outcomes is important.

METHODS

In a retrospective case series of lumbosacral plexus tumor surgeries performed from May 2000 to July 2021 by a single neurosurgeon, demographic information, clinical presentation, imaging studies, and operative outcomes were analyzed.

RESULTS

A total of 42 patients with mean age of 48.3 years (range, 16-84 years) underwent surgery for a lumbosacral plexus tumor. Patients presented with leg pain (n = 25; 59.5%), followed by back/flank pain (n = 5; 11.9%), abdominal/pelvic pain (n = 5; 11.9%), leg weakness (n = 5; 11.9%), and leg numbness (n = 3; 7.1%). The most common tumor pathology was schwannoma (n = 20; 50.0%) followed by neurofibroma (n = 9; 22.5%). A retroperitoneal approach was used in all cases. Gross total resection was achieved in 23 (54.8%) patients, and only 1 (2.4%) patient exhibited symptomatic tumor recurrence after subtotal resection of a malignant tumor. Mean follow-up was 33.1 months (range, 1-96 months). Postoperatively, patient neurological status remained unchanged or improved (n = 37; 88.1%). Complications were infrequent, with 4 (9.5%) patients experiencing new sensory symptoms and 1 patient (2.4%) experiencing new anticipated motor weakness after en bloc resection of a malignant tumor.

CONCLUSIONS

Indications for surgery include pain and/or neurological symptoms attributable to the lesion or large size if asymptomatic. Careful study of preoperative imaging is necessary to determine the best approach. Intraoperative nerve stimulation is essential to preserve function and guide extent of resection in benign tumors.

Association between intraoperative fluid overload and postoperative debridement in major sacrum tumor resection: A propensity score matching study

Intra-aortic balloon occlusion (IABO) is used to reduce intraoperative bleeding and facilitate successful sacrum tumor resection. Up to 20% of patients experience postoperative wound healing problems, but the risk factors related to this complication have not been clearly defined. The anesthetic database of Peking University People's Hospital, Beijing, China, was searched for all patients (aged 14-70 years old) who underwent sacrum tumor surgery with the application of IABO from 2014 to 2017. Data from 278 patients with an aortic occlusion duration of 72 ± 33 minutes were collected. Fifty-six patients required postoperative debridement because of wound infection. The independent risk factor identified by logistic regression was fluid excess (calculated as volume infused minus blood loss and urine output divided by body weight [kg]), and decision tree analysis revealed that the cutoff point for fluid excess was 38.5 mL/kg. Then patients were then divided into high fluid excess group (fluid excess > 38.5 mL/kg) and low fluid excess group (fluid excess ≤ 38.5 mL/kg) and 91 pairs of patients were generated through propensity score matching (PSM). Fluid excess was significantly higher in the high fluid excess group (46 vs 30 mL/kg, P < .001), and more patients required postoperative debridement than in the low fluid excess group (24 (26.3%) vs 12 (13.1%), P < .001). In this retrospective PSM study on sacrum tumor resection, fluid overload was related to postoperative debridement and further studies are needed to improve the clinical prognosis.

Surgical Management of Symptomatic Lumbar, Sacral, and Lumbosacral Plexus Tumors: a Peripheral Nerve Unit Experience

OBJECTIVE

Data concerning the surgical treatment of lumbosacral plexus tumors (LSPTs) is scarce. This study aims to present our experience with a series of 19 patients surgically treated for symptomatic LSPTs at our institution.

METHODS

This is a retrospective study of 19 patients surgically treated for symptomatic LSPTs from 2011 to 2019. Clinical data were retrieved from medical records and consisted of age, gender, clinical presentation, location of the lesion, surgical approach, final histopathologic diagnosis, follow-up time, outcomes, and complications.

RESULTS

Nineteen surgical procedures were conducted. Thirteen patients were female and six, male. The median age of patients was 45 years (range 20 to 63 years). No patients harbored genetic syndromes. Surgical treatment appears to be correlated to the reduction of pain in patients with peripheral nerve sheath tumors (PNSTs), as assessed by visual analog scale (VAS). Sixteen patients did not present with new-onset deficits during follow-up (84.2%), two of whom recovered from their preoperative deficit. Four patients presented with postoperative weakness. The histopathological diagnoses were 11 schwannomas, four neurofibromas, three metastases, and one lymphoma.

CONCLUSIONS

LSPTs are rare. When surgical treatment is indicated, it usually requires multidisciplinary management. Surgery appears to be effective concerning the reduction of pain in PNSTs and may also recover neurological deficits. Iatrogenic neurological deficits are an evident risk, such that intraoperative multimodal monitoring should always be performed if available. In lesions involving the sacral plexus, we found it to be indispensable.

[Resection of S1 root schwannoma with extravertebral retroperitoneal spread via posterior median and laparoscopic approach]

The authors report simultaneous surgical treatment of the right S1 root schwannoma with extravertebral retroperitoneal spread. Well-equipped operating theatre, professional experience and multidisciplinary approach involving neurosurgeons and abdominal surgeons ensure total minimally invasive simultaneous resection of schwannoma via posterior median and laparoscopic approach.

Surgical Strategy for Sacral Tumor Resection

PURPOSE

This study aimed to present our experiences with a precise surgical strategy for sacrectomy.

MATERIALS AND METHODS

This study comprised a retrospective review of 16 patients (6 males and 10 females) who underwent sacrectomy from 2011 to 2019. The average age was 42.4 years old, and the mean follow-up period was 40.8 months. Clinical data, including age, sex, history, pathology, radiographs, surgical approaches, onset of recurrence, and prognosis, were analyzed.

RESULTS

The main preoperative symptom was non-specific local pain. Nine patients (56%) complained of bladder and bowel symptoms. All patients required spinopelvic reconstruction after sacrectomy. Three patients, one high, one middle, and one hemi-sacrectomy, underwent spinopelvic reconstruction. The pathology findings of tumors varied (chordoma, n=7; nerve sheath tumor, n=4; giant cell tumor, n=3, etc.). Adjuvant radiotherapy was performed for 5 patients, chemotherapy for three, and combined chemoradiotherapy for another three. Six patients (38%) reported postoperative motor weakness, and newly postoperative bladder and bowel symptoms occurred in 5 patients. Three patients (12%) experienced recurrence and expired.

CONCLUSION

In surgical resection of sacral tumors, the surgical approach depends on the size, location, extension, and pathology of the tumors. The recommended treatment option for sacral tumors is to remove as much of the tumor as possible. The level of root sacrifice is a predicting factor for postoperative neurologic functional impairment and the potential for morbidity. Pre-operative angiography and embolization are recommended to prevent excessive bleeding during surgery. Spinopelvic reconstruction must be considered following a total or high sacrectomy or sacroiliac joint removal.

Preliminary investigation of bilateral internal iliac artery ligation and anterior tumor separation through laparoscopy before posterior resection of a giant sacral tumor

BACKGROUND

Surgical is the optimal therapeutic strategy for sacral tumors, and complete resection can effectively improve the recurrence and survival rates. However, the specialized anatomy, massive bleeding and adhesion to the anterior tissue, especially that caused by giant sacral tumors, makes complete resection difficult. The laparoscopic technique provides a new method to resect sacral tumors.

METHODS

34 patients with primary giant sacral tumors who underwent surgical resection were enrolled. After bilateral internal iliac artery ligation and anterior laparoscopic tumor separation, the sacral tumors were successfully resected posteriorly. The clinical, radiological and follow-up data were collected and analyzed.

RESULTS

The average operative time was 276.47 min and that for laparoscopy was 76.24 min. The average intraoperative blood loss was 1757.64 ml. No complications associated with laparoscopic surgery, such as intestinal, urinary tract, or vascular injuries, occurred. Ten patients (29.41%) had perioperative complications, including infection, unhealed wounds, and cerebrospinal fluid leaks in 10, 5 and 2 patients, respectively. Patients with complications had significantly longer total (55.00 ± 34.53 vs 25.13 ± 14.60, P = 0.001) and postoperative (39.10 ± 30.61 vs 14.83 ± 10.00, P = 0.002) hospitalization stays than patients without complications. Postoperatively, bowel and bladder dysfunction, intestinal obstruction, pain, and perianal numbness occurred in 21, 5, 8, and 2 patients, respectively. The recurrence rate was 11.76%.

CONCLUSIONS

Laparoscopically assisted sacral tumor resection is a technically feasible and effective surgical method to resect giant sacral tumors, with the advantages of reduced operative blood loss during internal iliac artery ligation and anterior tumor separation.

Desmoid Tumor Presenting as a Typical Cervical Dumbbell Tumor:A Case Report and Literature Review

BACKGROUND

Dumbbell-shaped tumor is a type of the inner and outer cervical spinal canal tumor, and most of them are neurogenic tumors. Desmoid tumor is a rare tumor, and no case of them involving intervertebral foramen formed dumbbell-shaped in cervical spine have been reported before in English literature. Here we report a case of desmoid tumor arising in the cervical spine which is presented as typical dumbbell-shaped tumor.

CASE DESCRIPTION

A 47-year-old female was admitted to our department with a mass in her left neck. The tumor was initially thought to be a neurogenic cervical dumbbell tumor based on physical and radiological examination. Postoperative HE and immunohistochemical staining verified the diagnosis of a cervical dumbbell desmoid tumor, which had never been reported before. We report our experience and reviewed literature about desmoid tumor to share our experience and explore proper treatment option of such lesion.

CONCLUSION

Desmoid tumors in the head and neck may present as cervical dumbbell-shaped tumors. Before the treatment plan was undertaken, thorough examinations including surgical pathology were necessary.

Surgical treatment of primary solitary fibrous tumors involving the pelvic ring

The surgical treatment of primary solitary fibrous tumors (SFT) involving the pelvic ring has not been reported previously. In this study, we aimed to evaluate the efficacy of surgical treatment for this disease. From 2009 to 2015, 13 patients underwent tumor resection at our hospital, with an average age of 49.5 years (27–68 years). Four patients underwent en bloc resection, and 9 patients underwent piecemeal resections. A Chi-square test was used to compare the postoperative recurrence rates between the en bloc resection and the piecemeal resection groups (p = 0.68), and no significant difference was found between the benign and malignant solitary fibrous tumor groups (p = 0.44). The 5-year survival rate of the patients in this study was 83.3%, and the 5-year progression-free survival rate was 63.5%. The progression-free survival rate was not significantly different between the en bloc resection and piecemeal resection groups (p = 0.97). Piecemeal resection can also achieve acceptable local control, particularly for patients with sacral tumors, as they may achieve even better postoperative function with sacral nerve preservation. Recurrence and metastasis occur relatively late in the course of this disease. Therefore, long-term follow-up is required.

The extended posterior approach for resection of sacral tumours

PURPOSE

The conventional posterior approach is mostly advocated for excision of sacral tumours below S2. We describe an operative technique of single-stage en bloc resection of sacral tumours, extending up to S1, through an extended posterior approach.

METHOD

Nine patients, who had undergone resection of sacral tumours, by the described technique formed the basis of this study. Four patients had chordomas, whereas schwannoma, neurilemmoma, giant-cell tumour, malignant paraganglioma and recurrent Ewing's sarcoma were seen in one patient each. They were followed up at regular intervals with a mean follow-up of 45.4 months. Perioperative complications, their functional and oncological outcomes at final follow-up were analysed.

RESULT

None of the patients had any perioperative complications like uncontrolled haemorrhage, injury to the rectum, deep vein thrombosis or pulmonary embolism. One patient had a superficial wound infection which subsided with regular dressing, and another patient developed a wound breakdown that required an additional flap procedure. At final follow-up, six patients were able to walk without any assistive devices, six patients had normal bladder function, and five patients had normal bowel function. Five patients did not have any recurrence at final follow-up, whereas two were alive with the disease and two had died.

CONCLUSION

The reported technique allows en bloc resection of sacral tumours up to S1, through a posterior-only approach. It is less invasive with minimal morbidity. The functional and oncological outcomes are similar to those reported by other investigators. These slides can be retrieved from electronic supplementary material.

Single Stage Posterior Approach for Total Resection of Presacral Giant Schwannoma: A Technical Case Report

The neurogenic tumor of frequent occurrence in the presacral area is a schwannoma. Giant presacral schwannoma has a risk for anterior surgical approach because of its massive size and proximity to abundant vascularity of presacral region. We report a single stage posterior approach for total resection of a giant presacral schwannoma. A 40-year-old female patient experienced left buttock pain and tingling sensation at left S1 dermatome. Magnetic resonance imaging showed that the presacral huge mass at S1–3 level with osseous extension and structural remodeling in left sacral ala. The presacral mass was ranging in maximum diameter from 8.0 to 8.6 cm. S2 foramen laminectomy was performed to expose the mass. The tumor capsule and the root were carefully dissected away. The tumor was removed while preserving the capsule by dissecting the plane between the inner wall of the capsule and the tumor. The single stage posterior approach for presacral giant schwannoma is feasible, and it can be a good surgical alternative to prevent pelvic organ or vascular damage and anterior approach related dystocia and infertility.

Surgical Treatment of Sacral Neurogenic Tumor: A 10-year Experience with 64 Cases

OBJECTIVE

To explore the outcomes of surgical treatment of sacral neurogenic tumors

METHODS

Between 1 January 2003 and 31 December 2012, data on 64 patients with sacral neurogenic tumors treated with surgery were retrospectively analyzed. The mean age of the 64 cases (35 males and 29 females) was 37.2 years (range, 21-69 years); 38 had neurilemmomas and 26 neurofibromas. Thirty-four of the tumors involved S 1 and S 2 , 11 S 3 or lower, and 19 were single presacral soft tissue masses. Tumors were removed via anterior, posterior or combined anteroposterior approaches. Patients with unstable sacroiliac joints underwent iliolumbar fixation.

RESULTS

Depending on the extent of tumor involvement, one of three surgical approaches was used: a single anterior approach (19 patients), single posterior approach (25 patients), or a combined anteroposterior approach (20 patients). The mean operation time was 3 h (range, 2-6 h) and the mean blood loss 878 mL (range, 400-3120 mL). The mean duration of follow-up was 58.2 months (range, 24-93 months). These surgeries had the following complications. Three patients had massive intraoperative hemorrhage and posterior back pain and discomfort postoperatively. One patient had intraoperative ureteral injuries requiring intraoperative ureteral catheterization. In two patients, the tumor involved the S 1 nerve roots bilaterally, necessitating their removal, which resulted in obvious lower limb motion and sphincteric dysfunction. In 13 patients with unilateral tumor involvement of the nerve roots of S 1 and lower spinal levels, only the contralateral nerve roots of the S1 and lower levels were preserved; eight of these patients had impaired bladder and bowel function. Posterior incisions failed to heal in 10 patients, secondary wound healing occurred in nine of them and one required a gluteus maximus myocutaneous flap. Three patients developed postoperative cerebrospinal fluid leaks that were and alleviated by waist belt compression bandaging and placing them in the Trendelenburg position. Eight patients developed tumor recurrences postoperatively; pathological examination of the tissue excised in the second surgeries revealed malignant changes in the three patients with neurilemmomas. There were no intraoperative deaths. Rod fractures occurred in three of the 18 patients requiring iliolumbar reconstruction.

CONCLUSIONS

The clinical characteristics of sacral neurogenic tumors make them easy to diagnose. The approach to resection should be determined by the location and size of the tumor. Patients with huge tumors may lose considerable blood intraoperatively and a have higher risk rate of postoperative complications.

Gelfoam embolization or 125I seed implantation may be a more effective treatment than surgical treatment for giant benign sacral neurogenic tumors

Background

The goal of the present study was to assess the effects of computed tomography (CT)-guided iodine-125 (¹²⁵I) seed implantation or gelatin sponge particle (GSP) embolization on patients with giant benign sacral neurogenic tumors.

Methods

A total of 24 cases with giant sacral neurogenic tumor were performed in a retrospective study between 2000 and 2012. Nineteen cases received surgical resection, and five cases received non-surgical treatment. In surgical group, patients with type III sacral tumor had received a combined anterior-posterior approach and patients with type IV were treated with simple anterior approach. In non-surgical group, CT-guided ¹²⁵I seed implantation or GSP embolization was applied to occlude vessels. Besides, CT scanning or magnetic resonance imaging was used to assess the size and development of tumors.

Results

Two of the five patients were treated three times with GSP embolization, one had received GSP embolization combined with CT-guided ¹²⁵I seed implantation, one case did not receive any treatment, and one patient was lost to follow-up. Patients in non-surgical group were followed up for 2–8 years.

Conclusions

Our study suggested that CT-guided ¹²⁵I seed implantation or GSP embolization treatment is very useful to slow down the development of giant benign sacral neurogenic tumors.

Total sacrectomy for low-grade malignant peripheral nerve sheath tumour: a case report

We report on a 58-year-old woman who underwent total sacrectomy and spinopelvic reconstruction for a low-grade malignant peripheral nerve sheath tumour involving the sacrum. One week later, she developed deep wound infection, and the entire spinopelvic reconstruction was removed. At the 36-month followup, the patient had no pain and was able to walk with a walking frame. There was no sign of recurrence or metastasis.

Sacrococcygeal sinus angle: as a new anatomic landmark for the posterior approach of presacral lesions

PURPOSE

We have discussed the importance of sacrococcygeal sinus angle (SSA), which is a new anatomical landmark in the surgery of presacral lesions. Because of its anatomical structure, the sacrum limits the surgical exposure like a compact barrier for the posterior surgical approach. The main aim of this paper is to explain the anatomical description and clinical importance of SSA in the surgery of presacral lesions.

METHODS

Three groups were designated, consisting of ten patients in each group, as early childhood (group 1), late childhood (group 2) and adulthood (group 3). Patients were selected randomly. The degree of SSA measurement was performed between the line tangent to the anterior margin of the first sacral vertebra and the line from the promontorium to the tip of the coccyx. The measurement of SSA was performed on patients' lumbosacral magnetic resonance images. When the SSA forms a triangle via a parallel line starting from the inferior tip of the sacrum and running parallel to the ground, the area of the triangle also covers the field of view of the presacral region. In addition, the sacral region needed to be resected for maximum exposure is also within this area.

RESULTS

The mean SSA was measured to be 53.9 ± 11.4° in group 1, 77.8 ± 11.2° in group 2 and 74.5 ± 12.5° in group 3. Intergroup comparisons revealed a significant difference between group 1 and the other two groups statistically. It was found that the SSA was 20° less in group 1 as compared to the other age groups (p = 0.0005). The area of a triangle is calculated using the sine area formula, and according to this formula the area of a triangle increases when the degree of the angle increases, thus comprising larger part of the sacrum. This condition requires more and wide sacral resection to obtain maximum exposure in the presacral zone.

CONCLUSIONS

We have observed that the SSA is significantly smaller during early childhood compared with the other age groups. This feature provides an anatomical superiority in this age group for the posterior approach in the surgical treatment of presacral masses.

Pre-operative embolization facilitating a posterior approach for the surgical resection of giant sacral neurogenic tumors

The present study aimed to assess a posterior approach for the surgical resection of giant sacral neurogenic tumors, and to evaluate the oncological and functional outcomes. A total of 16 patients with giant sacral neurogenic tumors underwent pre-operative embolization and subsequent posterior sacral resection between January 2000 and June 2010. Benign tumors were identified in 12 cases, while four cases exhibited malignant peripheral nerve sheath tumors (MPNSTs). An evaluation of the operative techniques used, the level of blood loss, any complications and the functional and oncological outcomes was performed. All tumor masses were removed completely without intra-operative shock or fatalities. The mean tumor size was 17.5 cm (range, 11.5–28 cm) at the greatest diameter. The average level of intra-operative blood loss was 1,293 ml (range, 400–4,500 ml). Wound complications occurred in four patients (25%), including three cases of cutaneous necrosis and one wound infection. The mean follow-up time was 59 months (range, 24–110 months). Tumor recurrence or patient mortality as a result of the disease did not occur in any of the patients with benign sacral neurogenic tumors. The survival rate of the patients with malignant lesions was 75% (3/4 patients) since 25 % (1/4 patients) had multiple local recurrences and succumbed to the disease. The patients with benign tumors scored an average of 92.8% on the Musculoskeletal Tumor Society (MSTS) score functional evaluation, while the patients with malignant tumors scored an average of 60.3%. A posterior approach for the surgical resection of giant sacral neurogenic tumors, combined with pre-operative embolization may be safely conducted with satisfactory oncological and functional outcomes.

Tumours of the retrorectal space: management and outcome of a heterogeneous group of diseases

AIM

Retrorectal tumours are a rare and complex entity in adults and children. They present a varied symptomatology and their treatment is very different according to their histology. We aimed to evaluate our experience of tumours of the retrorectal space.

METHOD

Forty patients with retrorectal tumours were divided into two groups according to age. The variables analysed were sex, signs and symptoms, complementary examinations, surgical approaches, adjuvant therapies, pathological analyses, recurrence and survival.

RESULTS

Symptoms across the 30 adults varied--back pain (18) was the most common. Surgical intervention was performed on 20 patients; the rest were candidates for other treatments: five metastatic disease, two lymphomas and two Ewing tumour. The most common surgical approach was posterior, with 10 cases (50%). In all, 70% of adult tumours were malignant, with chordoma (30%) and metastases (20%) being the most common lesions. The most frequent benign lesion was hamartoma (10%). The 1- and 5-year mortality rates were 23.8% and 38.1%, respectively. In the paediatric group, three patients were diagnosed in utero. The symptoms among children varied and all were operated upon. The most frequent tumour was teratoma. Overall mortality was 20%.

CONCLUSIONS

Given their complexity, these tumours should be addressed by experts and all treatment options must be contemplated. They continue to present a challenge, above all in malignant tumours where the tumour cannot be controlled at a locoregional level.