Presacral tumours: a rare case of a dermoid cyst in a paediatric patient

Presacral Keratinous and Dermoid Cyst Masquerading as Meningocele - A Rare Case Report

ABSTRACT

Presacral tumours are rare developmental tumours associated with midline closure defects. A fifteen-month-old girl presented with pain in the lower abdomen and dysuria. After examination, the child underwent investigations and was diagnosed as a presacral mass with intergluteal extension and caudal mass in the subcutaneous tissue of the left gluteal region. Complete excision of mass along with coccygectomy was done. Histopathology showed presacral as a keratinous cyst and gluteal as a dermoid cyst. Later on, the child also developed a left facial dermoid cyst which was also excised.

Presacral dermoid cyst in a young female patient: A case report

Presacral dermoid cysts are rare, benign tumors of developmental origin that primarily affect women. Surgical resection is the mainstay of treatment for these cysts, even if asymptomatic, with the laparoscopic approach being safer and more efficient.

MRI of Tumors and Tumor Mimics in the Female Pelvis: Anatomic Pelvic Space-based Approach

Pelvic masses can present a diagnostic challenge owing to the difficulty in assessing their origin and the overlap in imaging features. The majority of pelvic tumors arise from gastrointestinal or genitourinary organs, with less common sites of origin including the connective tissues, nerves, and lymphovascular structures. Lesion evaluation usually starts with clinical assessment followed by imaging, or the lesion may be an incidental finding at imaging performed for other clinical indications. Since accurate diagnosis is essential for optimal management, imaging is useful for suggesting the correct diagnosis or narrowing the differential possibilities and distinguishing tumors from their mimics. Some masses may require histologic confirmation of the diagnosis with biopsy and/or up-front surgical resection. In this case, imaging is essential for presurgical planning to assess mass size and location, evaluate the relationship to adjacent pelvic structures, and narrow differential possibilities. Pelvic US is often the first imaging modality performed in women with pelvic symptoms. While US is often useful to detect a pelvic mass, it has significant limitations in assessing masses located deep in the pelvis or near gas-filled organs. CT also has limited value in the pelvis owing to its inferior soft-tissue contrast. MRI is frequently the optimal imaging modality, as it offers both multiplanar capability and excellent soft-tissue contrast. This article highlights the normal anatomy of the pelvic spaces in the female pelvis and focuses on MRI features of common tumors and tumor mimics that arise in these spaces. It provides an interpretative algorithm for approaching an unknown pelvic lesion at MRI. It also discusses surgical management, emphasizing the value of MRI as a road map to surgery and highlighting anatomic locations where surgical resection may present a challenge. ^©RSNA, 2019.

A systematic review of minimally invasive surgery for retrorectal tumors

Retrorectal tumors are rare tumors that require resection for symptoms, malignancy and potential malignant transformation. Traditional approaches have included laparotomy, perineal excision or a combination. Multiple minimally invasive techniques are available which have the potential to minimize morbidity and enhance recovery. We performed a systematic review of the literature to determine the feasibility and surgical outcomes of retrorectal tumors approached using minimally invasive surgical techniques. Publications in which adult patients (≥ 18 years) had a minimally invasive approach (laparoscopic or robotic) for resection of a primary retrorectal tumor were included. Data were collected on approach, preoperative investigation, size and sacral level of the tumor, operating time, length of stay, perioperative complications, margins and recurrence. Thirty-five articles which included a total of 82 patients met the inclusion criteria. The majority of patients were female (n = 65; 79.2%), with a mean age of 41.7 years (range 18-89 years). Seventy-three patients (89.0%) underwent laparoscopic or combined laparoscopic-perineal resection, and 9 (10.8%) had a robotic approach. The conversion rate was 5.5%. The overall 30-day morbidity rate was 15.7%, including 1 intraoperative rectal injury (1.2%). Ninety-five percent (n = 78) of the retrorectal tumors were benign. Median length of stay was 4 days for both laparoscopic and robotic groups, with ranges of 1-8 and 2-10 days, respectively. No tumor recurrence was noted during follow-up [median 28 months (range 5-71 months)]. A minimally invasive approach for the resection of retrorectal tumors is feasible in selected patients. Careful patient selection is necessary to avoid incomplete resection and higher morbidity than traditional approaches.

Retrorectal Tumors: A Comprehensive Literature Review

IMPORTANCE

Retrorectal tumors are rare lesions that comprise a multitude of histologic types. Reports are limited to small single-institution case series, and recommendations on the ideal surgical approaches are lacking.

OBJECTIVE

The purpose of the study was to provide a comprehensive review of the epidemiology, pathologic subtypes, surgical approaches, and clinical outcomes of retrorectal tumors.

EVIDENCE REVIEW

We conducted a review of the literature using PubMed and searched the reference lists of published studies.

RESULTS

A total of 341 studies comprising 1708 patients were included. Overall, 68 % of patients were female. The mean age was 44.6 ± 13.7 years. Of all patients, 1194 (70 %) had benign lesions, and 514 patients (30 %) had malignant tumors. Congenital tumors (60.5 %) were the most frequent histologic type. Other pathologic types were neurogenic tumors (14.8 %), osseous tumors (3.1 %), inflammatory tumors (2.6 %), and miscellaneous tumors (19.1 %). Biopsy was performed in 27 % of the patients. Of these patients, incorrect diagnoses occurred in 44 %. An anterior surgical approach (AA) was performed in 299 patients (35 %); a posterior approach (PA) was performed in 443 (52 %), and a combined approach (CA) was performed in 119 patients (14 %). The mean length of stay (LOS) of PA was 7 ± 5 days compared to 8 ± 7 days for AA and 11 ± 7 days for CA (p < 0.05). The overall morbidity rate was 13.2 %: 19.3 % associated with anterior approach, 7.2 % associated with posterior approach, and 24.7 % after a combined approach (p < 0.05). Overall postoperative recurrence rate was 21.6 %; 6.7 % after an anterior approach, 26.6 % after a posterior approach, and 28.6 % after a combined approach (p < 0.05). A minimally invasive approach (MIS) was employed in 83 patients. MIS provided shorter hospital stays than open surgery (4 ± 2 vs. 9 ± 7 days; p < 0.05). Differences in complication rate were 19.8 % in MIS and 12.2 % in open surgery and not statistically significant.

CONCLUSIONS AND RELEVANCE

Retrorectal tumors are most commonly benign in etiology, of a congenital nature, and have a female predominance. Complete surgical resection is the cornerstone of retrorectal tumor management. A minimal access surgery approach, when feasible, appears to be a safe option for the management of retrorectal tumors, with shorter operative time and length of stay.

Management approach and surgical strategies for retrorectal tumours: a systematic review

AIM

The management strategy for retrorectal tumours is complex. Due to their rarity, few surgeons have expertise in management.

METHOD

A systematic literature review was conducted using the PubMed database. English language publications in the years 2011-2015 that assessed preoperative management, surgical strategies and chemoradiotherapy for presacral tumours were included. Two hundred and fifty-one abstracts were screened of which 88 met the inclusion criteria. After review of the full text, this resulted in a final list of 42 studies eligible for review.

RESULTS

In all, 932 patients (63.2% female, 36.8% male; P < 0.01) with a retrorectal tumour were identified. Most were benign (65.9% vs. 33.7%, P < 0.01). Imaging distinguished benign from malignant lesions in 88.1% of cases; preoperative biopsy was superior to imaging in providing an accurate definitive diagnosis (91.3% vs. 61.4%, P < 0.05) with negligible seeding risk. Biopsy should be performed in solid tumours. It is useful in guiding neoadjuvant therapy for gastrointestinal stromal tumours, sarcomas and desmoid type fibromatosis and may alter the management strategy in cases of diffuse large B-cell lymphoma and metastases. Biopsies for cystic lesions are not recommended. The gold standard in imaging is MRI. The posterior Kraske procedure is the most common surgical approach. Overall, the reported recurrence rate was 19.7%.

CONCLUSION

This review evaluated the management strategies for retrorectal tumours. A preoperative biopsy should be performed for solid tumours. MRI is the most useful imaging modality. Surgery is the mainstay of treatment. There is limited information on robotic surgery, single-port surgery, transanal endoscopic microsurgery, chemoradiotherapy and reconstruction.