A 20-year-old woman presented with a 6x6 cm sacral swelling that had slowly grown over 10 years. MRI revealed a large multiloculated cystic mass overlying the lower sacrum with an intrapelvic component displacing nearby organs. The patient underwent complete excision of the cyst along with coccyxectomy. Histopathology identified it as a dermoid cyst, a benign congenital tumor that commonly occurs in the pre-sacral space.

1. A Case of Pre-Sacral Tumor Surgical Unit-6 Dr. K. M. Garg Nilesh N. Agrawal

2. 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.

3. 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

5. No h/o trauma

6. No h/o fever

7. No h/o constipation or bleeding p/r

8. No h/o urinary complaints

9. No h/o menstrual irregularity

10. No h/o loss of weight or appetite

12. No h/o any surgical intervention

14. Bladder and bowel habits normal

17. 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

20. 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

24. EXTERNAL COMPONENT COCCYX INTRA PELVIC COMPONENT

26. 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

27. POST OPERATIVE COURSE Un-eventful Closed suction drain removed on day 4 Pt. discharged on day 5 Skin staplers removed after 2 weeks

30. Histopathology report Dermoid cyst

31. DISCUSSION

32. 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

35. Developmental cysts constitute most of congenital lesions

36. Dermoid and epidermoid are benign and arise from ectoderm

37. Enterogeneous cyst arise from primitive hindgut (endodermal)

40. 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

41. 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

42. 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.