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.

Retrorectal mucinous adenocarcinoma arising from a tailgut cyst:A case report and review of literature

BACKGROUND Tailgut cysts are defined as congenital cysts that develop in the rectosacral space from the residue of the primitive tail.As a congenital disease,caudal cysts are very rare,and their canceration is even rarer,which makes the disease prone to misdiagnosis and delayed treatment.We describe a case of caudal cyst with adenocarcinogenesis and summarize in detail the characteristics of cases with analytical value reported since 1990.CASE SUMMARY A 35-year-old woman found a mass in her lower abdomen 2 mo ago.She was asymptomatic at that time and was not treated because of the coronavirus disease 2019 pandemic.Two weeks ago,the patient developed abdominal distension and right waist discomfort and came to our hospital.Except for the high level of serum carcinoembryonic antigen,the medical history and laboratory tests were not remarkable.Magnetic resonance imaging showed a well-defined,slightly lobulated cystic-solid mass with a straight diameter of approximately 10 cm×9 cm in the presacral space,slightly high signal intensity on T2-weighted imaging,and moderate signal intensity on T1-weighted imaging.The mass was completely removed by laparoscopic surgery.Histopathological examination showed that the lesion was an intestinal mucinous adenocarcinoma,and the multidisciplinary team decided to implement postoperative chemotherapy.The patient recovered well,the tumor marker levels returned to normal,and tumor-free survival has been achieved thus far.CONCLUSION The case and literature summary can help clinicians and researchers develop appropriate examination and therapeutic methods for diagnosis and treatment of this rare disease.

Risk factors for perioperative complications in laparoscopic surgeries of retrorectal cystic lesions

BACKGROUNDThe incidence of retrorectal lesions is low, and no consensus has been reachedregarding the most optimal surgical approach. Laparoscopic approach has theadvantage of minimally invasive. The risk factors influencing perioperativecomplications of laparoscopic surgery are rarely discussed.AIMTo investigate the risk factors for perioperative complications in laparoscopicsurgeries of retrorectal cystic lesions.METHODSWe retrospectively reviewed the medical records of patients who underwentlaparoscopic excision of retrorectal cystic lesions between August 2012 and May2020 at our hospital. All surgeries were performed in the general surgerydepartment. Patients were divided into groups based on the lesion location anddiameter. We analysed the risk factors like type 2 diabetes mellitus, hypertension,the history of abdominal surgery, previous treatment, clinical manifestation,operation duration, blood loss, perioperative complications, and readmission ratewithin 90 d retrospectively.RESULTSSevere perioperative complications occurred in seven patients. Prophylactictransverse colostomy was performed in four patients with suspected rectal injury.Two patients underwent puncture drainage due to postoperative pelvic infection.One patient underwent debridement in the operating room due to incisioninfection. The massive-lesion group had a significantly longer surgery duration,higher blood loss, higher incidence of perioperative complications, and higherreadmission rate within 90 d (P < 0.05). Univariate analysis, multivariate analysis,and logistic regression showed that lesion diameter was an independent riskfactor for the development of perioperative complications in patients whounderwent laparoscopic excision of retrorectal cystic lesions.CONCLUSIONThe diameter of the lesion is an independent risk factor for perioperative complicationsin patients who undergo laparoscopic excision of retrorectal cystic lesions.The location of the lesion was not a determining factor of the surgical approach.Laparoscopic surgery is minimally invasive, high-resolution, and flexible, and itsuse in retrorectal cystic lesions is safe and feasible, also for lesions below the S3level.

Retrorectal tumors:A challenge for the surgeons

Retrorectal or presacral tumors are rare lesions located in the presacral area and considered as being derived from multiple embryological remnants.These tumors are classified as congenital,neurogenic,osseous,inflammatory,or miscellaneous.The most common among these are congenital benign lesions that present with non-specific symptoms,such as lower back pain and change in bowel habit.Although congenital and developmental tumors occur in younger patients,the median age of presentation is reported to be 45 years.Magnetic resonance imaging plays a crucial role in treatment management through accurate diagnosis of the lesion,the evaluation of invasion to adjacent structures,and the decision of appropriate surgical approach.The usefulness of preoperative biopsy is still debated;currently,it is only indicated for solid or heterogeneous tumors if it will alter the treatment management.Surgical resection with clear margins is considered the optimal treatment;described approaches are transabdominal,perineal,combined abdominoperineal,and minimally invasive.Benign retrorectal tumors have favorable long-term outcomes with a low incidence of recurrence,whereas malignant tumors have a potential for distant organ metastasis in addition to local recurrence.

Benign retrorectal tumours: Contribution of laparoscopic approach

Introduction: Presacral tumours are extremely rare entities as the asymptomatic retrorectal mass, although its clinical presentation includes infectious complications and signs of malignant degeneration. Magnetic resonance imaging is the most efficient imaging study for its diagnosis. The treatment of choice is complete surgical excision and traditional approaches are mainly through abdominal, posterior and perineal approach, depending on anatomical characteristics of the lesion. Laparoscopic excision of these retrorectal lesions has been reported in a few cases. Patients and methods: We report two cases of 38 and 24-year-old women who complained of anorectal symptoms and were diagnosed as retrorectal tumour by imaging studies. One of them was infected. Both cases were resected by means of laparoscopic techniques. There was no surgical complication and they were discharged on the 3rd and 4th postoperative day, respectively. Histopathologic findings revealed benign cystic teratoma in both cases. A follow-up after 36 months showed no recurrence. Our surgical endoscopic technique and a brief review of perioperative cares are presented and discussed. Discussion: Laparoscopic excision could be indicated in selected retrorectal tumours and a great surgeon’s resolve is always required. A meticulous dissection must be performed in order to identify and preserve vital structures. It’s only absolute contraindications seemed to be the suspicion of malignancy and operative inexperience. Conclusions: The complete laparoscopic removal of presacral lesions is a responsible surgical procedure which offers advantages from the sanitary and aesthetic point of view. This new endoscopic indication could be considered probably as a better technique than open approach in selected patients.

Retrorectal Cystic Hamartoma with Malignant Transformation

Retrorectal cystic hamartomas are rare congenital lesions that can undergo malignant transformation, and adenocarcinoma is the most frequently described histological type. The authors describe a case of a 53-year-old female patient with a localized well-differentiated adenocarcinoma that developed in a retrorectal cystic hamartoma. The patient was submitted to surgery (a Kraske procedure), with an R1 resection, followed by adjuvant radio-chemotherapy. After 23 months of follow up, the patient remains free from disease recurrence. Given the rarity of this entity, this case allows us to reflect on the differential diagnosis, therapeutic approach and patients’ follow-up.

Surgical treatment of retrorectal(presacral) tumors

Retrorectal(also known as presacral) tumor(RT) is a rare disease of retrorectal space. They can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history and physical examination. The primary and only satisfactory treatment is surgery for RTs. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primary local control, which is often difficult to achieve for malignantlesions.

Primary malignant tumours and malignant transformation of cysts in the retrorectal space:MRI diagnosis and treatment outcomes

Background:There are no clear guidelines for the diagnosis and treatment of malignant retrorectal tumours.The purpose of this study was to increase preoperative diagnostic knowledge and to describe the outcomes of treatment for these patients.Methods:This retrospective study was conducted on patients who underwent complete retrorectal tumour resection between May 2006 and July 2018,and had confirmed post-operative pathology reports.Demographic and clinical data(including imaging,perioperative,pathological,and prognostic data)were collected and analysed.Results:Malignant lesions were identified in 15(9[60%],female)patients.The median age of the patients was 59 years(range,34–72 years).Primary malignant tumours were identified in seven patients with solid tumours,in which gastrointestinal stromal tumours accounted for 71.4%(five of seven)and the remainder were chordoma or mucinous adenocarcinoma.Malignant transformation of cysts occurred in another eight patients with heterogeneous tumours,while histopathological features were present in 75%(six of eight)of patients with mucinous adenocarcinoma,and the remainder were squamouscell carcinoma or neuroendocrine tumour(Grade 2).The malignant characteristics of the solid portions observed using magnetic resonance imaging(MRI)were as follows:the cyst wall of the tumour was irregularly thickened;the surface was convex or lobed;the solid tumour had no capsule,or the capsule was destroyed;and the surface had a gyrus-like morphology.At a median follow-up time of 52 months(range,13–100 months),the overall recurrence-free survival rate was 40.0%and the survival rate was 46.7%.Conclusion:Some MRI features can be used to distinguish malignant retrorectal tumours from benign retrorectal tumours.The survival rate of patients with malignant retrorectal tumours is poor.

Mucinous adenocarcinoma arising from a tailgut cyst: A case report

BACKGROUND Retrorectal hamartomas or tailgut cysts(TCs)are rare.In most cases,they are asymptomatic and benign;however,rarely,they undergo malignant transformation,mainly in the form of adenocarcinoma.CASE SUMMARY A 55-year-old woman presented to our hospital with lower back pain.On magnetic resonance imaging,a large pelvic mass was found,which was located on the right of the ischiorectal fossa,extending to the minor pelvis.The patient underwent extensive surgical resection of the lesion through the right buttock.Histological examination confirmed the diagnosis of a retrorectal mucinous adenocarcinoma originating from a TC.Surgical resection of the tumour was complete,and the patient recovered without complications.The pilonidal sinus was then excised.One year later,semi-annual positron emission tomographycomputed tomography and magnetic resonance imaging scans did not reveal any evidence of local recurrence or metastatic disease.CONCLUSION Preoperative recognition,histological diagnosis,and treatment of TCs pose significant challenges.In addition,the possibility of developing invasive mucinous adenocarcinoma,although rare,should be considered.

Double tailgut cysts (presacral and precoccygeal hamartomas) with CA 19-9 elevation

Tailgut cyst, also called retrorectal hamartoma, is a rare congenital lesion and is usually located anterior to the sacrum and posterior to the rectum. We report a case of double tailgut cyst (presacral and precoccygeal hamartoma). A 62-year- old female visited the hospital complaining of anal pain and pressure in the perianal area for one month. Digital rectal examination revealed a round mass with hard consistency in the lateral and posterior part of rectum 5 cm from the anal verge. Pelvic magnetic resonance imaging showed two cystic and solid presacral masses (lateral and posterior part of rectum) compressing the rectum. The patient underwent surgical resection for pathologic diagnosis. At operation, two masses were located in the left presacral space without invasion to adjacent organs and soft tissue. Pathologic examination revealed double tailgut cysts without malignant transformation. A differential diagnosis of perirectal cystic hamartoma includes epidermal cysts, cystic teratomas, dermoid cysts, anal gland cysts, sarcoma and rectal duplications. Regional inflammatory process frequently complicates this lesion and perirectal fistula can develop. Tailgut cyst also has a malignancy potential, with development of adenocarcinomas. To establish a definite diagnosis and prevent complication, complete surgical resection is recommended.

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.