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PRESACRAL MASSES
speaker: kiran
MODERATOR:
PROF.O.P. SHARMA
INTRODUCTION
Mass present between perirectal fascia
and the sacrococcygeal part of spine.
Imaging plays an important role in the
detection and differentiation of these masses.
Information obtained is critical for
management ,especially surgical planning.
Usual symptoms are ,change in bowel
habits,low back and sacral pain, abdominal
pain,palpable mass, urinary symptoms, anal
discharge and bleeding.
TYPES OF MASS
A. SOLID
.sacrococcygeal teratoma
.neuroblastoma
.rhabdomyosarcoma
.fibroma
.lipoma
.lymphoma
.sacral bone tumours etc
CYSTIC
Abscess
Rectal duplication
Hematoma
Lymhocele
Neurentric cyst
Sacral osteomyelitis
Ulcerative colitis
Anterior meningocele
CONGENITAL AND
DEVELOPMENTAL MASSES
Germ cell tumors - sacrococcygeal
teratoma,germinomatous and
nongerminomatous germ cell tumors.
Anterior sacral meningocele
Developmental cysts - epidermoid cyst,
dermoid cyst, enteric cysts [rectal duplication
cyst, tailgut cyst])
Cystic lymphangioma
Lipoma
SACROCOCCYGEAL TERATOMA
Type I - Predominantly
external masses with a
small presacral component.
Type II - External masses
with a significant intrapelvic
component.
Type III- External masses
with a pelvic and abdominal
component.
Type IV - Internal masses
with an intrapelvic and
abdominal location.
IMAGING FINDINGS
Cystic components typically appear as anechoic
areas on USG.
MRI is the modality of choice because of the superior
depiction of soft tissues and preferred for both initial
diagnosis and recurrence survillence.
Benign are predominantly cystic have attenuation
similar to that of fluid on CT.
On MRI cystic areas appear as fluid on T1 and T2
images ,areas of fatty tissue show high signal
intensity, calification and bone dipicted as signal
void.
MATURE SACROCOCCYGEAL TERATOMA
Frontal pelvic
radiograph reveals
ischiopubic separation
due to a presacral
mass.
MATURE SACROCOCCYGEAL TERATOMA
Axial unenhanced CT
scan through the upper
portion of the lesion
shows attenuation similar
to that of water, a finding
indicative of a
predominant cystic
component.
BENIGN SACROCOCCYGEAL TERATOMA
Axial unenhanced CT
scan at the level of the
coccyx shows a
presacral mass with
multilocular cystic (C)
and solid (S)
components. The
rectosigmoid (R)
segment of the colon
is displaced anteriorly.
RECURRENT SACROCOCCYGEAL
TERATOMA
Axial T1-weighted
spin-echo MR image
(a)axial T2-weighted
fat-saturated turbo
spin-echo image
RECURRENT SACROCOCCYGEAL
TERATOMA
Two well-defined
round cystic masses
with predominantly
intermediate signal
intensity in a and high
signal intensity in b.
High-signal-intensity
areas in a represent
fat. The rectum (R) was
displaced
anterolaterally. The
coccyx previously was
removed.
MALIGNANT SACROCOCCYGEAL
TERATOMA
Intermediate to low
signal intensity on
the T2-weighted fat-
saturated image
MALIGNANT SACROCOCCYGEAL
TERATOMA
(a, b) Axial
unenhanced T1-
weighted MR image
(a)Axial T2-weighted
fat-saturated turbo
spin-echo image
MALIGNANT SACROCOCCYGEAL
TERATOMA
Pelvic radiograph
shows a scimitar
sacrum with
osseous defect on
the right side
(arrows).
CURRARINO TRIAD
Axial unenhanced CT
scan demonstrates a
welldefined mass
(arrow) with
attenuation slightly
lower than that of fluid,
a feature that
represents fatty tissue
in a dermoid, and
leftward displacement
of the rectum. B
bladder.
CURRARINO TRIAD
Image from a
barium enema
study performed
after atresia repair
also shows the
dermoid at the low
presacral level and
anterior
displacement of the
rectum (arrow).
ANTERIOR SACRAL
MENINGOCELE.
Herniation of csf filled dura through
sacral foramen or a defect in sacrum.
Incidence 1 in 40000.
80% in first decade.
Nerve roots ,neural elements within
sac & various osseous defects should
be assessed.
MRI modality of choice.
DERMOID CYST
Oblique radiograph of
the pelvis, obtained
during a barium enema
examination,
demonstrates a well-
defined retrorectal
tubular communication
(arrowheads) with the
rectum.
TAILGUT CYST
Axial T2-weighted
fat-saturated MR
imageshows high
signal intensity in
the mass. The
intermediate
attenuation seen in
the mass in a
reflects its mucoid
content. R rectum.
NEUROGENIC MASSES
Neuroblastoma.
Ganglioneuroblastoma.
Ganglioneuroma.
Neurofibroma.
Schwannoma.
NEUROBLASTOMA
Accounts for 10% of peadiatric cancers
Median age of diagnosis 22 months.
95% are diagnosed within first decade.
70% abdominal,20% mediastinal &
2-3% are pelvic.
Because of midline location ,considered
stage III.
70% show calcification.
IMAGING FINDINGS.
Detection and staging of neuroblastoma is
accomplished by CT,MRI and nuclear imaging.
Bone scintigraphy with technitium 99 and
skeletal radiography are used to determine
areas of involvement.
Radiographic findings are nonspecific and
include calcifications in 30%.
USG shows an heterogenous mass if areas of
hemorrhage and necrosis are present.
Doppler US helps to determine relation of
tumour with the vessels.
Imaging findings.
CT demonstrates location , boundries and extension of
tumours.
Calcifications are seen in more than 80% at CT.
Small tumours are homogenous in appearance , larger
show heterogenous attenuation because of
hemorrhage and necrosis.
On MRI , lesions show low signal intensity and
heterogenous contrast enhancement on T1 and high
signal intensity in T2 weighted images.
Hemorrhagic areas are of high signal intensity on T1
and cystic & necrotic areas show high intensity on T2
weighted images.
NEUROBLASTOMA
Axial unenhanced CT
scan of the pelvis
reveals a low-
attenuation presacral
mass that has
displaced the
rectosigmoid (R) colon
segment leftward and
that contains subtle
punctate calcifications
(arrows).
PRESACRAL NEUROBLASTOMA
Axial CT scan
obtained with
intravenous contrast
material shows
heterogeneous
enhancement in the
mass but no pelvic
vessel involvement.
NEUROBLASTOMA
Sagittal T1-weighted
MR image of the pelvis
demonstrates a large
presacral mass that
extends to the neural
foramen (arrow). The
mass has predominant
intermediate signal
intensity and multiple
rimlike areas of high
signal intensity
(arrowheads) that are
presumably due to
hemorrhage.
NEUROBLASTOMA
Sagittal T2-weighted
fat-saturated MR
image shows
heterogeneous,
predominantly high
signal intensity in
the mass
(arrowheads).
GANGLIONEUROMA
Rare benign tumour.
Evolve from regressed neuroblastoma or
ganglioneuroblastoma
Seen typically in second decade.
Most common locations in order of
frequency are, posteriormediastinum,
retroperitoneum,adrenals & neck.
More homogenous & two thirds show
calcification in imaging.
GANGLIONEUROMA
Sagittal T2-weighted
MR image shows a
high-signalintensity
presacral
ganglioneuroma that
distorts the distal
sacrum (arrow) and has
displaced the
bladder(B) anteriorly.
NEUROFIBROMA
Occur singly or in multiples in NF-1.
NF_1 autosomal dominant.
Occurs 1 in 2000-4000.
Abdominal involvement most likely to occur in
retroperitoneal,mesentric & paraspinal regions.
resembles lymphadenopathy on CT with attenuation less
than that of soft tissues.
On T1 weighted image, homogenously isointense or mildly
hyperintense in comparision to muscle.
On T2 weighted image,”target” like appearance with a rim of
myxomatus material and a central zone of low signal intensity
indicating a fibrous core.
NEUROFIBROMATOSIS
Rhabdomyo sarcoma
Undifferentiated sarcoma
Vascular mass
Fibroma
RHABDOMYOSARCOMA
.
Aggressive tumour accounts for 4-8%
of pediatric cancers.
A presacral mass in a child older than
8 yrs is highly suggestive of
rhabdomyosarcoma
Bimodal 2-6yrs &14-18yrs.
IMAGING FINDINGS
Sagittal T2-weighted
MR image more
clearly depicts
involvement of the
sacrococcygeal
vertebrae (arrow) as
well as the spinal
canal soft-tissuemass
(arrowheads).
VASCULAR MASSES
This include venous, capillary,lymphatic
or arterio-venous malformations.
Hemangioma is the neoplastic variety.
Pelvic hemangiomas present as large
lesions extending to mesentry,pelvic
sidewalls & rectum.
Pelvic vascular masses associated with
klippel trenaunay syndrome.
IMAGING FINDINGS
Axial T2-weighted MR
image demonstrates a
mixedsignal- intensity
mass (arrows) that
involves the posterior
sacrum as well as the
presacral space.
LYMPHOMATOUS
MASSES
These include
- true lymphomas –NHL (6% )
-Hodgkins(5%)
-post trasplantation lymphoproliferative disorder.
Among NHL burkitt,burkitt like and B-cell lymphomas
are more common and present as primary abdominal
mass.
Lymphnode involvement may be discrete or
conglomerate.
Isolated presacral mass very rare and usually involves
iliac nodes.
IMAGING FINDINGS
First assessed with USG and then with CT
for primary site and staging.
USG demonstrates a solid hypoechoeic
mass.
On MR mass appears heterogenous with
low signal intensity on T1 and high signal
intensity on T2 weighted images.
Post transplantation lymphomas are
indistinguishable from other lymphomas.
BURKITT LYMPHOMA
Axial T1-weighted MR
image shows an area
of low signal intensity
in the mass, a finding
that indicates
penetration into the
bone marrow. The
spinal canal is
markedly narrowed,
and the left sacroiliac
joint is irregular.
ANEURYSMAL BONE
CYST
Blood filled expansile masses.
Most are manifested in first two decades of
life ,more commonly in second decade.
20% of these tumours arise from vertebral
column ,among these 20% arise from posteror
elements of sacrum.
Classically they appear as multiple blood filled
spaces seperated by septa.
In contrast to giant cell tumours ,these tumours
are delimited by a thin rim of bone.
IMAGING FINDINGS
Anteroposterior
pelvic radiograph
demonstrates
distortion of the
sacrum (arrows).
ANEURYSMAL BONE CYST
Sagittal T2-weighted
MR image of the pelvis
shows the origin of the
heterogeneous
presacral mass in the
distal sacrum.
CHORDOMA
These are the most common primary sacral
neoplasms.
They accont for 2-4% of primary bone
tumours.
50% arise in sacrococcygeal region.
Upto 60% of chodomas in sc region appear
as midline lytic lesions often with
calcifications.
This type usually includes a presacral
component and involves iliac bones.
IMAGING FINDINGS
Axial unenhanced
CT scan shows a
predominantly
sclerotic sacrum
with indistinct
anterior margins.
OSTEOGENIC SARCOMA
Axial T1-weighted MR
image at the level of the
middle sacrum shows
replacement of the bone
marrow of the right sacral
ala and body by a low-
signal-intensity mass. The
tumor extends anteriorly to
efface the fat plane
adjacent to the right psoas
muscle and presacral space
(arrows). The right
sacroiliac joint is indistinct,
but there is no evident
involvement of the right
iliac bone or spinal canal.
EWINGS SARCOMA.
Ewings sarcoma ,extraosseous
ewings sacoma and PNET belong
same family of round cell tumours.
Present in first three decades of life.
3-10% originate in spine,metastatic
involvement is more common.
Lumbosacral region is the most
common site of origin.
EWINGS SARCOMA
Sagittal T2-
weighted MR image
demonstrates a
heterogeneous
presacral mass with
extension posterior
to the sacrum
(arrow).
OTHER MASSES
Hematoma
Extension or metastasis to the
presacral space from another site
PRESACRAL MASS
Sagittal contrast-
enhanced T1-
weighted fat-
saturated MR image
PRESACRAL MASS
A homogeneous
presacral mass
(arrows) with
persistent high
signal intensity
despite fat
saturation in b, a
finding indicative of
a hematoma.
CONCLUSIONS