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| Year : 1986 | Volume
: 32
| Issue : 4 | Page : 231-2 |
Large pre-sacral teratoma in an adult male (a case report).
Kripalani AK, Sharma LK
How to cite this article:
Kripalani A K, Sharma L K. Large pre-sacral teratoma in an adult male (a case report). J Postgrad Med 1986;32:231 |
Tumours arising in the presacral area are uncommon and account for about l in 10,000 hospital admissions.[6] The incidence of teratoma amongst presacral tumours is between 9 and 12 per cent,[3] They occur mostly in infants and newborns and only 10 per cent of patients are adults of whom eighty per cent are females.[4], [9] Less than 10 cases have been reported in adult males.[3], [4] Rarity of this tumour, particularly in adult males, and its unusually large size, have prompted us to report the present case.
A 46 year old male complained of weakness for the last 3 years and occasional, pain deep in the pelvis for the last one year. He had a continuous feeling of heaviness in the pelvis with occasional exacerbation of pain relieved by rest and analgesics. There were, no urinary or bowel symptoms. There was no history of loss of weight, loss of appetite or fever. A plain X-ray of the abdomen revealed a calcified mass in the pelvis; [Fig. 1] and he was referred to us with the radiological diagnosis of vesical calcification,? tumor'.
He was the first child of his parents and there was no history of twinning in the family. General physical examination was unrevealing. Abdominal examination failed to show presence of any mass or organomegaly. However, rectal examination revealed an extra-luminal, smooth, hard, non-tender. spherical mass, anterior to the sacrum. Its upper limit could not be reached, Anal sphincter tone was normal. There was no perianal sinus, fistula or excoriation.
Routine biochemical tests and chest X-ray revealed no abnormality. Intravenous urography demonstrated the mass to be extravesical with normal kidneys and ureters. Pelvic segment of the left ureter was coursing close to the mass [Fig. 2]. On ultrasonography. the mass was partly solid and partly cystic. Sigmoidoscopy revealed extra-luminal pressure with normal sigmoid mucosa.
To relieve the patient of his symptoms and to exclude the presence of any malignant change in the mass by histological studies, it was decided to excise the tumour. At laparotomy, a spherical mass was found lying anterior to the sacrum with white areas of calcification. The tumour was mobilised by incising the posterior parietal peritoneum on both the sides. Ureters were identified and safe-guarded. while mobilising the tumour from the sacral hollow posteriorly, middle sacral vessels were identified and ligated. The tumour was then dissected free from the rectum anteriorly and removed. The pelvic peritoneum was closed and presacral space drained extra-peritoneally. Recovery was uneventful.
The tumour was 9 x 7 x 7 cm in size. Its surface was smooth and a definite capsule was present. Cut surface showed multiple cystic spaces interspersed in the solid tumour. Histopathology report was teratoma. There was no evidence of malignancy.
A teratoma arises from a totepotent cell or cell rests in the embryo and hence is composed of tissue derived from all the three germ layers. This distinguishes it from a dermoid cyst which contains only ectodermal derivatives.[7] The peculiar location of sacro-coccygeal teratoma has suggested the thesis that the totepotent cells are sequestrated from the vicinity of Hensen's node in the caudal part of the embryo. There is an abnormally high incidence of twinning in individuals who present with sacrococcygeal teratoma. The existence of double monsters attached at the coccyx, known instances of suppressed twins and the presence of well formed structures such as fingers and toes in the sacrococcygeal teratoma have been interpreted to indicate that they perhaps represent a thwarted attempt at twinning in the embryo.
These tumours may be totally asymptomatic and 15 per cent of them are discovered incidentally on rectal and pelvic examination[4] or on radiology.[1] The commonest presentation is as a perineal or pilonidal sinus which might be persisting despite repeated surgery.[7],[8],[9] Due to their size, they may cause pelvic discomfort,[4] or bladder symptoms.[1], [9] On physical examination, the most constant finding is a mass ventral to the sacrum. Neurological signs and symptoms are absent and this differentiates it from chordoma, another congenital tumour in the presacral area. A plain x-ray will demonstrate calcification in 50 per cent of cases,[8] the sacrum being normal while sacral involvement is characteristic of chordoma.
The treatment of presacral teratoma it complete surgical removal. For small tumours, a posterior trans-sacral approach similar to Kraske approach to the rectum with the patient in prone position has been quite popular.[3], [8] Removal of the coccyx has been emphasised to reduce the chance of recurrence.[4], [8], [9] It is rare for a presacral teratoma to be large enough to necessitate a laparotomy for its removal and we could find only three such instances in the past 40 years.[1], [2], [7] Removal of a low lying presacral tumour by a vaginal incision has been reported in females.
| 1. | Browne, M. K.: A case of presacral teratoid tumor. Brit. J. Urol., 35: 179-181, 1963.  |
| 2. | Ewing, J. B. and Prakash, A.: sacrococcygeal teratoma in adults. Canad. J. Surg., 4: 287-292, 1961. |
| 3. | Jackman, R. J., Clark, P. L. and Smith. N. D.: Retrorectal tumors. J. Amer. Med. Assoc., 145: 956-962, 1951. |
| 4. | Killen, D. A. and Jackson, L. M.: Sacrococcygeal teratoma in the adult. Arch. Surg., 88: 425-433, 1964. |
| 5. | Madanes, A. E., Kennison, R. D. anti Mitchell, G. W.: Removal of a presacral tumor via a Schuchardt incision. Obstet. and Gynecol., 57 (6 suppl.): 94 S-96 S. 1981. |
| 6. | Ross, S. T.: Sacral and presacral tumor. Amer. J. Surg., 76: 687-693, 1948. |
| 7. | Swinton, N. W. and Lehman, G.: Presacral tumors. Surg. Clin. North Amer.. 38: 849-859, 1958. |
| 8. | Tolins, S. H. and Cooper, P.: Presacral teratoma. Amer. J. Surg., 115: 734-737. 1968. |
| 9. | Waldhausen, J. A., Kilman, J. W., Vellios, F. and Battersby, J. S.: Sacrococcygeal teratoma. Surgery, 54: 933-949. 1963. |
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