Presacral myelolipoma in a geriatric patient

Background

Presacral tumors are most frequently benign, occasionally malignant with a slow growth. Their incidence is 1:40000 and they are asymptomatic in the 26–50% of cases. When visible symptoms occur, these are related to the dimensions of the tumor, to its location and to the presence of infection. We believe all presacral tumors should undergo a surgical resection, even if the patient is asymptomatic and these are more frequently benign tumors.

Materials and methods

We report the case of a 69-year old woman with a lower abdominal pain associated with paresthesia and hypostenia of the right inferior limb. Digital examination of the rectum let esteem a fixed, mild tender and hard tumor of the posterior external wall of the rectum. The C.T. guided biopsy gave insufficient results for a diagnosis. MRI allowed to appreciate and reveal a solid, dishomogeneous structure, capsulate mass located in the presacral region with diameters of about 9.5 × 7.5 × 9 cm, adherent to the body of the sacrum, with connective likely origin, in the absence of lymphoadenopathy of the small basin. Surgical intervention showed a tumor tenaciously adherent to the sacrum.

Results

Patients with myelipoma are generally old-aged, female and without alterations in the periferic blood slide or hepato-splenomegalia, however these tumors can be associated with endocrine disfunctions. Usually myelipomas are single and the adrenal gland is the most common location however in a half of the cases reported in literature they are located in the presacral region. They are often asymptomatic and this characteristic could be a good aid for the differential diagnosis with symptomatic tumors or those having a bony envolvement like "cordomi". Usually these neoplasms result capsulate, strictly adherent without infiltrating the neighboring structures, well circumscribed, with variable dimensions up to several cm in diameters (maximum 12) and weights between 70 and 400 gr.

Conclusion

In literature the surgical approach to the presacral space is described by anterior or posterior way or a combination of these. The Authors' opinion is that the en-block resection of these tumors with an anterior surgical approach allows a diagnosis of the nature of the disease and it is the best treatment for malignant lesions, which are frequently radio and chemo-resistent. Anyway it is important to consider that these tumors are easily bleeding because of their connections with the presacral venuos plexus.