PICTURES IN DIGESTIVE PATHOLOGY

 

Presacral mass as a cause of constipation

Masa presacra como causa de estreñimiento

 

 

L. I. Fernández-Salazar, B. Guantes-de-Vigo¹, J. Calabia-del-Campo¹, C. Abril-Vega², J. Herreros-Rodríguez², M. L. del-Valle-Rivero³, B. Velayos-Jiménez and J. M. González-Hernández

Services of Gastroenterology, ¹Radiology, ²General Surgery and Digestive Diseases, and ³Oncology and Radiotherapy. Hospital Clínico Universitario. Valladolid. School of Medicine. University of Valladolid. Spain

 

Clinical case

A 41-year-old male with schizophrenia and treated with Risperdal^® and Noctamid^® was cared for in our hospital because of constipation. He also reported lower back pain for months, and a pelvic radiographic exam was available (Fig. 1). The physical exam was unremarkable. Colonoscopy revealed an extrinsic compression in the posterior wall of the rectum, which did not prevent the exam of the proximal colon. A thoracic-abdominal and pelvic CT scan (Fig. 2) did not demonstrate thoracic or liver metastases, or distant, local or regional lymphatic extension. Under ultrasonographic control the mass was biopsied (bio-pince 18G). The pathologic exam revealed that the mass was a chordoma. The patient was operated on - the mass occupied the whole pelvis, infiltrating and eroding the sacrum and growing into the posterior space. The tumor was excised with a combined abdominosacral approach, and the coccyx was also resected. An interruption and section of the rectum with terminal colostomy was performed. The final pathology exam demonstrated a benign mass with a very low mitotic index and sacral infiltration. The patient was treated with external radiotherapy. Three years of follow-up with radiographic exams have shown no disease progression.

 

 

Discussion

Chordomas are rare malignant tumors that originate from embryonic notochordal remnants. They account for 17.5% of malignant bone tumors of the axial skeleton with an incidence of 0.5 to 0.8 per 1,000,000 population (1). Half of them arise in the sacrococcygeal region, 35% at the base of the skull, and 15% from the vertebral bodies. They are more frequent in males between 40 and 70 years of age, grow slowly, and have distant metastases in 10 to 15% of cases. They can reach more than 11 cm of maximum diameter (1). Symptoms are lumbosacral (irradiating to the legs) and anal pain, constipation or impotence (2). A sacral or a rectal elastic mass can be appreciated during physical examination. CT and MRI are the two preferred diagnostic techniques. Histology allows and confirms the diagnosis. Treatment is surgical excision with wide margins, usually with a posterior approach. It is recommended to resect the piriformis and glutei muscles adjacent to the sacrum, and part of the sacroiliac joints to reduce local recurrence risks related to tumor extension to the space posterior to the sacrum (1). Embolization reduces the bleeding risk of surgery (2). External radiotherapy has been evaluated without clear results (1), and is considered for unresectable tumors (3). Imatinib mesylate is effective when associated to surgery and radiotherapy. Zolendronic acid could also be effective for pain management (3).

 

References

1. Hanna SA, Aston WJS, Briggs TWR, Cannon SR, Saifuddin A. Sacral chordoma. Can local recurrence after sacrectomy be predicted? Clin Orthop Relat Res 2008; 466: 2217-23.        [ Links ]

2. Camps Lasa J, Navarro Luca A, García Bach M, Pando López JA, Marco Molina C. Cordoma sacrococcígeo por vía posterior. Cir Esp 2008; 84: 340-1.        [ Links ]

3. Montella L, Addeo R, Faiola V, Cennamo G, Guarrasi R, Capasso E, et al. Zolendronic acid in metastatic chondrosarcoma and advanced sacrum chordoma: two case reports. J Exp & Clin Cancer Res 2009; 28: 7-11.        [ Links ]