DOI: 10.1148/rg.263055102
Pediatric Presacral Masses1
Murat Kocaoglu, MD and
Donald P. Frush, MD
1 From the Department of Radiology, Gulhane Military Medical School, Ankara, Turkey (M.K.); and Division of Pediatric Radiology, Department of Radiology, 1905 McGovern-Davison Children’s Health Center, Box 3808, Duke University Medical Center, Erwin Rd, Durham, NC 27710 (D.P.F.). Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received April 25, 2005; revision requested May 26 and received July 20; accepted July 29. Both authors have no financial relationships to disclose.
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Figure 1. Schema shows the Altman classification system for sacrococcygeal teratomas. Type I (A, left) and type II (A, right) teratomas have predominant extrapelvic components. Type III (B, left) and type IV (B, right) teratomas have a primarily intrapelvic location. Types II and III resemble a dumbbell. (Reprinted, with permission, from reference 11.)
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Figure 2a. Mature (benign) sacrococcygeal teratoma in an 11-day-old girl with a perineal mass. (a) Frontal pelvic radiograph reveals ischiopubic separation due to a presacral mass. (b) 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. (Reprinted, with permission, from reference 6.)
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Figure 2b. Mature (benign) sacrococcygeal teratoma in an 11-day-old girl with a perineal mass. (a) Frontal pelvic radiograph reveals ischiopubic separation due to a presacral mass. (b) 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. (Reprinted, with permission, from reference 6.)
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Figure 3. Benign sacrococcygeal teratoma in an infant boy. 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.
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Figure 4a. Recurrent sacrococcygeal teratoma in a 2-year-old girl. Axial T1-weighted (repetition time msec/echo time msec, 600/17) spin-echo MR image (a) and axial T2-weighted (5500/132) fat-saturated turbo spin-echo image (b) show 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.
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Figure 4b. Recurrent sacrococcygeal teratoma in a 2-year-old girl. Axial T1-weighted (repetition time msec/echo time msec, 600/17) spin-echo MR image (a) and axial T2-weighted (5500/132) fat-saturated turbo spin-echo image (b) show 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.
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Figure 5a. Malignant sacrococcygeal teratoma with an abdominopelvic component in an 18-month-old girl. Sagittal MR images show a midline region of fat with high signal intensity on the T1-weighted image (arrows in a) and intermediate to low signal intensity on the T2-weighted fat-saturated image (b). Also visible are involvement of the distal sacrum and coccyx (arrowheads in b), anterior displacement of the vagina and uterus (arrows in b), and superior and anterior displacement of the bladder (B). (Reprinted, with permission, from reference 6.)
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Figure 5b. Malignant sacrococcygeal teratoma with an abdominopelvic component in an 18-month-old girl. Sagittal MR images show a midline region of fat with high signal intensity on the T1-weighted image (arrows in a) and intermediate to low signal intensity on the T2-weighted fat-saturated image (b). Also visible are involvement of the distal sacrum and coccyx (arrowheads in b), anterior displacement of the vagina and uterus (arrows in b), and superior and anterior displacement of the bladder (B). (Reprinted, with permission, from reference 6.)
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Figure 6a. Malignant sacrococcygeal teratoma in a 2-year-old girl. (a, b) Axial unenhanced T1-weighted (540/12) MR image (a) and axial T2-weighted (4333/99) fat-saturated turbo spin-echo image (b) at the level of the pelvis demonstrate a well-defined lobular cystic mass with multiple septa that has displaced the rectum (R), uterus (U), and bladder (B) anteriorly. The images also show a subcutaneous left inguinal soft-tissue mass (arrow). (c) Axial T1-weighted fat-saturated image obtained with intravenous contrast material shows contrast enhancement of the septa and rim of the cystic mass and the left inguinal soft-tissue mass (arrow). The latter was diagnosed as metastatic adenopathy.
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Figure 6b. Malignant sacrococcygeal teratoma in a 2-year-old girl. (a, b) Axial unenhanced T1-weighted (540/12) MR image (a) and axial T2-weighted (4333/99) fat-saturated turbo spin-echo image (b) at the level of the pelvis demonstrate a well-defined lobular cystic mass with multiple septa that has displaced the rectum (R), uterus (U), and bladder (B) anteriorly. The images also show a subcutaneous left inguinal soft-tissue mass (arrow). (c) Axial T1-weighted fat-saturated image obtained with intravenous contrast material shows contrast enhancement of the septa and rim of the cystic mass and the left inguinal soft-tissue mass (arrow). The latter was diagnosed as metastatic adenopathy.
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Figure 6c. Malignant sacrococcygeal teratoma in a 2-year-old girl. (a, b) Axial unenhanced T1-weighted (540/12) MR image (a) and axial T2-weighted (4333/99) fat-saturated turbo spin-echo image (b) at the level of the pelvis demonstrate a well-defined lobular cystic mass with multiple septa that has displaced the rectum (R), uterus (U), and bladder (B) anteriorly. The images also show a subcutaneous left inguinal soft-tissue mass (arrow). (c) Axial T1-weighted fat-saturated image obtained with intravenous contrast material shows contrast enhancement of the septa and rim of the cystic mass and the left inguinal soft-tissue mass (arrow). The latter was diagnosed as metastatic adenopathy.
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Figure 7a. Currarino triad (ASP complex) in a 7-year-old girl with urinary incontinence and a history of anal atresia repair. (a) Pelvic radiograph shows a scimitar sacrum with osseous defect on the right side (arrows). (b) Axial unenhanced CT scan demonstrates a well-defined 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. (c) 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). (Reprinted, with permission, from reference 6.)
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Figure 7b. Currarino triad (ASP complex) in a 7-year-old girl with urinary incontinence and a history of anal atresia repair. (a) Pelvic radiograph shows a scimitar sacrum with osseous defect on the right side (arrows). (b) Axial unenhanced CT scan demonstrates a well-defined 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. (c) 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). (Reprinted, with permission, from reference 6.)
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Figure 7c. Currarino triad (ASP complex) in a 7-year-old girl with urinary incontinence and a history of anal atresia repair. (a) Pelvic radiograph shows a scimitar sacrum with osseous defect on the right side (arrows). (b) Axial unenhanced CT scan demonstrates a well-defined 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. (c) 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). (Reprinted, with permission, from reference 6.)
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Figure 8. Rectal duplication cyst in a 6-month-old girl with recurrent infection. Oblique radiograph of the pelvis, obtained during a barium enema examination, demonstrates a well-defined retrorectal tubular communication (arrowheads) with the rectum.
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Figure 9a. Tailgut cyst in a 17-year-old boy with rectal fullness. (a) Axial CT scan obtained with oral and intravenous contrast material at the level of the symphysis pubis demonstrates a lobular well-defined fluid-attenuation mass that compresses the barium-filled rectum (R) anterolaterally. (b) Axial T2-weighted (3500/80) fat-saturated MR image shows high signal intensity in the mass. The intermediate attenuation seen in the mass in a reflects its mucoid content. R = rectum.
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Figure 9b. Tailgut cyst in a 17-year-old boy with rectal fullness. (a) Axial CT scan obtained with oral and intravenous contrast material at the level of the symphysis pubis demonstrates a lobular well-defined fluid-attenuation mass that compresses the barium-filled rectum (R) anterolaterally. (b) Axial T2-weighted (3500/80) fat-saturated MR image shows high signal intensity in the mass. The intermediate attenuation seen in the mass in a reflects its mucoid content. R = rectum.
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Figure 10a. Neuroblastoma detected incidentally at US in a 9-week-old girl with a urinary tract infection. (a) Axial US image of the upper pelvis demonstrates a large, well-defined, solid mass that contains a small cystic area (curved arrow); multiple smaller areas of high echogenicity representing calcifications; the right iliac bone (straight arrow); and the sacral vertebrae (arrowhead). (b) Axial CT scan of the pelvis, obtained with intravenous contrast material, demonstrates a well-defined and heterogeneously enhanced presacral mass that contains scattered foci of calcifications. The mass has encroached on the neural foramen (arrow) in the left side and has displaced the rectosigmoid (R) colon segment anterolaterally.
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Figure 10b. Neuroblastoma detected incidentally at US in a 9-week-old girl with a urinary tract infection. (a) Axial US image of the upper pelvis demonstrates a large, well-defined, solid mass that contains a small cystic area (curved arrow); multiple smaller areas of high echogenicity representing calcifications; the right iliac bone (straight arrow); and the sacral vertebrae (arrowhead). (b) Axial CT scan of the pelvis, obtained with intravenous contrast material, demonstrates a well-defined and heterogeneously enhanced presacral mass that contains scattered foci of calcifications. The mass has encroached on the neural foramen (arrow) in the left side and has displaced the rectosigmoid (R) colon segment anterolaterally.
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Figure 11a. Stage 1 presacral neuroblastoma detected incidentally in a 3-year-old boy at routine physical examination. (a) 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). (b) Axial CT scan obtained with intravenous contrast material shows heterogeneous enhancement in the mass but no pelvic vessel involvement. (Reprinted, with permission, from reference 6.)
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Figure 11b. Stage 1 presacral neuroblastoma detected incidentally in a 3-year-old boy at routine physical examination. (a) 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). (b) Axial CT scan obtained with intravenous contrast material shows heterogeneous enhancement in the mass but no pelvic vessel involvement. (Reprinted, with permission, from reference 6.)
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Figure 12a. Neuroblastoma in a 2-year-old boy with constipation. (a) Axial pelvic CT scan obtained with intravenous contrast material shows a large mass that contains areas of low attenuation consistent with necrosis. The mass extends to the right S1 vertebral foramen (arrow) and has displaced the rectum to the right side and the bladder (arrowhead) anteriorly. (b) 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. (c) Sagittal T2-weighted fat-saturated MR image shows heterogeneous, predominantly high signal intensity in the mass (arrowheads).
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Figure 12b. Neuroblastoma in a 2-year-old boy with constipation. (a) Axial pelvic CT scan obtained with intravenous contrast material shows a large mass that contains areas of low attenuation consistent with necrosis. The mass extends to the right S1 vertebral foramen (arrow) and has displaced the rectum to the right side and the bladder (arrowhead) anteriorly. (b) 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. (c) Sagittal T2-weighted fat-saturated MR image shows heterogeneous, predominantly high signal intensity in the mass (arrowheads).
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Figure 12c. Neuroblastoma in a 2-year-old boy with constipation. (a) Axial pelvic CT scan obtained with intravenous contrast material shows a large mass that contains areas of low attenuation consistent with necrosis. The mass extends to the right S1 vertebral foramen (arrow) and has displaced the rectum to the right side and the bladder (arrowhead) anteriorly. (b) 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. (c) Sagittal T2-weighted fat-saturated MR image shows heterogeneous, predominantly high signal intensity in the mass (arrowheads).
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Figure 13. Ganglioneuroma in a 14-year-old boy. Sagittal T2-weighted MR image shows a high-signal-intensity presacral ganglioneuroma that distorts the distal sacrum (arrow) and has displaced the bladder (B) anteriorly.
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Figure 14. Type 1 neurofibromatosis in a 17-year-old boy. Axial pelvic CT scan obtained with intravenous contrast material shows well-circumscribed bilateral masses with soft-tissue attenuation, anterior to the sacrum, that have compressed the rectosigmoid colon segment and displaced the bladder. Neurofibromas also are visible in the inguinal regions.
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Figure 15. Type 1 neurofibromatosis. Axial T2-weighted (4500/120) fat-saturated MR image of the middle pelvis in an 18-year-old male patient shows multiple bilateral target signs indicative of intrapelvic neurofibromas, which extend into the inguinal regions. A subcutaneous lesion also is visible in the left buttock.
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Figure 16. Type 1 neurofibromatosis. Axial T2-weighted MR image in an 11-year-old girl with spasticity of the lower extremities shows multiple lesions with the characteristic target sign: a large central region of hypointense signal representing a fibrous core, surrounded by a rim of hyperintense signal indicative of myxoid material. Abnormal soft tissue has filled and expanded the spinal canal. The mass effect of the pelvic lesions has caused lateral displacement of the rectosigmoid (R) colon segment and anterosuperior displacement of the bladder (B).
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Figure 17. Abscess in a 17-year-old girl with fever and pelvic discomfort after bladder augmentation surgery. Axial pelvic CT scan obtained with oral and intravenous contrast material demonstrates multiple fluid collections with peripheral enhancement that represent a postoperative abscess. The rectosigmoid colon segment (arrow) has been displaced laterally. U = uterus.
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Figure 18. Rhabdomyosarcoma. Axial pelvic CT scan obtained with intravenous contrast material in a 15-year-old boy initially treated for proctitis depicts a presacral mass that has displaced the bladder (B) anteriorly and the rectosigmoid colon segment (arrow) to the left. The mass, which is predominantly necrotic, shows peripheral enhancement and some linear central enhancement. (Reprinted, with permission, from reference 6.)
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Figure 19. Rhabdomyosarcoma. Axial pelvic CT scan obtained with oral and intravenous contrast material in an 8-month-old boy demonstrates an infiltrative soft-tissue mass that extends anteriorly, causing deviation of the urinary bladder (B), and posteriorly into both sciatic notch regions. The mass contains punctate calcifications. The spinal canal is abnormally wide and shows increased soft-tissue attenuation (arrow). A bladder catheter (F) also is visible.
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Figure 20a. Undifferentiated sarcoma in a 15-year-old girl with intermittent left thigh pain. (a) Sagittal T1-weighted MR image shows a low-signal-intensity presacral soft-tissue mass that has displaced the rectum (R) anteriorly and has infiltrated the upper sacral vertebrae, which have an irregular appearance. Intermediate-signal-intensity soft tissue also is visible in the sacral spinal canal (arrows). (b) Sagittal T2-weighted MR image more clearly depicts involvement of the sacrococcygeal vertebrae (arrow) as well as the spinal canal soft-tissue mass (arrowheads).
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Figure 20b. Undifferentiated sarcoma in a 15-year-old girl with intermittent left thigh pain. (a) Sagittal T1-weighted MR image shows a low-signal-intensity presacral soft-tissue mass that has displaced the rectum (R) anteriorly and has infiltrated the upper sacral vertebrae, which have an irregular appearance. Intermediate-signal-intensity soft tissue also is visible in the sacral spinal canal (arrows). (b) Sagittal T2-weighted MR image more clearly depicts involvement of the sacrococcygeal vertebrae (arrow) as well as the spinal canal soft-tissue mass (arrowheads).
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Figure 21. Burkitt lymphoma in a 3-year-old boy. Axial pelvic CT scan obtained with oral and intravenous contrast material shows a large heterogeneous mass with soft-tissue attenuation that extends to the presacral space and superior pelvis and encases the rectosigmoid colon segment (arrows).
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Figure 22a. Burkitt lymphoma in a 16-year-old boy. Axial (a, b) and sagittal (c) T2-weighted (3500/80) turbo spin-echo MR images obtained with (a) and without (b, c) fat saturation reveal a large heterogeneous pelvic mass with high signal intensity that has surrounded the rectum (arrow in a and c) and displaced the small-bowel loops superiorly. In b, note the left inguinal lymphadenopathy (arrowhead) and left acetabular involvement.
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Figure 22b. Burkitt lymphoma in a 16-year-old boy. Axial (a, b) and sagittal (c) T2-weighted (3500/80) turbo spin-echo MR images obtained with (a) and without (b, c) fat saturation reveal a large heterogeneous pelvic mass with high signal intensity that has surrounded the rectum (arrow in a and c) and displaced the small-bowel loops superiorly. In b, note the left inguinal lymphadenopathy (arrowhead) and left acetabular involvement.
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Figure 22c. Burkitt lymphoma in a 16-year-old boy. Axial (a, b) and sagittal (c) T2-weighted (3500/80) turbo spin-echo MR images obtained with (a) and without (b, c) fat saturation reveal a large heterogeneous pelvic mass with high signal intensity that has surrounded the rectum (arrow in a and c) and displaced the small-bowel loops superiorly. In b, note the left inguinal lymphadenopathy (arrowhead) and left acetabular involvement.
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Figure 23. Lymphoproliferative disease related to Epstein-Barr virus in a 7-year-old girl after a cord blood transplant for metachromatic leukodystrophy. Axial CT scan obtained with oral and intravenous contrast material shows a minimally heterogeneous presacral mass.
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Figure 24. Vascular malformation in an infant girl. Axial T2-weighted MR image demonstrates a mixed-signal-intensity mass (arrows) that involves the posterior sacrum as well as the presacral space.
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Figure 25a. Giant cell tumor in a 15-year-old girl with hip pain. (a) Axial pelvic CT scan obtained with intravenous contrast material shows a large and expansile osteolytic mass (arrow) in the upper sacrum, with involvement of the sacral neural foramina and spinal canal and extension into the presacral space. (b) 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.
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Figure 25b. Giant cell tumor in a 15-year-old girl with hip pain. (a) Axial pelvic CT scan obtained with intravenous contrast material shows a large and expansile osteolytic mass (arrow) in the upper sacrum, with involvement of the sacral neural foramina and spinal canal and extension into the presacral space. (b) 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.
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Figure 26a. Aneurysmal bone cyst in a 15-year-old boy with back pain, lower extremity pain, paresthesia, and a palpable mass in the buttock. (a) Anteroposterior pelvic radiograph demonstrates distortion of the sacrum (arrows). (b) Axial CT scan obtained with intravenous contrast material at the level of the inferior sacrum shows an expansile osteolytic mass (arrows) with cortical destruction, involvement of the sacral spinal canal, and disruption of the left sacroiliac joint.
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Figure 26b. Aneurysmal bone cyst in a 15-year-old boy with back pain, lower extremity pain, paresthesia, and a palpable mass in the buttock. (a) Anteroposterior pelvic radiograph demonstrates distortion of the sacrum (arrows). (b) Axial CT scan obtained with intravenous contrast material at the level of the inferior sacrum shows an expansile osteolytic mass (arrows) with cortical destruction, involvement of the sacral spinal canal, and disruption of the left sacroiliac joint.
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Figure 27. Osteoblastoma in a 16-year-old girl. Sagittal T2-weighted (4790/122) MR image of the pelvis shows the origin of the heterogeneous presacral mass in the distal sacrum.
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Figure 28. Chordoma in a 14-year-old girl with hip and back pain. Axial CT scan obtained with intravenous contrast material at the level of the middle sacrum shows an expansile soft-tissue mass with calcifications (arrows), cortical destruction, extension into the presacral space, and involvement of the epidural space of the sacral spinal canal. (Reprinted, with permission, from reference 6.)
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Figure 29a. Osteogenic sarcoma of the sacrum in a 16-year-old boy with back and right hip pain. (a) Axial unenhanced CT scan shows a predominantly sclerotic sacrum with indistinct anterior margins. (b) 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.
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Figure 29b. Osteogenic sarcoma of the sacrum in a 16-year-old boy with back and right hip pain. (a) Axial unenhanced CT scan shows a predominantly sclerotic sacrum with indistinct anterior margins. (b) 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.
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Figure 30. Ewing sarcoma. Axial pelvic CT scan obtained with intravenous contrast material in a 15-year-old girl with back and bilateral hip pain shows destruction of the lower sacrum by a mass with a significant soft-tissue component. The mass has extended into the presacral space dorsal to the sacrum, displaced the uterus (U) and bladder (B) anteriorly, and obliterated the neural foramina.
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Figure 31a. Ewing sarcoma. Axial pelvic CT scan obtained with intravenous contrast material in a 14-year-old girl with hip pain shows an enhanced soft-tissue mass that has displaced the rectum (white arrow) and invaded a sacral foramen (black arrow). Sagittal T2-weighted MR image demonstrates a heterogeneous presacral mass with extension posterior to the sacrum (arrow).
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Figure 31b. Ewing sarcoma. Axial pelvic CT scan obtained with intravenous contrast material in a 14-year-old girl with hip pain shows an enhanced soft-tissue mass that has displaced the rectum (white arrow) and invaded a sacral foramen (black arrow). Sagittal T2-weighted MR image demonstrates a heterogeneous presacral mass with extension posterior to the sacrum (arrow).
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Figure 32a. Presacral mass in a male neonate after ostomy placement for anal atresia. Sagittal unenhanced T2-weighted MR image (a) and sagittal contrast-enhanced T1-weighted fat-saturated MR image (b) show a homogeneous presacral mass (arrows) with persistent high signal intensity despite fat saturation in b, a finding indicative of a hematoma.
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Figure 32b. Presacral mass in a male neonate after ostomy placement for anal atresia. Sagittal unenhanced T2-weighted MR image (a) and sagittal contrast-enhanced T1-weighted fat-saturated MR image (b) show a homogeneous presacral mass (arrows) with persistent high signal intensity despite fat saturation in b, a finding indicative of a hematoma.
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Copyright © 2006 by the Radiological Society of North America.
