Sacral chordoma

Case contributed by Aravinda Perera

Presentation

Lower back pain and right lower limb radicular pain.

Patient Data

Age: 60 years
Gender: Male
CT

Multilobulated, homogenous soft tissue mass centered on the sacrum with associated destruction of the sacrum and internal calcifications. The mass extends into the presacral space, displacing the rectum and anterior sacral nerve roots anteriorly. Further extraosseous extension posteriorly into the subcutaneous tissues overlying the sacrum. No pelvic or abdominal lymphadenopathy by size criteria.

Arterial supply of the mass like originates from bilateral internal iliac artery branches.

Incidental ovoid hypoattenuating focus within hepatic segment 3 may represent a hepatic cyst.

No intra-abdominal free fluid or gas. Colonic fecal loading and diverticulosis. Bilateral direct fat-containing inguinal hernias. Small fat-containing umbilical hernia.

Vertebral body hemangiomas within T10, T11, L3, and L4. Minimally displaced sacral alar fractures are discernible.

Indwelling catheter within the urinary bladder.

MRI

A heterogeneous T2 hyperintense mass replaces much of the sacrum. The mass possesses fairly circumscribed hypointense margins with lobulation, mild patchy enhancement and extensive areas of restricted diffusion.

The sacral canal and all sacral foramina, except the right ventral S1 foramen, are obliterated within the mass. The anterior aspect of the mass slightly compresses the posterior aspect of the mid to lower rectum, with preserved intervening fat.

No size-significant intrapelvic or inguinal lymphadenopathy.

Persisting mild edema of the erector spinae muscles at the L5 and S1 levels.

Indwelling catheter within the urinary bladder.

Case Discussion

A biopsy of the sacral mass was performed and histological analysis confirmed a diagnosis of chordoma.

The patient underwent multiple consecutive surgeries to facilitate resection of the chordoma and subsequent reconstruction of skeletal and soft tissue structures. Initially, a laparotomy with stoma formation was performed. Following this, in order to resect the chordoma, a total sacrectomy was performed followed by spinopelvic fixation. Finally, the soft tissue defect was reconstructed with bilateral gluteus maximus and erector spinae advancement flaps.

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