Laparoscopic management of presacral myelolipoma.
ABSTRACT Myelolipomas are rare, benign nonfunctioning tumors, most commonly found in the adrenal glands. At least 43 cases of extra adrenal myelolipomas have been reported, with at least 50% of these reported cases occurring in the presacral region. Herein we report a case of presacral myelolipoma managed laparoscopically.
Laparoscopic Management of Presacral Myelolipoma
Stella E. Asuquo, MD, Scott Q. Nguyen, MD, Irini Scordi-Bello, MD, PhD, Celia M. Divino, MD
Myelolipomas are rare, benign nonfunctioning tumors,
most commonly found in the adrenal glands. At least 43
cases of extra adrenal myelolipomas have been reported,
with at least 50% of these reported cases occurring in the
presacral region. Herein we report a case of presacral
myelolipoma managed laparoscopically.
Key Words: Presacral myelolipoma, laparoscopy, benign
Myelolipomas are rare, benign tumors, consisting of he-
matopoietic cells and mature adipose tissue.1,2They are
most commonly found in the adrenal glands; however,
there have been several reported cases of extra adrenal
myelolipomas with at least 50% of those reported cases
occurring in the presacral region.2-5We present a case of
a patient undergoing laparoscopic colectomy for divertic-
ulitis with simultaneous resection of a presacral myeloli-
A 74-year-old woman with a history of recurrent divertic-
ulitis was found to have an incidental pelvic mass discov-
ered on an abdominal/pelvic CT (Figure 1). The trilobed
pelvic mass was noted to have increased in size over
several months. The patient’s past medical history was
significant for squamous cell carcinoma of the cervix di-
agnosed and treated 10 years prior with a total abdominal
hysterectomy and bilateral salpingo-oophorectomy. Other
medical problems included a recent episode of pulmo-
nary embolism, hyperlipidemia, and hypertension.
She was without any abdominal or pelvic symptoms de-
nying any pelvic pressure, pain, hematuria, or changes in
bowel function. Given the patient’s prior history of malig-
nancy, a workup for possible metastatic disease was per-
formed. Tumor markers (CA 125, CA 19-9, and CEA) were
all within normal limits, and physicians in the gynecolog-
ical oncology consultation felt confident that the tumor
was not a recurrence.
Positron emission tomography scan showed the tumor to
be hypermetabolic, and CT-guided biopsy of the mass
was attempted, with inconclusive results. The patient con-
sented to laparoscopic sigmoid resection for the divertic-
ulitis along with an excisional biopsy of the pelvic mass
given the inconclusive nature of imaging studies and bi-
Intraoperatively, the sigmoid colon was first dissected off
the lateral peritoneal attachments using a Harmonic scal-
pel. The peritoneum was then scored along the mesentery
of the medial and lateral side of the sigmoid colon down
Department of General Surgery, Albert Einstein School of Medicine-Montefiore,
Bronx, New York, USA (Dr Asuquo).
Department of General Surgery, Mount Sinai School of Medicine, New York, New
York, USA (Drs Nguyen, Divino).
Department of Pathology, Mount Sinai School of Medicine, New York, New York,
USA (Dr. Scordi-Bello).
Address correspondence to: Scott Q. Nguyen, MD, Mount Sinai School of Medi-
cine, Department of General Surgery, 5 East 98th Street, New York, New York
10029, USA. Telephone: (212) 241-1483, Fax: (212) 241-5979, E-mail:
© 2011 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
to the bilateral gutters of the medial pelvis, respectively.
The mesentery of the sigmoid colon was then divided
down to the level of the sacral promontory. The rectosig-
moid was subsequently divided and the rectal stump re-
tracted anterosuperiorly so as to gain access into the
presacral space for biopsy of the lesion.
The mass was found to be a multilobulated, coalescing,
well-encapsulated lesion. It was surrounded by a thin
friable membrane, and each lobe contained a hemor-
rhagic gelatinous, parenchyma. A frozen section of the
mass was reported as fibrous tissue, mature adipose tis-
sue, and hematopoietic cells without evidence of tumor.
The majority of tumor was removed with moderate
amounts of presacral bleeding controlled with pressure
and hemostatic compounds. Given the nonmalignant fro-
zen pathology results, we felt that subtotal excision was
appropriate, and no further attempts were made at com-
plete removal. The patient had an uneventful postopera-
On pathologic examination, the resected lesion consisted
of a 3.5 x 1.7 x 0.6-cm aggregate of tan-brown, soft,
hemorrhagic tissue. Permanent sections disclosed adipose
tissue with scattered foci of hematopoietic tissue, includ-
ing myeloid, erythroid, and megakaryocytic elements
(Figure 2), and the final pathology report was consistent
with a myelolipoma.
To our knowledge, laparoscopic management of pre-
sacral myelolipoma has never been described before
this case. Given the benign nature of this tumor, surgi-
cal resections are only indicated when the nature of the
tumor is in question, as in this case. Several retroperi-
toneal malignancies, such as teratomas, chordomas, li-
posarcomas, lymphomas, and neurogenic tumors, must
be in the differential diagnosis for lesions in the pre-
sacral area.4,5Additionally, with this patient’s prior his-
tory of gynecological malignancy, interval increase in
tumor size and inconclusive preoperative workup, a
surgical biopsy to evaluate the lesion was necessary.
Given the necessity of a sigmoidectomy for recurrent
diverticulitis, we felt a combined laparoscopic proce-
dure would be best.
To date, at least 20 cases of presacral myelolipomas have
been reported in the literature. They classically occur in
older patients with the majority of cases being diagnosed
in the fifth to seventh decades, and many reports showing
an increased incidence in women.2,3Most presacral my-
elolipomas are usually asymptomatic and are discovered
incidentally by abdominal/pelvic CT scans and encapsu-
lated round masses with no infiltrative pattern.4When
symptomatic, it is usually because of mass effect on adja-
cent structures, such as the bladder, ureters, sacral nerve
plexus, and the rectum such that patients may present
with symptoms of urinary retention, lower extremity ra-
diculopathy, sciatica type pain or constipation.3
Several aspects of the case were difficult. CT-guided bi-
opsies of the lesion were inconclusive, yielding only in-
flammatory connective tissue, pushing us to define this
lesion surgically. In retrospect, such findings can be ex-
pected after a needle biopsy of a myelolipoma. It was
serendipitous that the patient required a sigmoidectomy
for diverticulitis, because gaining access to this lesion
Figure 1. The trilobed lobulated pelvic mass located immedi-
ately anterior to the sacrum with no invasion of surrounding
Figure 2. Histological appearance showing mature adipocytes
admixed with hematopoietic tissue: myeloid, erythroid, and
megakaryocytic elements (Hematoxylin-eosin x400).
without performing a bowel resection would be quite
arduous. To gain access to the lesion, a mesorectal plane
had to be followed during the sigmoid resection; there-
fore, a deeper and more extensive dissection than a stan-
dard sigmoid resection for diverticulitis was required.
Consequently, we needed to resect a larger amount of
rectosigmoid distally for fear of leaving devascularized
proximal rectum. Despite staying in a mesorectal plane,
presacral bleeding was also encountered as the lesion was
excised. The bleeding was moderate and could be con-
trolled with local hemostatic agents. However, it compli-
cated the resection enough that a subtotal resection was
satisfactory, especially after the benign frozen section re-
sults were noted.
Given the benign nature of these lesions, the risk of
recurrence after excision is minimal, so no interval screen-
ing abdominopelvic imaging is indicated. In this case, if an
interval increase is seen in the size of the mass inciden-
tally, it is important to rule out the more common retro-
peritoneal malignancies mentioned previously with a per-
cutaneous needle biopsy. Surgical intervention would not
be indicated if the biopsy showed tissue elements consis-
tent with myelolipoma and patient was without the afore-
mentioned size effect symptoms.
We present the case of a presacral myelolipoma that was
difficult to identify without a surgical excision. Laparo-
scopic management of the mass and of the diverticular
disease was successful and is a reasonable approach to a
lesion in such a challenging location.
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