A 67-year-old woman underwent polypectomy for a tumor at the descending colon. Pathologically, the tumor was diagnosed as adenocarcinoma with an invasion of 2000 μm. Computed tomography showed a swollen paracolic lymph node and a mass lesion in the presacral space. Magnetic resonance imaging revealed a multio-cular cystic lesion. On diagnosis of descending colon cancer and tailgut cyst, she underwent synchronous lapa-roscopic resection. Histopathologically, the colon cancer was diagnosed as pT1bN1M0, pStage IIIa. The pre-sacral cystic lesion was diagnosed as a nonmalignant tailgut cyst with negative surgical margin. The patient is currently doing well without recurrence at 28 months

Inada, Ryo

Iwata, Jun

Katsura, Yuki

Matsumoto, Manabu

Oishi, Kazuyuki

Okabayashi, Takehiro

Ozaki, Kazuhide

Sato, Takuji

Shibuya, Yuichi

Sui, Kenta

Toshima, Toshiaki

Watanabe, Ayako

English

Okayama University Scientific Achievement Repository

T ailgut cysts are rare congenital lesions that usually develop in the presacral space [1 , 2].  These cysts are believed to arise from embryonic hindgut remnants [3].  More than 50% of patients with tailgut cysts are asymptomatic,  and the lesions are frequently detected incidentally during radiographic examinations [4].  Tailgut cysts should be resected with appropriate onco-logical margins,  because they present a risk for malig-nant transformation [1 , 4-6].  We describe a patient with a tailgut cyst identified during preoperative exam-inations for descending colon cancer who underwent simultaneous laparoscopic resection during treatment.Case PresentationA 67-year-old woman presented with fecal occult blood identified in a routine medical examination.  She underwent a colonoscopy,  and a protruded tumor was detected at the descending colon.  Polypectomy was performed for the lesion.  Pathologically,  the tumor was diagnosed as moderately differentiated adenocarcinoma with an invasion of 2000 μm.  She was referred to Kochi Health Sciences Center for additional surgical resection.  Preoperative computed tomography showed a swollen paracolic lymph node and a mass lesion in the presacral space.  Magnetic resonance imaging (MRI) revealed a multiocular cystic lesion with high signal intensity on T2-weighted images (Fig. 1).  The serum level of carci-noembryonic Antigen (CEA) and carbohydrate associated antigen (CA19-9) were not elevated (CEA 1.3 ng/mL,  CA19-9 < 0.3 U/mL).  On diagnosis of descending colon cancer with lymph node metastasis and a tailgut cyst,  we performed simultaneous laparoscopic resection.A pneumoperitoneum was created,  and 5 ports were used.  First,  we exfoliated between the mesocolon and renal fascia using a medial to lateral approach.  We performed Japanese D3 lymph node dissection while Acta Med.  Okayama,  2021Vol.  75,  No.  4,  pp.  529-532CopyrightⒸ 2021 by Okayama University Medical School.http ://escholarship.lib.okayama-u.ac.jp/amo/Case ReportLaparoscopic Synchronous Resection for Descending  Colon Cancer and Tailgut CystRyo Inadaa＊,  Ayako Watanabea,  Toshiaki Toshimaa,  Yuki Katsuraa,   Takuji Satoa,  Kenta Suia,  Kazuyuki Oishia,  Takehiro Okabayashia,   Kazuhide Ozakia,  Yuichi Shibuyaa,  Manabu Matsumotob,  and Jun IwatabDepartments of aGastroenterological Surgery,  bDiagnostic Pathology,  Kochi Health Sciences Center,  Kochi 781-8555,  JapanA 67-year-old woman underwent polypectomy for a tumor at the descending colon.  Pathologically,  the tumor was diagnosed as adenocarcinoma with an invasion of 2000 μm.  Computed tomography showed a swollen paracolic lymph node and a mass lesion in the presacral space.  Magnetic resonance imaging revealed a multio-cular cystic lesion.  On diagnosis of descending colon cancer and tailgut cyst,  she underwent synchronous lapa-roscopic resection.  Histopathologically,  the colon cancer was diagnosed as pT1bN1M0,  pStage IIIa.  The pre-sacral cystic lesion was diagnosed as a nonmalignant tailgut cyst with negative surgical margin.  The patient is currently doing well without recurrence at 28 months.Key words:  anterior approach,  laparoscopic resection,  tailgut cystReceived August 11, 2020 ; accepted February 15, 2021.＊Corresponding author. Phone : +81-88-837-3000; Fax : +81-88-837-6766E-mail : ryo_inada@hotmail.com (R. Inada)Conflict of Interest Disclosures: No potential conflict of interest relevant to this article was reported.successively preserving the superior rectal artery7.  In other words,  we ligated the left colic artery in bifurca-tion,  after dissecting the main lymph nodes around the origin of the superior rectal artery.  A lateral approach was used,  and we finished the mobilization of the sig-moid and descending colon.  Then,  we exfoliated the presacral space to the levator ani muscle,  while keeping the mesorectal layer,  and confirmed the presence of the tumor on the pelvic surface of the sacrum.  We resected the tumor on the sacrum in an en bloc fashion using ultrasonic coagulating shears while attaching some peritosteums.  The contents of the tumor were not exposed on resection.  Extraction of the descending colon and creation of an external anastomosis was done through extension of the umbilical port to a 4 cm mid-line incision.  The duration of surgery was 199 minutes,  with small amount of bleeding.  (Fig. 2).  Histopathologically,  although no tumor cells per-sisted at the resected colon specimen,  one of the dis-sected lymph nodes had metastasized.  The colon cancer was diagnosed as pT1b,  pN1,  pM0,  pStage IIIa,  based on the Japanese Classification of Colorectal Carcinoma8.  The inside of the presacral cystic lesion was covered with stratified squamous epithelium,  stratified cuboidal epithelium,  and columnar epithelium without dyspla-sia.  Therefore,  the cystic lesion was diagnosed as a tailgut cyst without malignancy,  and the surgical mar-gin was negative (Fig. 3).  The postoperative course was uneventful,  and she underwent capecitabine treatment for 6 months as adjuvant therapy for descending colon cancer.  She is currently doing well without recurrence 28 months after treatment.530 Inada et al. Acta Med.  Okayama　Vol.  75,  No.  4Fig.  1　 Magnetic resonance imaging showing a presacral multio-cular cystic lesion.  The lesion shows high signal intensity on T2-weighted images (arrow).ABFig.  2　 Intraoperative images after lymph node dissection (A) and before and after resection of the tailgut cyst (B).  D3 lymph node dissection while preserving the superior rectal artery (arrowhead) was performed.  The presacral tail gut cyst (arrow) was resected in en bloc.DiscussionThe presacral space is one of the common sites of congenital lesions,  such as dermoid cysts,  epidermoid cysts,  and tailgut cysts [2].  Tailgut cysts arise from the remnants of the embryonic hindgut.  During the embryologic process,  the hindgut extends to the tail and forms the tailgut.  By 8 weeks of gestation,  the tailgut normally regresses.  Failure to regress leads to the development of a tailgut cyst [3 , 6].More than 50% of patients with a tailgut cyst are asymptomatic,  and the cyst is incidentally detected during radiological examinations,  as in our case [4].  There are case reports of the occurrence of a tailgut cyst with colorectal cancer [8].  In symptomatic patients with a tailgut cyst,  the clinical presentation is usually manifested by the effect of a local mass and may include anal pain,  constipation,  obstructed defecation,  tenesmus,  painless rectal bleeding,  dysuria,  urinary frequency,  lower abdominal pain,  back pain,  and lower limb neurological problems [1].Pelvic MRI is a useful radiological examination for diagnosing tailgut cysts.  Tailgut cysts have been described as multiocular cystic lesions with low signal intensity on T1-weighted images and high signal inten-sity on T2-weighted images [9].  Tailgut cysts are asso-ciated with a risk for malignant transformation,  with an incidence of malignant transformation reported to be 6-13% [4 , 6 , 10].  A recent systematic review of 196 cases with tailgut cysts revealed that the overall rate of malignant transformation was 26.6% [5].  Some MRI findings of malignant transformation were reported,  including nodular thickness of the cyst wall and bloody or mucinous components of the cyst [5 , 6 , 9].  However,  a definite diagnosis of malignant transformation can only be made by surgical resection and histological examination [6].  In case of tailgut cyst is radiologically suspected,  complete resection with sufficient margin should be performed.  In general,  three approaches are used for surgical excision of a tailgut cyst: an anterior approach,  a pos-terior approach,  or a combined approach.  Several fac-tors should be considered when choosing an approach,  including the location and size of the cyst,  the presence or absence of infection,  adherence of neighboring structures,  and the presence or absence of evidence of malignant transformation [1 , 10].  The anterior approach tends to be used for a lesion on the supraleva-tor ani muscle,  whereas the posterior approach tends to be used for a lesion on the intralevator ani muscle [6].  The combined approach is often selected for larger lesions [6].  A recent large case series of a single institu-tion reported that,  when comparing the anterior approach and posterior approach,  operation time was shorter with the posterior approach,  and the preopera-tive complication rate was lower with the anterior approach [6].  Regardless,  we should determine a surgi-cal approach with the goal of securing a certain margin and avoiding injury to neighboring pelvic organs.  In our case,  the tailgut cyst of appropriate size was in the presacral space of the supralevator ani muscle,  and was removed during the resection for descending colon cancer.  We planned to simultaneously resect both the tailgut cyst and the descending colon cancer in the same surgical position and field,  and we selected a laparo-scopic anterior approach.  After lymph node dissection August 2021 Laparoscopic Resection of Tailgut Cyst 531ABFig.  3　 Resected specimen (A) and microscopic findings (B).The inside of the cystic lesion was covered with stratified squamous epithelium,  stratified cuboidal epithelium,  and columnar epithelium without dysplasia,  and the surgical margin was negative.and colon mobilization for the descending colon cancer,  we started treatment for the tailgut cyst.  Laparoscopic surgery using magnification and meticulous dissection was useful for fine manipulation in the narrow space,  and we could resect the cystic lesion in the pelvis while securing a certain margin without injuring neighboring organs.  There are a few reports of laparoscopic resec-tion for tailgut cysts [6 , 11].  In the retrospective analy-sis of eight cases with laparoscopic resection for pre-sacral tumor,  Zhou et al.  showed promising results without serious postoperative complications nor tumor recurrence [11].  To our knowledge,  our case is the first report of laparoscopic synchronous resection for descending colon cancer and a tailgut cyst.  In conclusion,  en bloc resection with a certain mar-gin is important for treatment of a tailgut cyst,  and an appropriate approach should be selected.  A laparo-scopic anterior approach may be effective for lesions on the supralevator ani muscle.References 1. Hjermstad BM and Helwig EB: Tailgut cysts.  Report of 53 cases.  Am J Clin Pathol (1988) 89: 139-147. 2. Jao SW,  Beart RW,  Jr.,  Spencer RJ,  Reiman HM and Ilstrup DM:  Retrorectal tumors.  Mayo Clinic experience,  1960-1979.  Dis Colon Rectum (1985) 28: 644-652. 3. Prasad AR,  Amin MB,  Randolph TL,  Lee CS and Ma CK:  Retrorectal cystic hamartoma: report of 5 cases with malignancy arising in 2.  Arch Pathol Lab Med (2000) 124: 725-729. 4. Patsouras D,  Pawa N,  Osmani H and Phillips RK: Management of tailgut cysts in a tertiary referral centre: a 10-year experience.  Colorectal Dis (2015) 17: 724-729. 5. Nicoll K,  Bartrop C,  Walsh S,  Foster R,  Duncan G,  Payne C and Carden C: Malignant transformation of tailgut cysts is significantly higher than previously reported: systematic review of cases in the literature.  Colorectal Dis (2019) 21: 869-878. 6. Sakr A,  Kim HS,  Han YD,  Cho MS,  Hur H,  Min BS,  Lee KY and Kim NK: Single-center Experience of 24 Cases of Tailgut Cyst.  Ann Coloproctol (2019) 35: 268-274. 7. Japanese Society for Cancer of the Colon and Rectum: Japanese Classification of Colorectal,  Appendiceal,  and Anal Carcinoma:  the 3d English Edition.  J Anus Rectum Colon (2019) 3: 175-195. 8. Fujitaka T,  Nakayama H,  Fukuda S,  Ojima Y,  Toyota K,  Ono E and Dohi K: A tailgut cyst found accompanying rectal cancerreport of a case.  Surg Today (1995) 25: 65-67. 9. Yang DM,  Park CH,  Jin W,  Chang SK,  Kim JE,  Choi SJ and Jung DH: Tailgut cyst: MRI evaluation.  AJR Am J Roentgenol (2005) 184: 1519-1523.10. Mathis KL,  Dozois EJ,  Grewal MS,  Metzger P,  Larson DW and Devine RM: Malignant risk and surgical outcomes of presacral tail-gut cysts.  Br J Surg (2010) 97: 575-579.11. Zhou JL,  Wu B,  Xiao Y,  Lin GL,  Wang WZ,  Zhang GN and Qiu HZ:  A laparoscopic approach to benign retrorectal tumors.  Tech Coloproctol (2014) 18: 825-833.532 Inada et al. Acta Med.  Okayama　Vol.  75,  No.  4

Laparoscopic Synchronous Resection for Descending Colon Cancer and Tailgut Cyst

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Laparoscopic Synchronous Resection for Descending Colon Cancer and Tailgut Cyst

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