IMAGING OF

PRESACRAL MASSES

speaker: kiran

MODERATOR:
PROF.O.P. SHARMA
 INTRODUCTION
 Mass present between perirectal fascia
and the sacrococcygeal part of spine.
 Imaging plays an important role in the
detection and differentiation of these masses.
 Information obtained is critical for
management ,especially surgical planning.
 Usual symptoms are ,change in bowel
habits,low back and sacral pain, abdominal
pain,palpable mass, urinary symptoms, anal
discharge and bleeding.
 TYPES OF MASS

 Congenital and developmental masses.

 Neurogenic Masses
 Inflammatory Masses
 Mesenchymal Masses
 Lymphomatous Masses
 Extension of sacral bone tumors
 Other presacral masses
CLASSIFICATION 2

A. SOLID
.sacrococcygeal teratoma
.neuroblastoma
.rhabdomyosarcoma
.fibroma
.lipoma
.lymphoma
.sacral bone tumours etc
 CYSTIC
 Abscess
 Rectal duplication
 Hematoma
 Lymhocele
 Neurentric cyst
 Sacral osteomyelitis
 Ulcerative colitis
 Anterior meningocele
 CONGENITAL AND
DEVELOPMENTAL MASSES
 Germ cell tumors - sacrococcygeal
teratoma,germinomatous and
nongerminomatous germ cell tumors.
 Anterior sacral meningocele
 Developmental cysts - epidermoid cyst,
dermoid cyst, enteric cysts [rectal duplication
cyst, tailgut cyst])
 Cystic lymphangioma
 Lipoma
SACROCOCCYGEAL TERATOMA

 Teratoma located at the base of the coccyx.

 Most common tumor of the newborn period,
with a prevalence of 0.25-0.28:10,000 live
births; M:F 1:4 ratio.
 Derived from the pleuripotent cells of
Hensen"s nodes that migrate caudally and
come to lie within the coccyx.
 Tumors before 2mnths of age & cystic
lesions are usually benign.
 ALTMAN CLASSIFICATION SYSTEM
FOR SACROCOCCYGEAL TERATOMAS

 Type I - Predominantly
external masses with a
small presacral component.
 Type II - External masses
with a significant intrapelvic
component.
 Type III- External masses
with a pelvic and abdominal
component.
 Type IV - Internal masses
with an intrapelvic and
abdominal location.
 IMAGING FINDINGS
 Cystic components typically appear as anechoic
areas on USG.
 MRI is the modality of choice because of the superior
depiction of soft tissues and preferred for both initial
diagnosis and recurrence survillence.
 Benign are predominantly cystic have attenuation
similar to that of fluid on CT.
 On MRI cystic areas appear as fluid on T1 and T2
images ,areas of fatty tissue show high signal
intensity, calification and bone dipicted as signal
void.
MATURE SACROCOCCYGEAL TERATOMA

 Frontal pelvic
radiograph reveals
ischiopubic separation
due to a presacral
mass.
MATURE SACROCOCCYGEAL TERATOMA

 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.
BENIGN SACROCOCCYGEAL TERATOMA

 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.
 RECURRENT SACROCOCCYGEAL
TERATOMA

 Axial T1-weighted
spin-echo MR image
(a)axial T2-weighted
fat-saturated turbo
spin-echo image
 RECURRENT SACROCOCCYGEAL
TERATOMA

 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.
 MALIGNANT SACROCOCCYGEAL
TERATOMA

 Intermediate to low
signal intensity on
the T2-weighted fat-
saturated image
 MALIGNANT SACROCOCCYGEAL
TERATOMA

 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).
 MALIGNANT SACROCOCCYGEAL
TERATOMA

 (a, b) Axial
unenhanced T1-
weighted MR image

(a)Axial T2-weighted
fat-saturated turbo
spin-echo image
 MALIGNANT SACROCOCCYGEAL
TERATOMA

 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).
 MALIGNANT SACROCOCCYGEAL
TERATOMA

 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.
First trimester detection of a sacral mass
 Longitudinal view of lumbosacral spine reveals an
intact neural tube, differentiating the teratoma from
a complicated meningomyclocele.
Fig 1- Caudal view at delivery.
Fig 2 - The complexity of the teratoma is appreciated
prior to surgical resection. The primary mass originated
from the ischium while the pedunculated aspect
originated from the coccyx.
 CURRARINO TRIAD

 Also known as ASP triad.

 Anorectal malformations,
Sacrococcygeal osseus defect &
Presacral masses.
 Autosomal dominant in 50% of cases
 Meningocele and teratoma are most
commonly associated.
 CURRARINO TRIAD

 Pelvic radiograph
shows a scimitar
sacrum with
osseous defect on
the right side
(arrows).
 CURRARINO TRIAD

 Axial unenhanced CT
scan demonstrates a
welldefined 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.
 CURRARINO TRIAD

 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).
 ANTERIOR SACRAL
MENINGOCELE.
 Herniation of csf filled dura through
sacral foramen or a defect in sacrum.
 Incidence 1 in 40000.
 80% in first decade.
 Nerve roots ,neural elements within
sac & various osseous defects should
be assessed.
 MRI modality of choice.
 DERMOID CYST

 Contains mucoid,fatty ( 67-75%)

&calcific components(31%).
 Only a minority are presacral in
location.
 Demonstration of fatty tissue and
calcific tissue pathognomonic.
RECTAL DUPLICATION
CYST
 Three histologic criterias.
1. Presence of two layers of smooth
muscle.
2. Continuity with the rectum.
3. Mucosal lining similar to rectal
mucosa.
 RECTAL DUPLICATION

 Oblique radiograph of
the pelvis, obtained
during a barium enema
examination,
demonstrates a well-
defined retrorectal
tubular communication
(arrowheads) with the
rectum.
 TAILGUT CYST

 Persistent remnants of embyologic gut.

 They are uni or multilocular.
 Contain mucin secreting cells.
 Content is predominantly mucoid.
 No smooth muscle layer
IMAGING FINDINGS-
Enteric cysts.
 Conventional radiograph shows widening of
retrorectal space.
 Barium study show communication between
cyst and intestinal lumen.
 USG shows uni or multilocular cystic lesions
with varying echogenecities of mucoid and
inflmmatory debris.
 CT shows welldefined uni or multilocular thin
walled cysts with low attenuation , without
contrast enhancement.
Imaging findings.
 MRI demonstrates well marginated ,thin walled
lesions with low signal intensity on T1 and high
signal intensity on T2 weighted images.
 Mucoid content of tailgut cysts cause them to
have high signal intensity on T1 weighted
images.
 Malignant degeneration if present will have
asymmetric ,irregular wall thickening with
heterogenous contrast enhancement.
 TAILGUT CYST

 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.
 TAILGUT CYST

 Axial T2-weighted
fat-saturated MR
imageshows high
signal intensity in
the mass. The
intermediate
attenuation seen in
the mass in a
reflects its mucoid
content. R rectum.
NEUROGENIC MASSES

 Neuroblastoma.
 Ganglioneuroblastoma.
 Ganglioneuroma.
 Neurofibroma.
 Schwannoma.
 NEUROBLASTOMA
 Accounts for 10% of peadiatric cancers
 Median age of diagnosis 22 months.
 95% are diagnosed within first decade.
 70% abdominal,20% mediastinal &
 2-3% are pelvic.
 Because of midline location ,considered
stage III.
 70% show calcification.
IMAGING FINDINGS.
 Detection and staging of neuroblastoma is
accomplished by CT,MRI and nuclear imaging.
 Bone scintigraphy with technitium 99 and
skeletal radiography are used to determine
areas of involvement.
 Radiographic findings are nonspecific and
include calcifications in 30%.
 USG shows an heterogenous mass if areas of
hemorrhage and necrosis are present.
 Doppler US helps to determine relation of
tumour with the vessels.
Imaging findings.
 CT demonstrates location , boundries and extension of
tumours.
 Calcifications are seen in more than 80% at CT.
 Small tumours are homogenous in appearance , larger
show heterogenous attenuation because of
hemorrhage and necrosis.
 On MRI , lesions show low signal intensity and
heterogenous contrast enhancement on T1 and high
signal intensity in T2 weighted images.
 Hemorrhagic areas are of high signal intensity on T1
and cystic & necrotic areas show high intensity on T2
weighted images.
 NEUROBLASTOMA

 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).
 NEUROBLASTOMA

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.
PRESACRAL NEUROBLASTOMA

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).
PRESACRAL NEUROBLASTOMA

Axial CT scan
obtained with
intravenous contrast
material shows
heterogeneous
enhancement in the
mass but no pelvic
vessel involvement.
 NEUROBLASTOMA

 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.
 NEUROBLASTOMA

 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.
 NEUROBLASTOMA

 Sagittal T2-weighted
fat-saturated MR
image shows
heterogeneous,
predominantly high
signal intensity in
the mass
(arrowheads).
 GANGLIONEUROMA
 Rare benign tumour.
 Evolve from regressed neuroblastoma or
ganglioneuroblastoma
 Seen typically in second decade.
 Most common locations in order of
frequency are, posteriormediastinum,
retroperitoneum,adrenals & neck.
 More homogenous & two thirds show
calcification in imaging.
 GANGLIONEUROMA

 Sagittal T2-weighted
MR image shows a
high-signalintensity
presacral
ganglioneuroma that
distorts the distal
sacrum (arrow) and has
displaced the
bladder(B) anteriorly.
 NEUROFIBROMA
 Occur singly or in multiples in NF-1.
 NF_1 autosomal dominant.
 Occurs 1 in 2000-4000.
 Abdominal involvement most likely to occur in
retroperitoneal,mesentric & paraspinal regions.
 resembles lymphadenopathy on CT with attenuation less
than that of soft tissues.
 On T1 weighted image, homogenously isointense or mildly
hyperintense in comparision to muscle.
 On T2 weighted image,”target” like appearance with a rim of
myxomatus material and a central zone of low signal intensity
indicating a fibrous core.
 NEUROFIBROMATOSIS

 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.
 NEUROFIBROMATOSIS

 Axial T2-weighted fat-  NF

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.
 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).
 SHWANNOMA

 1-5% originate in sacrum.

 Presents as large mass.
 On MRI ,heterogenous low signal
intensity on T1 & high signal intensity
on T2 weighted images.
 Small cystic areas and a thin
pseudocapsule is noted.
INFLAMMATORY MASSES

 Inflammatory bowel disease

(ulcerative colitis,Crohn disease).
 Perirectal abscess.
 Granuloma.
 PELVIC ABSCESSES

 Secondary to, complicated

appendicitis,inflamatory bowel
disorders & postoperative
complications.
 May be related to extension from
upper primary site.
IMAGING
CHARACTERISTICS
 Conventional radiograph show
intralesional air and air fluid levels.
 US shows a complex fluid
content,homogenosly echogenic &
may have multiple septa.
 PELVIC ABSCESS

 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.
MESENCHYMAL MASSES

 Rhabdomyo sarcoma
 Undifferentiated sarcoma
 Vascular mass
 Fibroma
RHABDOMYOSARCOMA
.
 Aggressive tumour accounts for 4-8%
of pediatric cancers.
 A presacral mass in a child older than
8 yrs is highly suggestive of
rhabdomyosarcoma
 Bimodal 2-6yrs &14-18yrs.
 IMAGING FINDINGS

 Findings are general & nonspecific

 Rational approach including age
,clinical data & lab findings needed.
 CT shows heterogenous mass that
rarely shows calcification and shows
variable enhancement.
 On contrast MRI heterogenous
enhancement is noted.
 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
 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.
 UNDIFFERENTIATED SARCOMA

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.
Intermediatesignal-
intensity soft tissue also
is visible in the sacral
spinal canal (arrows).
UNDIFFERENTIATED SARCOMA

Sagittal T2-weighted
MR image more
clearly depicts
involvement of the
sacrococcygeal
vertebrae (arrow) as
well as the spinal
canal soft-tissuemass
(arrowheads).
 VASCULAR MASSES
 This include venous, capillary,lymphatic
or arterio-venous malformations.
 Hemangioma is the neoplastic variety.
 Pelvic hemangiomas present as large
lesions extending to mesentry,pelvic
sidewalls & rectum.
 Pelvic vascular masses associated with
klippel trenaunay syndrome.
 IMAGING FINDINGS

 CECT and MRI provide best depiction

of constituent and extent.
 MRI shows a mixed intensity mass.
 VASCULAR MALFORMATION

 Axial T2-weighted MR
image demonstrates a
mixedsignal- intensity
mass (arrows) that
involves the posterior
sacrum as well as the
presacral space.
LYMPHOMATOUS
MASSES
 These include
- true lymphomas –NHL (6% )
-Hodgkins(5%)
-post trasplantation lymphoproliferative disorder.
 Among NHL burkitt,burkitt like and B-cell lymphomas
are more common and present as primary abdominal
mass.
 Lymphnode involvement may be discrete or
conglomerate.
 Isolated presacral mass very rare and usually involves
iliac nodes.
 IMAGING FINDINGS
 First assessed with USG and then with CT
for primary site and staging.
 USG demonstrates a solid hypoechoeic
mass.
 On MR mass appears heterogenous with
low signal intensity on T1 and high signal
intensity on T2 weighted images.
 Post transplantation lymphomas are
indistinguishable from other lymphomas.
 BURKITT LYMPHOMA

 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).
 BURKITT LYMPHOMA

(a, b)and sagittal (c) T2-weighted 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.
BURKITT LYMPHOMA
 LYMPHOPROLIFERATIVE DISEASE

 Axial CT scan obtained

with oral and
intravenous contrast
material shows a
minimally
heterogeneous presacral
mass.
EXTENSION OF SACRAL
BONE TUMORS
 Giant cell tumor
 Aneurysmal bone cyst
 Chordoma
 Osteoblastoma
 Ewing sarcoma family
 Osteogenic sarcoma
GIANT CELL TUMOUR
 3-7% of all giant cell tumour arise from
vertebrae.
 And most of it is from sacrum.
 Its second most common tumour of sacrum
after chordoma.
 Occur in second and through fourth decade
of life.
 These are mostly lytic and destructive and
contain no calcifications.
 IMAGING FINDINGS
 These tumours appear heterogenous on
both CT and MRI.
 Low attenuation areas on CT scan
represent necrosis.
 Hemorrhage is present when there is high
signal intensity on both T1 and T2 weighted
images.
 Both CT and MRI show contrast
enhancement.
 GIANT CELL TUMOR

 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.
 GIANT CELL TUMOR

 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.
ANEURYSMAL BONE
CYST
 Blood filled expansile masses.
 Most are manifested in first two decades of
life ,more commonly in second decade.
 20% of these tumours arise from vertebral
column ,among these 20% arise from posteror
elements of sacrum.
 Classically they appear as multiple blood filled
spaces seperated by septa.
 In contrast to giant cell tumours ,these tumours
are delimited by a thin rim of bone.
 IMAGING FINDINGS

 Both CT and MRI are usefull for

depicting the lesion.
 CT and MRI display fluid –fluid levels
representing hemorrhages which is
charecteristics.
 ANEURYSMAL BONE CYST

 Anteroposterior
pelvic radiograph
demonstrates
distortion of the
sacrum (arrows).
 ANEURYSMAL BONE CYST

 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.
OSTEOBLASTOMA AND
OSTEOD OSTEOMA
 These very rarely occur in sacrum and
usually involve posterior elements.
 Because of similar histopathological
features ,they are considered variants.
 Rarely osteoblastoma show cortical
destruction and extension to adjacent
tissues.
 However presacral extension is very
unusual.
 OSTEOBLASTOMA

 Sagittal T2-weighted
MR image of the pelvis
shows the origin of the
heterogeneous
presacral mass in the
distal sacrum.
 CHORDOMA
 These are the most common primary sacral
neoplasms.
 They accont for 2-4% of primary bone
tumours.
 50% arise in sacrococcygeal region.
 Upto 60% of chodomas in sc region appear
as midline lytic lesions often with
calcifications.
 This type usually includes a presacral
component and involves iliac bones.
 IMAGING FINDINGS

 On T1 weighted MRI they show low to

intermediate signal intensity.
 On T2 weighted images they show
significantly increased signal intensity
and variable contrast enhancement.
 CHORDOMA

 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.
OSTEOGENIC
SARCOMA.
 They are the most frequent primary
malignant bone tumour.
 Spinal involvement in less than 3%.
 Two thirds are in lumbosacral region.
 They may occur after radiation
therapy.
 IMAGING FINDINGS

 They appear as lytic ,osteoblastic or

mixed types on radiographs and CT
scans.
 CT depicts extension into
paravertebral region and spinal canal.
 On MRI low intensity on T1 and high
intensity in T2 weighted images.
 OSTEOGENIC SARCOMA

 Axial unenhanced
CT scan shows a
predominantly
sclerotic sacrum
with indistinct
anterior margins.
 OSTEOGENIC SARCOMA

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.
 EWINGS SARCOMA.
 Ewings sarcoma ,extraosseous
ewings sacoma and PNET belong
same family of round cell tumours.
 Present in first three decades of life.
 3-10% originate in spine,metastatic
involvement is more common.
 Lumbosacral region is the most
common site of origin.
 EWINGS SARCOMA

 These typically fill marrow cavity,destroy

cortex and produce a soft tissue mass that
is usually larger than bony component.
 IMAGING FINDINGS

 Radiography and CT show lytic,sclerotic

and mixed features.
 MRI clearly depicts both intra and
extraosseous components of the tumour
including paraspinal ,extra dural and
presacral involvement.
 Exraosseuos part is usually the
predominant component of the tumour and
may include thin fibrous septa.
 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.
 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).
 EWING SARCOMA

 Sagittal T2-
weighted MR image
demonstrates a
heterogeneous
presacral mass with
extension posterior
to the sacrum
(arrow).
 OTHER MASSES

 Hematoma
 Extension or metastasis to the
presacral space from another site
 PRESACRAL MASS

 Sagittal contrast-
enhanced T1-
weighted fat-
saturated MR image
 PRESACRAL MASS

 A homogeneous
presacral mass
(arrows) with
persistent high
signal intensity
despite fat
saturation in b, a
finding indicative of
a hematoma.
 CONCLUSIONS

 The presacral space is a complex anatomic region that

may be affected by a wide variety of masses
 CT and MR imaging play a central role in the evaluation
of primary lesions that occur in this region.
 Knowledge of the normal anatomy and familiarity with
the imaging features and clinical manifestations of these
lesions are important for determining the type of mass or
narrowing the differential diagnosis, as well as for
defining the extent of the mass, and especially important
for surgical consideration.
THANK YOU