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Retrorectal dermoid cyst in a male adult: case report
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  Retrorectal dermoid cyst in a male adult: case report A. Erden, 1 E. Ustuner, 1 I. Erden, 1 M. A. Kuzu, 2 A. O. Heper 3 1 Department of Radiology, Ankara University, School of Medicine, Cebeci, 06100, Ankara, Turkey 2 Department of Surgery, Ankara University, School of Medicine, Sihhiye, 06100, Ankara, Turkey 3 Department of Pathology, Ankara University, School of Medicine, Sihhiye, 06100, Ankara, Turkey Abstract We describe a 48-year-old male patient who presentedwith rectal fullness and pain. Magnetic resonance imag-ing (MRI) and computed tomographic studies revealed anoncalcified, unilocular, cystic mass lesion with well-defined borders. On MRI nondependent fat spheres weredetected inside the cyst. The same pattern has been de-scribed in dermoid cyst of the ovary. We suggest that thisMRI pattern is specific to dermoid cysts. Key words:  Dermoid cyst—Retrorectal space—Mag-netic resonance imaging—Developmental cyst.Cystic lesions of the retrorectal space are rare, especiallyamong adults. Although rare in occurrence, a wide varietyof lesions that are inflammatory, neoplastic, and congen-ital in srcin can be encountered [1, 2]. Dermoid cysts areof developmental srcin and are included in the differen-tial diagnosis of retrorectal cystic lesions [1]. Retrorectaldermoid cysts are more common in females [1]. Adultand male cases are fewer [1–4]. Accurate diagnosis,localization, and characterization of retrorectal lesionswill affect surgical management [5, 6]. We describe com-puted tomographic (CT) and magnetic resonance (MR)findings of a retrorectal dermoid cyst in a male adultpatient. Imaging features helped us to establish the spe-cific diagnosis of dermoid cyst. Case report A 48-year-old male patient presented with rectal fullnessand pain of 1 month’s duration. On digital rectal exami-nation, a mass was palpated on the left side of the rectum.Fistulas or dimples involving the anal and perianal re-gions were not present. The patient had no history of surgery, and laboratory studies were insignificant. Recto-scopy showed bulging and displacement of the left rectalwall. No mucosal lesions were detected.CT of the pelvis showed a noncalcified retrorectalmass with an attenuation lower than that of the urine inthe bladder. The mass filled the left ischiorectal fossa,displacing the anal canal to the right and the rectumanteriorly. MR imaging revealed a unilocular cystic massmeasuring 9    7    6.5 cm with smooth, well-definedborders surrounded by a hypointense thin wall on T1-weighted images. The cyst was hypointense on T1-weighted and hyperintense on T2-weighted sequences,and there were multiple nondependent spheres of fatmeasuring up to 2 cm distributed evenly inside the cyst,which were hyperintense on T1-weighted images andhypointense on T2-weighted images compared with mus-cle (Fig. 1A,B). On fast spoiled gradient in-phase andout-of-phase imaging, the loss of signal intensity in theintracystic spheres on out-of-phase imaging as opposedto in-phase imaging confirmed their fatty nature (Fig.2A,B). No invasion was detected and tissue planesbetween the mass and the surrounding tissues werepreserved. The mass enhanced peripherally after intra-venous gadolinium injection. No anomaly of the bonypelvis was detected. A radiologic diagnosis of dermoidcyst was made preoperatively. The cyst was excised bya posterior parasacrococcygeal approach. Macroscopi-cally, the mass had smooth gray and brown walls andcontained yellow-white sebaceous material. Tufts of hair were present inside the mass. Histologically, thecyst contained sebum and was lined with keratinizedstratified squamous epithelium. There were hair folli-cules and sebaceous glands within the cyst wall. Nobone elements or calcification were detected. His-topathologic diagnosis was retrorectal dermoid cyst(Fig. 3). Correspondence to:  A. ErdenAbdom Imaging 28:725–727 (2003)DOI: 10.1007/s00261-002-0093-4  A   bdominal I maging © Springer-Verlag New York Inc. 2003  Discussion What makes this case special is that imaging findings,especially those of MR imaging, helped us to make theaccurate diagnosis and distinguish dermoid cyst fromother cystic lesions included in the differential diagnosisof retrorectal cystic masses.The clinical presentation of retrorectal developmentalcyst is nonspecific and usually asymptomatic. Dimples orfistulas involving the perianal skin or the anal canal maybe present. As in this case, symptoms due to local masseffect can be encountered [1].Preoperative biopsy for cystic masses within the pel-vis is not considered essential because it may not assist inproper lesion differentiation and may cause spillage of cells into the peritoneal cavity and seeding of the biopsytract [7]. Therefore, when cystic lesions of the retrorectalspace are involved, we depend more on radiologic studiesthan on biopsy and clinical symptoms for differentialdiagnosis. Fig. 1. A  T1-weighted axial MR image shows well-defined cystic mass containing nondependent spheres of high-intensity fat.  B  On T2-weightedcoronal MR image, fat spheres of hypo-intermediate intensity are clearly visible inside the mass contrasting with the hyperintense fluid inside the cyst.The rectum is displaced superolaterally. No sign of invasion is detected. Fig. 2. A  Fast spoiled gradient-echo in phase MR image shows hyperintense spheres within dermoid cyst.  B  Out-of-phase MR image shows decreaseof signal intensity of spheres compared with in-phase images. This finding confirmed the fatty nature of the spheres inside the cyst.726 A. Erden et al.: Retrorectal dermoid cyst in a male adult  The differential diagnosis of a dermoid cyst includesother developmental cysts such as epidermoid cysts, en-teric cysts, tailgut cysts, and rectal duplication cysts.Other cystic lesions such as cystic sacrococcygeal tera-toma, anterior sacral meningocele, anal duct cyst, necroticrectal leiomyosarcoma, extraperitoneal adenomucinosis,cystic lymphangioma, pyogenic abcess, neurogenic cyst,and necrotic sacral chordoma are included in the differ-ential diagnosis [1].In our case malignancy was unlikely because no en-hancing solid soft tissue component or invasion waspresent. Absence of solid soft tissue components andcalcifications also helped us to rule out sacrococcygealteratomas, which appear as well-defined lesions withmixed cystic and solid components. The patient’s historyand imaging findings were not compatible with an abcess.The cyst was not in communication with the spinal canal,and no bony defect was detected. These findings ruled outanterior sacral meningocele and chordoma. A tailgut cystwas also unlikely because of the absence of sacral bonydefect and multiloculation. Currarino syndrome was alsoconsidered but ruled out because of the absence of ano-rectal malformation and sacral bony defect. CT findingsin this patient also suggested hydatid disease of the pelvis,which is occasionally encountered in Turkey, but detec-tion of fat spheres intracystically by MR imaging helpedus to diagnose the lesion as a dermoid cyst.The MR imaging findings in this patient were quitestriking. Nondependent round spheres of fat were distrib-uted evenly in the contrasting high signal intensity fluidwithin the cyst on T2-weighted images. These fat ballswere also quite appearent on T1-weighted images becausethey were hyperintense due to their fat content. Fat ballswithin the cyst were correlated histopathologically tosebum inside the cyst cavity. The same MR imagingpattern was also described in ovarian mature cystic tera-tomas (dermoid cysts of the ovary) in females [8, 9]. Wesuggest that this MR imaging pattern is specific to der-moid cysts.Imaging is important because management of thelesion changes according to the findings. The nature, size,and location of the lesion should be assessed [2, 5].Malignant changes and infection are reported complica-tions [1]. Complete surgical excision of the retrorectalcysts is indicated with care to avoid spillage of the con-tents [5, 10]. To achieve this goal, the best surgicalapproach had to be chosen. The posterior approach is therecommended surgical management; the anterior abdom-inal approach could provide an alternative in large retro-rectal tumors and lesions situated above the sacral prom-ontory [5–7, 11, 12]. References 1. Dahan H, Arrive L, Wendum D, et al. Retrorectal developmentalcysts in adults: clinical and radiologic-histopathologic review, dif-ferential diagnosis and treatment.  Radiographics  2001;21:575–5842. Bozzo LH, Larrachea P, Castro A. Presacral cystic teratoma: aclinical case.  Tech Coloproctol  2000;4:55–583. Bull J Jr, Yeh KA, McDonnel D, et al. Mature presacral teratoma inan adult male: a case report.  Am Surg  1999;65:587–5914. Nouri M, Tazi K, El Khader K, et al. Vestigial retrorectal dermoidcyst. Apropos of a case.  Ann Urol (Paris)  1998;32:160–1655. Godlewski G, Phillippe O, Ould Said H, et al. Vestigial retrorectalcyst in adults.  Ann Chir   2000;125:844–8496. Shu-Wen J, Beart RW, Spencer JR, et al. Retrorectal tumors, MayoClinic experience, 1960–1979.  Dis Colon Rectum  1985;28:644–6527. Schwarz RE, Lyda M, Lew M, Paz IB. A carcinoembryonic anti-gen-secreting adenocarcinoma arising within a retrorectal tailgutcyst: clinicopathological considerations.  Am J Gastroenterol  2000;95:1344–13478. Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: tumortypes and imaging characteristics.  Radiographics  2001;21:475–4909. Muramatsu Y, Moriyama N, Takayasu K, et al. CT and MR imag-ing of cystic ovarian teratoma with intracystic fat balls.  J Comput  Assist Tomogr   1991;15:528–52910. Ko SF, Ng SH, Lai CJ, et al. Posttraumatic gluteal epidermal cystwith ischiorectal and presacral extension.  Eur Radiol  1996;6:69–7111. Guillem P, Ernst O, Herjean M, Triboulet JP. Retrorectal tumors: anassessment of the abdominal approach.  Ann Chir   2001;126:138–14212. Kanemitsu T, Kojima T, Yamamoto S, et al. The transsphinctericand transsacral approaches for the surgical excision of rectal andpresacral lesions.  Surg Today  1993;23:860–866 Fig. 3.  Histopathologic examination of the specimen shows a dermoidcyst with keratinized stratified squamous epithelium and skin append-ages such as sebaceous cysts and hair follicules. Fat spheres correspondto sebum within the cyst. Hematoxylin and eosin; magnification, 40  .A. Erden et al.: Retrorectal dermoid cyst in a male adult 727
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