A report of presacral epidermoid cyst in perimenopausal women: An extremely rare site and an unusual cause of chronic constipation

Abstract

Background: Epidermoid cyst is rare congenital lesion of ectodermal origin that arises from the remnants of the embryonic tissues. Although epidermal cysts are frequently observed throughout the body, they are rarely found in the presacral regions. It more commonly occurs in women of reproductive age as an asymptomatic, incidental finding during routine physical examination or imaging studies, or during obstetric and gynecologic events.

Case presentation: A 48-year-old female patient presented with intermittent constipation, lower abdominal and pelvic pain that had developed progressively during the previous six months, which was temporarily relieved with regular laxatives. Magnetic resonance imaging showed a presacral cystic tumor with a high signal intensity on T1-weighted images and, low signal on T2-weighted images with no significant enhancement post-contrast administration. The mass pushed the rectum laterally by external compression. This tumor was diagnosed as a developmental cyst, and total mass resection with negative margins was performed. After that, tumor was histopathologically diagnosed as an epidermoid cyst.

Discussion and conclusion: Epidermoid cyst is a common entity but is rare at presacral space. Also, an epidermoid cyst is an uncommon entity among cystic pathologies found in the presacral region, which includes benign and malignant pathologies. Due to the potential of subsequent infection or cancer, a meticulous clinical examination with correlated radiographic imaging, followed by total mass excision and histopathological evaluation are crucial.

Keywords: Case report; Epidermoid cyst; Pelvic mass; Presacral.

Fig. 1

Magnetic resonance imaging (MRI) showed entirely capsulated cystic mass which was located in the right dorsal side of the rectum . The main bulk of the lesion appears hypo-intense on T2-weighted imaging (A), but homogeneously hyper-intense on T1-weighted imaging (B and C) with no significant enhancement post contrast administration (D).

Fig. 2

Sections of an epidermoid cyst showed: (A) a cystic structure occupying the entire dermis. The lesion is unilocular .The lining of the cyst composed of an epithelium which is flattened and contains a granular layer of keratohyaline granules. The cyst lining is similar to the surface epithelium but lacks rete ridges which are seen in the overlying epidermis. (B) Foci of rupture are noted and the keratin exposed to the adjacent dermis elicits a neutrophilic and then granulomatous reaction.