Daniel Diaz-Aguilar, Sergei Terterov, Rudi Scharnweber, Catherine Merna, Stephanie Wang, Shayan Rahman
  1. Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
  2. Department of Neurosurgery, Kaiser Permanente Medical Center, Los Angeles, California, USA

Correspondence Address:
Daniel Diaz-Aguilar
Department of Neurosurgery, Kaiser Permanente Medical Center, Los Angeles, California, USA


Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Daniel Diaz-Aguilar, Sergei Terterov, Rudi Scharnweber, Catherine Merna, Stephanie Wang, Shayan Rahman. Adult sacrococcygeal teratoma with coccygectomy: A case report with a review of the literature. 24-Oct-2017;8:260

How to cite this URL: Daniel Diaz-Aguilar, Sergei Terterov, Rudi Scharnweber, Catherine Merna, Stephanie Wang, Shayan Rahman. Adult sacrococcygeal teratoma with coccygectomy: A case report with a review of the literature. 24-Oct-2017;8:260. Available from:

Date of Submission

Date of Acceptance

Date of Web Publication


Background:Saccrococcygeal teratomas (SCT) are derived from embryonic germ cell layers. They frequently present at the base of the coccyx within the pelvis. While these tumors are common in children, they are exceedingly rare in adults. In adults, a majority of these tumors are intrapelvic and associated with a low risk of malignant transformation. Therefore, this contributes to a good prognosis following resection of mostly benign lesions.

Case Description:An adult female with chronic pelvic pain presented with a sacral teratoma. She failed conservative treatment and underwent a coccygectomy with an en-bloc excision of the tumor. Microscopic histological analysis showed no evidence of immature or malignant elements, confirming the diagnosis of a mature, benign, cystic SCT.

Conclusions:Mature SCTs in adults are rare malignant lesions. In this case, the patient was cured following primary surgical excision requiring en-bloc coccygectomy.

Keywords: Adult, mature teratoma, sacral coccygectomy


Sacrococcygeal teratomas (SCT) are multipotential cell tumors most commonly seen in neonates but only rarely in adults. SCTs carry a female preponderance of 4:1, and a prevalence of 1:30,000 births.[ 2 ] A vast majority of SCT are benign and have a low potential for malignancy. Although surgical resection carries an excellent prognosis, there is a high 37% postoperative recurrence rate for these lesions.[ 2 3 ] Here, we present the case of an adult female with chronic pelvic pain and an SCT, who was successfully treated with an en-bloc coccygectomy resulting in successful gross total removal of her sacral teratoma.


Clinical presentation

A 23-year-old female presented with pelvic pain. Magnetic resonance imaging (MRI) of the pelvis revealed a complex cystic structure anterior to the coccyx [ Figure 1 ]. The lesion, measuring approximately 3 × 2 × 4 cm, contained both cystic and proteinaceous components consistent with the diagnosis of a pre-sacral intraspinal teratoma; notably, it did not enhance with contrast. The differential diagnosis included meningocele and chordoma [ Figure 2 ]. A fine needle biopsy anterior to the coccyx revealed scattered histiocytes and keratinocytes consistent with the diagnosis of an Altman type IV SCT. She failed conservative measures to treat her intractable pelvic pain, and ultimately underwent successful surgical intervention at the age of 26.

Figure 1

Axial T1-weighted (a), T2-weighted fat-saturated (b), sagittal T1-weighted post-gadolinium fat-saturated (c), coronal T1-weighted (d), and T2 fat-saturated (e) images demonstrating a complex precoccygeal cystic structure with multiple septations and fluid content of different signals and fluid levels


Figure 2

Coronal CT (a) and 3D reconstruction (b) of the coccyx status post resection of previously identified teratoma in the precoccygeal region



The patient underwent an en-bloc posterior coccygectomy. Following exposure of the coccyx and lower part of the sacrum, the rectum was carefully dissected away from the tumor. An osteotome cut through the coccyx 6 cm above the tip [ Figure 3 ]. The final tumor specimen was 1.9 × 2.5 × 1.6 cm. Gross analysis revealed an irregular tumor with cystic nodules attached to a firm portion of the coccyx [ Figure 4 ]. The microscopic analysis confirmed a benign, mature sacrococcygeal cystic teratoma. The patient was discharged home without any complications. One year later, her she had no tumor recurrence or residual symptoms/signs.

Figure 3

A solid cystic tumor (a, gross) containing yellow seromucoid fluid (b, gross)


Figure 4

Histology of the mass demonstrating various types of mature tissue elements including lobules of smooth muscle, adipose tissue, stratified squamous epithelium (a, H and E, ×4; b, H and E, ×20) respiratory type ciliated epithelium (c, H and E, ×40; and mucous glandular tissue adjacent to stratified squamous epithelium (d, H and E, ×10)



Incidence and symptoms of sacrococcygeal teratoma

SCT are the most common fetal neoplasm. They account for 50% of teratomas in children but are rarely seen in adults.[ 3 ] The clinical presentation in adults includes bowel dysfunctions, urinary incontinence, lower back pain, and/or venous engorgement of the lower limbs.

Sacrococcygeal teratoma characteristics in adults

SCTs are divided into Types I–IV (criteria proposed by Altman et al.) [ Table 1 ]. Most adult SCTs are type III and type IV; they are cystic and less liable to demonstrate malignant transformation (incidence 1–2%) compared to those seen in children and infants. Adult SCT are also primarily intrapelvic with no obvious physical cutaneous or dermatologic presence, and are often recognized following unresolved symptoms associated with a tumor mass compressing adjacent organs (e.g., vagina, uterus, or rectum).[ 4 5 ]

Table 1

Classification of sacrococcygeal teratomas[ 3]


Histopathology and use of markers

Mature SCT can be distinguished from immature teratomas by the presence of epithelial structures along with well-distinguished cartilage and muscular tissue. Immature teratomas contain primitive combinations of germ layers with occasional mature elements.[ 1 ] The final diagnosis of mature vs. immature teratoma is dependent on histopathological examination. Several biochemical markers, including β-human chorionic gonadotropin (β-hCG) and α-fetoprotien (AFP), are used for initial screenings or the detection of tumor recurrences. However, their application is less applicable to mature teratomas as they often secrete fewer of these markers than immature or malignant teratomas.[ 2 ]


Computed tomography and MRI are both vital preoperative diagnostic studies for the visualization of a SCT.[ 2 ] Our patient's studies revealed a lobulated solid and cystic mass in the presacral area anterior to the coccyx without calcifications.[ 5 7 ] These tumors frequently contain multiple cystic or solid components with necrotic areas that are highly suspicious for malignant transformation; however, the reported lesion was benign.[ 6 ] This SCT was curable with surgical excision/coccygectomy.


SCT, rarely observed in adults, are frequently benign, slowly growing intrapelvic masses best seen on MR studies. Mature benign SCT are highly susceptible to complete and early excision, without the additional need for chemotherapy or radiation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1. Al-Essa A-A, Malik TA, Baghdadi MK, Tayeb El AA. Adult sacrococcygeal teratomas. Saudi Med J. 2004. 25: 367-9

2. Allsopp G, Sgouros S, Barber P, Walsh AR. Spinal teratoma: Is there a place for adjuvant treatment? Two cases and a review of the literature. Br J Neurosurg. 2000. 14: 482-8

3. Altman RP, Randolph JG, Lilly JR. Sacrococcygeal teratoma: American Academy of Pediatrics Surgical Section Survey-1973. J Pediatr Surg. 1974. 9: 389-98

4. Audet IM, Goldhahn RT, Dent TL. Adult sacrococcygeal teratomas. Am Surg. 2000. 66: 61-5

5. Bruneton JN, Diard F, Drouillard JP, Sabatier JC, Tavernier JF. Primary retroperitoneal teratoma in adults: Presentation of two cases and review of the literature. Radiology. 1980. 134: 613-6

6. Miles RM, Stewart GS. Sacrococcygeal teratomas in adult. Ann Surg. 1974. 179: 676-83

7. Panageas E. General diagnosis case of the day. Primary retroperitoneal teratoma. AJR Am J Roentgenol. 1991. 156: 1292-4

Leave a Reply

Your email address will not be published. Required fields are marked *