Sacrococcygeal teratoma surgery

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Overview
Sacrococcygeal teratoma (SCT) is a teratoma (a kind of tumor) located at the base of the coccyx (tailbone). It is thought to be a derivative of the primitive streak.

Management of fetal SCTs
Management of most fetal SCTs involves watch and wait, also known as expectant management. An often used decision tree is as follows:


 * Perform detailed ultrasound exam including fetal echocardiogram and Doppler flow analysis
 * If fetal high output failure, placentomegaly, or hydrops
 * If fetus not mature, perform pregnancy termination or fetal intervention
 * Else fetus mature, perform emergency Cesarean section
 * Else no emergent problems, perform serial non-stress tests and ultrasound biophysical profiles and plan delivery
 * If emergent problems develop, return to top of decision tree
 * Else if SCT over 5–10cm or polyhydramnios, perform early (37 weeks gestation) elective Cesarean section
 * Else SCT small and no complications, permit term spontaneous vaginal delivery

Emergent problems include maternal mirror syndrome, polyhydramnios, and preterm labor. Poor management decisions, including interventions that are either premature or delayed, can have dire consequences.

In many cases, a fetus with a small SCT (under 5 or 10 cm) may be delivered vaginally.

Treatment
The preferred first treatment for SCT is complete surgical removal (ie, complete resection). The preferred approach to a small SCT is through the perineum; a large SCT may require an additional approach through the abdomen. Resection should include the coccyx and may also include portions of the sacrum. The surgery should include reattachment of the small muscles and ligaments formerly attached to the coccyx, in effect reconstructing the posterior perineum.

SCTs are classified morphologically according to how much of them is outside or inside the body:
 * Altman Type I — entirely external, sometimes attached to the body only by a narrow stalk
 * Altman Type II
 * Altman Type III
 * Altman Type IV — entirely internal; this is a presacral teratoma

The Altman Type has a significant influence on management, surgical approach, and complications of SCT. Serial ultrasound and MRI monitoring of SCTs in fetuses in utero has demonstrated that the Altman Type can change over time.

Regardless of location in the body, teratomas are classified according to a cancer staging system. This indicates whether chemotherapy or radiation therapy may be needed.