Sacral Area Research Articles

Comparing Diagnostic Accuracy of Purple line with Transvers Diagonal of Michaelis Sacral to Predict labor Progress

Background and Aim: One of the key aspects of maternal care is observing the progress of labor. Careful assessment of labor progress could provide mothers to be referred on time and could decrease the maternal and neonatal morbidity. This study aimed to compare diagnostic accuracy of purple line with transvers diagonal of Michaelis sacral rhomboid to predict labor progress in nulliparous and multiparous women. Methods: In this double-blind diagnostic accuracy study, 350 nulliparous and multiparous womenwith a single pregnancy in vertex presentation and gestational age of 38-42 week, who admitted in Om-ol-Banin Hospital, Mashhad, Iran, from April to August 2012, were selected using convenience sampling. At first, the transvers diagonal of the Michaelis sacral rhomboid area was measured in cervical dilatation of ≤ 3 centimeters. Then, labor progress and presence or absence of purple lines between the buttocks in the lateral position was hourly controlled in the active phase of labor. Data were analyzed by SPSS Version 16 using Mann-Whitney and Chi-square test. Results: The mean age of the women was 25/22 (±5) years. Out of the 350 women enrolled, 61/2% were primigravidas and 38/8% were multigravidas. The presence of purple line was accompanied with normal labor progress with 68.57% sensitivity, 42.66% specificity, and 80.57% validity. The transverse diagonal of the Michaelis sacral cut-off point was ≥98.5 millimeter with 86.5% sensitivity, 59.45% specificity and 79.65% validity, which was also accompanied with normal progress of labor. Conclusion: Considering the diagnostic accuracy of transverse diagonal of the Michaelis sacral and purple line, thetransvers diagonal of Michaelis Sacral is more accurate predictor of labor progress.

Sirenomelia Sequence and Malposition of the Penis

Sirenomelia is a rare anomaly of the caudal region of the body, presenting with fusion of the lower limbs. Genitourinary, gastrointestinal, neural tube and vertebral anomalies are found in most cases. Herein, a very rare case with the sirenomelia sequence is presented. The patient had fusion of both lower limbs, absent genitalia, absent anal orifice, absent ureteral orifice, pelvic and sacral dysplasia and a single umbilical artery. In addition, he had a malpositioned penis in the posterior sacral area. He died 11 hours after birth.

Religious Institutions in Landscape of Polish City

Religious institutions are kind integral areas, in which spatial complex is subordinated to social complexes. Intellectuals as order of society owns big influence as idea on forming integral area relatively and as realities. Total institutions are invariable kind of integral area from many year. Sacral area is not enclave from social conditionality excluded entirely, can be treated independently on social context. Modern sacral buildings refer to trends of modern architecture frequently more, separateness of sacral area in smallest degree underlining, on symbolic pronunciation more putting.

Presacral Schwannoma Causing Infertility in a Young Woman: Report of a Case

Introduction: Schwannoma is one of the tumors that may occur in the sacral or presacral area. It is often asymptomatic and found incidentally by obstetricians or other clinicians. In this study, we report a case of presacral schwannoma as a rare cause of infertility. Case Presentation: A 33 year-old woman referred to a gynecology clinic with complain of two years infertility and one abortion. All examinations and clinical evaluations were normal except one homogenous mass on transvaginal ultrasound. After resection via a transabdominal approach her infertility resolved after thirteen months. Histopathologic examination revealed benign schwannoma. Conclusion: Presacral schwannoma should be considered as a rare cause of infertility which could be resolved successfully after operation.

Objective evaluation by reflectance spectrophotometry can be of clinical value for the verification of blanching/non blanching erythema in the sacral area

Early detection of non blanching erythema (pressure ulcer category I) is necessary to prevent any further skin damage. An objective method to discriminate between blanching/non blanching erythema is presently not available. The purpose of this investigation was to explore if a non invasive objective method could differentiate between blanching/non blanching erythema in the sacral area of patients undergoing hip fracture surgery. Seventy-eight patients were included. The sacral area of all patients was assessed using (i) conventional finger-press test and (ii) digital reading of the erythema index assessed with reflectance spectrophotometry. The patients were examined at admission and during 5 days postsurgery. Reflectance spectrophotometry measurements proved able to discriminate between blanching/non blanching erythema. The reliability, quantified by the intra-class correlation coefficient, was excellent between repeated measurements over the measurement period, varying between 0·82 and 0·96, and a significant change was recorded in the areas from day 1 to day 5 (P < 0·0001). The value from the reference point did not show any significant changes over the same period (P = 0·32). An objective method proven to identify early pressure damage to tissue can be a valuable tool in clinical practice.

Do High Frequency Ultrasound Images Support Clinical Skin Assessment?

High frequency ultrasound imaging has been reported as a potential method of identifying the suspected tissue damage in patients “at risk” of pressure ulceration. The aim of this study was to explore whether ultrasound images supported the clinical skin assessment in an inpatient population through identification of subcutaneous tissue damage. Skin on the heels and/or sacral coccygeal area of fifty vascular surgery inpatients was assessed clinically by tissue viability nurses and with ultrasound pre operatively and at least every other day until discharge. Images were compared to routine clinical skin assessment outcomes. Qualitative classification of ultrasound images did not match outcomes yielded through the clinical skin assessment. Images corresponding to 16 participants were classified as subgroup 3 damage at the heels (equivalent to grade 2 pressure ulceration); clinical skin assessment rated no heels as greater than grade 1a (blanching erythema). Conversely, all images captured of the sacral coccygeal area were classified as normal; the clinical skin assessment rated two participants as grade 1b (non-blanching erythema). Ultrasound imaging is a potentially useful adjunct to the clinical skin assessment in providing information about the underlying tissue. However, further longitudinal clinical assessment is required to characterise images against actual and “staged” pressure ulceration.

Multiple Giant Tumoral Calcinosis in Pelvic Region

Tumoral calcinosis is a very rare disease in which calcium deposit is accumulated on soft tissue around joints without specific metabolic disorder of calcium or predisposing illnesses. Its causes have not been revealed clearly, and the disease has been known to occur rarely among Asian patients. We report a case of a multiple giant tumoral calcinosis patient who complained of painful masses in the groin region as well as in both buttocks and sacral area. The patient was evaluated to differentiate with other causes and have been treated with surgical excision. We present this case with a review of literature.

First Case of Metastasis of a Chordoma in the Abdominal Wall

Chordomas are rare malignant primary bone tumors of ectodermal origin, that arise from notochordal remnants of the developing spine, which most often occur in the sacral area. It is an aggressive, locally invasive neoplasm, which carries a poor prognosis. Chordomas’ metastatic incidence ranges from 5 to 40%. It is generally believed that metastases without local recurrence of primary neoplasm are extremely rare. En-bloc excision with wide margins and postoperative radiation therapy remains the only curative treatment of primary chordoma. Its metastases should also be resected surgically. We present the first case of metastasis of a previously surgically treated primary sacrococcygeal chordoma. Metastatic lesions developed in the abdominal wall of a 42-year-old man without local recurrence and were discovered incidentally. We also describe the surgical management of this case. This phenomenon has not yet been described. We demonstrate that, incidentally discovered chordoma metastasis in the abdominal wall can occur and present a diagnostic challenge. This case report focuses on the importance of follow up with magnetic resonance imaging or computerized tomography scan after resection of sacral chordoma paying attention to the entire abdomen. After this experience we feel that surgery could be considered a valid option for the treatment of chordoma metastasis in this scenario.

Intramedullary and Retroperitoneal Melanocytic Tumor Associated With Congenital Blue Nevus and Nevus Flammeus: An Uncommon Combination of Neurocutaneous Melanosis and Phacomatosis Pigmentovascularis—Case Report

Neurocutaneous melanosis (NCM) is a rare condition characterized by central nervous system melanocytic tumors associated with congenital melanocytic nevi. Phacomatosis pigmentovascularis (PPV) is an association of vascular nevus with pigmentary nevus. Aberrant maturation of neural crest-derived cells is considered to be related to pathogenesis in both conditions. However, association of NCM and PPV has not been reported to the best of our knowledge. Melanocytoma, which usually involves the leptomeninges or spinal cord, is extremely rare in the retroperitoneum. We present here a case of a patient with NCM, PPV, and melanocytic tumors in the spinal cord and retroperitoneum, which were treated surgically. A 40-year-old woman had a 2-year history of dysesthesia and weakness in the left leg. History included congenital giant blue nevus-like lesion in the trunk, a port-wine stain in the sacral area, and Caesarean section performed 8 years before, when diffuse pigmentation in the peritoneum was noted. Magnetic resonance (MR) imaging of the spine revealed an intramedullary tumor at T10 level with paramagnetic signal characteristics. The spinal cord tumor was totally removed, and the histological diagnosis was melanocytoma. Three months later, a left retroperitoneal mass with histological features of melanocytic tumor was removed. Neither tumors recurred and the patient stays ambulatory 4 years after the surgery. Multiple subtypes of melanocytic tumors with distinctive features of NCM and PPV can develop simultaneously, mimicking malignant melanoma. Gross total resection of each tumor, when indicated, is beneficial.

Update in the Surgical Management of Decubitus Ulcers

Decubitus ulcers remain a common and recurring problem amongst overly ill patients, especially those who are bed-bound. They are caused by unrelieved pressure over tissues, mainly over bony prominences, such as the trochanteric, ischial, and sacral areas, and are classified from stage I to IV. Many forms of management have been described, with prevention being the most important of them. For stages I and II a conservative, non-surgical approach can be used, compared to stages III and IV which normally require surgical management. Post-operative care has also been shown to play a major role in avoiding the high rate of recurrences. Because of their location, high recurrence rates and increase in mortality, pressure sores continue to be a challenge for the medical and nursing staff, and are extremely costly to treat. In this manuscript we review the literature to expose the latest non-surgical and surgical techniques for the management of Decubitus Ulcers.

Image-Guided Percutaneous Lipiodol-Pingyangmycin Suspension Injection Therapy for Sacral Chordoma

A 74-year-old man presented with a progressively worsening pain in sacrum and was diagnosed to have a sacral chordoma by biopsy in May, 2004. Percutaneous intratumoral injection with lipiodol-pingyangmycin suspension (LPS) was carried out under image guidance and repeated when the pain in sacrum recurred and the tumor increased. During a 6-year follow-up period, three sessions of this treatment were executed. CT imaging and Karnofsky Performance Score were used to evaluate the size of tumor and quality of life, respectively. The patient was free of pain after each procedure and had a high quality of life with a Karnofsky Performance Score above 80 points. The tumor lesion in sacral area was effectively controlled. No complications were observed. Percutaneous intratumoral injection with LPS under image guidance may be an effective and safe alternative for the patients with sacral chordoma.

Mongolian spots

Mongolian spots (MS) are birthmarks that are present at birth and their most common location is sacrococcygeal or lumbar area. Lesions may be single or multiple and usually involve < 5% total body surface area. They are macular and round, oval or irregular in shape. The color varies from blue to greenish, gray, black or a combination of any of the above. The size varies from few to more than 20 centimetres. Pigmentation is most intense at the age of one year and gradually fades thereafter. It is rarely seen after the age of 6 years. Aberrant MS over occiput, temple, mandibular area, shoulders and limbs may be confused with other dermal melanocytoses and bruises secondary to child abuse, thus necessitating documentation at birth. Although regarded as benign, recent data suggest that MS may be associated with inborn errors of metabolism and neurocristopathies. Mongolian spots usually resolve by early childhood and hence no treatment is generally needed if they are located in the sacral area. However, sometimes it may be required for extrasacral lesions for cosmesis.

Osteomyelitis After Robotically Assisted Laparoscopic Sacral Colpopexy

Dear Editor, Osteomyelitis following robot assisted sacral colpopexy is a rare entity. Till now only two cases have been reported (1, 2). In 2010, Muffly et al described a life-threatening case of osseous infection (L5/S1) and epidural abscess 4 months after robot assisted sacral colpopexy using a synthetic mesh. The correction of complications required surgical intervention, including sacral debridement, discectomy, mesh removal and abscess drainage. However, in the case reported by Nosseir, the sacral osteomyelitis did not require neither reoperation or mesh removal. The infection was treated with 8 weeks of outpatient antibiotic treatment. Sacral osseous infections after colpopexy are likely to have a multifactorial origin. Innovative surgical procedures, such as robotic assisted laparoscopic operations, present the advantage of a key hole operation which have as a consequence significantly less pain, less blood loss, better aesthetic result, more precise surgical manipulations and shorter hospital stay as well as shorter recovery time. Nevertheless, the absence of haptic feedback in manipulations through robot can lead the surgeon to place sutures deeper in the tissues, especially in periosteum of the sacral promontory, creating a site of potential infection. In theory, another risk factor that could lead to this complication is the possible ischemia resulted from the devascularization during routine dissection and the foreign body implantation. At this point, this disadvantage could be bypassed with the palpation of the promontory by the assistant surgeon, who through conventional laparoscopy, can direct the surgeon to the precise position for suture placement. Moreover, the utilization of braided sutures in the vaginal fibromuscular tissue for the attachment of the mesh may represent another possible risk factor of osteomyelitis. There is a hypothesis that with the use of braided sutures, the bacterial adherence of suture materials is increased (3, 4). In addition, the use of monofilament sutures can avoid surgical infections from any microorganisms. The concurrent placement of the mesh immediately after hysterectomy could also be considered as another potential risk factor of sacral osteomyelitis (5). The creation of multiple layers of tissue over vaginal apex before attaching the mesh could form an extra tissue barrier that may avoid vaginal mesh erosion. Furthermore, the immunologic status of the patient as well as various medical comorbidities (such as diabetes mellitus) could be another reason for the appearance of infections in this type of surgical operations. In sacrocolpopexy, the suspension of the vaginal vault most frequently is performed by attaching the vault to the anterior longitudinal ligament of the sacrum by utilizing sutures. In order to facilitate laparoscopic procedures, the sacral fixation is realized with the insertion of bone anchors, which very often are made by titanium (6). The use of titanium tacks have been used in pubic fixation during urinary incontinence procedures for more than 10 years. In addition, these types of bone anchors decrease the total operative time and reduce the risk of life-threatening haemorrhage from the vessels collocated at the sacrum area. Until now, the rate of pubic osteomyelitis related to such procedures has been reported to be 1.3% (7). Though, the anatomic difference between sacral and pubic bone fixation may differs in the fact that it is a clean procedure as opposed to urinary incontinence operations as clean contaminated procedure. Thus, the relative infection rate may also be different. In the treatment of sacral bone infections, the surgical debridement of the infected area from the necrotic materials might be necessary, while proper antimicrobial therapy should be established as soon as possible. Currently, the antibiotic treatment may include prolonged antibiotic courses, which according to the available recommendations in the literature for management of lumbar osteomyelitis, should durate at least 4 to 6 weeks of parenteral administration, in order to penetrate bone and joint cavities (8). For example, in the case reports identified in the current literature, the cultures revealed either methicillin-resistant coagulase-negative Staphylococcus aureus treated with intravenous vancomycin and ampicillin–sulbactam for 6 weeks or methicillin-sensitive Staphylococcus aureus treated with intravenous nafcillin for 8 weeks (1, 2). In conclusion, patients with referred back pain and vaginal drainage subsequent sacral colpopexy with use of synthetic mesh and fixation materials should be evaluated with a high level of suspicion for osteomyelitis. Clinical decisions as well as follow-up can be assisted by the assessment of magnetic resonance imaging, white cells blood count and c-reactive protein. Nevertheless, surgeons should always inform, independently of the surgical route selected, their patients about the possible complications of such procedures including sacral osteomyelitis.

A Find of an Istrian Cast ‘Wheel Coin’ at Koshary (Ukraine)

This article’s aim is to publish a cast Istrian ‘wheel coin’ found at the Koshary site. The site is located on the northern shore of the Black Sea on the right bank of the Tiligulskii Liman and consists of a settlement, a sacral zone around an open air altar (eschara) and a necropolis. The settlement existed between the end of the 5th and the middle of the 3rd centuries BC. Among other artifacts, 55 coins have been found at the site during regular archaeological excavations. Apart from a bronze coin of Tyras and the discussed Istrian piece, all the other coins found at Koshary are Olbian. The ‘wheel coin’ was discovered in a dugout located in the southern part of the sacral area around the eschara. The cast ‘wheel coins’ were produced in the 5th-4th centuries BC in Istros and were in circulation in a wide area covering a great part of the western and northwestern Black Sea shore. The find at Koshary, when combined with other finds in Luzanivka and Ochakov, marks a trade route between Istros, Nikonion and Olbia. As it was found in the eschara area, one can suppose that the Istrian coin was not used as currency, but possessed a sacral nature instead.

Salvage of a recurrent trochanteric pressure sore with coxofemoral osteoarthritis using a superficial inferior epigastric artery propeller flap

Sir, The recurrence of pressure sores remains a problem in paraplegic patients. More than 35 % of operated patients will have a recurrence [1–3]. Recurrent ulcers can occur after fasciocutaneous flaps and also musculocutaneous flaps. Then, flaps must be parsimoniously used for covering pressure sores. The superficial inferior epigastric artery (SIEA) flap is well known as a free flap, especially for breast reconstruction. We report the interest of the SIEA propeller flap for covering a recurrent trochanteric pressure sore in a paraplegic patient. Mr. D. is a 52-year-old male, having a T3 paraplegia, secondary to a spinal cord injury 29 years ago. In less than 25 years, he experienced pressure sores in sacral, trochanteric, and ischiatic areas. On the right trochanteric region, he was successively treated by a tensor fascia lata myocutaneous flap, a vastus lateralis muscle flap, and a groin flap for two recurrences in 20 years. Recently, he developed another trochanteric pressure sore, associated with an osteoarthritis of the right coxofemoral joint (Fig. 1). The patient complained about hyperthermia and a limitation of the hip mobility (10° in flexion, 0° in adduction, and 0° in abduction), making the chest to bed transfers more difficult. A multidetector-row computed tomography was made to confirm the osteoarthritis and evaluate the cutaneous perforators of the abdominal region. No reliable perforators was found from the deep inferior epigastric artery, but the caliber (2.6 mm) and the course (130 mm) of the SIEA were appropriate to raise a skin flap. The larger direct perforator of the SIEA had a 1.2-mm caliber, a 41-mm length, and the ascendant directionality adequate for a large skin flap. The surgery started by a large excision of the infected soft tissues around the ulcer. A femoral head–neck resection was performed. After a large cleaning and freshening of the acetabulum, the origin of the SIEA was dissected. The dominant direct perforator was found and included in the flap. A skin paddle measuring 15 × 20 cm was raised. The flap was rotated up to 100° for covering the trochanteric defect, as a propeller flap [4] (Fig. 2). The donor site was primarily closed. The operative time was 3 h, including the femoral head–neck resection, flap raising, and coverage of the coxofemoral defect. The patient was completely healed 2 weeks postoperatively. No recurrence or postoperative infection occurred during a follow-up of 24 months (Fig. 3). At 1 month, the patient recovered a mobility of 65° (45–110°) in flexion, 20° (0–20°) in adduction, and 40° (0–40°) in abduction. The chest to bed transfers and the dressing were significantly improved postoperatively. Fig. 1 Preoperative view of the trochanteric pressure sore. A central suppurative fistula is surrounded with inflammatory skin lesions. This trochanteric ulcer is associated with an osteoarthritis of the right coxofemoral joint Fig. 2 Intraoperative view of the superficial inferior epigastric artery propeller flap. The superficial inferior epigastric artery (yellow arrow) is dissected at the lower part of the abdomen. The proximal dominant perforator and the superficial inferior epigastric ... Fig. 3 Postoperative view of the trochanteric reconstruction. The trochanteric area is completely healed without infection 24 months postoperatively. No recurrence has occurred 24 months after the surgery. A few visible longitudinal scar can ... Pressure sores reconstructive surgery in paraplegics is known for a high risk of recurrence. Musculocutaneous flaps have been mainly used for their thickness and blood supply in this indication. However, the results of this complex case confirm that there is no statistical difference in ulcer recurrence between myocutaneous flaps and fasciocutaneous flaps [5]. Reeducation and prevention of skin hyperpressure seem to be more important than a muscle transfer. This case also reports the interest of the SIEA flap when classical flaps are not available for local reconstructions, and when no reliable perforators (>0.5 mm) are present for a deep inferior epigastric perforator flap. The SIEA flap can be safely rotated around its pedicle, as a propeller flap, without venous congestion or flap necrosis. It is a versatile flap for the coverage of large and infected trochanteric pressure sore.

A right atrial mass—but where is it coming from?

We present a case of a 70-year-old male who attended our emergency department with prolonged weight loss and a 3-week history of progressive swelling of his lower limbs and scrotum with haematuria. On examination there was pitting oedema up to his sacral area, with significant scrotal enlargement. The abdomen was distended with a large left-sided abdominal mass extending across the midline. This was in addition to 5 cm of hepatomegaly. On auscultation a pansystolic murmur was noted, which was loudest over the cardiac apex, with bibasal lung crepitations. Engorged neck veins and goitre were also noted. Acute renal failure was diagnosed with a creatinine level of 171.

Pressure Ulcer Prevalence in Turkey

The purpose of this study was to identify pressure ulcer prevalence among hospitalized patients in a university hospital setting. The study setting was medical and surgical inpatient wards and critical care units in a university hospital in Adana, Turkey. The sample population comprised 404 patients who were aged 18 years or older and admitted to the intensive care units and internal and surgery units at least 24 hours before data collection. Each participating patient's skin was assessed and pressure ulcers were classified according to the National Pressure Ulcers Advisory Panel grading system. Pressure ulcer risk was assessed using the Braden Scale. Data were recorded on a patient observation form designed for this study. The following tools were used to collect data: (a) data collection form in identifying sociodemographic and medical characteristics of the patients, (b) the classification developed by the National Pressure Ulcers Advisory Panel in identifying the phases and localization of pressure ulcers, and (c) Braden Risk Assessment Scale in assessing risks. The average age of patients was 51.22 ± 0.84 years (mean ± SD); 51.7% were male. The mean hospital length of stay was 9.6 ± 0.5 days. Pressure ulcer risk assessment revealed that 34.2% of the patients were at increased risk. The prevalence of pressure ulcers was 10.4%. Pressure ulcers occurred most frequently in the sacral area (43.9%); 45.2% of them were stage (grade) II. The pressure ulcer prevalence identified in this study is comparable with studies conducted in other countries.

Intraoperative fluoroscopy in percutaneous sacroiliac screw fixation based on anatomic measurement and digital reconstructed CT data

Objective To explore the intraoperative fluoroscopy in percutaneous sacroiliac screw fixation based on anatomic measurement and digital reconstructed CT data. Methods The CT data of the pelvis at prostration were collected for 3D reconstruction of the pelvic models from 30 patients with injury to the pelvis or acetabulum.Then the anatomical boundaries of the safe zone of sacroiliac screw insertion were marked on the 3D models,including the upper,front and back cortex boundaries of S1 vertebra,the front and bottom cortex boundaries of sacral foramen area,and the sacral alar slope. The angles between these anatomical boundaries and the pelvic baseline were measured on the sagittal plane.The digital reconstructed radiology (DRR) was applied to form the inlet,outlet and lateral images of fluoroscopy.The standard protocol to acquire accurate intraoperative images was analyzed by characterization of important anatomic landmarks.Results The angles between the upper,front and back cortex boundaries of S1 vertebra and the baseline (αl,α2,α3) were respectively 37.7°± 8.6°(from 23.2°to 50.8°),22.9° ± 6.7° (from 13.1° to 32.0°),41.9°± 6.8° (from 33.0°to 54.8°).The angles between the front and bottom cortex boundaries of sacral foramen area and the baseline (α4,α5) were 37.0°± 12.0° (from 19.9° to 63.1°) and 38.8°± 8.0° (from 25.7°to 54.6°).The angle between the alar slope and the baseline (α6) was 82.4°± 13.0°(from 70.3°to117.3°).The characteristic manifestations of important anatomic landmarks were observed in the simulated fluoroscopy images. Conclusions It is recommended that the projecting angles in the inlet and outlet views should be decided according to the specific data of each patient.Because the alar slope can not be clearly identified in the outlet view due to its large inclination,the position of screw insertion should be verified in the lateral view to prevent the screw from penetrating the slope to hurt the L5 nerve and iliac vessels. Key words: Bone nails; Pelvis; Tomography, X-ray computed; Image processing, computer-assisted; Sacroiliac joint

Incidentally discovered distant cutaneous metastasis of sacral chordoma: a case with variation in S100 protein expression (compared to the primary tumor) and review of the literature

Chordomas represent rare malignant primary bone tumors most often occurring in the sacral area. These tumors uncommonly involve the skin and often follow a progressive course with multiple recurrences, metastases and eventual death. Reports of cutaneous metastases from chordoma are very rare. The immunohistochemical staining characteristics of these cutaneous metastases with comparison to the primary tumors are similarly rarely addressed in the literature. We report a rare case of incidentally discovered, small, solitary distant cutaneous metastasis of sacral chordoma that developed on the right upper back of a 44-year-old man with a history of multiple completely excised melanomas who had also been previously diagnosed with chordoma involving the sacrum 12 years earlier. We describe its pathologic features with comparison to the primary tumor and briefly review the literature. Immunohistochemically, the cutaneous metastasis and primary tumor both stained positively for pancytokeratin and vimentin, as expected. However, the cutaneous metastasis unexpectedly lacked S100 protein expression, whereas the primary tumor was S100 positive. This phenomenon has only been documented in one other case report. We demonstrate that late, incidentally discovered cutaneous metastasis with unexpected immunohistochemical staining features rarely occur and can present a diagnostic challenge.

Germ cell tumour compressing the right atrium

Germ cell tumours are relatively rare and most commonly described in the gonads. These tumours can also be seen in other locations, such as in the retroperitoneum, the pineal gland, mediastinum, and sacral area. Primary mediastinal germ cell tumours are very rare and have been documented in the literature as only sporadic cases [1].