Role of Interventional Radiology in Sacral Mass resection

Learning Objectives: To discuss clinical presentation, risk factors, imaging characteristics and interventional management of sacral masses

Background: Tumors of the sacrum are managed typically through surgery and radiotherapy, but due to the variable vascularity found in these masses, there is often a role for Interventional Radiology through embolization, whether to help with intraoperative bleeding or therapeutically to aid with inoperable metastases. These masses are broken down into benign, neural, or malignant/metastatic lesions, with the most common cause in adults being metastases of distant lesions such as breast, multiple myeloma, prostate, and lung. Sacral tumors are frequently biopsied for tissue diagnosis with CT-guided needle biopsy, and from this, decisions can be made for interventions such as radiotherapy or partial/total resection. In the case of surgical resection, the tenuous vascular structures within the pelvis and the hypervascularity of many sacral masses creates a significant risk for intraoperative hemorrhage. Traditionally, surgery was performed without any pretreatment, and studies such as Hulen et. al. reported mean blood losses of 5,000 mL during resection of primary sacral tumors. The current literature today recommends that interventional radiology play a role in the management for these tumors using preoperative angiography and embolization. This has significantly reduced blood loss to < 1,500 mL in most studies, making this a very viable option to manage this potentially lethal complication during resection of sacral tumors.

Clinical Findings/Procedure Details: In this educational exhibit, we discuss clinical presentation, risk factors, multimodal imaging findings and management of sacral masses with illustrations from our institution, with special attention given to the role of trans-arterial embolization for management.

Conclusion and/or Teaching Points: Without pre-treatment, there is a significant risk of large volume bleeding intraoperatively, leading to significant morbidity and mortality. The current literature suggests that there is great benefit in the preoperative angiographic embolization of sacral masses, compared to the alternative of attempting surgery without embolization. This has been shown to be a minimally invasive, safe, and effective addition for these patients, allowing interventional radiologist to play an integral role for the management of sacral masses through trans-arterial embolization.