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Presacral Myelolipoma Mimicking Liposarcoma Complicated by Massive Intraoperative Hemorrhage: A Case Report

Year: 2026

Type: article

Abstract: INTRODUCTION: Myelolipoma is a benign tumor composed of mature adipose tissue and hematopoietic elements. Extra-adrenal lesions can occur in the presacral region and may mimic liposarcoma. Resection of a large presacral tumor can also cause life-threatening hemorrhage. We report a presacral myelolipoma that was difficult to diagnose preoperatively and was complicated by massive intraoperative hemorrhage. CASE PRESENTATION: A 71-year-old woman had an incidentally detected 75 × 75 × 125-mm presacral mass with mixed fatty and solid components on contrast-enhanced CT. MRI showed restricted diffusion, and fluorodeoxyglucose PET/CT showed mild uptake (maximum standardized uptake value, 3.93). No growth occurred over approximately 3 months. Because liposarcoma could not be excluded, the patient chose open resection without biopsy for diagnosis and treatment. During cranial dissection along the anterior sacrum, massive bleeding occurred from the right internal iliac venous system, and systolic blood pressure decreased to 50-60 mmHg. Manual compression was insufficient, and massive transfusion was initiated. Intraoperatively, a vein communicating with the right internal iliac vein was found to enter the tumor, and the main trunk of the right internal iliac vein was ligated near its junction with the right common iliac vein. Persistent bleeding required ligation of a tumor-entering branch of the right internal iliac artery; the arterial main trunk was preserved. Hemostasis was prioritized, and the tumor was removed in 2 pieces; the capsule was disrupted without macroscopic tumor spillage. Diffuse presacral venous plexus bleeding was controlled with electrocautery and oxidized cellulose. Operative time was 3 h 21 min, and blood loss was 4850 mL; 10 units of leukocyte-reduced red blood cells and 6 units of fresh frozen plasma were transfused. Histopathological examination established the diagnosis of myelolipoma. No vascular complications occurred, and contrast-enhanced CT at approximately 1 year showed no residual or recurrent tumor. CONCLUSIONS: Presacral myelolipoma should be considered in the differential diagnosis of fat-containing presacral tumors. In large tumors, the relationship with the internal iliac vessels and presacral venous plexus should be carefully assessed, and adequate blood products, early vascular control, and source-specific hemostatic techniques should be prepared before resection.

Source: Surgical Case Reports

DOI: 10.70352/scrj.cr.26-0452