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DOI: 10.1055/s-0045-1810631
A Practical Guide to Presacral Masses: Imaging Characteristics and a Proposed Classification System
Authors
- Abstract
- Introduction
- Classification
- Imaging Features
- Malignant
- Management
- Conclusion
- References
Abstract
The presacral space is an anatomically intricate region that can host a wide spectrum of pathologies ranging from benign developmental cysts to aggressive malignancies. Due to the rarity and diverse etiology of presacral masses, their diagnosis and management remain a significant challenge necessitating a multidisciplinary approach. This article provides a comprehensive review of the imaging features, classification, and management strategies for presacral masses. An imaging-based classification system is proposed, grouping the lesions into benign and malignant based on aggressive imaging features such as irregular margins, bone erosion, and pelvic sidewall invasion. Additionally, surgical approaches tailored to lesion characteristics and anatomical extent are discussed. This review article aims to aid radiologists in the effective diagnosis of presacral lesions.
Keywords
presacral masses - presacral space - presacral masses radiology - radiological classificationIntroduction
The presacral space is an anatomically complex and potential space, located at the convergence of the hindgut, axial skeleton, and spinal cord, which can give rise to diverse lesions of varying etiologies.[1] The reported incidence is 1.4 to 6.3 patients per year.2 Most presacral masses are benign, with congenital tumors being the most prevalent.[2] The rarity and heterogeneity of presacral tumors make diagnosis and treatment challenging, necessitating a multidisciplinary approach.
The presacral space is bounded anteriorly by the mesorectal fascia covering the rectum and posteriorly by the presacral fascia covering the sacrum and coccyx. It is limited inferiorly by the levator ani and superiorly by the peritoneal reflection ([Fig. 1]). This region typically contains loose connective tissues and important neurovascular structures, including the sacral nerve roots that innervate the bowel and bladder sphincters, as well as the sacral plexus that continues as the sciatic nerve. Patients with presacral masses often present with nonspecific symptoms, such as vague pain, constipation, or neurological compression-related issues, like bowel and bladder incontinence, sexual dysfunction, or sciatica.[1] [3]
Classification
Based on the site of origin the tumors can be classified as follows ([Table 1]):
The existing classification systems, like Uhlig and Johnson[4] and the Mayo classification,[3] are based on the pathological characteristics of presacral masses. A more practical and comprehensive classification system is necessary to improve the evaluation and management of these complex lesions. We propose an alternative classification system based on imaging characteristics ([Table 2]). We group the lesions as benign and malignant based on the aggressive imaging findings, which include irregular margins, bone erosions, or pelvic side wall invasion. The distal ureters or the internal iliac artery and its branches may also be involved.
|
Benign (no aggressive imaging features) |
Centered in sacrum |
Giant cell tumor |
||
|
Aneurysmal bone cyst |
||||
|
Simple bone cyst |
||||
|
Osteoblastoma |
||||
|
Anterior to sacrum |
Predominantly solid |
Fat containing |
Mature teratoma |
|
|
Lipoma |
||||
|
Extramedullary hematopoiesis[a] |
||||
|
Myelolipoma |
||||
|
Nonfat containing |
Neurogenic tumor: Neurofibroma, schwannoma, ganglioneuroma |
|||
|
Leiomyoma |
||||
|
Solitary fibrous tumor |
||||
|
Desmoid tumor |
||||
|
Extramedullary hematopoiesis[a] |
||||
|
Predominantly cystic |
Developmental cysts: epidermoid cyst, rectal duplication cyst, tailgut cyst |
|||
|
Anterior sacral meningocele |
||||
|
Cystic teratoma |
||||
|
Abscess (tubercular, postoperative) |
||||
|
Malignant (aggressive imaging features) |
Children |
Germ cell tumor: immature teratoma, yolk sac tumor |
||
|
Neurogenic: neuroblastoma |
||||
|
Soft tissue sarcoma: rhabdomyosarcoma |
||||
|
Osseous: Ewing's sarcoma |
||||
|
Adults |
Chordoma |
|||
|
Neurogenic: malignant peripheral nerve sheath tumor |
||||
|
Lymphoma |
||||
|
Soft tissue sarcoma: leiomyosarcoma, liposarcoma, angiosarcoma |
||||
|
Gastrointestinal stromal tumor (GIST) |
||||
|
Chondrosarcoma |
||||
|
Metastasis |
||||
a Chronic inactive lesions of extramedullary hematopoiesis show areas of fat deposition.
Imaging Features
Benign
Lesions Centered in the Sacrum
These include benign osteogenic lesions like giant cell tumor (GCT), aneurysmal bone cyst (ABC), simple bone cyst, and osteoblastoma.
Giant Cell Tumor
They are the second most common primary sacral lesions after chordoma. Sacrum accounts for 4 to 9% of all the GCTs.[5] They are expansile, eccentric, and geographic lytic lesions that can extend across the sacroiliac joints. They show intermediate signal intensity in T1- and T2-weighed images and show heterogeneous enhancement. They have high rates of recurrence of almost 50% after partial curettage. Lesions not involving the sacroiliac joints or the S1 segment are suitable for complete excision.[1] Selective transcatheter arterial embolization may be an option for unresectable tumors or preoperative embolization. While various embolic materials are available, superabsorbent polymer microspheres are recommended due to their precise and long-lasting occlusion.[6]
Aneurysmal Bone Cyst
ABCs are benign, rapidly growing neoplasms that predominantly affect adolescents. These lesions most frequently develop in the distal femur or proximal tibia, although the pelvis and posterior spinal elements are also commonly involved sites. Rarely, ABCs are seen in the sacrum.[7] Radiography and computed tomography (CT) typically depict these tumors as expansile, multiloculated, and lytic in appearance. Magnetic resonance imaging (MRI) often demonstrates fluid-fluid levels within the cystic components, resulting from the sedimentation of blood products within the lesion.[8]
Lesions Anterior to the Sacrum
Predominantly Solid, Fat-Containing Lesions
Extramedullary Hematopoiesis
Extramedullary hematopoiesis is the production of blood cells outside the bone marrow, often occurring in patients with chronic anemia or hematological disorders. Paravertebral involvement is an uncommon manifestation, typically presenting as paravertebral fat-containing masses on imaging. Presacral and pelvic involvement in extramedullary hematopoiesis is very rare with only a few case reports.[9] Lobulated soft tissue dense lesions are seen in CT, which show minimal heterogeneous postcontrast enhancement. In MRI, the lesions are T1 and T2 intermediate signal intense showing minimal enhancement.[10] Inactive chronic lesions show fatty deposition in the form of T1/ T2 hyperintensity or iron deposition in the form of T1/ T2 decreased signal intensity[11] ([Fig. 2]).
Myelolipoma
Myelolipomas are relatively uncommon benign neoplasms composed of varying amounts of mature adipose tissue and hematopoietic elements. While the adrenal gland is the most frequent site of involvement, these lesions may rarely occur in extra-adrenal locations, with the presacral space being the most common extra-adrenal location. These lesions typically present as circumscribed, heterogeneous masses with predominantly fat-containing areas and some enhancing soft-tissue components ([Fig. 3]). On MRI, T1and T2 hyperintense areas that demonstrate signal loss on fat-suppressed sequences are characteristic features that confirm the presence of intratumoral adipose tissue.[12]
Predominantly Solid, Nonfat-Containing Lesions
Neurofibroma
Neurofibromas are benign tumors that diffusely infiltrate and expand along the nerve, originating from neural elements, composed of fibroblasts and Schwann cells. While they typically occur in isolation, multiple neurofibromas may be present in patients with neurofibromatosis type 1 ([Fig. 4]). They demonstrate low attenuation on CT, lower than the surrounding soft tissues. They characteristically widen the neural foramina or sacral notch and extend along the expected course of a nerve. Hallmark MRI finding is a “target sign” on T2-weighted sequences, consisting of a hyperintense peripheral rim of myxoid material surrounding a central zone of low signal intensity from the fibrous component. While isolated neurofibromas can be difficult to distinguish from schwannomas, it is important to recognize the potential for malignant transformation of these lesions[1] ([Fig. 5]).
Schwannoma
Schwannomas are slow-growing, benign encapsulated nerve sheath tumors that originate from the Schwann cells. Sacral schwannomas are uncommon, accounting for only around 1 to 5% of spinal schwannomas. They are usually seen as large lesions displacing the bowel loops and the pelvic organs and causing bony remodeling. In MRI, heterogeneity of the tumors is the rule, and they have cystic areas within. The solid component is heterogeneously hyperintense in T2-weighted images and shows heterogeneous postcontrast enhancement.[13]
Ganglioneuroma
Ganglioneuromas are uncommon benign tumors that originate from the neural crest cells. They constitute a class of tumors that show a broad spectrum of differentiation, with neuroblastoma being malignant and ganglioneuroma benign. They are seen along the sympathetic chain, most commonly in the abdomen (52%) and infrequently in the pelvis or neck (9%). Although they are mostly asymptomatic, presacral ganglioneuromas can occasionally cause discomfort, constipation, or amenorrhea. Ganglioneuromas often appear as near-homogeneous oval masses on CT and MRI, often exhibiting intraspinal extension and sometimes delayed contrast enhancement ([Fig. 6]). Note that 20 to 30% of tumors have calcifications, which are usually fine as opposed to neuroblastomas, which have stippled calcifications.[14]
Predominantly Cystic Lesions
Developmental Cysts
Developmental cysts include epidermoid cysts, dermoid cysts, rectal duplication cysts, and tailgut cysts. They are the most common congenital presacral lesions.[13]
An epidermoid is a unilocular cystic lesion lined by stratified squamous epithelium and containing clear fluid. These lesions are mildly hyperdense in CT and show no contrast enhancement. In MRI, the lesions are predominantly hyperintense in T2-weighted images with dirty hypointensities within. The lesions show significant restricted diffusion and no postcontrast enhancement ([Fig. 7]).
Tailgut cysts are mucin-filled multilocular cystic lesions, lined with squamous or columnar epithelium. Almost half of the patients are asymptomatic, and the lesions are incidentally detected. Sometimes the patients present with a skin dimple in the midline or due to mass effect on the rectum or bladder. Ultrasound sometimes shows internal echoes due to the mucin or the inflammatory debris. CT shows unilocular or multilocular thin-walled cysts and are associated rarely with calcified walls. In MRI the lesions are usually hypointense in T1-weighted images and hyperintense in T2-weighted images. Sometimes if the mucin content is high, the lesions can appear hyperintense in T1-weighted images. Complications include infection, bleeding, and rarely malignant degeneration[15] ([Fig. 8]).
Rectal duplication cyst is rare, accounting for approximately 5% of all duplication cysts and it is defined by three criteria histologically: a lining mucosa, two layers of smooth muscles, and demonstrating rectal continuity. During a barium enema study, they demonstrate communication between the cyst and the intestinal lumen. The typical gut signature can be seen in the ultrasound.[15]
Anterior Sacral Meningocele
This congenital anomaly results from a defect in the sacrum with associated herniation of the meninges, which is filled with cerebrospinal fluid ([Fig. 9]). It affects 1 in 40,000 children. They are mostly asymptomatic; however, when symptoms do occur, they are often brought on by neurologic impairment, mass effect, rupture of the meningocele, and meningitis. The scimitar sacrum seen in radiograph raises the possibility of anterior meningocele. Nerve roots may be present in an anterior sacral meningocele, and surgical planning requires the ability to see any neural components inside the hernial sac. Numerous osseous abnormalities, including aplasia and hypoplasia of the sacrum and other vertebrae, may also be seen. This disease can be seen as a part of the Currarino triad or is often associated with other abnormalities or syndromes, such as renal, anorectal, uterine, and bladder malformations, Marfan syndrome, and type 1 neurofibromatosis.[13]
Abscess
Presacral fluid collections can arise from multiple etiologies, including complicated fistulizing Crohn's disease with extension into the presacral space,[16] tubercular abscesses originating from vertebral osteomyelitis or enteric infections, acute diverticulitis, rectal carcinoma, hollow viscus perforation, and postoperative collections (particularly after rectosigmoid surgery).[17] The challenge in managing these collections is in achieving adequate drainage. CT-guided percutaneous transgluteal approach, positioned just lateral to the outer border of the sacrum, is generally preferred for placing a drainage catheter. When only a single aspiration is needed, an endocavitatory route (either transrectal or transvaginal) may be indicated.
Malignant
Children
Teratoma
Teratomas are classified as mature or immature histologically, depending on the level of cell differentiation. Tissues from almost any organ system can be found in these tumors. Solid components are more commonly associated with malignant degeneration, while cystic components are generally benign. Immature teratoma is the most common congenital malignancy in neonates occurring in 1 in 40,000 births.[18] Almost half the tumors have an external component. The contents of the teratoma determine their imaging findings. Usually, benign teratomas are cystic, including mature tissues, fat, calcium, and a small nonenhancing soft tissue component, if any ([Fig. 10]). Hemorrhage and necrosis occur frequently in malignant tumors, with more solid tissue than in benign tumors, which shows heterogeneous enhancement. The rate of malignancy is significantly related to age and is lower in the second decade. Teratomas are associated with vertebral, urinary tract, and anorectal anomalies.[19]
Yolk Sac Tumor
Yolk sac tumors are uncommon germ cell tumors that can develop in various sites, including the sacrococcygeal region. They are generally more aggressive than teratomas, often presenting as large, well-defined solid-cystic masses that may exhibit intratumoral bleeding, capsular rupture, significant heterogeneous enhancement, and enlarged vessels within the tumor. MRI reveals varied signal intensity on T1- and T2-weighted images with heterogeneous postcontrast enhancement ([Fig. 11]). Monitoring serum alpha-fetoprotein levels is crucial for both diagnosis and follow-up.[20] [21]
Neuroblastoma
Neuroblastoma is a common childhood solid tumor originating from neural crest cells. They predominantly originate from the adrenal medulla, the organ of Zuckerkandl, or along the sympathetic ganglia in the paraspinal regions. Primary pelvic neuroblastoma is rare and constitutes approximately 2 to 3% of occurrences.[22] Additionally, the pelvis may also be affected by metastatic disease. The tumor typically is heterogeneous with areas of necrosis and calcifications (in 80–90% of cases). It may extend through the neural foramina into the spinal canal and frequently encases surrounding vessels, potentially causing compression. Locoregional invasion of the psoas muscles can be seen[23] ([Fig. 12]). Nuclear medicine imaging is instrumental in evaluating bone marrow metastases, with 123I-metaiodobenzylguanidine (MIBG) scintigraphy being the preferred modality. Over 90% of primary neuroblastomas demonstrate avidity for MIBG.[24] However, 131I MIBG scan is done in India.
Ewing's Sarcoma
The pelvis is one of the most common sites of Ewing's sarcoma, while lesions centered in the sacrum are rare, accounting for approximately 5%.[25] Ewing's sarcoma is common in young patients, with a peak prevalence between 10 and 15 years. It shows a permeative pattern of spread with bony expansion and sclerosis, with aggressive periosteal reaction. They show T1/ T2 intermediate signal intensity or sometimes hyperintense in T2. They are mostly associated with a soft tissue mass.[25]
Soft Tissue Sarcomas
Rhabdomyosarcoma is the most common soft tissue sarcoma in pediatric population. It is the third most common solid extracranial tumor in children after neuroblastoma and Wilms tumor, although retroperitoneal and presacral location is rare. The median age at diagnosis is 5 years. In imaging, the lesions are locally aggressive showing heterogeneous contrast enhancement in CT and MRI with areas of hemorrhage and necrosis. In MRI, the lesion shows intense restricted diffusion. The embryonal subtype shows a good prognosis, whereas the alveolar and pleomorphic subtypes carry a poor prognosis.[26]
Other soft tissue sarcomas include leiomyosarcoma ([Fig. 13]), fibrosarcoma, angiosarcoma, and malignant solitary fibrous tumor, which are seen in adults ([Fig. 14]).
Adults
Chordoma
Sacral chordomas are the most common primary lesions of the sacrum and are characterized by high recurrence rates, often presenting as large masses at initial diagnosis. Approximately half of these lesions are located in the sacrococcygeal region, with the remainder occurring in the clivus and other regions of the spine.[1] These tumors are lytic and destructive, frequently extending across the sacroiliac joints. A significant presacral soft-tissue component, which may exhibit calcifications and neural foraminal extension, is typically present. Chordomas generally show low to intermediate signal intensity on T1-weighted MRI and high signal intensity on T2-weighted MRI, with moderate enhancement following contrast administration[27] ([Fig. 15]). Extension of the tumor above the L5/S1 level, involvement of the sacroiliac joint, and piriformis muscle invasion are potential predictors of local recurrence.[28]
Lymphoma
Lymphomas can affect both nodal and extranodal structures within the abdomen and pelvis. On CT, they often present as large, rounded masses or as homogeneously enhancing lobulated lesions. Enlarged lymph nodes may coalesce, forming large masses that appear as homogeneously enhancing, uniformly dense lesions. These tumors tend to displace and grow around adjacent structures, including blood vessels and bowel loops ([Fig. 16]). On MRI, lymphomas are typically hypointense on T1-weighted images and iso- to hypointense on T2-weighted images showing significant restricted diffusion.[29]
Gastrointestinal Stromal Tumor
While gastrointestinal stromal tumors (GISTs) are the most common malignant mesenchymal tumors of the gastrointestinal tract, anorectal GISTs are relatively uncommon, accounting for approximately 5% of the tumors.[30] Patients may present with rectal bleeding, symptoms of bowel obstruction, or may be asymptomatic with the tumor detected incidentally. These tumors typically appear as circumscribed, exophytic, or intramural masses with a noncircumferential growth pattern, extending into the ischiorectal or presacral space without pelvic lymphadenopathy ([Fig. 17]). They often contain large central areas of necrosis and exhibit avidity on fluorodeoxyglucose-positron emission tomography imaging.[31]
Chondrosarcoma
Though pelvis is a common site for chondrosarcoma, primary involvement of the sacrum is rare. At the time of diagnosis, they are usually large due to the delay in the onset of clinical symptoms. They are lytic lesions with chondroid matrix in the form of ring and arc calcifications. The soft tissue component is usually hypodense in CT and is hyperintense in T2-weighted images due to the high water content in the hyaline cartilage.[32]
Extraosseous Myeloma
Though a large number of patients with multiple myeloma have extraosseous manifestations found in autopsies, only a small percentage of them (10–15%) have radiologically detectable disease.[33] It is more commonly seen in younger patients, and they have poorer prognosis. Bulky soft tissue dense masses can be seen in the retroperitoneum or the pelvis, which are homogeneously enhancing and also can have low signal intensity in T2-weighted imaging in MRI, mimicking lymphoma ([Fig. 18]).
Management
Image-Guided Biopsy
A percutaneous approach is generally preferred as it allows the biopsy tract to be included within the surgical resection area. Transvaginal, transrectal, or transperitoneal approaches for the biopsy should be avoided due to the risk of tumor seeding. Radiologists have three main percutaneous approaches for performing biopsies ([Fig. 19]): the transgluteal route, which is lateral to the sacrum's lateral margin; the extraperitoneal anterolateral route, which goes through the iliopsoas muscles; or the transosseous route, which crosses the sacrum. In cases of highly vascular lesions, preoperative selective embolization of the tumor may also be considered.[34]
Surgical Management
A multidisciplinary team is essential in guiding the appropriate treatment plan. Small, asymptomatic, completely cystic lesions can typically be followed up. In contrast, lesions exhibiting aggressive features or those with the potential for malignant degeneration require surgical intervention. Symptomatic lesions and the lesions that show growth on follow-up imaging also need to be addressed surgically. In cases where the treatment plan may be tailored based on the biopsy, a preoperative biopsy can be considered. Malignant lesions necessitate an en bloc surgical approach, while benign lesions can often be treated with a function-sparing technique. Certain malignancies, such as Ewing's sarcoma, have been found to respond well to neoadjuvant chemotherapy.
A pelvic approach is preferred for lesions situated below the level of the S3 vertebra, while an abdominal approach is suitable for those situated entirely above the S3 vertebra. For lesions extending across the S3 vertebra, a combined surgical approach is typically required. Aggressive lesions that involve the pelvic side wall or sacrum will also necessitate a combined approach.[3]
Conclusion
Presacral masses, though rare, encompass a broad range of pathologies with varied clinical implications. Imaging plays a pivotal role in their diagnosis, classification, and management, allowing for differentiation between benign and malignant entities. The proposed imaging-based classification system provides a practical framework for radiologists and clinicians to assess these lesions and formulate treatment plans. While the majority of benign lesions may be managed conservatively or with minimally invasive surgery, aggressive or malignant masses require en bloc resection and, in some cases, adjuvant therapies. Multidisciplinary collaboration remains essential for optimizing outcomes. Future research should focus on validating imaging-based classifications and exploring advanced imaging modalities to refine diagnostic accuracy and prognostication.
Conflict of Interest
None declared.
-
References
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- 7 Brastianos P, Gokaslan Z, McCarthy EF. Aneurysmal bone cysts of the sacrum: a report of ten cases and review of the literature. Iowa Orthop J 2009; 29: 74-78
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- 15 Dahan H, Arrivé L, Wendum D, Docou le Pointe H, Djouhri H, Tubiana JM. Retrorectal developmental cysts in adults: clinical and radiologic-histopathologic review, differential diagnosis, and treatment. Radiographics 2001; 21 (03) 575-584
- 16 Jwa HJ, Song HJ, Jun H. et al. Gluteal and presacral abscess due to Crohn's disease with multiple fistulas. Korean J Gastroenterol 2022; 80 (06) 267-272
- 17 Franceschi P, Attinà D, Niro F, Sportoletti C, Buia F, Lovato L. Percutaneous computed tomography-guided drainage of presacral fluid collections: a comprehensive analysis of 93 cases in a single-center experience. J Med Imaging Intervent Radiol 2024; 11 (01) 7
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18. September 2025
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References
- 1 Hain KS, Pickhardt PJ, Lubner MG, Menias CO, Bhalla S. Presacral masses: multimodality imaging of a multidisciplinary space. Radiographics 2013; 33 (04) 1145-1167
- 2 Li Z, Lu M. Presacral tumor: insights from a decade's experience of this rare and diverse disease. Front Oncol 2021; 11: 639028
- 3 Kelley SR, Dozois EJ. Presacral Tumors. In: Steele SR, Hull TL, Hyman N, Maykel JA, Read TE, Whitlow CB. eds. The ASCRS Textbook of Colon and Rectal Surgery . Switzerland: Springer International Publishing; 2022: 375-396
- 4 Uhlig BE, Johnson RL. Presacral tumors and cysts in adults. Dis Colon Rectum 1975; 18 (07) 581-589
- 5 Murphey MD, Nomikos GC, Flemming DJ, Gannon FH, Temple HT, Kransdorf MJ. From the archives of AFIP. Imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic correlation. Radiographics 2001; 21 (05) 1283-1309
- 6 He SH, Xu W, Sun ZW. et al. Selective arterial embolization for the treatment of sacral and pelvic giant cell tumor: a systematic review. Orthop Surg 2017; 9 (02) 139-144
- 7 Brastianos P, Gokaslan Z, McCarthy EF. Aneurysmal bone cysts of the sacrum: a report of ten cases and review of the literature. Iowa Orthop J 2009; 29: 74-78
- 8 Deventer N, Budny T, Gosheger G, de Vaal M, Burkhardt J, Deventer N. Aneurysmal bone cyst of the pelvis and sacrum: a single-center study of 17 cases. BMC Musculoskelet Disord 2022; 23 (01) 405
- 9 Denies E, Duwel V, Delvaux P. Presacral extramedullary haematopoiesis: a diagnostic update and case report of a late diagnosis. Int J Surg Case Rep 2012; 3 (09) 474-476
- 10 Roberts AS, Shetty AS, Mellnick VM, Pickhardt PJ, Bhalla S, Menias CO. Extramedullary haematopoiesis: radiological imaging features. Clin Radiol 2016; 71 (09) 807-814
- 11 Haidar R, Mhaidli H, Taher AT. Paraspinal extramedullary hematopoiesis in patients with thalassemia intermedia. Eur Spine J 2010; 19 (06) 871-878
- 12 Fourati H, Fourati M, Hentati Y, Daoud E, Mnif Z. Presacral myelolipoma: imaging features. Presse Med 2015; 44 (11) 1196-1198
- 13 Kocaoglu M, Frush DP. Pediatric presacral masses. Radiographics 2006; 26 (03) 833-857
- 14 Mut DT, Orhan Soylemez UP, Demir M, Tanık C, Ozer A. Diagnostic imaging findings of pelvic retroperitoneal ganglioneuroma in a child: a case report with the emphasis on initial ultrasound findings. Med Ultrason 2016; 18 (01) 120-122
- 15 Dahan H, Arrivé L, Wendum D, Docou le Pointe H, Djouhri H, Tubiana JM. Retrorectal developmental cysts in adults: clinical and radiologic-histopathologic review, differential diagnosis, and treatment. Radiographics 2001; 21 (03) 575-584
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