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Purpose: Tumors occurring within the presacral space are a heterogeneous group and occur with very low incidence. Their low incidence has led to a paucity of published experience regarding surgical approaches, recurrence rates, and survival. This study aims to update the current literature on these tumors from a single-center with three decades of experience.
Methods: Patients were identified using a combination of a natural language search and SNOWMED codes queried from a prospectively maintained Pathology database from 1981-2011. A retrospective chart review was conducted recording patient demographics, tumor characteristics, operative procedure, recurrence, and survival data. Only patients ≥18 years old and with complete data were included.
Results: Presacral tumors were identified in 87 patients; 77% (67/87) female, median age at diagnosis was 44 years (19-88), and median follow-up was 8 months (0.1-225). Fourteen patients developed recurrence. Of the 27 different histologic tumors diagnosed, hamartomas were the most common (29%; n=28) followed by both teratomas and epidermal cysts each at 10% (n=9). 52% (14/27) of tumor types were malignant totaling 43% (37/87) of all tumors. CT scans were obtained in 84% (73/87) of patients, MRI in 59% (51/87), and TRUS in only 16% (14/87). While 74% (64/87) of tumors were at or below the S4 level, operative approach was strictly posterior in 73% (46/63) of those tumors (one tumor not resected). Cumulatively, 3/87 patients were treated non-operatively. 28% (24/87) of patients had a diagnostic biopsy with no reported biopsy site recurrences. Malignant tumors recurred in 24% (8/34), while benign tumors recurred in 12% (6/50). Chordomas recurred in 5/7 patients. Overall survival was 93% (81/87), 84% (31/37) for malignant tumors and 98% (49/50) for benign tumors.
Conclusions: Presacral tumors remain a heterogeneous group and continue to be a diagnostic and treatment challenge. Even though these tumors are confined to one space, surgeons must individualize preoperative work-up and operative approach based on each individual patient. A selective biopsy, which would influence treatment decisions, appears to be safe for tumors not associated with cord lesions. Presacral tumors are rare and studies such as this add to our understanding and guide patient recommendations regarding treatment.

Histologic Types of Presacral Tumors

Hamartoma	28
Teratomas*	9
Epidermal Cyst	9
Schwannoma	7
Chordoma	7
Dermoid Cyst	4
B-Cell Lymphoma	2
Myelolipoma	2
Neuroendocrine Tumor	2
Rectal Duplication Cyst	2
Chondrosarcoma	1
Ewing's Sarcoma	1
Fibrosarcoma	1
Fibrous Histiosarcoma	1
Ganglioneuroma	1
Gastrointestinal Stromal Tumor	1
Hemangiopericytoma	1
Liposarcoma	1
Mucinous Cystic Neoplasm	1
Pecoma	1
Neurofibroma	1
Smooth Muscle Tumor	1
Spindle Cell Tumor	1
Squamous Cell Tumor (metastasis)	1
Squamous Cell Cyst (Ovarian)	1

*Teratomas included those that were only teratomas (6) and those with both adenocarcinoma (2) and carcinoid (1) components, totalling 27 different histologic types of presacral tumors