EP392 - Clinical Characteristics, Management Patterns, and Surgical Outcomes of Presacral Masses

Purpose/Background: Presacral tumors are rare lesions that pose unique diagnostic and treatment challenges due to their variable presentation, histology, and complex anatomic location. Contemporary outcomes data are limited. Therefore, we sought to characterize the clinical, radiographic, and pathologic features of presacral tumors managed surgically vs. non-surgically within the multi-institutional Fairview/University of Minnesota health system.

Methods/Interventions: A retrospective cohort study was conducted using a central data repository from a large regional hospital system. Patients 18 years and older who were diagnosed with a presacral tumor between 2011 and 2023 were identified. Those with presacral tumors due to colorectal adenocarcinoma or metastatic disease were excluded. Demographic, clinical, imaging, histopathologic, management (surgical vs. non-surgical), and outcomes data were collected. Continuous variables were compared using the Mann-Whitney U test, and categorical variables were compared using chi-square or Fisher's exact tests as appropriate. A multivariable analysis could not be performed due to limited sample size.

Results/Outcomes: A total of 77 patients met inclusion criteria (median age, 56 years [range 23-83 years]; 74% female, and 90% white, Table 1). CT imaging initially identified 66% of presacral tumors, most commonly prompted by pain (65%). The median tumor size was 5 cm (range 1-22 cm), with 48% (n=37) cystic lesions, 52% (n=40) heterogeneous tumors, and 39% (n=30) demonstrating a malignant radiologic differential. About 41% (n=34) underwent a biopsy, usually a core needle (n=16) or open biopsy (n=11). Of the 31 patients (40%) who underwent surgery, most procedures were performed by a colorectal surgeon (65%, n=20) using a posterior approach (61%) and often included a coccygectomy (52%). Among resected tumors, most were benign (68%), predominantly tailgut cysts, while the most common malignant lesions were chordomas (n=5) and sarcomas (n=3). For non-surgical patients, 71.8% had 2 or less follow-up scans and 41.3% underwent a biopsy with the majority showing benign pathology (78.9%, n=15) such as retroperitoneal fibrosis (n=4) or myelolipoma (n=3), Compared to those who underwent surgery, non-surgical patients were significantly older (61 vs. 45 years p=0.011), female (82.6% vs. 61.3% p=0.036), higher BMI (32 vs. 29 p=0.041), more likely to be publicly insured (43.5% vs. 19.4% p=0.028), have a ≥3 Charlson comorbidity index (45.7% vs. 19.4% p=0.008), and less likely to be symptomatic at presentation (34.8% vs. 61.3% p=0.022). There was no difference in all-cause mortality between surgical and non-surgical patients (6.5% vs. 13.0%, p=0.463) with 3 post-operative recurrences.

Conclusion/Discussion: In this large regional cohort, patients with presacral tumors demonstrated diverse diagnostic and management patterns. Most lesions were benign, and many were safely managed non-operatively without an observed increase in all-cause mortality compared to those undergoing resection. These findings suggest, in appropriately selected patients, non-operative management of benign presacral tumors may be a feasible and safe approach.

Table 1. Comparison of Demographics, Tumor Features, and Outcomes in Surgical and Non-Surgical Presacral Tumor Management