EP654 - Presacral Teratoma in Adult population. The Mayo Clinic experience.

Purpose/Background: Sacrococcygeal teratomas are composed of fully differentiated tissues and represent the most common germ cell tumors of infancy and childhood, with a female predominance. When undiagnosed in infancy, they may present in adults with bowel or urinary dysfunction, pelvic pain, or venous congestion. This study reviews presentation, management, and outcomes of adult patients undergoing resection of benign and malignant sacrococcygeal teratomas.

Methods/Interventions: Following Institutional Review Board approval, a retrospective review of prospectively maintained surgical pathology and tumor registries was conducted across all three Mayo Clinic campuses (Rochester, Florida, Arizona). Adults (≥18 years) with pathologically confirmed sacrococcygeal teratoma treated between January 1, 1980, and June 1, 2025, were included. Teratomas of gonadal origin and patients lacking research authorization were excluded.

Results/Outcomes: Thirty-one patients were identified, 79% female, with a median age of 39 years (range, 18-82). Most presented with pelvic pain (70%) and/or a palpable mass (61%), while 13% were incidental findings. One patient had Currarino syndrome.

Imaging showed 13 cystic, 14 mixed solid-cystic, and 4 solid lesions. CT was obtained in 27, MRI in 19, and ultrasound in 4 patients. Teratoma was suspected radiographically in 33%, and imaging correctly identified malignancy in 35%. Preoperative biopsy was performed in 18 cases, demonstrating 100% concordance with final pathology (14 benign, 4 malignant). Final histology confirmed 26 benign and 5 malignant lesions.

Surgical approaches included posterior-only (n=20), anterior-only (n=5), and combined (n=6). Distal sacrectomy was performed in all malignant cases and in 57% of benign cases. Median tumor size was 7 cm (range, 2-24 cm). R0 resection was achieved in all malignant cases.

No perioperative mortality occurred. Thirty-day complications occurred in 57% of patients: Grade I (36%), Grade II (27%), and Grade III (18%), most commonly bleeding requiring transfusion and wound infection requiring intervention.

Median follow-up for benign cases was 27 months (range, 10 days-396 months). One benign recurrence occurred six years post-resection. Among malignant cases, three patients died of metastatic disease within 10-22 months of surgery.

Conclusion/Discussion: Adult sacrococcygeal teratomas are rare and predominantly benign. Accurate preoperative differentiation between benign and malignant lesions is essential. For benign tumors, complete excision including the coccyx minimizes recurrence risk while preserving function. Malignant tumors require en bloc resection with negative margins; the benefit of adjuvant therapy remains uncertain and should be individualized. Given the complexity of these tumors, multidisciplinary management at specialized centers is recommended.

Figure 1. Update Algorithm for Management of Presacral Teratoma
Management of Presacral Teratoma