Presacral tumors: a retrospective analysis of 112 cases with emphasis on diagnostic challenges and surgical outcomes

Abstract

Background: Presacral tumors are rare entities with heterogeneous pathology including malignant potential. Due to nonspecific symptoms mimicking common anorectal diseases, misdiagnosis remains a major challenge that may delay treatment and worsen prognosis, particularly for malignant variants. This study analyzes diagnostic pitfalls and surgical outcomes in a large single-center cohort.

Methods: We retrospectively reviewed 112 presacral tumor cases treated at our tertiary colorectal center (2015-2025). Data included demographics, clinical presentation, misdiagnosis rates, imaging accuracy, surgical approaches, and complications. Statistical analysis utilized descriptive methods and Chi-square tests.

Results: Among 112 patients (male 62, female 50; median age 52 years, range 18-93), 57% presented with anal/rectal pain, while 20.5% were asymptomatic. 85.7% of patients were referred from non-specialized centers. Misdiagnosis occurred in 29.5% (predominantly as anal fistula/abscess or pilonidal sinus). Preoperative imaging (MRI/CT) correctly diagnosed 60% of tumors >3 cm vs. 21.2% of smaller tumors (P < 0.001). Surgical approaches: 93.8% underwent transsacral/transanal resection, 6.2% required laparoscopic/combined abdominoperineal resection. Major complications (Clavien-Dindo grade III) occurred in 4.5% of patients (n = 5/112), including hemorrhage, rectal injury, and sacral nerve injury. No mortality occurred. Pathology revealed 11.6% malignancy risk.

Conclusion: High misdiagnosis rates (29.5%) data support for heightened suspicion in patients with "refractory perianal sepsis", especially given the potential for malignancy. MRI showed significantly higher diagnostic accuracy for tumors >3 cm. Transsacral/transanal resection is safe and effective for most cases (93.8%), with low major morbidity. Centralized management in specialized centers optimizes outcomes.

Keywords: case series; diagnostic error burden; presacral tumor; surgical approach; tertiary referral center.

Figure 1

Patient selection flowchart (STROBE-compliant).

Figure 2

A 31-year-old female with an asymptomatic 20 × 15 cm presacral mass discovered incidentally and monitored for 2 years. (A) Preoperative clinical photograph (knee-chest position) demonstrating a 20 × 15 cm sacrococcygeal mass with normal overlying skin, firm-elastic consistency, and no tenderness. (B) Preoperative sagittal T2-weighted MRI revealing a multiloculated cystic-solid mass (maximum diameter: 18.5 cm) causing significant rectal compression. (C) Intraoperative view via sacral approach showing tumor exposure following coccygectomy (forceps indicate sacral resection margin). (D) Gross specimen (18.5 × 12.5 × 6.2 cm) with predominant solid component (dotted line). (E) Histopathology showed diagnostic uncertainty between malignant teratoma and primary adenocarcinoma, resolved through expert consultation at our referral center. (F) Postoperative 6-month follow-up demonstrating preserved gluteal fold symmetry after reconstruction (patient consent obtained). Perineal region obscured for privacy.

Figure 3

Diagnostic algorithm for suspected presacral tumors.