Presacral tumors

Presacral or retrorectal tumors are very rare tumors that develop in a space between the rectum and sacrum or back of the pelvis.  Presacral tumors arising in this area represent a variety of lesions from simple benign cysts to complex cancers that can invade surrounding structures.  This region contains structures derived from embryological development from which many tumors arise.  Approximately 40% of the lesions are congenital and 60% are acquired or develop over time.  The vast variety of tumors and their classifications are listed below.

What are the symptoms of presacral tumors?
Symptoms of presacral tumors are often nonspecific and are related to the location and size of the lesion.  Most benign cysts are asymptomatic and are discovered on routine rectal examination.  Pain is the most common presenting symptom.  Other symptoms include constipation, urinary or fecal incontinence, sexual dysfunction or drainage.

How is a presacral tumor diagnosed?
Evaluation begins with a neurologic and musculoskeletal exam as well as a rectal exam and sigmoidoscopy.  Once a lesion is diagnosed, it is further evaluated with Magnetic Resonance Imaging (MRI) to aid in determining the type of tumor, size of the tumor and if there is any invasion of surrounding structures.  This, in turn, helps to determine the surgical approach and the intraoperative extent of resection.

How is a presacral tumor treated?
Treatment of presacral tumors is surgical resection.  The approach depends on the nature and location of the tumor.  Lesions that are located high in the space between the rectum and sacrum are generally removed from a transabominal approach or through an incision in the abdomen.  Lower lesions can be resected through a posterior approach, which is an incision in the back between the tailbone and rectum.  Some tumors may require a combined abdominal and posterior approach.  In these complicated cases, a multidisciplinary team including a colorectal surgeon, neurosurgeon or orthopedic surgeon is critical.

What is the prognosis after treatment?
Long-term outcome after resection of a presacral tumor depends on the type of tumor and on adequate resection at the initial operation. The surgeon will review this with the patient both before and after surgery has been performed.

Classification of Presacral Tumors

Congenital

Benign

Developmental cysts (teratoma, epidermoid, dermoid)

Duplication of rectum

Anterior sacral meningocele

Malignant

Chordoma

Teratocarcinoma

Neurogenic

Benign

Neurofibroma

Neurilemoma (schwannoma)

Ganglioneuroblastoma

Ependymoma

Malignant

Neuroblastoma

Ganglioneuroblastoma

Ependymoma

Osseous

Benign

Giant-cell tumor

Osteoblastoma

Aneurysmal bone cyst

Malignant

Osteogenic sarcoma

Ewing’s sarcoma

Myeloma

Chondrosarcoma

Miscellaneous

Benign

Lipoma

Fibroma

Leiomyoma

Hemangioma

Endothelioma

Desmoid

Malignant

Liposarcoma

Fibrosarcoma