The surgical management of presacral tumors

A case report of a large presacral ganglioneuroma in a three and a half year old female child has been presented. It was removed by a two-stage abdominoperineal approach. The patient has been free of recurrence for twenty-nine months. Only twelve similar cases have been reported in the literature. The majority of these tumors occur in patients under the age of twenty. They appear to have a congenital origin. Twenty-five per cent may have anaplastic changes and 18 per cent will metastasize. The benign types are cured by complete excision but frequently occur in such inaccessible locations that complete excision may be very difficult and mutilating. The occurrence of a presacral fibrosarcoma in a sixty-seven year old white woman also has been reported The majority of these neoplasms grow slowly and spread by direct extension, but the high degree of malignancy of certain fibrosarcomas was demonstrated in this patient. They are the most common of the soft tissue sarcomas but occur infrequently in the presacral area. Only three other cases of fibrosarcomas occurring in this location could be found in the literature. Sixty per cent recur locally but cure may be effected by a wide excision of tissue which includes a safe margin outside the capsule of the tumor. A case of localized Hodgkin's disease of the presacral area has been reported. No other similar case could be found in the literature. The presence of a tumor was detected by examination under anesthesia and lateral films of the rectum filled with barium. The histologic diagnosis was made from a biospy specimen taken through a posterior approach after removal of the coccyx. The tumor disappeared rapidly under x-ray therapy. A thorough history, examination under anesthesia, lateral views of the rectum filled with barium, roentgenograms of the bony pelvis, retroperitoneal pneumography and surgical exploration are important in the diagnosis of tumors in the presacral area. Location of the sacral cornua, sacral hiatus, inferolateral angles of the sacrum and the foramens is helpful in identifying the sacral segments prior to their removal. The use of needles in locating the foramens and the logic of unroofing the sacral canal for identification of the sacral nerves was confirmed by cadaver dissections. Extensive or vascular tumors may require an abdominoperineal technic to insure their radical removal and in order to control the blood supply to this area.