Presacral Masses: Comprehensive Guide with Radiologic-Pathologic Correlation

The presacral space is a complex anatomic region that harbors a heterogeneous group of masses arising from diverse embryologic remnants. These lesions are uncommon and often detected incidentally. Surgical resection remains the mainstay of treatment, as approximately 60% of solid and 10% of cystic lesions are malignant. Cystic lesions, particularly developmental cysts, may also become infected or undergo malignant transformation. In selected cases of benign-appearing, small, asymptomatic cystic lesions, periodic imaging surveillance may be considered, with surgery reserved for those that develop worrisome changes at follow-up. MRI is the modality of choice for lesion characterization and preoperative planning. Distinguishing benign from malignant lesions depends on internal composition, morphology, and enhancement pattern. In cystic lesions, the presence of solid enhancing components represents the most reliable indicator of malignancy. The authors describe the role of different imaging techniques in the evaluation of these lesions and highlight key radiologic features as part of an image-based algorithm for lesion characterization, with emphasis on radiologic-pathologic correlation. This framework can help radiologists narrow the differential diagnosis and, in selected cases, establish a definitive diagnosis. Information that should be included in the MRI report and the current role of preoperative biopsy in the management of these lesions are also discussed. ^©RSNA, 2026 Supplemental material is available for this article.