PM1055: Percutaneous versus Open Fetal Surgical Intervention for Sacrococcygeal Teratomas: Is Less Really More?

Background: Sacrococcygeal teratomas (SCTs), the most common tumors in newborns, may require in-utero intervention for survival. Open fetal surgical resection was the first intervention described, but there are increasing reports of percutaneous (PI) approaches with variable indications and outcomes. The purpose of this study was to review the literature for all published cases of fetal intervention and compare open surgical intervention (OSI) to PI cohorts.

Methods: A search of pubmed was conducted utilizing key words, “sacrococcygeal teratoma,” “percutaneous intervention,” “radiofrequency ablation,” “laser,” “coiling,” “sclerosis,” “aspiration,” “drainage,” “shunt,” “fetal surgery,” “antenatal diagnosis,” “fetal intervention,” and “outcome.” Articles were reviewed by title, abstract, and in full for those that met inclusion criteria: data available per individual fetus including gestational age at intervention, type of intervention, primary indication, survival, gestational age at birth, and complications when possible. Articles that gave data only in aggregate for the study cohort were excluded. Complications were grouped into three categories: placenta/membranes, procedural, or hemorrhagic. Failure was defined as little to no improvement or recurrence of the primary indication for intervention. Primary indication definitions are available in table 1. Simple Chi square analysis was performed for solid tumor PI vs OSI to provide some insight regarding significant trends in these intervention groups. While a meta-analysis is more appropriate, that was not feasible due to small numbers and significant heterogeneity between studies.

Results: Thirty unique articles met inclusion criteria, 21 for PI yielding 63 unique fetuses, and 9 for OSI, yielding 18 unique fetuses. In the PI group, 38 fetuses underwent intervention for solid tumors, 22 for cystic tumors, and 3 had intervention for both solid and cystic tumor components. For those fetuses with solid tumors (table 2), OSI was associated with lower need for multiple interventions (0% vs. 31.6%, p=0.01) and higher survival to discharge (50% vs. 39.5%, p=0.02). A fetal intervention was performed in the absence of hydrops/early hydrops in 45% of fetuses having PI, compared to 21% of those having OSI. Failure to resolve the primary indication was higher in the PI group (55.9% vs. 11.1% OSI, p=0.02). The overall complication rates were quite high in both groups (90% OSI and 87% PI), though bleeding complications were only described in the PI group (23.5%). Preemptive cyst drainage (“to prevent future complications or facilitate delivery”) was universally successful and associated with a low complication risk (18.2%).

Conclusion: For solid tumors, open surgical intervention appears to be superior with regard to survival to discharge, fewer interventions, and lower failure rates. Percutaneous interventions to drain a cyst may facilitate delivery or preempt future complications, though it may have effects on long-term oncologic outcome due to tumor rupture and thus should be considered thoughtfully.