Rib malignancies masquerading as benign mediastinal tumours

Mediastinal tumours are commonly encountered in general thoracic surgery practice. Benign tumours like thymoma and teratoma often need direct surgical resection if resectable. Pre-operative biopsy is not recommended. We report 2 cases which were radiologically diagnosed as thymoma and teratoma turned out to be Ewing sarcoma and chondrosarcoma respectively after surgical excision. This has challenged the notion whether biopsy is really not needed. More elaborate studies are needed to find out tumour characteristics which would warrant a biopsy even if they are resectable. In our cases, pre-operative biopsy would have changed the line of management in both patients. This has led to a change in institutional protocol that now, we do biopsy for any mediastinal tumour more than 8 cm and abutting the chest wall.

Alternative In Vivo Models to Study Teratoma

Embryonic stem cells give rise to teratomas when injected in vivo in experimental animal models. The characterization, the manipulation, and the breaking off of this specific characteristic are doubtlessly the last frontier for the applications of stem cells in translational medicine. Moreover, the urgency to adapt to new scientific demands drives the researcher to find alternative and faster models for testing the teratogenic properties of embryonic stem cells. Here, we compare the emerging model of the chick embryo chorioallantoic membrane (CAM) to the murine model, which represents the gold standard procedure for teratogenesis.

An unusual case of oropharyngeal mature teratoma in a kitten

Background

Extragonadal teratoma in the head and neck region is unusual in veterinary medicine. So far, only one case of oropharyngeal teratoma has been reported in a cat.

Case description

In this report, a 5-month-old kitten was brought to the clinic with the complaint of difficulty breathing, food intake, and oropharyngeal mass. In clinical examination, there was a large mass, protruding from the localization included left buccal mucosa, soft palate, and extending into the oropharynx but no cranial extension was observed in CT scans. The mass was completely resected. Macroscopically, the mass measured 4.5 × 6.5 cm2 and contained solid and cystic areas associated with soft and hard tissue components.

Findings/treatment and outcome

Histopathology revealed an extragonadal solid-cystic (grade 0) oropharyngeal mature teratoma containing structures from endoderm, mesoderm, and ectoderm. After an 8-month follow-up control period, no signs of recurrence were observed.

Conclusion

The case was deemed worthy of being presented with its clinical, radiological, and pathological findings, and complete resection was curative for mature teratoma.

Large Retroperitoneal Teratoma Presenting with Unilateral Hydronephrosis in an Infant: A Case Report and Review of the Literature

Teratoma is a type of germ cell tumor layer that appears in the gonadal, sacrococcygeal, mediastinal, and retroperitoneal regions. Primary retroperitoneal teratoma is rare and asymptomatic but can present with symptoms due to a mass effect on neighboring organs. These tumors have to be considered in the differential diagnosis of a mass in the abdominal cavity of children to distinguish between Wilms' tumor, neuroblastoma, and other intra-abdominal lesions. We presented an infant boy with protrusion of the left upper quadrant of the abdomen and a palpable abdominal mass that had progressively enlarged. An abdominal computed tomography scan revealed a large retroperitoneal cystic, solid mass on the left side of the abdominal cavity, causing pressure on the left ureter. Also, hydronephrosis of the left kidney was seen with a decreased enhancement of the left kidney due to obstruction uropathy. The mass was suspicious on imaging for a retroperitoneal teratoma. The patient underwent laparotomy, and excision of the huge retroperitoneal mass was done. The final diagnosis was an immature teratoma grade 3, and the patient was discharged in good condition. Retroperitoneal teratomas are rare tumors in infants. These tumors would be an incident diagnosis or diagnosed by the mass effect of giant tumors on other organs. They must be considered in the differential diagnosis of intra-abdominal tumors in children. Hydronephrosis and obstructive uropathy can be rare consequences of the mass effects of these tumors.

A neuroendocrine tumor within an anterior mediastinal mature teratoma: a case report

BACKGROUND

Mature teratomas are benign germ cell tumors. On rare occasions, they have been associated with somatic malignancies and are termed rare germ cell tumors with a somatic-type malignancy (GCTSM). Mature teratomas commonly comprise adenocarcinomas; only seven previous cases of mature teratomas with neuroendocrine tumors have been reported to date. Here, we report a patient with a neuroendocrine tumor whithin a mature teratoma.

CASE PRESENTATION

A 26-year-old man visited our department complaining of chest tightness. Contrast-enhanced computed tomography (CT) scans showed a strongly enhanced lesion within a 10-cm encapsulated cystic lesion in the anterior mediastinum. Positron emission tomography (PET) scans showed no areas of significant ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) accumulation. He underwent complete tumor resection via the transsternal approach. Histopathological examination of the specimen indicated a neuroendocrine tumor contained within a mature teratoma.

CONCLUSIONS

In this case, a neuroendocrine tumor was contained within a mature teratoma. Our patient had no specific symptoms and his serum markers were within the normal range. Although PET is beneficial for diagnosing other GCTSM, it is not useful in detecting a neuroendocrine tumor. Therefore, the preoperative diagnosis of neuroendocrine tumors contained within mature teratomas remains challenging. However, GCTSM should be suspected in patients exhibiting CT findings of a mediastinal tumor, measuring ≥ 6 cm, in addition to characteristic GCTSM findings. Moreover, surgery should be performed carefully in such cases.

Anesthesia for ovarian teratoma resection using remimazolam and remifentanil in a patient with anti-N-methyl-D-aspartate receptor encephalitis -two case reports

BACKGROUND

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a type of autoimmune encephalitis that causes characteristic symptoms through the formation of antibodies against NMDA receptors. If ovarian teratomas are detected, surgical removal under general anesthesia is often considered. Many general anesthetic agents inhibit NMDA receptors. As such, anesthetic agents may have unexpected effects on disease progression. For anesthesiologists, providing general anesthesia for these patients is challenging and there are few studies on which anesthetic is most appropriate.

CASE

Two female patients were diagnosed with anti-NMDA receptor encephalitis and ovarian teratomas. Successful teratoma resection was performed under general anesthesia using remimazolam and remifentanil. After the surgery, one patient showed some improvement but died a month later. The other patient progressively improved over time.

CONCLUSIONS

Remimazolam and remifentanil are useful general anesthetic agents for patients with anti-NMDA receptor encephalitis. Further studies are warranted.

[Current view on testicular tumors from a developmental biological perspective : Important biomarkers and molecular pathological investigations]

BACKGROUND

Germ cell tumors (GCTs) are the most common type of cancer in Germany in young men between 15 and 44 years of age. The routinely performed diagnostic procedures are essential for the patient's treatment, but can be difficult due to heterogenous histologies. Additionally, the molecular mechanisms of the development of the special forms growing teratoma syndrome (GTS) and testicular tumors with malignant somatic transformation (MST) as well as of therapy resistance are not fully understood.

OBJECTIVES

Updated understanding of the molecular processes underlying GCT development and their special forms as well as recommendations for new and useful biomarkers.

RESULTS

The development of GCTs is a dynamic process largely influenced by the microenvironment. Seminomas (SEs) in particular seem to posses a higher cellular plasticity than previously assumed, allowing SEs to be reprogrammed into an embryonal carcinoma (EC) or differentiate into extra-embryonal tissues (yolk sac tumors [YSTs], trophoblastic differentiation). Novel serological (mi371a-3p) and pathological (FOXA2) biomarkers are well suited to early detect GCTs and YSTs, respectively. For more aggressive tumors and special cases (GTS, MST), there are still no reliable diagnostics or specific/tailored therapies available.

CONCLUSION

The ability of SEs to transit into EC or YSTs should be considered during therapy. Future research should focus on deciphering the special forms GTS and MST as well as the early recognition of YSTs, since their development seems to be an escape mechanism to chemotherapy.

Fetal thoracic teratomas: mediastinal or pericardial?

BACKGROUND

Mediastinal and pericardial teratomas have overlapping imaging features that may make accurate prenatal diagnosis challenging.

OBJECTIVE

To identify prenatal imaging features that may aid in distinguishing between mediastinal and pericardial teratomas.

MATERIALS AND METHODS

Prenatally diagnosed pericardial and mediastinal teratomas evaluated at our fetal center from 1995 to 2020 were included in this Institutional Review Board-approved study. Lesion volume was calculated using prospectively reported ultrasound (US) measurements and the formula of a prolate ellipsoid, which was then normalized to head circumference. Prenatal US and magnetic resonance imaging (MRI) studies were anonymized with two fetal imagers reviewing the US studies and two different fetal imagers reviewing the MRI studies. These experienced reviewers scored location of the mass in the craniocaudal axis and in the transverse axis. MRI reviewers also scored the presence of inferior cardiac compression by the lesion and whether there was identifiable thymic tissue. Reviewer disagreements were resolved by consensus review.

RESULTS

Eleven pericardial teratomas and 10 mediastinal teratomas were identified. All cases underwent detailed fetal anatomic US and fetal echocardiogram and 10/11 (91%) pericardial teratomas and 8/10 (80%) mediastinal teratomas underwent fetal MRI. Median volume was higher for mediastinal teratomas compared to pericardial teratomas (42.5 mL [interquartile range (IQR) 15.9 - 67.2 mL] vs. 8.1 mL [IQR 7.7 - 27.7 mL], P=0.01) and median volume/head circumference was also statistically higher in mediastinal teratomas (1.33 [IQR 0.78 - 2.61] vs. 0.43 [IQR 0.38 - 1.10], P=0.01). Logistic regression analysis demonstrated a statistical difference between teratoma types with respect to location in the craniocaudal axis by both modalities with mediastinal teratomas more commonly located in the upper and upper-middle thorax compared to pericardial teratomas, which were more commonly found in the middle thorax (US, P=0.03; MRI, P=0.04). Logistic regression analysis also demonstrated a statistical difference between teratoma types with respect to position along the transverse axis by both modalities with mediastinal teratomas more commonly located midline or left paramedian and pericardial teratomas more often right paramedian in location (US, P<0.01; MRI, P=0.02). Inferior cardiac compression observed by MRI was associated more commonly with mediastinal teratomas compared to pericardial teratomas (87.5% [7/8] vs. 10% [1/10], P<0.01). Identifiable thymus by MRI was more commonly observed in cases of pericardial teratomas, however, this difference was not statistically significant (P=0.32).

CONCLUSION

Mediastinal teratomas are associated with larger lesion size and inferior cardiac compression when compared to pericardial teratomas. These features combined with lesion location in the craniocaudal and transverse axes may allow for more accurate prenatal diagnosis and optimal perinatal and surgical management.

Mature teratoma of the anterior mediastinum revealed by supravalvular pulmonary stenosis: a case report

The mature teratoma of the mediastinum is a benign tumour made up of several adult-type tissue components which result from the abnormal development of two or three embryonic layers (ectoderm, endoderm or mesoderm). We report the case of a 31-year-old patient, admitted for management of a mediastinal tumour, revealed by a pulmonary supravalvular stenosis, symptomatic of exertional dyspnea and mid-thoracic pain. The clinical examination objectified a respiratory rate at 18 c/min and an oxygen saturation at 96% in ambient air. The chest X-ray showed a mediastinal enlargement with a left paracardiac opacity, while the echocardiac showed a supravalvular pulmonary stenosis, hence the realization of a thoracic computed tomography (CT), which objectified a voluminous anterior mediastinal cystic formation and superior lateralized on the left, with an effect of compression on the trunk of the pulmonary artery. The median sternotomy allowed the complete exeresis of this tumor and the postoperative course was simple. The mature teratoma of the anterior mediastinum should be suspected in view of these clinical and radiological signs in a young patient. Surgery with a complete resection remains the treatment of choice.

Umbilical Cord Teratoma - A Short Case Report

Background: Teratomas can occur in the umbilical cord, and may or may not be associated with other congenital abnormalities. Case report: This 35-year-old primigravida gave birth 37-38 weeks to a 3290-g normal female. The umbilical cord, at 10 cm from the abdominal insertion, had an 8 cm mature teratoma. Work-up revealed no other abnormalities. Discussion: Mature teratomas may occur in the umbilical cord, and may or may not have additional clinical sequalae.

Organoid (hypermature) ovarian teratomas: Report of four cases, one of which harbored a well-differentiated neuroendocrine tumor

Organoid (hypermature) teratomas are highly specialized teratomas showing organ formation, most frequently from the digestive tract or bronchial wall. We present four cases of ovarian organoid teratomas, one with a distinguishable mandible with teeth, one with small intestine, one with large intestine containing a well differentiated neuroendocrine tumor and another with both large intestine and bronchial wall. These tumors have a distribution similar to conventional teratomas and usually behave benignly, although cases of malignancy have been reported.

Spontaneous intrapleural rupture of mediastinal teratoma in child

Introduction

Mediastinal teratomas are rare in children. Nevertheless, they represent the most frequent mediastinal germ cell tumor. Most often, they are discovered incidentally in older children or adolescents on chest X-ray. There are other signs of discovery but less frequent: chest pain, hemoptysis and signs of mediastinal compression. Rupture into pleural space, pericardium or tracheobronchial tree are exceptional.

Case presentation

We report the case of 7-years old girl admitted for chest pain. The chest x-ray showed a mediastinal mass with calcifications and pleural effusion. Chest CT scan revealed a well limited heterogeneous anterior mediastinal mass with calcifications and a left pleural effusion. She underwent a median sternotomy and the tumor was completely excised. Histopathology confirmed the diagnosis of mature teratoma.

Conclusion

Intrapleural rupture is a rare complication of mature teratoma. Calcifications on chest imaging in afebrile children with pleural effusion should be suspected of mediastinal teratoma.

Spectrum of Germ Cell Tumor (GCT): 5 Years' Experience in a Tertiary Care Center and Utility of OCT4 as a Diagnostic Adjunct

Germ cell tumors (GCT) are an intriguing group of neoplasm having myriad clinical and morphological presentation. More and more transcription factors are being evaluated for identification of same. To study the spectrum of GCTs in a tertiary care center and the use of a stem cell marker OCT4 as a diagnostic adjunct, a retrospective 5-year (2008-2013) study was carried out. Immunohistochemistry (IHC) with OCT4 was performed on all cases and IHC for α feto protein (AFP), CD30, and epithelial membrane antigen (EMA) as per requirement. Cohort included 73 cases (23 males and 50 females). Testicular and ovarian GCTs accounted for 95.83% and 35.71% respectively. In males, seminoma was the commonest (34.78%) followed by mixed GCT (26%). 17.85% of ovarian GCTs were malignant mostly constituted by dysgerminoma (18%). Benign mature cystic teratoma (MCT) constituted 50% of ovarian GCTs. OCT4 immunoexpression was seen in all cases of seminoma/dysgerminoma, embryonal carcinoma, immature teratoma, and seminomatous/embryomatous component of mixed GCTs. Pure yolk sac tumor (YST) and MCT were consistently negative. OCT4 was especially helpful in identification of mixed GCT. A panel of immunohistochemical markers would be a more ideal way to identify and clarify the components because correct identification of the components is important for therapeutic intervention and prognostication. OCT4 being a primordial germ cell marker predicts aggressive behavior and targeted therapy against this should be investigated.

[Gastric metastases with a choriocarcinoma component from a postpuberal teratoma with mature histology]

Germ cell tumors are the most frequent neoplasia in young males. The aims of this study is to describe a case in which a postpuberal teratoma suffers a transformation to choriocarcinoma and metastasize to stomach. We have made a systematic review in PubMed and consensus documents to study this mismatch between the tumour, metastasis and the exception of gastric metastatic affectation. We describe three options to explain this discordance: a mixed germ cells tumour, a burned out tumour or a germ cells tumour derived from a malignant germ cell tumour precursor or different clonal strains. After made a thorough investigation we conclude that the most truly option is the last one as we extensive explain below. Once the gastric metastatic lesions are extremely rare and reach to <5%, but there are not conclusive assessments.

Management of malignant struma ovarii: is aggressive therapy justified? Case report and literature review

Background

Struma ovarii (SO) is a rare ovarian teratoma containing predominantly thyroid tissue. In rare situations SO may develop malignancy. Most cases of malignant struma ovarii (MSO) are diagnosed after surgical removal, based on histopathological examination. There are still controversies regarding the extent of surgery and postoperative management in MSO, due to its unpredictable behavior, possible risk of metastasis and relatively high rate of recurrence.

Case Presentation

We present the case of a patient diagnosed with a right ovarian cyst discovered incidentally during routine ultrasound examination. Its rapid growth and pelvic MRI raised the suspicion of a neoplastic process. She underwent total hysterectomy and bilateral adnexectomy. The anatomopathological diagnosis was MSO with follicular variant of papillary thyroid carcinoma. Prophylactic total thyroidectomy was performed, followed by radioactive iodine ablation (RAI), and suppressive therapy with levothyroxine. At 1 year follow-up, the patient was disease free.

Conclusions

Even if latest literature reports consider that completion of local surgery with total thyroidectomy and RAI might be too aggressive in cases of MSO without extraovarian extension, in our case it was decided to follow the protocol for primary thyroid carcinoma, in order to reduce the recurrence risk.

What Is Different about Teratoma-Associated Anti-LGI1 Encephalitis? A Long-Term Clinical and Neuroimaging Case Series

INTRODUCTION

Anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis is clinically heterogeneous, especially at presentation, and though it is sometimes found in association with tumor, this is by no means the rule.

METHODS

Clinical data for 10 patients with anti-LGI1 encephalitis were collected including one case with teratoma and nine cases without and compared for clinical characteristics. Microscopic pathological examination and immunohistochemical assay of the LGI1 antibody were performed on teratoma tissue obtained by laparoscopic oophorocystectomy.

RESULTS

In our teratoma-associated anti-LGI1 encephalitis case, teratoma pathology was characterized by mostly thyroid tissue and immunohistochemical assay confirmed positive nuclear staining of LGI1 in some tumor cells. The anti-LGl1 patient with teratoma was similar to the non-teratoma cases in many ways: age at onset (average 47.3 in non-teratoma cases); percent presenting with rapidly progressive dementia (67% of non-teratoma cases) and psychiatric symptoms (33%); hyponatremia (78%); normal cerebrospinal fluid results except for positive LGI1 antibody (78%); bilateral hippocampal hyperintensity on magnetic resonance imaging (44%); diffuse slow waves on electroencephalography (33%); good response to immunotherapy (67%); and mild residual cognitive deficit (22%). Her chronic anxiety and presentation with status epilepticus were the biggest differences compared with the non-teratoma cases.

CONCLUSION

In our series, anti-LGI1 encephalitis included common clinical features in our series: rapidly progressive dementia, faciobrachial dystonic seizures, behavioral disorders, hyponatremia, hippocampal hyperintensity on magnetic resonance imaging, and residual cognitive deficit. We observed some differences (chronic anxiety and status epilepticus) in our case with teratoma, but a larger accumulation of cases is needed to improve our knowledge base.

Caffeic acid selectively eliminates teratogenic human-induced pluripotent stem cells via apoptotic cell death

BACKGROUND

Induced pluripotent stem cells (iPSCs) generated from reprogrammed adult somatic cells are considered as a promising cell source in cell-based regenerative medicine. To avoid teratoma formation, which is a safety issue in iPSC-based cell therapy, it is important to selectively remove undifferentiated iPSCs that remain in the differentiated cell product before in vivo transplantation. Caffeic acid (CAA, 3,4-dihydroxy-cinnamic acid) is a phenolic compound synthesized from various vegetables, fruits, and herbs; it has shown various pharmacological activities against inflammation, cancer, infection, diabetes, and neurodegenerative diseases. However, the beneficial effects of CAA in iPSC-based cell therapy, such as the selective elimination of iPSCs and anti-teratoma effects, have not yet been explored.

RESULTS

Here, we found that CAA induced apoptotic cell death in iPSCs; this process did not occur in iPSC-derived mesenchymal progenitor cells (MPCs) or human dermal fibroblast (hDFs). Under co-culture conditions with MPCs and hDFs, CAA treatment selectively removed iPSCs. In addition, CAA treatment in mixed cell culture with iPSCs and MPCs prior to grafting markedly suppressed iPSC-derived teratoma formation. Finally, CAA did not induce DNA damage in MPCs or hDFs.

CONCLUSION

Taken together, these results suggest that CAA is effective in preparing safe iPSC-based therapeutic cells without the risk of teratoma formation and DNA damage in normal cells and iPSC-derived differentiated cells.

Addressing the diagnostic and therapeutic dilemmas of ovarian immature teratoma: Report from a clinicopathologic consensus conference

Ovarian immature teratoma is a rare subtype of germ cell tumour that can be pure or associated with non-teratomatous germ cell tumour elements and is graded based on extent of the immature neuroectodermal component. Immature teratoma (IT) can also be associated with somatic differentiation in the form of sarcoma, carcinoma, or extensive immature neuroectodermal elements and may produce low levels of serum alpha-fetoprotein. Variable interpretation of these issues underlies diagnostic and management dilemmas, resulting in substantial practice differences between paediatric and adult women with IT. The Malignant Germ Cell International Consortium (MaGIC) convened oncologists, surgeons, and pathologists to address the following crucial clinicopathologic issues related to IT: (1) grading of IT, (2) definition and significance of 'microscopic' yolk sac tumour, (3) transformation to a somatic malignancy, and (4) interpretation of serum tumour biomarkers. This review highlights the discussion, conclusions, and suggested next steps from this clinicopathologic conference.

Evaluating the incidence and predictors of anti-NMDAR encephalitis in a contemporary cohort of patients diagnosed with dermoid tumors: A national inpatient sample analysis

INTRODUCTION

Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a form of encephalitis previously associated with dermoid tumors. However, most studies in the literature evaluating the disease are case reports and small patient cohorts, limiting robust statistical analysis. Here, we demonstrate predictors of anti-NMDAR encephalitis in a large cohort of US patients.

METHODS

We used the 2016 National Inpatient Sample (NIS) to identify a cohort of 24,270 admitted for an ovarian dermoid tumor. Of these patients, 50 (0.21%) were diagnosed with anti-NMDAR encephalitis. Patient demographics, hospital characteristics, length of stay (LOS), and complications were collected. Statistical analysis consisted of odds ratios with chi-square testing to compare categorical variables.

RESULTS

The mean age of all patients with dermoid tumors was 45.5 ± 18.0 years, and the mean age of patients with diagnosed anti-NMDAR encephalitis was 27.4 ± 4.9 years. The mean LOS in the dermoid tumor cohort was 3.5 ± 4.9 days, while the mean LOS in the anti-NMDAR encephalitis cohort was 31.9 ± 25.9 days (p < 0.001). The mean cost in the dermoid tumor cohort was $44,813.18±$54,305.90, while the mean cost in the anti-NMDAR encephalitis cohort was $445,628.60±$665,423.40 (p < 0.001). Patients with age above 30 years with dermoid tumors had significantly lower odds of developing anti-NMDAR encephalitis compared to patients younger than 30 years (OR: 0.19; 95%CI: 0.045-0.67; p-value: 0.003). White patients had significantly lower odds of developing anti-NMDAR encephalitis (OR: 0.19; 95%CI: 0.026-0.77; p-value: 0.013), and Black patients had significantly higher odds of developing anti-NMDAR encephalitis (OR: 3.45; 95%CI: 1.00-12.46; p-value: 0.044).

CONCLUSION

Patient predictors of developing anti-NMDAR encephalitis include age, race, ethnicity and patients who go on to develop anti-NMDAR encephalitis have a significantly increased hospital LOS and cost compared to those who do not. Future research, including multi-center clinical trials and longitudinal data, is necessary to fully cement the findings of this manuscript.

Pineal region teratoma with metastases in uncommon locations: a case report

Background

We report a rare case in medical literature of a patient with pineal gland teratoma and uncommon metastases. Usually, metastases of this kind of tumor are located in several organs such as lung and breast, but here we found metastases to the spinal cord and vertebrae.

Case presentation

A 35-year-old Asian white man presented with diplopia and acute neural symptoms in the lower limbs such as numbness, tingling, and paralysis. His medical history was notable for pineal teratoma, treated 1 year previously with surgery, radiotherapy, and chemotherapy. Physical examination of the lower limbs showed absent reflexes and sensation with muscle power scale score of 1 in both limbs. Magnetic resonance imaging of brain and spine revealed many lesions in various locations, most compatible with neural, spinal, and vertebral metastases. Unfortunately, the patient died suddenly before any intervention was carried out.

Conclusion

It is extremely rare for pineal region teratoma to metastasize to the spinal cord and vertebrae, thus more vigilant observation and examination should be provided to patients with pineal teratoma to detect any new lesions and prevent them from becoming dangerous.

Anti-N-methyl-D-aspartate receptor encephalitis: characteristics and rapid diagnostic approach in the emergency department

Background

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a common type of autoimmune encephalitis. Patients with this condition are frequently very ill but are often misdiagnosed in the Emergency Department (ED). The objective of this study was to analyze the clinical characteristics of anti-NMDAR patients in the ED and to identify any associations with a diagnosis of anti-NMDAR encephalitis.

Methods

We performed a retrospective analysis of a prospectively obtained cohort of ED patients from May 2011 to December 2017. We identified patients diagnosed with anti-NMDAR encephalitis in this cohort and extracted key patient characteristics and clinical data, including patient gender, age, presentation, modified Rank Score (m-RS), laboratory test results, significant treatments, and mortality.

Results

Eighty-seven patients with anti-NMDAR encephalitis were identified. 54 (62.1%) were female, 23 (26.4%) were < 18 years old, 14 (16.1%) had teratoma, and 45 (51.7%) had an m-RS ≥ 4. Fever, altered mental status, and seizures were the most common symptoms, with a > 50% incidence of each symptom in the cohort. The sensitivity of CSF oligoclonal band (OB) testing was 78.9%. 22 (25.3%) were admitted to the ICU, 20 (23.0%) patients were intubated, but only one patient died (1.1%). 47 (54.0%) were misdiagnosed prior to ED arrival. All patients underwent immunotherapy as first-line treatment for anti-NMDAR encephalitis.

Conclusions

A majority of anti-NMDAR encephalitis patients presenting to the ED were female and were likely to be misdiagnosed prior to arrival. Patients with symptoms of fever, altered mental status, and seizures need a lumbar puncture, including CSF OB testing, for definitive diagnosis.

Struma ovarii: A case report and review the literature

INTRODUCTION AND IMPORTANCE

Struma ovarii is a monodermal teratoma which characterized by the presence of thyroid tissue. The symptoms of this tumor are nonspecific and thus misdiagnosis and indifference to other ovarian lesions are very common.

CASE PRESENTATION

Herein, we described a case of struma ovarii that was successfully diagnosed and managed. The tumor is mimicking a malignant tumor based on ascites and tumor marker assessments. Although, thyroid function indices are normal.

CLINICAL DISCUSSION

The initial footprint of the tumor is mostly based on incidental imaging, but definitive diagnosis is possible based on pathological studies. Surgical resection of the tumor can be led to successful treatment and prognosis.

CONCLUSION

Struma ovarii is a rare tumor and also misdiagnosis is common. Regarding rarity of Struma Ovarii, the treatment option is debated. However, in postmenopausal cases with the aim of completely removing the symptoms, total abdominal hysterectomy with bilateral salpingo-oophorectomy can be occasionally indicative.

Germ cell tumors with neuroglial differentiation do not show molecular features akin to their central nervous system counterpart: experience from extra-gynecological sites

Teratomas with secondary somatic malignancy showing neuroglial differentiation (central nervous system (CNS)-type tumors) arising from a glial or neuroepithelial component is a very uncommon event and primarily described in the ovary. We aimed to describe the morphological spectrum and molecular features of CNS type of neuroepithelial tumors arising from the germ cell tumors (GCT) in the extra-gynecological sites. All cases of teratoma and mixed GCT arising from the non-gynecological sites over 7 years were screened for CNS type of neuroepithelial tumors. Detailed histological and immunohistochemical analysis was performed. IDH1 and 2 sequencings were performed in the glial tumors. Fluorescent in situ hybridization (FISH) was performed for EWSR1 rearrangement, 19/19q co-deletion, CDKN2A homozygous deletion, EGFR amplification, and C19MC amplification, wherever required. Out of 302 GCTs examined, the neuroglial tumor was detected in 15 cases. It included nine cases of glial tumors (including one pilocytic astrocytoma (grade I), two diffuse astrocytomas (grade II), one oligodendroglioma (grade II), one gemistocytic astrocytoma (grade II), three anaplastic astrocytomas (grade III), and one case of glioblastoma (grade IV)) and six cases of the embryonal tumor with multilayered rosettes (ETMR). None of the gliomas showed IDH mutation by immunohistochemistry or sequencing. The ETMR cases did not show Lin28 expression or C19MC amplification. To conclude, the spectrum of neuroglial tumors arising from teratoma in the extragonadal sites is vast and most commonly includes glial neoplasms and embryonal tumors. Our findings indicate that the genotype and pathogenesis of tumors with neuroglial differentiation in teratoma are distinct from their CNS counterpart.