Teratomas of the neck and mediastinum in children

Diagnosis and Management of Fetal Cervical Masses

N/A.

Clinical Features and Survival Outcomes in Children and Adolescents With Malignant Mediastinal Germ Cell Tumors Based on Surveillance, Epidemiology, and End Results Database Analysis

INTRODUCTION

The purpose of this study was to perform a population-based investigation to assess the disease characteristics and prognosis of children and adolescents with malignant mediastinal germ cell tumors (MMGCT).

METHODS

Data on the demographics, treatment, and survival outcomes of children and adolescents with MMGCT from January 1, 2000 to December 31, 2018 were obtained. To compare survival curves, the log-rank test was employed. The generation of survival curves based on different parameters was done using Kaplan-Meier estimations. Cox proportional hazards regression was performed to determine the variables linked to disease-specific survival.

RESULTS

The selection criteria were met by 152 MMGCT patients, 130 of whom were male. Fifty three cases of mixed germ cell tumors (GCTs), 41 cases of malignant teratomas, 26 cases of yolk sac tumors, 14 cases of seminoma, 13 cases of choriocarcinomas, and five cases of embryonal carcinoma were reported. Overall survival at 3 and 5 y for all patients was 63.1% and 61.2%, respectively. Malignant teratoma, yolk sac tumors, and mixed GCTs in children and adolescents had comparable survival rates, while those with choriocarcinoma and embryonal carcinoma showed the worst prognosis. Embryonal carcinoma, malignant teratoma, mixed GCTs, and choriocarcinoma were found as risk factors by multivariate Cox proportional hazards analysis. In contrast, surgery and younger age were protective factors. However, chemotherapy alone showed no survival benefits.

CONCLUSIONS

Our population-based evidence showed that MMGCT had worse prognosis in older children and adolescents. Choriocarcinomas and embryonal carcinomas had the worst prognosis. Surgery can prolong survival time. Chemotherapy and radiotherapy were not associated with improved prognosis.

Thyroid teratoma in a newborn

A newborn girl presenting with respiratory distress soon after birth was found to have a neck mass and required transfer to a paediatric intensive care unit with neonatal expertise. She subsequently underwent endoscopic airway assessment with microlaryngoscopy and bronchoscopy proceeding to open excision of the lesion in the right thyroid lobe on day thirteen of life, resulting in resolution of airway compromise and complete pathological clearance. The baby was discharged 10 days after surgery. Histology confirmed a thyroid teratoma. At 12 months, the child was thriving with no evidence of recurrence. This case illustrates a rare but serious diagnosis that, if not managed in a timely manner, can lead to significant morbidity and mortality.

Ex utero intrapartum technique (EXIT): Indications, procedure methods and materno-fetal complications - A literature review

A congenital malformation of the head, neck or thorax can lead to upper airway compression with a risk of asphyxia or neonatal death. To secure and protect the upper airway, the Ex Utero Intrapartum Therapy (EXIT) procedure has been developed. The procedure allows delivery of the fetus via a hysterotomy while relying on the placenta as the organ of respiration for the fetus prior to clamping of the umbilical cord. A high level of expertise is necessary for successful completion of the EXIT procedure, which is not void of maternal and fetal risks. In this literature review, we present the indications, procedure methods and materno-fetal complications associated with the EXIT procedure.

EXIT-to-airway: Fundamentals, prenatal work-up, and technical aspects

Ex-utero intrapartum treatment (EXIT) is a delivery strategy developed to manage a variety of prenatally diagnosed conditions in the transition to newborn life. This procedure allows control and provides time for intervention in otherwise life-threatening malformations, such as congenital upper airway obstructions. EXIT-to-airway has changed the outcome of fetuses with these anomalies. The main purpose of this intervention is to improve the safety of establishing a reliable airway at birth. Maximal but controlled uterine relaxation to maintain feto-maternal perfusion and thus gas exchange, while keeping the fetal and maternal well-being are the paradigms of any type of EXIT. The most important aspect of fetal airway management is to consolidate a highly trained, well-coordinated, multidisciplinary team that is prepared for every contingency. A comprehensive prenatal assessment, including ultrasound, fetal echocardiogram, fetal MRI, and genetic testing is imperative for patient selection. Extensive preoperative planning, ad-hoc team meetings, and surgical simulations for challenging cases are critical strategies to achieve the best outcomes. This article outlines the prenatal work-up, decision making, technical aspects, and principles for a successful EXIT-to-airway procedure.

A SEER database study of malignant teratomas in the head and neck region

OBJECTIVE

To review tumor and patient characteristics as well as survival of pediatric head and neck malignant teratomas (HNMT) in comparison to the adult population.

DESIGN

This investigation was a retrospective cohort study. The Surveillance, Epidemiology, and End Results (SEER) database (SEER-18 Regs Custom registry, November 2018) was reviewed for all cases of head and neck malignant teratomas from 1975 to 2016. A log rank test was used to compare survival between infant, pediatric, and adult HNMT, and between head and neck and non-head and neck malignant teratomas. Infant, pediatric, and adult patients were defined as younger than one year old, younger than 18 years old, and older than 18 years old, respectively.

RESULTS

Sixty-three malignant teratoma cases (1.96%) occurred in the head and neck region from 1975 to 2016, including 11 adult (17.46%) and 52 (82.54%) pediatric patients. 79.37% (50 patients) were diagnosed during infancy. The most common location was the soft tissue of the head and neck in pediatric patients (65.38%) and the thyroid gland in adults (54.54%). The 5-year survival was 45.83% (±7.19%) in infants and 46.00% (±7.05%) in pediatric patients. There were differences in 1-year and 5-year survival between pediatric HNMT and non-head and neck malignant teratomas, (76.01% versus 86.20%) (p = 0.022) and (46.00% versus 67.10%) (p < 0.001), respectively. There was no difference in 1-year and 5-year survival between pediatric patients and adults with HNMT, (76.01% versus 81.81%) (p = 0.618) and (46.00% versus 54.54%) (p = 0.560), respectively.

CONCLUSION

HNMT occurred most frequently in patients under the age of 1. Prognosis of pediatric HNMT is poor in comparison to pediatric non-head and neck malignant teratomas. Repeat studies after accumulating more patients in the database would be beneficial to confirm our findings.

Cesarean Section Is Associated with an Increased Risk of Acute Lymphoblastic Leukemia and Hepatoblastoma in Children from Minnesota

BACKGROUND

In recent decades, Cesarean section (C-section) rates have increased. C-section is hypothesized to negatively impact the developing immune system by altering activation of the hypothalamic-pituitary-adrenal axis and the infant microbiome, among other mechanisms, thereby potentially modulating childhood cancer risk.

METHODS

Using linked birth and cancer registry data from Minnesota (1976-2014), we included individuals ages 0-14 at diagnosis with one of 19 cancers. Cases and controls were frequency matched by birth year. We used logistic regression to estimate ORs and 95% confidence intervals (95% CI) as the measure of association between C-section and cancer. We assessed sex-C-section interactions for each cancer and conducted stratified analyses in acute lymphoblastic leukemia (ALL) for birth year, age at diagnosis, and maternal race.

RESULTS

There were 3,166 cases and 20,589 controls. One third (n = 1,174) of controls born during 2004-2014 were delivered via C-section compared with 42.2% of cases (n = 285). C-section was associated with ALL (n = 819; OR: 1.20; 95% CI: 1.01-1.43) and hepatoblastoma (n = 50; OR: 1.89; 95% CI: 1.03-3.48), particularly among females (ALL OR: 1.34; 95% CI: 1.04-1.72; hepatoblastoma OR: 3.87; 95% CI: 1.30-11.57). The risk of ALL was highest during 2005-2014 (OR: 1.62; 95% CI: 1.11-2.34) and among children ages 1-5 years (OR: 1.28; 95% CI: 1.02-1.61).

CONCLUSIONS

C-section was associated with an increased risk of ALL and hepatoblastoma.

IMPACT

These associations require investigation to determine causality and rule out confounding by indication or reverse causality. The mechanisms underlying these associations may depend on neonatal immune system processes altered during C-section deliveries.

Fetal head and neck tumors

Imaging plays a leading role in detection and diagnosis of fetal head and neck lesions. These lesions comprise a heterogeneous group of congenital tumors and malformations. Complementary imaging modalities that can be used in prenatal medicine are ultrasound and MRI. The authors discuss imaging characteristics of fetal lesions, assessment of potential complications and pregnancy management options for the most common pathology of the fetal head and neck.

Superior Vena Cava Syndrome and Hypoxic Ischemic Encephalopathy Secondary to a Massive, Right-Sided Immature Cervical Teratoma

Cervical teratomas are a rare form of fetal teratoma that can grow to massive size. Generally, these masses can be surgically excised after birth with excellent physical and functional prognosis because the benign variants respect anatomical borders. The primary complications of these masses are associated with compromise of the trachea and esophagus: upper airway obstruction and polyhydramnios. We report the first documented occurrence of superior vena cava syndrome and hypoxic ischemic encephalopathy associated with a massive, right-sided cervical teratoma. This case highlights that when cervical teratomas are right-sided and sufficiently large, they can extend inferiorly and compromise central venous return to the heart. This unique presentation would likely have required fetal surgical excision to avoid catastrophic cerebral injury.

Management and Long-term Outcomes of Giant Mediastinal Germ Cell Tumors in Children

Purpose: The purpose of the study is to evaluate the outcome of children with giant mediastinal germ cell tumors (GCTs). Materials and Methods: A retrospective study of children diagnosed with GCTs treated at our hospital from 1998 to 2014 was performed. They were evaluated for their tumor size, malignancy, treatment, complications, and outcome. Results: Twelve giant mediastinal GCT patients were included in the study. Age ranged from 7 to 144 months (median 12 months) and all except one were males. The average tumor size was 10.4 cm (range 6 cm × 5 cm–16 cm × 13 cm) and in four patients, they were large enough to occupy nearly the entire hemithorax. Nine children had benign tumors, and these were resected upfront. The remaining three cases with malignant disease received neoadjuvant chemotherapy. No significant reduction in size was noticed in these patients, but alpha-fetoprotein levels decreased in all the three, and they were later resected. Eight (67%) were resected through posterolateral thoracotomy and 4 (33%) through median sternotomy approach. One patient had a dumbbell-shaped thoracoabdominal tumor extending through a Bochdalek hernia. He required additional laparotomy as well as diaphragmatic repair. There were no postoperative complications. The malignant GCTs received total four courses of PEB. All patients were alive and asymptomatic at a mean follow-up of 55.4 months (range 10–146 months). Conclusions: Mediastinal GCTs have bimodal age distribution and show male preponderance. Malignant mediastinal GCTs responded well to neoadjuvant chemotherapy through a reduction in size was not noticed. Complete excision often in coordination with cardiothoracic-vascular surgeons can lead to long-term symptom-free survival even in giant tumors.

Management of fetal tumors

In this review article, we discuss the most common fetal tumors, their prenatal management, and outcomes. Overall, the most important outcome predictors are tumor histology, size, vascularity, and location. Very large lesions, lesions causing cardiac failure, and hydrops and lesions obstructing the fetal airway have the poorest outcome, as they may cause fetal death or complications at the time of delivery. Fetal therapy has been developed to improve outcomes for the most severe cases and can consist of transplacental therapy (sirolimus for rhabdomyomas or steroids for hemangiomas and microcystic lung lesions) or surgical intervention (shunting of cystic masses, tumor ablation, occlusion of blood flow or airway exploration, and protection). Given the rarity of fetal tumors, patients should be referred to expert centers where care can be optimized and individualized to allow the best possible outcomes.

Emergency Imaging of the Nontraumatic Pediatric Head and Neck

Pediatric patients present emergently with a wide variety of infectious, inflammatory, congenital, traumatic, and neoplastic conditions. Imaging plays a crucial role in distinguishing among the potential diagnoses, as often, history and physical exam is limited in these young sick patients. Understanding the imaging appearance of the range of conditions which are commonly encountered and their potential complications, facilitates appropriate and expedient management. The radiologist must recognize the benefits of the various imaging modalities available and help the clinician choose among the possibilities depending on the clinical status of the patient.

Pediatric Surgery remains the only true General Surgery

This article states that Pediatric Surgery remains probably the only remaining General Surgery because it is not about organs and systems but rather the whole Surgery from fetal life until completion of growth and maturation. Pediatric surgeons are currently involved in prenatal treatments for fetal diseases, they take in charge the surgery of congenital malformations, acquired neonatal diseases, common conditions like hernias, undescended testes and appendicitis, but also of the more complex gastrointestinal, broncho-pulmonary or genitourinary conditions, tumors, trauma and solid organ transplantation. For this, like other surgical specialists, they use open, endoscopic and minimally invasive techniques. The broad spectrum of diseases, many of them scarcely prevalent, makes training long and hard, but this challenge accounts for the greatness of this specialty. Pediatric surgeons also carry out research work in their field because they are aware that understanding of why the conditions treated by them occur is mandatory. In summary, Pediatric Surgery is a lively, exciting, difficult specialty that offers an attractive alternative to young doctors interested in surgery.

Mediastinal teratoma in a neonate with acute respiratory failure

Background: While teratomas account for the leading cause of germ cell tumors, the mediastinal teratomas represent one of the infrequent types of congenital germ cell tumors. Neonates with large mediastinal teratomas generally show severe respiratory distress, and the immediate surgical treatment is needed to alleviate their problems.

Objectives: Report clinical symptoms, diagnostic procedures, treatment option, and outcomes after the treatment for a neonate with a large mediastinal teratoma.

Methods: A 2-day-old female infant presented with acute respiratory failure diagnosed as mediastinal teratoma. It was followed with surgical treatment. The removed tissues were examined pathologically.

Results: The girl suffered an acute respiratory failure two days after birth. The chest radiography, echocardiography, and chest computerized tomography results showed the considerable size of the mediastinal teratoma. A median sternotomy was performed on the third day of infant life to remove the tumor without rupturing the capsule. Pathological diagnosis was germ cell tumor. Clinical follow-ups reported no complication.

Conclusion: The successful management of a neonate with large mediastinal teratomas was presented. Immediate detection and proper treatment of the large mediastinal teratoma in a neonate was most important to decrease the morbidity and mortality of the infant.

Long-term outcomes of pediatric and adolescent mediastinal germ cell tumors: a single pediatric oncology institutional experience

PURPOSE

To evaluate the epidemiologic, demographic, and clinical characteristics, as well as prognostic factors and long-term outcomes of mediastinal germ cell tumors (MGCT) in children.

PATIENTS AND METHODS

A retrospective study of pediatric patients diagnosed with a primary MGCT between January 1963 and August of 2014 was performed.

RESULTS

Twenty-five patients were identified. Six children with teratomas were treated with resection alone (median age 7.8 years, range newborn to 15 years) and were cured without recurrence or progression. Nineteen children were treated for a malignant MGCT (median age 11.7 years, range 7 months-18 years); 5 year overall survival (OS) was 0.39 ± 0.12. For malignant non-seminomatous mediastinal germ cell tumors, platinum-based chemotherapy regimen (OS 0.56 vs 0.14, p = 0.03), complete surgical resection with negative margins (OS 0.73 vs 0.11, p = 0.03); and localized disease (OS 0.76 vs 0.0, p = 0.004) demonstrated a survival advantage.

CONCLUSIONS

Initial surgical resection is appropriate for teratomas. Localized disease, complete resection, and platinum-based chemotherapy are associated with improved survival in malignant non-seminomatous mediastinal germ cell tumors. Neoadjuvant, platinum-based three drug regimens followed by delayed surgical resection is the appropriate treatment modality for malignant mediastinal germ cell tumors.

Prenatally diagnosed fetal tumors of the head and neck: a systematic review with antenatal and postnatal outcomes over the past 20 years

AIM

The aim of this study was to review prenatally diagnosed tumors of the head and neck in the fetus and to report antenatal and postnatal outcomes.

METHODS

PubMed/Medline, EMBASE/SCOPUS, Cochrane database and Google Scholar were reviewed over the last 20 years. No language or article type restriction was used.

RESULTS

A total of 1940 record were retrieved. Of the 713 records screened, 566 full-text articles were assessed for eligibility. After 445 articles were excluded for specified reasons, 111 studies met the research criteria and were included for qualitative analysis. Overall, 306 cases of fetal tumors of the head and neck were reviewed. Maternal age was an independent factor. The mean maternal age was 28.2 years and gestational age at prenatal diagnosis was 27.1 weeks. Conventional 2D ultrasound was the standard diagnostic procedure in 27.9% of cases and was implemented in 27.3% of cases by 3D ultrasound and fetal magnetic resonance imaging (MRI). Diagnostic evaluation of intracranial spreading and high-airway obstructions was greatly enhanced by fetal MRI. The more common type of fetal tumor was hemangioma/lymphangioms (42.1%), followed by teratomas (29.7%), tumors of the gingiva (10.1%) and lymphatic venous malformations (9.1%), respectively. Fetal karyotyping was performed only in 9.8% of cases; within fetuses undergoing karyotype, chromosomal abnormalities accounted for 20% of cases. The most common pregnancy complication was polyhydramnios (26.3%). Ex utero intrapartum treatment (EXIT) procedure was performed in 30.1% of cases while surgical excision was used in 22.9% during postnatal life. The survival rate was 35.35%.

CONCLUSION

Fetal tumors of the head and neck are rare congenital malformations. Two-dimensional ultrasound is diagnostic in almost all cases; however, MRI may be an important diagnostic adjunct in targeted cases and help patient selection for immediate intubation at the time of delivery. EXIT procedure and surgical removal of the tumor was associated with good prognosis.

Cervico mediastinal teratoma in adult: A very rare presentation

Teratoma is a rare presentation in adult, specifically in cervico-mediastinal region. We reported two adult patients with diagnosis of cervico-mediastinal teratoma and operated them. In adult patients who present with cervico-mediastinal mass, benign teratoma could be one of a differential diagnosis although it is a rare presentation.

Ex-utero intrapartum treatment in the Indian scenario: Anesthetic challenges and positioning

Ex-utero intrapartum treatment (EXIT) is performed for fetuses diagnosed with large neck masses. A case report of a fetus diagnosed with a large cystic hygroma and cord around the neck who was delivered by EXIT is presented. The airway challenges and optimal positioning is discussed.

Bloody pericardial tamponade in a child treated for pneumonia mimicking a lung tumor and infiltration of the heart

We present the dramatic course of a female 5-year-old child with pneumonia and symptoms similar to local compression of the pericardium by a tumorous mass originating from the left lung. The child was treated with antibiotics for pneumonia with bilateral pleural effusions that required chest drainage. On the 10^th day of therapy there was sudden anemia observed with the echocardiographic finding of acute cardiac tamponade. The child was referred for emergency life-saving surgical intervention. The chest was opened via a minimally invasive mini-incision in the area of the xiphoid process and bloody tension pericardial effusion was evacuated. The laboratory and histopathology investigations were not specific for neoplastic disease or tuberculosis infection. In the further observation the girl recovered and was discharged home two weeks after tamponade drainage. Fortunately our initial suspicion of neoplastic disease was not proved; nevertheless we would like to emphasize the need for oncologic vigilance in similar cases.

Fetal and neonatal germ cell tumors

Germ cell tumors (GCTs) arise from the 'germline' - the primordial germ cells which are destined to become either the egg or the sperm. GCTs can be challenging to understand because their intrinsic pluripotency results in a wide spectrum of histologies and biologic behaviors. However, the histology of GCTs in the fetus and neonate is more restricted and the clinical spectrum more narrow than when these tumors occur later in life. GCTs in the fetus and neonate are predominately mature and immature teratomas, usually curable with surgery alone. And, given the efficacy of cisplatin-based regimens in GCTs, cure is likely even for those patients whose tumors contain the more malignant histologies, which in the neonate is usually yolk sac tumor. Recent advances in understanding the underlying aberrations in germline development continue to shed light on the genesis of these tumors and possible new avenues for treatment.

Stridor in asian infants: assessment and treatment

Stridor is the main symptom of upper airway obstruction in infants. It can be congenital or acquired, acute or chronic. Pathologies can be located from the nose down to the trachea. Common causes include laryngomalacia, vocal cord palsy, subglottic stenosis, tracheal anomaly, laryngeal cleft, vascular and lymphatic malformation, laryngeal papillomas, craniofacial abnormalities and even head and neck tumours. In this paper, we will discuss our approach to infants with stridor including assessment with flexible and rigid endoscopy and treatments to various conditions in a tertiary centre. Causes of stridor in infants undergoing rigid laryngotracheobronchoscopy in Queen Mary Hospital, University of Hong Kong Medical Centre between 2005 and 2011 will be retrospectively reviewed. Treatments according to various conditions will be discussed. Successful management of these neonates requires accurate diagnosis, early intervention, and multidisciplinary care by ENT surgeons, paediatricians, and paediatric anaesthetists.

Successful management of a large fetal mediastinal teratoma complicated by hydrops fetalis

This report describes a case of fetal mediastinal teratoma complicated by hydrops fetalis managed successfully by aspiration of the tumor cyst fluid. Fetal mediastinal teratomas are rare tumors that cause hydrops fetalis or fetal demise in the prenatal period and respiratory distress in the neonatal period. The patient presented with a large cystic mass in the thoracic cavity complicated by hydrops fetalis. The hydrops resolved after fetal aspiration of the tumor cyst fluid. The infant was born without respiratory distress, and tumor resection was performed at the age of 30 days. The postoperative course was uneventful, and the patient was in good health 6 months postoperatively.

Neonatal teratomas

Teratomas are composed of multiple tissues foreign to the organ or site in which they arise. Their origin is postulated by 3 theories one of which is the origin from totipotent primodial germ cells. Anatomically, teratomas are divided into gonadal or extragonadal lesions and histologically they are classified as mature or immature tumors. Teratomas are mainy isolated lesions and may occur anywhere in the body. In the neonatal age group most of these tumors are benign and occur mainly in the sacrococcygeal area followed by the anterior mediastinum. Diagnosis is usually established prenatally and may require intervention in compromised fetuses. Postnatal imaging with ultrasound, CT scan or MRI provides useful information for surgical intervention. Complete surgical excision is the treatment of choice for neonatal teratomas. Alpha feto protein is the tumor marker of choice and is particularly useful for assessing the presence of residual or recurrent disease.

Early resection and reconstruction of head and neck masses in infants with upper airway obstruction

OBJECTIVE

Congenital airway obstruction can be caused by tumors or lesions arising from the neck, tongue and oral cavity. Neonates may require prolonged intubation or tracheostomy before curative resection and reconstruction. The aim of the study was to carry out surgical resection and reconstruction with locoregional flap and free bone graft in the neonatal and early infantile period for definitive management of head and neck masses and treatment of potential airway obstruction.

METHODS

Newborns with obstructive head and neck masses in Queen Mary Hospital, University of Hong Kong Medical Centre between 2006 and 2009 were operated on in the neonatal period.

RESULTS

There were one obstructive neck teratoma, two intraoral teratomas and one neuroglial heterotopia. All tumors were resected within the first 3 months of life without major complication. A local cervical cutaneous flap was first used to reconstruct the lateral pharyngeal wall defect in a neonate with a huge neck teratoma, followed by another infant with a neuroglial heterotopia. A piece of cranial bone was used for reconstruction of the skull base defect. None of them required tracheostomy or prolonged intubation. Oral feeding was resumed in the early postoperative period.

CONCLUSION

Surgical resection and reconstruction with locoregional flap and bone graft can be performed safely in neonatal and early infantile period as management of head and neck masses and treatment of upper airway obstruction.

Selective pathologies of the head and neck in children: a developmental perspective

The range of pathology seen in the head and neck region is truly amazing and to a large extent probably mirrors the complex signaling pathways and careful orchestration of events that occurs between the primordial germ layers during the development of this region. As is true in general for the entire discipline of pediatric pathology, the head and neck pathology within this age group is as diverse and different as its adult counterpart. Cases that come across the pediatric head and neck surgical pathology bench are more heavily weighted toward developmental and congenital lesions such as branchial cleft anomalies, thyroglossal duct cysts, ectopias, heterotopias, choristomas, and primitive tumors. Many congenital "benign" lesions can cause significant morbidity and even mortality if they compress the airway or other vital structures. Exciting investigations into the molecular embryology of craniofacial development have begun to shed light on the pathogenesis of craniofacial developmental lesions and syndromes. Much more investigation is needed, however, to intertwine aberrations in the molecular ontogeny and development of the head and neck regions to the represented pathology. This review will integrate traditional morphologic embryology with some of the recent advances in the molecular pathways of head and neck development followed by a discussion of a variety of developmental lesions finishing with tumors presumed to be derived from pluripotent/progenitor cells and tumors that show anomalous or aborted development.

Germ cell tumors of the head and neck: report from the MAKEI Study Group

BACKGROUND

Germ cell tumors (GCTs) of the head and neck region are rare but may pose significant problems for perinatal management as well as surgical and adjuvant therapy.

PROCEDURE

Thirty-two prospectively reported patients from the German MAKEI studies (Maligne Keimzelltumoren) were analyzed with regard to perinatal management and long-term survival.

RESULTS

Twenty-three tumors were diagnosed around birth and four during the first 3 months of life. All were primarily diagnosed as teratomas, but in two tumors, yolk sac tumor (YST) foci were identified. Another pure teratoma was diagnosed at 12 months. Four tumors were diagnosed after the first year of life and showed YST as leading histology. Most neonates presented with huge tumors causing external airway obstruction. All tumors were resected (complete resection, 16/26 patients with complete surgical information; incomplete resection, 10/26 patients). Eight tumors including five of six YSTs were treated with chemotherapy. In total, six patients relapsed. Relapse rate was higher after incomplete (5/10 patients) than after complete resection (1/16 patients). Accordingly, more relapses were observed in pharyngeal than in neck tumors due to incomplete resection. Nevertheless, half of the patients with incomplete resection remained in remission. One patient with YST died after multiple relapses.

CONCLUSIONS

GCTs of the head and neck region require a multidisciplinary approach in specialized centers. Most patients with antenatal tumor growth are identified by ultrasound and delivered preterm by cesarian section. After delivery, immediate intubation and ventilation aim for respiratory stabilization, followed by elective resection. With this approach, outcome was favorable.

Accumulation of gallium-67 within mature and immature teratoma in pediatric patients: investigation for the uptake mechanism

OBJECTIVE

We encountered cases of mature and immature teratoma with positive uptake of (67)Ga. The objective of this study is to investigate the mechanism of (67)Ga accumulation within mature and immature teratomas by comparing the findings of gallium scan, computed tomography (CT), and autoradiography of surgical specimens with the pathological findings.

METHODS

The subjects comprised 14 children who underwent surgical resection for intra-abdominal mature and immature teratomas, which were histologically proved to be of the mature and immature subtype. Their age ranged from 24 days to 14 years. The origins of the mature teratomas consisted of seven ovaries including one bilateral case, two retroperitoneal, and two sacrococcygeal regions. The origins of the immature teratomas were retroperitoneum in two cases, an ovary and a sacrococcygeal region. Complete surgical excision was feasible in all children. They underwent both gallium scan and CT prior to surgery. Single-photon emission computed tomography was added in some cases. For two gallium-positive cases, radiography and scintigraphy (autoradiography) of the resected specimen were performed.

RESULTS

Of the 14 children, 5 (one with immature and four with mature subtype) showed positive (67)Ga uptake within tumors, which originated from the retroperitoneum in the 3 boys, and from the ovary in the 2 girls. All had typical CT findings of teratoma, including calcifications, fat components, cystic areas, and solid parts. (67)Ga accumulation in the four mature teratomas appeared discretely strong, and was considered to correspond with intralesional calcifications. However, in the remaining one immature teratoma, the gallium distribution was diffuse within the tumor. The comparison between radiography and autoradiography of the resected mature teratomas confirmed the correlation between the intralesional calcifications and areas of (67)Ga accumulation.

CONCLUSIONS

A high-uptake ratio of (67)Ga in benign teratoma was indicated. A close correlation between gallium scan and CT helps to ascertain whether (67)Ga uptake results from malignant and/or immature elements, or mature tissue components.

Spectrum and outcome of prenatally diagnosed fetal tumors

OBJECTIVE

To describe the spectrum of prenatally diagnosed fetal tumors, and the course and fetal outcome in affected pregnancies.

METHODS

This was a retrospective study in two German tertiary referral centers of 84 fetuses with tumors diagnosed in the prenatal period. The tumors were classified according to their location and histology.

RESULTS

The most common site of origin was the heart (20/84, 23.8%), followed by the face and neck region (19/84, 22.6%) and the abdomen (16/84, 19%). Lymphangiomas (21/84, 25%) and rhabdomyomas (19/84, 22.6%) comprised half of the tumor histology. Less frequently, teratomas (14/84, 16.6%) and hemangiomas (12/84, 14.2%) were seen. Complications included arrhythmia in cases with rhabdomyoma (8/19, 42%) and signs of heart failure in cases with hemangioma (4/12, 33%) and teratoma (4/14, 28.6%). The overall survival rate was 75%. Cases with either a histological diagnosis of teratoma or tumor located in the brain had the worst prognosis.

CONCLUSION

The combination of sonographic features and their location allows reliable prediction of the histological type in the vast majority of fetal tumors. Malignancy, associated malformations and aneuploidy are observed infrequently. Knowledge of the presence of a fetal tumor facilitates close surveillance by a specialized team, which might lead to early recognition of problems and improve perinatal outcome.

Management of a rare cause of neonatal airway obstruction: cervical teratoma

Cervical teratomas are rare tumors during the prenatal period. Cervical teratomas account for 1.5-5.5% of all pediatric teratomas. Both mortality and morbidity are significantly high because of airway obstruction due to a mass effect of the tumor although good results are achieved with total excision of the mass. Antenatal diagnosis by routine ultrasound (US) screening helps in preparing a team to provide airway support and surgery. We present two cases of cervical teratomas with total excision and cure and a postmortem study from our pathology laboratory. The third case, the female infant who died soon after birth, demonstrates the paramount importance of antenatal diagnosis.

Nasal septal teratoma in a child

Background

Teratoma is a rare developmental neoplasm that arises from totipotential tumor stem cells. Head and neck teratomas constitute about 10% of all cases. Only two cases of mature teratoma of the nasal septum have previously been documented in the world literature.

Case presentation

We present a case of histologically confirmed mature teratoma arising from the nasal septum in an eighteen month old Nigerian female who presented with a history of noisy breathing associated with recurrent rhinorrhea since birth. Physical examination revealed obstruction of the right nasal cavity by a pale fleshy mass. She underwent a total surgical excision and to date, after thirty one months follow-up, she is free from recurrence.

Conclusion

The prognosis for benign teratoma of the nasal septum is good following total surgical excision.