A Rare Presentation of the Syndrome of Inappropriate Antidiuretic Hormone in a 12-Year-Old Girl as the Initial Presentation of an Immature Ovarian Teratoma

Immature ovarian teratoma with gliomatosis peritonei, paraneoplastic hyponatremia and growing teratoma syndrome: a case report and literature review

Introduction and relevance

Paraneoplastic hyponatremia is often secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH) by tumour cells. Immature ovarian teratomas (IOT) are uncommon and may present with SIADH.

Case report

A 26-year-old female presented with a 3-month history of abdominal pain and constipation. Imaging identified a mixed solid-cystic right ovarian mass containing fat and peritoneal deposits. Biochemistry showed severe, refractory hyponatremia (117 mmol/l). She underwent diagnostic fertility-preserving right salpingo-oophorectomy and resection of peritoneal nodules with the aim to achieve symptom control and hyponatraemia resolution. Pathology revealed a FIGO Stage 2 Grade 2 IOT with extensive benign peritoneal gliomatosis. Initial management was conservative. After 6 months of active follow-up, a rise in AFP, and recurrent hyponatremia supported the decision to administer three cycles of Bleomycin-Etoposide-Cisplatin chemotherapy. One month later, given radiological disease progression despite satisfactory biomarker response, cytoreductive surgery with complete macroscopic resection was performed. Pathology consisted solely of peritoneal mature glial elements: a growing teratoma syndrome (GTS). The patient remains disease-free after 2 years of surveillance.

Clinical discussion

Specimen histological assessment from the patient's initial surgery showed immature neuroectodermal tubules, which are thought to be the source of vasopressin secretion. The authors hypothesise that recurrent hyponatremia and rising AFP levels represented postoperative disease relapse. Biochemical response despite radiological disease progression was pathognomonic of a GTS.

Conclusion

Paraneoplastic SIADH secondary to an IOT must be considered in female patients presenting with abdominal symptoms and hyponatremia. Management requires a multidisciplinary approach. Serum electrolytes are useful surveillance biomarkers supplementary to tumour markers.

Syndrome of inappropriate antidiuretic hormone secretion associated with an ovarian immature teratoma: A case report and review of the literature

•

SIADH can be associated with an ovarian immature teratoma.

•

Medical management of SIADH improved but did not resolve the hyponatremia.

•

Complete resolution of the hyponatremia was only obtained after surgical debulking.

Inappropriate Secretion of Antidiuretic Hormone after Pancreatoduodenectomy for Pancreatic Head Cancer: A Case Report and Literature Review

Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a disease that leads to dilute hyponatremia through excessive secretion of antidiuretic hormone. SIADH has various causes, including ectopic ADH-producing tumors, drug properties, and can be idiopathic. But there have been very few reports of cases in which SIADH has developed after surgery for malignant tumors. In addition, few cases have been reported where this disease has developed after surgery for pancreatic cancer, because the symptoms of hyponatremia are non-specific. These symptoms are particularly gastrointestinal symptoms; therefore, it is difficult to differentiate them, even if SIADH has developed after gastrointestinal surgery. The patient in our case was an 80-year-old woman. She had persistent epigastralgia and left back pain. Imaging studies revealed a tumor in the head of the pancreas, which was diagnosed as pancreatic head cancer. We performed subtotal stomach-preserving pancreatoduodenectomy. After the operation, she complained of appetite loss and general fatigue. Her serum sodium levels decreased to 109 mEq/L on postoperative day 11. She was diagnosed with SIADH using the SIADH diagnostic criteria listed by the Japanese Ministry of Health, Labor and Welfare. We treated the patient with sodium supplementation for hyponatremia, and her symptoms ameliorated. After the event, she did not relapse with hyponatremia. This case is significant in that we performed differential diagnosis after major gastrointestinal surgery for pancreatic cancer and diagnosed SIADH at an early stage.

Review of paraneoplastic syndromes in children

Paraneoplastic syndromes are defined as clinical syndromes that are not related to direct tumor invasion or compression but are secondary to tumor secretion of functional peptides/hormones or related to immune cross-reactivity with normal host tissue. Paraneoplastic syndromes have a wide range of presentations and can present before the primary malignancy or tumor recurrence is diagnosed. They can mimic non-neoplastic processes, making detection, diagnosis and treatment difficult. However, they can also provide clues to the presence of an underlying malignancy. In this paper, we reviewed a range of paraneoplastic syndromes that can occur in children including: (1) neurologic (opsoclonus-myoclonus, limbic, anti-N-methyl-d-aspartate [NMDA] and anti-Ma2 encephalitis and myasthenia gravis); (2) endocrine (neuroendocrine tumors, hypercalcemia, SIADH [syndrome of inappropriate antidiuretic hormone secretion], osteomalacia/rickets and ROHHAD [rapid onset of obesity, hypoventilation, hypothalamic dysfunction and autonomic dysregulation]); and (3) dermatologic/rheumatologic syndromes (hypertrophic osteoarthropathy and paraneoplastic pemphigus). Familiarity with these syndromes can aid in early diagnosis, treatment and imaging optimization.

Giant congenital right atrial epithelioid-capillary hemangioma with prolonged QT interval: Case report and practical surgical treatment strategy for primary cardiac tumors in children based on 25-year review of 299 cases

Cardiac hemangioma is very rare and accounts for 2%-3% of the primary cardiac tumors. Cardiac epitheloid-capillary hemangioma has not been reported in the pediatric population so far. We report the fatal outcome of a preterm neonate with a huge congenital right atrial epitheloid-capillary hemangioma and elevated serum alpha-fetoprotein, associated with prolonged QT interval. We describe the echocardiographic, computed tomographic (CT) imaging, microscopic and immunohistochemical features of the tumor. Complete resection of the tumor was done at operation necessitating extensive reconstruction of atrial walls. Intramural infiltration of this tumor into the surrounding myocardial walls is a challenging characteristic of cardiac hemangioma. The temptation to complete resection should be avoided in the setting of extensive intramural infiltration and entrapment of the tumoral cells into atrial walls, particularly in a preterm neonate. None of the current classifications for hemangioma was inclusive of our case. Based on a concise literature review of nine published classification systems from 1996 to 2017 , we discuss the shortcomings of the current classifications for hemangioma. We also performed a 25-year-review of 299 cases of primary cardiac tumors in neonates and children, from 1993 to May 2018. We suggest a stepwise surgical treatment strategy according to the characteristics of the patient and of the tumor, based on this review. The stepwise strategy includes watchful observation, partial resection, complete resection and cardiac transplantation.

Birth experience of fathers in the setting of teenage pregnancy: Are they prepared?

AIM

To explore the birth experiences of teenage fathers and determine the extent to which they are prepared for childbirth.

METHODS

A mixed methods observational study was undertaken comparing the birth experience of 50 fathers in the setting of teenage pregnancy (teenage) compared to a group of 50 older fathers. Fathers were recruited in the antenatal period and completed structured questionnaires following the birth of their child. Quantitative and qualitative analysis was undertaken.

RESULTS

Teenage fathers were younger, less educated and less likely to attend prenatal childbirth education classes (P < 0.0001). During birth, they were less prepared and consulted by attending staff (both P < 0.05). They reported limited roles in intrapartum decision-making (< 20%). In multivariate analysis being a father in the setting of teenage pregnancy remained significantly associated with feeling unprepared for birth. The major themes in qualitative analysis were feeling unprepared, shock, fear, a sense of detachment, happiness, pride, love of the baby and satisfaction with fertility.

CONCLUSION

Teenage fathers are less prepared for the birth of their child and this results in shock, fear and detachment that may impact on the early father-infant relationship.