The value of AFP in congenital cervical teratoma

A case report of a giant mature teratoma of the thyroid gland in a young girl

RATIONALE

Teratomas are extremely rare in the thyroid gland. A cervical teratoma presenting as a cystic or mixed thyroid lesion can be easily confused with a thyroglossal duct cyst. It is difficult for pediatricians to differentiate between these 2 types of lesions.

PATIENTS CONCERNS

A 2-year-old girl who presented a growing thyroid mass for 14 months showed a mass in her left thyroid lobe under contrast-enhanced computed tomography (CT).

DIAGNOSIS AND INTERVENTIONS

Ultrasonography found a mass of 5 × 3.5 cm within the left lobe of the thyroid gland, and the sonogram revealed areas with echo-free and mixed-echo patterns. There was no accumulation of technetium-99m pertechnetate on the thyroid scintigraphy (cold thyroid nodule). CT scan showed a mass (5.0 × 3.0 × 2.5 cm in size) that extended from the left thyroid lobe to the anterior mediastinum with no evident enhancement and clear margins that contained calcifications. Complete excision without intraoperative capsule disruption was achieved. Histologically, the thyroid mass was diagnosed as a mature teratoma.

OUTCOMES

The postoperative course was uneventful after follow-ups for 2 years, and the patient had no inflammatory signs or evidence of recurrence.

LESSONS

Thyroid teratoma is rare in infants and is usually benign; however, some thyroid teratomas are malignant and inclined to relapse. The authors emphasize that thyroid teratomas in children should be included in the differential diagnosis of cystic lesions located in the head and neck area. Complete resection is essential for good outcomes. In addition, long-term follow-ups are warranted to follow the complications of the malignant or recurrent disease.

Mature and immature pediatric head and neck teratomas: A 15-year review at a large tertiary center

INTRODUCTION

Pediatric head and neck teratomas account for less than 4% of congenital teratomas. The distinct presentations and outcomes of mature and immature head and neck teratomas have not been well established.

OBJECTIVES

To review the management and outcomes of pediatric head and neck teratomas. To distinguish differences between mature and immature tumors with respect to the age at presentation and surgery, tumor size and location, alpha fetoprotein (AFP) levels, airway management, and recurrence.

METHODS

A 15-year retrospective chart review of patients treated for head and neck teratomas at Texas Children's Hospital was performed. A total of 20 patients were included. Wilcoxon rank and Fisher's exact tests were used for statistical analysis.

RESULTS

Immature teratomas were associated with both higher AFP levels (80800 ng/ml, p = 0.02) and maximum tumor dimensions (14.4 cm, p = 0.0034) than mature teratomas (24400 ng/ml and 6.44 cm). Patients with immature tumors were younger at the time of surgical resection (19.8 days, p = 0.025) compared to those with mature tumors (348 days). 89% of immature teratomas involved anterior neck localization compared to 27% for mature teratomas (p = 0.0098); 88% of the immature teratomas required an EXIT (Ex Utero Intrapartum Treatment) procedure compared with 40% of the mature teratomas (p = 0.0656). Recurrence was noted in only two cases: an immature teratoma 51 months after incomplete resection and a mature teratoma 33 months after complete resection. Long-term consequences of surgical resection included cleft palate (38.9%), dysphagia (33.3%), facial nerve paresis/paralysis (16.7%) and tracheotomy (16.7%).

CONCLUSION

Immature teratomas had higher AFP levels, tumor dimensions, frequency of anterior neck localization, and requirement of EXIT than mature teratomas. Given that there was no significant difference between the recurrence rates of immature and mature teratomas, follow-up vigilance should be maintained equally regardless of tumor maturity.

Mucinous tumor arising in a giant sacrococcygeal teratoma: A rare case report

RATIONALE

Teratomas, which most frequently affect adult females, are the most common type of germ cell tumor, it always comprises derivatives of at least 2 germ layers. The most common site of primary teratomas is the ovary. Sacrococcygeal teratomas (SCTs), which are exceedingly rare in adults, are generally found in newborns or children.

PATIENT CONCERNS

A 39-year-old woman presented to our clinic with a 1-year history of gradually aggravated difficulty in micturition and defecation, and a tumor in her right buttock present since birth. Appropriate preoperative examinations showed a large (15.6 cm × 12.2 cm × 30.0 cm) multicystic SCT.

DIAGNOSES

Histologic examination confirmed a mucinous tumor arising in a giant SCT.

INTERVENTIONS

Abdominoperineal rectal resection was performed.

OUTCOMES

The patient recovered well and was discharged on day 33 of admission.

LESSONS

We report the first case of a mucinous tumor arising in an SCT, in which the teratoma presented mature tissue elements derived only from the endodermal germ layer (keratinous debris).

Head and neck teratomas in children--A series of 23 cases at Great Ormond Street Hospital

OBJECTIVE

Head and neck teratomas are rare and malignant change is rarer still. This is a report detailing all of the teratomas treated by the ear, nose and throat or craniofacial teams over the last 28 years at our institution. Examining the common presenting and radiological features as well as our success rates compared to the current literature.

METHOD

A retrospective review of all cases presenting to our institution with a head and neck teratoma were analysed. Data regarding the following characteristics were collected: antenatal history, clinical features, biological serum makers, radiological and pathological characteristics. Surgical treatment, rates of reoccurrence and the degree of post-operative follow up were also analysed.

RESULTS

23 cases in total were included: 8 cervical, 6 nasopharyngeal, 5 thyroid, 2 thymus, 2 temporal. One had malignant change. The majority of children presented at birth with respiratory distress, 5 cases were picked up antenatally and one case presented at 10 years of age. All were treated surgically; with complete excision in 20 patients. No clinical recurrence occurred but further surgery was performed for radiologically suspected residual disease in one case.

DISCUSSION

This is the largest detailed case series in literature in regard to head and neck teratomas. Illustrating that this is frequently a benign disease process disease in the head and neck region and has an excellent long term prognosis following surgery. In the situation of incomplete resection careful meticulous follow up with radiological imaging and a multidisciplinary team approach is a safe and viable alternative.

Treatment of a non-typical hepatic pseudolesion complicated by greatly elevated alpha fetoprotein: case report and literature review

Background

Hepatic pseudolesions detected by helical computed tomography (CT) are not rare, but it is difficult to make a final diagnosis when the hepatic lesion is complicated by the presence of greatly elevated alpha fetoprotein (AFP). Clinical treatment of non-typical hepatic pseudolesions complicated by greatly elevated AFP should confirm the diagnosis and minimize trauma.

Case presentation

Non-invasive procedures including ultrasonography, CT, and micro-invasive digital subtraction angiography could not safely differentiate this lesion from a malignant focus when it was complicated by greatly elevated AFP. Laparoscopic hepatectomy was performed, and pathological analysis showed chronic hepatitis, nodular regenerative hyperplasia, focal nodular hyperplasia of the liver, and mild vascular malformation. The tissue was HbsAg(−), HbcAg(−), and AFP(+).

Conclusion

Heightened awareness of hepatic pseudolesion complicated by primarily elevated AFP will help physicians avoid unnecessary invasive procedures. Hepatic biopsy is inevitable because of greatly elevated AFP. For suspected hepatic pseudolesion with elevated AFP, needle-core biopsy and follow-up surveillance instead of hepatectomy are recommended to find the source of AFP and make a final diagnosis of pseudolesion.

Perinatal airway management of neonatal cervical teratomas

Cervical teratomas are rare but life-threatening neonatal tumors and management of the fetus with a cervical teratoma that threatens the airway remains a clinical challenge. This has been revolutionized by advances in fetal imaging and management of the airway at delivery including the use of Ex-utero Intrapartum Treatments (EXIT procedures). We present a retrospective case series of three neonates managed over a 12-month period. Following pre-natal fetal MRI and a multi-disciplinary management approach, two newborns were managed by prompt post-natal endotracheal intubation while an EXIT procedure was required in one. All three underwent surgical resection in the first few days of life. A decision regarding the best means by which to manage the airway in fetal cervical teratoma requires fetal MRI and a multi-disciplinary team approach to determine whether EXIT, or a safer approach from a maternal perspective can be employed. We also recommend routine endotracheal intubation at birth, due to the risk of spontaneous intra-tumoral hemorrhage. The need for surgery should be planned early, as rapid growth of the tumor can threaten the viability of the overlying skin and surrounding structures.

Successful treatment of a huge congenital cervical teratoma

Congenital cervical teratomas are extremely rare tumors with high perinatal mortality and morbidity rates particularly due to compression and distortion of the infant's airway. Hence, these mostly benign malformations require immediate excision, whereas surgery of these tumors is challenging for a multidisciplinary team. We report on a recent case of congenital cervical mature teratoma with total excision and cure. The aim of this case study is to report the authors' experience in managing a case of congenital cervical teratoma to provide a structured approach and help in decision making, once prenatal diagnosis is made.

Sacrococcygeal teratoma in the newborn: a case study of prenatal management and clinical intervention

Sacrococcygeal teratomas (SCTs) are the most common germinal cell neoplasms of the fetus and neonate. They originate during embryonic development when the primitive streak fails to differentiate among mesodermal, ectodermal, and endodermal tissues in the embryonic disc. This article discusses the fetal pathophysiology of SCTs and the impact of the condition on the newborn. Fetal SCTs can have life-threatening physiologic effects--such as premature labor, dystocia, and high-output cardiac failure--if not managed appropriately. Clinical manifestations, prenatal diagnosis, therapeutic approaches and treatment options for the fetus and newborn, and current research related to SCTs are addressed to aid practitioners caring for a fetus or infant diagnosed with an SCT.

Teratomas of the neck and mediastinum in children

This retrospective study reviews a series of teratomas of the neck and mediastinum aiming at defining the features of these particular locations. We recorded prenatal diagnosis, perinatal management, clinical and radiologic features, pathology, surgical strategies and results in cervical and mediastinal teratomas treated over the last 10 years. During this period we treated 66 children with teratoma of which 11 (6 male and 5 female) had cervicomediastinal locations. Five babies had cervical teratomas extended into the anterior mediastinum in two cases. Prenatal diagnosis was made in three (two with polyhydramnios). Four babies were born by C-section and only one had a successful EXIT procedure. The diagnosis was confirmed by imaging and increased AFP. Surgical treatment involved total tumor removal and in one case subsequent removal of lymph node metastases. All children survived except one in whom airway could not be cleared at birth. Two children bear mild hypothyroidism. During the same period six patients aged 0-17 years were treated for mediastinal teratoma. Only one was prenatally diagnosed and only two had some dyspnea. Removal was performed either by median sternotomy, thoracotomy, or thoracoscopy. They all survive and are free of disease. Teratomas of the neck may cause fetal disease and unmanageable neonatal airway obstruction. Prenatal diagnosis and planned multidisciplinary management are mandatory at birth. In contrast, only some mediastinal tumors cause respiratory embarrassment. Although benign, these tumors are sometimes immature and may metastasize to regional lymph nodes. Total surgical removal is curative. Thyroid insufficiency may be present at birth in cervical teratomas and may be aggravated by surgery.

Malignant cervical teratoma: report of a case in a newborn

Malignant cervical teratoma (MCT) usually appears in newborns as an enlarging mass of the neck that causes respiratory distress, requiring prompt airway control. We report a case of MCT in an infant electively delivered at 32 weeks to prevent airway impairment. At first, the preoperative diagnosis was hygroma of the neck, and a surgical excision was performed when the newborn was 9 days old. Diagnosis was benign extragonadic immature teratoma, but it was changed in MCT when cervical metastases appeared and the alpha-fetoprotein (AFP) level increased. Subsequent surgical procedures and chemotherapy were necessary. The child has been free from disease and healthy for 7 years since the last surgery. The preoperative diagnosis of MCT is difficult because of its rarity and non-specific clinical findings. Surgical excision is required for an adequate cure and airway repair; a long-term follow-up is mandatory to promptly treat any recurrence.