Sacrococcygeal teratoma with spinal canal invasion prenatally diagnosed

Sacrococcygeal teratoma with intraspinal extension: A case series and review of literature

BACKGROUND

Sacrococcygeal teratoma (SCT) is the most common teratoma in neonates and arises from the coccyx. SCT with intraspinal invasion is extremely rare and only reported in a few cases.

METHODS

37 patients with SCT were identified at our institution between 2000 and 2018. Three of these patients had SCT with intraspinal extension. A literature review for intraspinal extension associated with SCT, including mode of diagnosis, presentation, surgical approach and neurological sequelae, between 1993 and 2018 was also conducted.

RESULTS

The authors report three cases of infants who were antenatally and/or postnatally diagnosed with a sacrococcygeal teratoma extending into the spinal canal. We illustrate the challenges of accurate diagnosis and therapeutic management. Postnatal magnet resonance imaging (MRI) was the best method to define spinal anatomy and extension of the tumors prior to surgery. Management with a multidisciplinary team approach including neuroradiology, neurosurgery and general surgery was used in our two most recent patients. The literature review yielded 6 cases of SCT with intraspinal extension.

CONCLUSION

Intraspinal extension in SCT is rare but should be excluded at birth before attempting any resection. In case of positive spinal invasion on Ultrasonography (US), MRI is essential to plan for surgery and possible laminectomy to be able to perform a radical resection of this congenital tumor. We recommend this multidisciplinary approach.

LEVEL OF EVIDENCE

Level IV.

Enlarging teratoma syndrome

INTRODUCTION

Teratomas are derived from all three germ layers and make up 3% of all childhood tumors. They are histologically classified as mature or immature. We present a case that was operated on when 30 days old for a sacrococcygeal mature teratoma and then showed long segment involvement in the thoracolumbar region 9 months after the surgery. The MRI (magnetic resonance imaging) showed a mass starting at the thoracal 4 level and extending to the lumbar 3 level with significant spinal cord compression in the extradural space.

RESULT

The laminae between thoracal 4 and lumbar 3 levels were removed en bloc at a single surgical session and laminoplasty was performed after tumor resection. We also removed the tumor growing into the extrapleural space at the thoracal 5, 6, and 9, 10, 11, 12 levels using the costotransversectomy procedure.

CONCLUSIONS

We emphasize with this case that mature teratomas can show aggressive growth following surgery and that the development of spinal deformities can be prevented with laminoplasty.

Surgical treatment of a type IV cystic sacrococcygeal teratoma with intraspinal extension utilizing a posterior-anterior-posterior approach: a case report

Type IV sacrococcygeal teratoma with intraspinal involvement is rare and to our knowledge has not been reported previously in the literature. The authors present the case of a 2-month-old infant with a type IV sacrococcygeal teratoma diagnosed on prenatal ultrasound. Postnatal MRI revealed intraspinal extension through an enlarged sacral neuroforamina on the right side. On surgical exploration, the authors discovered a dorsal cystic tumor involving the sacral spine that extended through an enlarged S4 foramen to a large presacral component. The tumor was successfully removed to achieve a complete en bloc surgical resection. The authors review the epidemiology, pathophysiology, and treatment of sacrococcygeal teratomas with intraspinal extension.

Fetal Body Imaging: When is MRI Indicated?

Recent improvements in fetal therapies and perinatal care and the multidisciplinary involvement in fetal medicine have increased the demand for more accurate prenatal diagnosis. Fetal Magnetic Resonance Imaging (MRI) is a complementary imaging technique for the assessment of thoraco-abdominal anomalies for which Ultrasonography (US) is not conclusive. It is indicated in selected situations to precise the prognosis in diaphragmatic hernia, to characterise the nature and extension of a pulmonary malformation, to locate a bowel atresia or to better depict an abdominal cystic lesion or tumoural extension. It has become a mandatory complementary diagnostic tool and improves the management of the fetuses and newborns.

Sacrococcygeal teratoma with intradural extension: case report

Intradural sacrococcygeal teratoma (SCT) is a rare entity that has been reported in only a few cases previously. The authors present the case of a 2-week-old, otherwise healthy neonate with a mass in the buttock. The imaging findings and the high level of serum alpha-fetoprotein were highly suggestive of SCT. On operation the authors found intradural extension of the teratoma. The lesion was managed successfully without any remaining sequelae. The authors briefly review the currently proposed etiology regarding teratoma formation and the intradural extension of SCT.

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.

Benign sacrococcygeal teratoma with spinal canal invasion and paraplegia

Sacrococcygeal teratomas can have a wide variety of clinical presentations depending on their size, vascularity, and degree of mass effect upon adjacent structures. Intradural invasion of a sacrococcygeal teratoma is a rare variant that has generally been associated with a favorable neurologic outcome. In this report, we present the case of a neonate with paraplegia secondary to a large Altman type III sacrococcygeal teratoma with extension into the spinal canal. The neoplasm was completely removed using a combined anterior and posterior approach after preoperative embolization of the lateral sacral arteries. Pathology showed a mature teratoma. The patient remains paraplegic without evidence of tumor recurrence at 1 year of age.