Massive fetal cervical teratoma managed with the ex utero intrapartum treatment (EXIT) procedure

A Case of Cervical Teratoma in an Infant

Cervical teratoma is a rare form of teratoma in neonates and is an unusual cause of cervical masses in them. Teratomas are unusual tumors derived from all 3 germs cell layers: endoderm, mesoderm, and ectoderm, with varying proportions. The cervical teratoma is a rare entity. Its prognosis mostly depends on the risk of neonatal respiratory distress, its extension and potential malignancy. Surgical management must be as complete as possible to avoid recurrences and malignant transformation. We report a case of a cervical immature teratoma in an infant with total excision and cure. No recurrence has been reported. The aim of our study is to review the diagnosis, management and outcomes of congenital cervical teratomas. Cervical teratoma although uncommon should be considered in the differential diagnosis of neck masses in neonates. Teratomas are rare tumors derived from all three germ cell layers affecting the neck in 3% of all cases. An early complete surgical approach to congenital cervical teratomas allows good results with low rates of complication and recurrence.

Antenatal detection of a thyrocervical teratoma in the third trimester - A case report

Introduction

Congenital teratomas are rare with less than 10% found in the cervical region. When they do occur in the neck, they are usually identified during the third trimester and, due to their location, they are associated with polyhydramnios.

Case report

Cervical teratoma was identified at 32 weeks gestation during a routine scan of a 33-year-old female expecting dichorionic diamniotic twins. Only one twin was affected and referral to a specialist hospital allowed a care plan to be arranged to ensure safe delivery followed by immediate treatment and surgery. To date, both twins are thriving.

Discussion

Cervical teratomas usually occur in the third trimester and are not always detected prenatally. Although usually benign, their size and location may cause polyhydramnios as well as increasing the risk of neonatal asphyxiation and death. It is therefore essential to assess the foetal neck when polyhydramnios is noted at any third trimester scan, to maximise detection and ensure appropriate multidisciplinary healthcare can be organised to optimise postnatal survival.

Conclusion

Antenatal detection of a rare cervical teratoma was pivotal in the management and survival of this infant. Ultrasound practitioners must consider the possibility of a neck teratoma in the presence of third trimester polyhydramnios and therefore evaluate carefully foetal head, neck and chest anatomy as part of their examination.

Case report: Fetal cervical immature teratoma and copy number variations

Fetal cervical teratoma is a rare congenital neck tumor. Here, we report a case of a fetus with an anterior solid neck tumor that was confirmed to have an immature teratoma by histology. A duplication was found at chromosome 14q24.1-q24.3 of the fetus in chromosome microarray (CMA) and whole exome sequencing (WES), which was a copy number variation (CNV) and a probably new-onset. Ultrasound coupled with magnetic resonance imaging (MRI) can be considered to be a relatively reliable diagnostic tool, whereas ex-utero intrapartum therapy or resection of the tumor mass on placental support may improve the chances of the newborn’s survival. Strangely, the same duplication occurred on her next fetus that was found with complex congenital heart malformations. CNV at chromosome 14q24.1-q24.3 needs to be paid more attention.

Large Neck Teratoma in a Newborn with Respiratory Distress Syndrome

Neonatal tumours in the neck region are a rare finding. Teratomas typically comprise all three germ cell layers with tissues usually foreign to the anatomic site of origin. Head and neck teratomas account a smaller part of congenital teratomas. They can cause major airway obstruction due to the external compression that oropharyngeal or neck masses produce. In addition, there can be an intrinsic lesion in the larynx or trachea. We describe a premature, 30-gestational week-old newborn with large subcutaneous neck mass. Pre-delivery ultrasound showed heterogeneous tumor structure and displaced larynx. The intubation was successful. The newborn developed respiratory distress syndrome immediately after birth which rendered the surgical removal of the neck tumor impossible. An autopsy was done, and the histopathology revealed mature teratoma comprising muscle, brain, salivary and pulmonary tissues, as well as well-developed hyaline membranes in the alveoli. The combination of the respiratory distress syndrome and the neck tumor compression proved fatal. Prenatal diagnosis, therapeutic options and ex utero intrapartum treatment (EXIT) procedures are discussed for the diagnosis and management of this very rare tumor.

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.

Fetal brain, head, and neck tumors: Prenatal imaging and management

Fetal tumors represent an infrequent pathology when compared to congenital malformations, although their true incidence may be underestimated. A variety of benign and malignant neoplasms may occur anywhere in the neural axis. Imaging plays an important role in the fetal tumor diagnosis and evaluation of their resultant complications. Discovery of a fetal mass on obstetric ultrasound necessitates further evaluation with prenatal magnetic resonance imaging (MRI). New MR sequences and new applications of existing techniques have been successfully implemented in prenatal imaging. A detailed assessment may be performed using a variety of MR. Fetal tumors may be histologically benign or malignant, but their prognosis generally remains poor, especially for intracranial lesions. Unfavorable tumor location or heightened metabolic demands on a developing fetus may result in severe complications and a fatal outcome, even in cases of benign lesions. Nowadays, prenatal treatment focuses mainly on alleviation of secondary complications caused by the tumors. In this article we review congenital tumors of the brain, face, and neck encountered in prenatal life, and discuss diagnostic clues for appropriate diagnosis.

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.

Ex utero intrapartum treatment (EXIT) for fetal neck masses: A tertiary center experience and literature review

OBJECTIVE

Currently no established criteria exist to guide use of ex utero intrapartum treatment (EXIT) for fetal neck mass management. This study aims to correlate prenatal radiographic findings with incidence of ex utero intrapartum treatment and necessity of airway intervention at delivery.

METHODS

We reviewed our EXIT experience between 2012 and 17. Furthermore, we performed a literature review of articles reporting incidences of fetal neck masses considered for EXIT. Articles that were included (1) discussed prenatal radiographic findings such as size, features, and evidence of compression and (2) reported extractable data on delivery outcomes and airway status.

RESULTS

Ten cases at our institution were reviewed. Another 137 cases across 81 studies met inclusion criteria. These studies showed aerodigestive tract compression to be significantly associated with neck masses undergoing EXIT. Additionally, there was significantly higher incidence of airway intervention in cases where polyhydramnios, anatomic compression, and solid masses were seen on prenatal diagnostic imaging, while mass location and size did not correlate with airway intervention.

CONCLUSION

With this data, we propose that any neck mass with anatomic compression on fetal imaging in the 3rd trimester should be considered for EXIT. When radiographic findings do not show compression but do display polyhydramnios or a solid neck mass (regardless of polyhydramnios), an airway surgeon should be available for perinatal airway assistance.

Anesthesia for predelivery procedures: ex-utero intrapartum treatment/intrauterine transfusion/surgery of the fetus

PURPOSE OF REVIEW

The aim of this study was to review the current literature on anesthesia for predelivery procedures and to summarize recent findings on anesthesiological methods used.

RECENT FINDINGS

Ex-utero intrapartum treatment (EXIT)-procedures are performed to secure the newborn's oxygenation in case of severe airway obstruction due to multiple conditions. A key feature of EXIT is continued intactness of the maternofetal circulation by uterine relaxation achieved by general anesthesia with high doses of anesthetic gases. A dose reduction may be achieved by combining inhaled anesthesia with propofol. After intrauterine transfusion the anesthesia team needs to be prepared for a potential need of emergency cesarean section. Temporary fetal endoluminal tracheal occlusion and laser coagulation for twin-to-twin transfusion syndrome may be either performed in monitored anesthesia care or neuraxial anesthesia. Neuraxial anesthesia also is a method of choice for fetal valvuloplasty and amniotic band release. Fetal myelomenigocele repair requires general anesthesia with tocolysis.

SUMMARY

Predelivery procedures require a differentiated anesthesia approach depending on the invasiveness of the intervention. Anesthesia ranges from monitored care to neuraxial anesthesia and general anesthesia. Depending on the procedure uterine relaxation and fetal immobilization are crucial for technical success. Interdisciplinary consultation optimizes the anesthesia plan for complex procedures.