Intradural Intramedullary Teratoma Presenting in the Lumbar Spine: Report of a Rare Case

Mature Teratoma at the Lumbar Spinal Cord: A Case Report and Literature Review

Mature spinal teratoma is a rare type of germ cell tumor that arises from any of the three germ cell layers (ectoderm, mesoderm, and endoderm) and consists of differentiated tissues and structures that reflect the cellular organization and morphology of normal adult tissues. It has the ability to grow independently and cause compressive symptoms when found in this rare location. In this article, we present the case of a 29-year-old male patient with the onset of neurological symptoms beginning with pelvic limb paresthesias and progressing to back pain. Magnetic resonance imaging (MRI) revealed a tumor at L1-L4, which was resected by laminotomy, and histopathology revealed a mature intradural teratoma. Fortunately, this histologic type had a good prognosis for our patient, who had a significant clinical improvement. A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology with PubMed and Google Scholar to find similar case reports and to summarize the main features of this disease, which contributes to the understanding of its diagnostic presentation, treatment, and prognosis, improving clinical practice in the management of similar cases. The rarity of this condition, together with its wide clinical heterogeneity and prognosis, underscores the importance of a thorough evaluation of cases of intramedullary lesions, where the consideration of uncommon diseases in the differential diagnosis should be highlighted.

Intramedullary cervical spinal cord teratoma

BACKGROUND

Intramedullary cervical spinal cord teratomas (ICTs) are extremely rare, and diagnosis and treatment are challenging. We conducted a systematic review of the literature on the diagnosis and treatment of ICT.

METHOD

The presentation, imaging manifestations, diagnosis, management, surgery findings, prognosis and histology were reviewed following Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. English-language studies and case reports published from inception to 2018 were retrieved. Data on presentation, imaging characteristics, diagnosis, management, surgery findings, outcomes, and histopathology were extracted.

RESULTS

Ten articles involving 10 patients were selected. The lesions were located in the upper cervical vertebrae in 4 cases, whereas in the lower cervical vertebrae in the remaining 6 cases. In 5 cases, the lesions were located on the dorsal side of the spinal cord, and in the center of the spinal cord in the remaining 5 cases. Quadriparesis (60%), paraplegia (30%), monoplegia (10%), and neck pain (50%) were the main presentations. The lesion appeared as a intramedullary heterogeneous signal during an MRI scan, and the lesion signal would be partially enhanced after the contrast medium was applied. All patients underwent surgical intervention through a posterior approach. Neurological function improved postoperatively in all patients. Two patients with pathology confirmed to be immature teratomas experienced recurrence.

CONCLUSION

ICTs are extremely rare entities that are mainly located in the center or dorsal part of the spinal cord which mainly manifest as quadriplegia and neck pain. MRI is a useful modality that provides diagnostic clues. Surgery from a posterior approach is the primary treatment, and the effect of adjuvant therapy remains uncertain. The prognosis is mainly related to the pathological nature of the tumor and not the method of resection.

Caudal Homeobox Gene-2 Staining Defines Intracranial Mature Teratoma with Differentiation to Colonic Adenocarcinoma

BACKGROUND

Malignant transformation of a mature intracranial teratoma into an adenocarcinoma is an extremely rare event and portends a poor prognosis. The clinical progression, radiographic changes, histopathological findings, and immunohistochemistry findings from these unique cases might provide clues regarding this transformation. Caudal homeobox gene-2 (CDX-2) is a specific and robust marker for colonic adenocarcinomas and can also be used to identify differentiation of mature intracranial teratoma into colonic-type adenocarcinoma. To the best of our knowledge, this is the first case report of the use of this specific marker for an intracranial malignancy.

CASE DESCRIPTION

We present the case of a 55-year-old right-handed Hispanic-American woman with progressive headaches who was found to have a left posterior parietotemporal tumor with intraventricular extension. Surgical debulking was performed, and the pathologic examination revealed a mature teratoma. Despite surgical resection and radiotherapy, the teratoma progressed to a malignant mature intracranial teratoma both radiographically and histologically. Histological analysis of the third specimen revealed a moderately differentiated adenocarcinoma. The tumor cells were positive for CDX-2 and cytokeratin 20 and negative for cytokeratin 7 and thyroid transcription factor-1, consistent with an enteric/colonic-type adenocarcinoma, demonstrating progressive atypia and malignancy.

CONCLUSIONS

Malignant transformation of a mature intracranial teratoma portends a poor prognosis. The exact histopathological diagnosis can facilitate treatment of these patients. CDX-2 is a specific robust marker for identifying differentiation of a mature intracranial teratoma into a colonic adenocarcinoma. This positive staining can also be observed in primary colonic and other adenocarcinomas. To the best of our knowledge, this is the first report of the use of CDX-2 in the diagnosis of an intracranial malignancy. The triangulation of clinical progression, radiographic findings, and histopathological and immunohistochemistry findings provided clues regarding this unique transformation.

A comprehensive review of adult onset spinal teratomas: analysis of factors related to outcomes and recurrences

PURPOSE

Spinal teratomas are rare tumours noted in adults and are commonly located in the thoracolumbar region. Currently, there appears to be a lack of clear consensus regarding the management and prognosis of these lesions. A comprehensive review along with an illustrative case managed at the author's institute has been presented.

MATERIALS AND METHODS

Online database search was performed for literature review.

RESULTS

A 26-year-old male presented with acute onset neurological deficits and imaging revealed features of conus teratoma. Subtotal resection was performed and patient achieved fair recovery. Including the present one, a total of 146 cases have been reported and were analysed. Mean age was 39.6 years (range 18-85 years) and males predominated. Limb weakness and backache were the commonest symptoms. Majority of the lesions were intramedullary and located in the thoracolumbar region. Complete resection (CR) was achieved in 45% of cases. All, except one, were mature teratomas. Recurrences were noted in nine (6.1%) cases. Outcome was good/excellent in 86 (60%) and fair/poor in 26 (18%) cases. The presence of pain, absence of limb weakness and CR were significantly associated with good outcomes. Furthermore, subtotal resection (STR) had significantly higher recurrence rates than CR. Four deaths (2.7%) were noted.

CONCLUSIONS

Total surgical resection is the standard treatment and appears to be beneficial both in terms of outcomes and recurrences. Overall, recurrences are rare and may be managed by re-surgery. In addition, the present report is the eighth case of adult spinal teratoma with an acute onset presentation. These slides can be retrieved under Electronic Supplementary Material.