Outcome of prenatally diagnosed solid fetal tumors

Diagnostic dilemma in a case of neonatal cardiac tumor - The importance of histopathology and mutation analysis in clinical practice

Fetal or neonatal cardiac tumors are rarely encountered in neonatal practice. Moreover, these can be the earliest manifestation of underlying systemic conditions, such as tuberous sclerosis. Cardiac tumors are primarily diagnosed by characteristic findings in transthoracic echocardiography. However, these findings are not absolute, and histopathology remains the gold standard in diagnosing cardiac tumors. Sometimes, doubtful imaging findings can delay the diagnosis and initiation of definitive management. We describe a case of fetal and neonatal cardiac tumor where histopathology served as a benchmark in making a diagnosis and helped in identifying the underlying systemic disease.

Fetal Mediastinal Fibrosarcoma. Report of Two Cases

Introduction: One-third of fetal soft tissue tumors are malignant and include congenital fibrosarcoma (CF). We report two fetal CFs arising in the posterior mediastinum. Case Presentation: In case 1, the CF resulted in a mediastinal shift, extensive infiltration of the tumor around adjacent structures, pulmonary hypoplasia, pleural effusion, and rapid growth. The pregnancy was terminated. Case 2 had multiple intrathoracic masses, thoracic hypoplasia, pleural effusion, and fetal death. Both were diagnosed as fibrosarcoma at fetopsy. Discussion: Although congenital CF tends to be locally aggressive with a low metastatic rate, it tends to grow rapidly and the tumor location can affect fetal survival. In Case 1, the tumor demonstrated locally aggressive behavior whereas multiple distant metastases such as lung, liver, adrenals, and left eye were detected in Case 2. The tumor was directly responsible for intrauterine fetal demise in the second case.

Case report: Ultrasound-guided intrauterine biopsy and RF ablation therapy for fetal posterior neck solid tumor: first successful report

Large fetal head and neck tumors are being increasingly identified during prenatal examination and tend to have a poor prognosis. Nevertheless, appropriate intrauterine interventions at suitable periods can improve pregnancy outcome. Ultrasound-guided puncture biopsy of the solid fetal head and neck mass and radiofrequency ablation of a portion of the tissue can clarify the tumor pathology and reduce the tumor size, respectively. These treatment methods are reproducible and associated with reduced trauma and complications.

Management of fetal tumors

In this review article, we discuss the most common fetal tumors, their prenatal management, and outcomes. Overall, the most important outcome predictors are tumor histology, size, vascularity, and location. Very large lesions, lesions causing cardiac failure, and hydrops and lesions obstructing the fetal airway have the poorest outcome, as they may cause fetal death or complications at the time of delivery. Fetal therapy has been developed to improve outcomes for the most severe cases and can consist of transplacental therapy (sirolimus for rhabdomyomas or steroids for hemangiomas and microcystic lung lesions) or surgical intervention (shunting of cystic masses, tumor ablation, occlusion of blood flow or airway exploration, and protection). Given the rarity of fetal tumors, patients should be referred to expert centers where care can be optimized and individualized to allow the best possible outcomes.

Neoplastic Pericardial Disease

Pericardial tumors are rare lesions that include a range of neoplastic conditions that may arise within the pericardium or metastasize to involve it secondarily. Understanding the spectrum of lesions that are included in the differential diagnosis of a pericardial mass-lesion is critical to making timely, accurate diagnoses and getting the appropriate therapy should one be necessary. This review summarizes the radiologic and pathologic findings of the most commonly encountered of these entities.

Management of fetal teratomas

Fetal teratomas are the most common tumors diagnosed prenatally. The majority of these tumors are benign and cured by complete resection of the mass during the neonatal period. Prenatal diagnosis has improved the perinatal management of these lesions and especially for the teratomas that might benefit from fetal intervention. A comprehensive prenatal evaluation including conventional ultrasounds, Doppler, echocardiography and fetal MRI, is essential for an effective counseling and perinatal management. Antenatal counseling helps the parents to better understand the natural history, fetal intervention, and perinatal management of these tumors, which differ dramatically depending on their size and location. Fetal surgical debulking improves survival in cases of sacrococcygeal teratoma with cardiac decompensation. Additionally, the use of an EXIT procedure reduces the morbidity and mortality if a complicated delivery in cases of cervical and mediastinal teratomas. Here, we offer an overview of all fetal teratomas and their recommended management, with emphasis on in utero treatment options.

Evaluation of the prenatally diagnosed mass

With the advent of advanced imaging technologies, the field of prenatal diagnosis and counseling has grown rapidly. The use of fetal ultrasound and ultrafast magnetic resonance imaging has allowed for prenatal identification of structural anomalies as well as neoplasm. The differential diagnosis of a fetal mass is dependent upon its location and the tissue characteristics of the mass on imaging. The use of amniocentesis for chromosomal analysis and genetic testing for known tumor-related genetic abnormalities may aid in further refining the diagnosis. Herein we describe a general diagnostic algorithm for fetal masses based upon their location within the body and how the appropriate diagnostic modalities may be applied in the clinical setting.

Prenatal intrarenal neuroblastoma mimicking a mesoblastic nephroma: a case report

Mesoblastic nephroma is by far the most frequent intrarenal fetal tumor. To the best of our knowledge, we report the first case of a newborn with an intrarenal neuroblastoma that was discovered prenatally. An intrarenal echogenic and homogenous mass was observed on routine prenatal ultrasonography, corroborated by magnetic resonance imaging, in a 30-week gestation fetus. A male weighing 3280 g was born with elevated blood pressure and cardiac failure. Postnatal ultrasound confirmed a left intrarenal tumor with microcalcifications and perirenal adenopathy. An open total left nephrectomy by laparotomy was performed. The pathologic study reported that the mass was an intrarenal neuroblastoma with local and regional invasion. Immediate postoperative urine analysis revealed a high level of vanillylmandelic acid, and blood samples showed high levels of normetanephrine. The purpose of this report is to demonstrate that prenatal intrarenal neuroblastoma can clinically and radiologically mimick a mesoblastic nephroma. High blood pressure, calcifications, and lymphadenopathy on ultrasound should raise the index of suspicion for a possible malignant process. Preoperative measurement of urinary vanillylmandelic acid (VMA) and metanephrines should be performed if the diagnosis is in doubt.

The surgical management and outcome of congenital mediastinal malformations

We reviewed our institutional experience with congenital mediastinal masses and compared the postnatal management and outcome of patients with or without prenatal diagnosis. Between January 1997 and August 2011, 24 patients underwent surgical procedures for congenital mediastinal mass. For eight patients, the mass was detected by prenatal ultrasonography at 27 weeks of gestation (range 22-35). Postnatal management consisted in open surgery for seven patients at a mean age of 9 months (range 1 day-20 months) and sclerotherapy for one lymphangioma at 5 months of life. Sixteen patients had postnatal diagnosis at 137 months (±194) of median age. Eight bronchogenic cysts, seven bronchopulmonary foregut malformations, five teratomas, three lymphangiomas and one haemangioma were operated on. The median age at resection was 28 months (1 day-15 years). There were four emergency procedures and no surgical mortality. The median follow-up was 45 months (3-144). The duration of mechanical ventilation and hospital stay was, respectively, 4.6 h and 7.5 days for antenatal patients and 24.3 h and 14.3 days for postnatal diagnosed patients. Prenatal diagnosis allows early management of congenital mediastinal malformations. Early resection can be performed prior to the occurrence of symptoms ∼1 year of life and is associated with an excellent outcome and less morbidity.

Tumours of the fetal body: a review

Tumours of the fetal body are rare, but lesions have been reported in all spaces, especially in the mediastinum, the pericardial space, the adrenals, the kidney, and the liver. Lymphangioma and teratoma are the commonest histological types encountered, followed by cardiac rhabdomyoma. Adrenal neuroblastoma is the commonest malignant tumour. Imaging plays an essential role in the detection and work-up of these tumours. In addition to assisting clinicians it also helps in counselling parents. Most tumours are detected by antenatal US, but fetal MRI is increasingly used as it brings significant additional information in terms of tumour extent, composition and complications.

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.

Metastatic malignant peripheral nerve sheath tumor in a newborn

Malignant peripheral nerve sheath tumors are rare tumors, especially in the newborn period. Diagnosis is based on clinical findings, radiography, and fine needle biopsy or tissue sampling. Ideal management is controversial and extremely difficult. The survival rate is extremely low. We present a case of a newborn in which this tumor is diagnosed in the first few days of life as an ulcerating tumor imbedded in the entire forefoot with already metastatic spread to the lymph nodes and abdomen. Questions arose on the best treatment in postpartum life. Below the knee amputation was performed for nursing purposes, but eventually a no-intention-to treat policy was chosen by the multidisciplinary team and parents. Detection of soft tissue tumors in the prenatal period is difficult and not as easy as for other structural defects. Would prenatal detection have changed the course of life of this young infant? Will future opportunities for detection of soft tissue tumors occur? Diagnostic and therapeutic considerations are discussed alongside the present literature.

Spectrum and outcome of prenatally diagnosed fetal tumors

OBJECTIVE

To describe the spectrum of prenatally diagnosed fetal tumors, and the course and fetal outcome in affected pregnancies.

METHODS

This was a retrospective study in two German tertiary referral centers of 84 fetuses with tumors diagnosed in the prenatal period. The tumors were classified according to their location and histology.

RESULTS

The most common site of origin was the heart (20/84, 23.8%), followed by the face and neck region (19/84, 22.6%) and the abdomen (16/84, 19%). Lymphangiomas (21/84, 25%) and rhabdomyomas (19/84, 22.6%) comprised half of the tumor histology. Less frequently, teratomas (14/84, 16.6%) and hemangiomas (12/84, 14.2%) were seen. Complications included arrhythmia in cases with rhabdomyoma (8/19, 42%) and signs of heart failure in cases with hemangioma (4/12, 33%) and teratoma (4/14, 28.6%). The overall survival rate was 75%. Cases with either a histological diagnosis of teratoma or tumor located in the brain had the worst prognosis.

CONCLUSION

The combination of sonographic features and their location allows reliable prediction of the histological type in the vast majority of fetal tumors. Malignancy, associated malformations and aneuploidy are observed infrequently. Knowledge of the presence of a fetal tumor facilitates close surveillance by a specialized team, which might lead to early recognition of problems and improve perinatal outcome.

Fetal oncology

A szerző áttekinti a magzatokban előforduló jó- és rosszindulatú daganatokat. A gyermek- és felnőttkori daganatok szinte minden alakja előfordul méhen belül a magzatokban, illetve világrajövetel után az újszülöttekben. A diagnózis létfontosságú eszköze a szonográfia és a mágneses rezonanciás vizsgálati módszer. Ez a két eljárás nagy előrelépés a kórismézés terén. A kezelések még kísérleti fázisban vannak, és csak néhány központi intézetben végeznek ilyen beavatkozásokat. A választás a műtéti beavatkozás kockázat-haszon arányától függ.

Fatal birth trauma due to an undiagnosed abdominal teratoma: case report and review of the literature

The fetus is subjected to mechanical forces during labor and delivery, which may result in traumatic injuries. Such injuries include intracranial hemorrhage, spinal cord lesions, cephalhematoma, cranial or peripheral nerve palsies, intraabdominal organ rupture, or bony fractures. Risk for perinatal trauma and mortality is increased in primigravidas, multiple gestations, abnormal presentations, maternal-fetal disproportion, oligohydramnios, forceps or vacuum extractions, and internal version maneuvers. Very-low-birth-weight neonates (<1500 g) are at high risk due to ease of deformity of the cranium. Infants with certain congenital anomalies or pathologic processes that distort normal anatomy are also at increased risk, especially when a prenatal diagnosis is lacking. The authors present a case of a term gestation neonate who sustained a cervical spine dislocation fracture of C5-7, with subtotal transection of the spinal cord and resultant paralysis. The fetus was in vertex presentation, and a manual vaginal delivery was attempted. When the infant lodged in the birth canal following a difficult delivery of the head and arms, its enlarged abdomen was palpated, and the delivery was converted to an emergent cesarean section. The infant lived for 3 days and then expired due to neurologic complications of trauma sustained during the attempted vaginal delivery. Autopsy revealed a previously undiagnosed intraabdominal immature teratoma. The pathology of teratomas, the most common neonatal tumor and occasionally implicated in cases of birth trauma, will be addressed, followed by a review of the literature concerning birth trauma.

Fetal intervention for mass lesions and hydrops improves outcome: a 15-year experience

PURPOSE

The natural history of certain prenatally diagnosed masses is well known. Large thoracic mass lesions can evolve one of 2 ways, either to regress and cause minimal morbidity, or to progress and enlarge, often resulting in hydropic changes in the fetus. This nonimmune hydrops carries a dismal prognosis, with nearly all fetuses expiring before or shortly after birth. However, hydrops associated with fetal mass lesions can be halted and even reversed with fetal intervention and treatment of the underlying defect. We examined our patients with fetal mass lesions to evaluate survival after intervention.

METHODS

Institutional approval was obtained by the Committee on Human Research. A retrospective review was performed of 294 fetuses evaluated over 15 years with large mass lesions. All patients were evaluated for evidence of fetal hydrops using ultrasound criteria. Patients were divided according to type of intervention. Primary outcome measure was 30-day survival after birth.

RESULTS

(1) Patients without fetal hydrops did not undergo fetal intervention and survived to 30 days after birth (167/172, 97%). (2) Patients with fetal mass lesions that developed hydrops fared poorly with no intervention (1/33 survival, 3%), whereas fetuses undergoing prenatal intervention fared much better (15/30 open, 50%; 3/10 percutaneous, 30%). (3) Four patients with hydropic congenital cystic adenomatoid malformation (n = 3) or pulmonary sequestration (n = 1) received steroids in preparation for surgery but underwent no intervention, and the patients survived the neonatal period.

CONCLUSION

Fetuses with prenatal diagnoses of masses not associated with hydrops have excellent prognosis with survival higher than 95%. Nonimmune hydrops associated with prenatal diagnosis of a fetal mass is a devastating complication with less than 5% survival. Open resection of a mass causing hydrops resulted in 50% survival, with reversal of hydrops in a group with near-uniform fatality. Further investigation is warranted regarding the use of minimally invasive prenatal therapies including steroid administration for hydropic fetuses.

Neoplasias neonatales: experiencia de un centro

INTRODUCTION

Malignant tumors are uncommon in the neonatal period and benign tumors may have malignant potential.

OBJECTIVES

To describe the neoplasms diagnosed and treated in newborns (</= 28 days of life) in the Hospital Universitario de Canarias and their association with congenital abnormalities and to evaluate prenatal diagnosis of these tumors.

PATIENTS AND METHODS

The medical records of patients with neoplasms diagnosed during the neonatal period in the previous 25 years in our hospital were retrospectively reviewed. The variables analyzed were the percentage of neonatal neoplasms among the total number of cancer cases in children aged less than 14 years, their incidence among all the newborns in our hospital, sex, year of diagnosis, age at clinical diagnosis, the presence or absence of prenatal diagnosis, type of tumor (histologic diagnosis), association with syndromes or other congenital anomalies, treatment, and long-term outcome.

RESULTS

Of 260 neoplasms diagnosed in our unit from 1980, 16 (6.1 %) were diagnosed in the neonatal period. The incidence of neonatal neoplasms was estimated to be 276.5 per million live births. Males accounted for 43.8 % and females for 56.2 %, with a mean age at diagnosis of 5.5 days (range 1-28 days). Five neonates (31.2 %) had a prenatal diagnosis, 60 % of which were made in the last 7 years of the study period. A further five newborns were diagnosed at the initial neonatal examination. Histologic diagnoses were neuroblastoma (n = 5; 31.2 %), teratoma/ germ cell tumor (n = 4; 25 %), soft tissue sarcoma (one fibrosarcoma of the thigh and two hemangiopericytoma of the back and heart; 18.8 %), and one case each of mesoblastic nephroma, cerebral tumor (ependymoblastoma), melanoma (associated with giant congenital melanocytic nevi), and acute leukemia (associated with Down syndrome). Treatment consisted of surgery alone (n = 10; 62.5 %) and surgery plus chemotherapy (n = 5; 31.2 %); one patient received no treatment. The overall actuarial survival rate was 87.5 %. Sequelae were observed in 33.3 % of survivors.

CONCLUSIONS

The neoplasms most frequently diagnosed in the neonatal period were solid tumors, mainly neuroblastoma and teratomas/germ cell tumors; 12.5 % were associated with syndromes or congenital anomalies. In the last 7 years, the prenatal diagnosis of these entities has improved. Most of the neoplasms responded to therapy, mainly surgery, and long-term outcome was favorable.

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.

Prenatal detection and evaluation of an extralobar pulmonary sequestration in the posterior mediastinum

Extralobar pulmonary sequestration (EPS) is a rare developmental anomaly with aberrant nonfunctioning parenchymal tissue, associated with an increased risk of perinatal morbidity and, rarely, mortality owing to possible neonatal respiratory distress. In most cases supernumerary lobes are detected as isolated intra- or extrapleural lesions with independent systemic arterial blood supply. We report an atypical case of prenatal detection and perinatal outcome of a mediastinal EPS.

Congenital cervical rhabdomyosarcoma arising in one fetus of a twin pregnancy

OBJECTIVE

To describe a huge congenital cervical rhabdomyosarcoma.

METHODS

We were recently confronted with a case of fetal solid neck mass arising in one fetus of a twin pregnancy. Prenatally, the cervical tumor was consistent with teratoma, but it was diagnosed histologically as a rhabdomyosarcoma. Genetic amniocentesis showed a mosaic pattern consisting of 46,XY/46,XY,t(2;8)(q35;q21.2).

RESULTS

EXIT procedure was proposed to the parents but declined. The twin with huge cervical tumor died in utero at 35 weeks' gestation due to hydrops fetalis.

CONCLUSION

Fetal cervical rhabdomyosarcoma is an extremely rare condition that has not been previously reported, but should be considered in the presentation of fetal solid neck mass.

Retroperitoneal germ cell tumors: a clinical study of 12 patients

PURPOSE

The aim of the study was to examine the clinical presentation, method(s) of treatment, complications, and results in newborns and infants with retroperitoneal germ cell tumors (GCTs).

METHODS

A retrospective chart review of all patients treated between 1974 and 2002 for GCT located in the retroperitoneum in 2 institutions identified 12 patients with histologically proven retroperitoneal GCT. Vital data concerning pregnancy and delivery were analyzed. Age at diagnosis and symptoms were recorded, as well as possibly associated anomalies. Data concerning surgical treatment, perioperative and postoperative complications, histological staging, and final outcome were all analyzed.

RESULTS

In 3 patients, the diagnosis had been made antenatally between 31 and 35 weeks of gestation. In 1 patient, the diagnosis was made at birth, and in 8 later in life (ages 3, 5, 7, 8, 8, 11, 18, and 24 months). Symptoms in these 8 boys and 4 girls were abdominal distension and a palpable upper abdominal mass, right-sided in 5, left-sided in 5, and central in 2; the tumor was usually big. Associated anomalies were noted in 4 patients and were chromosomal in 3 (Down syndrome in 2 and Klinefelter syndrome in 1). One baby died of uncontrollable bleeding during an emergency operation immediately after traumatic birth. The other 11 infants survived. Four other patients showed serious perioperative complications (1 caval vein tear, 1 choledochal tear, 1 cyst rupture, and 1 esophagogastric tear) which were managed without further consequences. Histologically, 4 tumors were mature teratomas, 6 were immature teratomas (grade I in 4, grade II in 1, and grade II-III in 1), and 2 were malignant yolk sac tumors (YSTs). The patients with YSTs underwent surgical biopsy, followed by chemotherapy and excision of the remaining tumor and of the metastases. No adjuvant treatment was administered in the patients with benign disease. Nine survivors with benign tumor are disease-free between 1 and 30 years after surgery. Two patients with YST have now been in remission for 6 and 5 years, respectively.

CONCLUSIONS

Both this study and the literature review performed testify to the extreme rarity of GCTs in the retroperitoneum. Surgical removal of the tumors appeared to be hazardous because of the extent of the tumor, the displacement and elongation of adjacent structures and organs, and/or the adhesion of the tumor to surrounding tissues; this resulted in several perioperative complications. The long-term results are good, however, with 9 of 10 patients with benign tumors in good health after a mean follow-up of 12 years, and with the 2 patients with YST in remission for 6 and 5 years, respectively.

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.

Strategy for management of newborns with cervical teratoma

BACKGROUND

Cervical teratomas are extremely rare tumors with high perinatal mortality and morbidity rates.

OBJECTIVE

To compare our experience and outcome in newborns with cervical teratoma with similar reports from the literature, in order to propose a structured approach.

METHODS

A retrospective review of seven patients treated between 1986 and 2000 was performed. The results of these seven patients were compared with and added to a series of 44 well-documented patients retrieved from the literature.

RESULTS

In four of the seven patients, the diagnosis was not suspected antenatally. Three of the patients survived, one died. In the other three, the diagnosis was made antenatally. Two were born using the ex-utero intrapartum treatment (EXIT) procedure, one by planned cesarean section. Only one of these three survived. Mortality in the total series of 51 patients was 33% overall, and 46% in the group in which the diagnosis had been made antenatally. Peri- and post-operative complications were reported in 27%. Although larger tumors caused polyhydramnios more frequently than smaller tumors, and were associated with more severe respiratory distress, the relationship between tumor volume at birth and final outcome could not be established. This makes difficult the identification of fetuses with a disastrous prognosis.

CONCLUSION

Although mostly benign, cervical teratomas are still associated with high mortality rates. Timely antenatal diagnosis is indispensable in reducing morbidity and mortality caused by upper airway obstruction. A structured approach to the management of cervical teratoma is proposed.

Management of fetal mediastinal teratoma

BACKGROUND/PURPOSE

Mediastinal teratomas are rare congenital germ cell tumors that prenatally can compress mediastinal structures and cause hydrops. Two possible presentations of massive fetal mediastinal teratoma include hydrops leading to fetal demise, or fetal esophageal and airway compression causing late-gestation polyhydramnios and preterm labor. The authors present 2 cases of fetal mediastinal teratoma that illustrate successful strategies for either of these presentations.

METHODS

A 37-year-old woman carrying a fetus with a mediastinal mass and secondary hydrops at 23 weeks of gestation underwent in utero resection of the mass. Delivery was by cesarean delivery at 25 weeks because of preterm labor. A 24-year-old mother carrying a fetus with a mediastinal mass and severe polyhydramnios at 36 weeks of gestation underwent an ex utero intrapartum therapy procedure for establishment of an airway and tumor resection on uteroplacental support.

RESULTS

These strategies resulted in physiologic improvement in the first case and controlled resection and resuscitation in the second. The first patient had significant sequelae of prematurity including bronchopulmonary dysplasia but is currently well at 9 months of age. The second patient is well at 1 year of age.

CONCLUSIONS

Massive fetal mediastinal teratoma can result in fetal or neonatal mortality by a variety of mechanisms. Optimal prenatal and perinatal management is required to salvage fetuses compromised by this lesion.

[Neonatal localized neuroblastoma: 52 cases treated from 1990 to 1999]

Neuroblastoma is the most frequent tumor observed in the newborn. The aim of this study was to review clinical features, treatment and outcome of newborns diagnosed with a localized neuroblastoma.

POPULATION AND METHODS

Data from 52 cases treated according to the NBL 90 and 94 protocols between 1990 and 1999 in 18 French centers of pediatric oncology were analyzed.

RESULTS

The median age at diagnosis was 12 days (range 0-28) with antenatal detection in 14 patients (27%). Tumor location was abdominal in 40 patients (adrenal in 20 of the 40), thoracic in eight, pelvic in three, and cervical in one. N-myc amplification was observed in one out of 40 evaluable cases. The size of the primary tumor was less than 5 cm in 25 cases, between 5 and 10 cm in 25 and more than 10 cm in two. Dumbbell tumor was observed in seven, of whom five had neurological deficit. One child died from hemorrhage after fine needle biopsy during diagnostic procedure. Primary surgical resection was attempted in 37 infants, of whom two died of surgery related complications and three had nephrectomy. Tumor was deemed as unresectable in 14 patients, and primary chemotherapy was given followed by surgical excision in 12. One of them died a few days after the beginning of chemotherapy. As a whole, continuous complete remission was achieved in 48 children, four of them after relapse. Overall survival was 92% with a median follow-up of 46 months (0-113 months).

CONCLUSION

The excellent prognosis of localized NB in neonates needs very restrictive surgical indications, with well-established anatomic and imaging criteria. Indeed, chemotherapy based on weight and managed by expert teams should allow to perform surgical excision in safer conditions for unresectable tumors.

Pericardial teratoma complicated by hydrops: successful fetal therapy by thoracoamniotic shunting

Pericardial teratoma is a potentially curable lesion that may become life threatening when it induces mediastinal compression and fetal hydrops. So far, cases with fetal hydrops have been managed by elective delivery or pericardial needle decompression. We report a case in which pericardial teratoma resulted in fetal hydrops. Following transpleural needling of the fetal pericardium at 29 weeks and 6 days, pericardial effusion decreased but hydrops persisted, while major unilateral pleural effusion appeared. A thoracoamniotic shunt was placed at 30 weeks and 5 days. Hydrops resolved, although incompletely. The baby was delivered at 32 weeks and was operated upon on day 3. This observation suggests that fetal hydrops associated with pericardial teratoma may improve following thoracoamniotic shunting. Fetal therapy may limit the risks of respiratory distress arising from the combined effect of airways compression and lung immaturity.

Prenatal presentation of cervical congenital neuroblastoma

OBJECTIVE

To describe a cervical neuroblastoma revealed in the prenatal period.

METHOD

We were recently confronted with a case of fetal solid neck mass suggestive of teratoma, which proved postnatally to be a neuroblastoma. Combining this case with a review of recent literature, we have evaluated the diagnostic tools required for increased precision in the prenatal diagnosis and perinatal management of fetal solid neck masses.

RESULTS

Detailed ultrasound and MRI of fetal neck and liver, in conjunction with amniocentesis for measurement of homovanillic acid levels, should enable fetal medical practitioners to consider the diagnosis of fetal cervical neuroblastoma.

CONCLUSION

Fetal cervical neuroblastoma is an extremely rare condition that has not been previously reported, but should be considered in the presentation of fetal solid neck masses.

Fetal therapy for giant hepatic cysts

Cystic mesenchymal hamartoma is an extremely rare, benign tumor. Rapid growth to a giant size can pose a threat not only in early childhood but also during fetal life. The experience with 2 antenatally diagnosed giant hepatic cysts with widely disparate approaches to management, treatment, and outcome is presented. A giant hepatic cyst was diagnosed on routine screening ultrasound scan. Because of its extremely massive size, the cyst was treated in utero with repeated aspirations, primarily for obstetric considerations. The infant did well, and the lesion was excised laparoscopically during the neonatal period. A second fetus with a giant hepatic cyst was not treated in utero, and the pregnancy continued to term. Nonimmune hydrops fetalis developed, and the fetus was delivered prematurely at 34 weeks. At birth, the infant was noted to have diffuse neurologic injury and no urine output despite normal-appearing kidneys. The lesion was excised during the neonatal period by open laparotomy. Observations at the time of surgery and pathologic studies of the placenta showed aneurysmal dilatation of the placental veins suggesting in utero compression of the fetal intraabdominal umbilical vein. The infant died shortly after birth. The experience with these 2 cases suggests the possibility that giant mesenchymal hamartoma diagnosed in utero may cause umbilical venous obstruction leading to ischemia during fetal life. Decompression of giant hepatic cysts may reverse this phenomenon and allow normal fetal development.