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Varlas VN, Cloțea EM, Varlas RG, Pop A, Peneș O, Crețoiu D, Dima V, Bălănescu L. Immature Sacrococcygeal Teratoma: A Case Report and Extensive Review of the Literature. Diagnostics (Basel) 2024; 14:246. [PMID: 38337762 PMCID: PMC10854813 DOI: 10.3390/diagnostics14030246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/11/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Immature sacrococcygeal teratoma represents a histological form with rapid tumor growth, a risk of premature birth, an enhanced rate of complications, an increased risk of recurrence, and a higher mortality rate than the mature type. Thus, prenatal diagnosis of immature forms would significantly improve the prognosis of these cases. To this end, we performed an extensive literature review on the diagnosis, therapeutic management, and follow-up of immature teratomas. Regarding this medical conduct, we also presented our case. In conclusion, the early identification of immature sacrococcygeal teratomas with or without other associated structural abnormalities and their correct therapeutic approach are basic principles for a favorable evolution of these cases.
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Affiliation(s)
- Valentin Nicolae Varlas
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (V.N.V.); (L.B.)
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania
| | - Eliza Maria Cloțea
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania
| | - Roxana Georgiana Varlas
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania
| | - Anca Pop
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (V.N.V.); (L.B.)
- Department of Clinical Laboratory, Food Safety, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania
| | - Ovidiu Peneș
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (V.N.V.); (L.B.)
- Department of Intensive Care, University Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania
| | - Dragoș Crețoiu
- Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
- Department of Genetics, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania
| | - Vlad Dima
- Department of Neonatology, Filantropia Clinical Hospital, 011132 Bucharest, Romania
| | - Laura Bălănescu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (V.N.V.); (L.B.)
- Department of Pediatric Surgery, Children Emergency Hospital “Grigore Alexandrescu”, 011743 Bucharest, Romania
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Salim A, Raitio A, Losty PD. Long-term functional outcomes of sacrococcygeal teratoma - A systematic review of published studies exploring 'real world' outcomes. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:16-20. [PMID: 36127201 DOI: 10.1016/j.ejso.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/02/2022] [Indexed: 01/24/2023]
Abstract
Sacrococcygeal teratoma (SCT) is a rare neoplasm affecting 1:35,000 newborns. Long-term follow-up from small observational studies report impaired bladder/bowel function. This current study comprehensively analyses all published studies to better define true long-term functional sequelae. Medline/Embase databases were searched with PRISMA guidelines. Final analysis yielded 37 studies involving 1116 patients (854 female; 77%). Individual datasets were available in 14 studies (222 patients). According to Altman classification - 298/845 (35%) were Type I, 252/845 (30%) Type II, 133/845 (16%) Type III, and 128/845 (15%) Type IV tumours. Most neoplasms were benign (640/858; 75%), 77/858 (9%) immature and 141/858 (16%) malignant. Abnormal bladder function was reported in 7/39 (18%) Altman Type I, 23/61 (37.7%) Type II, 11/34 (32.4%) Type III, and 15/25 (60%) Type IV cases (p = 0.007). Adverse urological outcomes were notably common in immature/malignant neoplasms vs benign tumours and in patients requiring reoperation(s); p = 0.002 and p = 0.01. Bowel dysfunction was evident in 19% index cases and constipation in 26% with no significant association(s) with tumour characteristics. Higher Altman stage, unfavourable tumour biology and reoperation are associated with poor functional outcome(s). Multidisciplinary management from primary diagnosis of SCT is crucially important for all patients to best optimise functional outcomes across surgical specialities.
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Affiliation(s)
- Adeline Salim
- Department of Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Arimatias Raitio
- Department of Paediatric Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Paul D Losty
- University of Liverpool, Liverpool, United Kingdom; Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Fumino S, Tajiri T, Usui N, Tamura M, Sago H, Ono S, Nosaka S, Yoneda A, Souzaki R, Higashi M, Sakai K, Takahashi K, Sugiura T, Taguchi T. Japanese clinical practice guidelines for sacrococcygeal teratoma, 2017. Pediatr Int 2019; 61:672-678. [PMID: 30903638 DOI: 10.1111/ped.13844] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/04/2019] [Accepted: 03/14/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sacrococcygeal teratoma (SCT) is the most common extragonadal germ cell tumor in neonates and infants. Although most cases of infantile SCT are benign tumors by nature, some develop into extremely large lesions, leading to massive bleeding, high-output heart failure, disseminated intravascular coagulation, and even fatal outcomes during the neonatal period. In addition, some patients may present with tumor recurrence, malignant transformation, long-term sequelae (including bladder and bowel dysfunction) and lower leg palsy during the long-term follow up. SCT, however, is very rare, and there are few opportunities to encounter this disease, therefore general physicians without expert credentials currently lack information relevant to clinical practice. For this reason, the research project committee has compiled guidelines concerning SCT. METHODS The purpose of these guidelines was to share information concerning the treatment and follow up of infantile SCT. The guidelines were developed using the methodologies in the Medical Information Network Distribution System. A comprehensive search of the English- and Japanese-language articles in PubMed and Ichu-Shi Web identified only case reports or case series, and the recommendations were developed through a process of informal consensus. RESULTS The clinical questions addressed the risk factors, the efficacy of cesarean section, the initial devascularization of tumor feeding vessels, interventional radiology, recommended clinical studies for follow up and possible long-term complications. CONCLUSIONS These are the first guidelines for SCT to be established in Japan, and they may have huge clinical value and significance in terms of developing therapeutic strategies and follow up, potentially contributing to the improvement of the prognosis and quality of life of SCT patients.
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Affiliation(s)
- Shigehisa Fumino
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tatsuro Tajiri
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Masanori Tamura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Haruhiko Sago
- Department of Maternal-Fetal and Neonatal Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Shigeru Ono
- Department of Pediatric Surgery, Jichi Children's Medical Center Tochigi, Jichi Medical University, Tochigi, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Akihiro Yoneda
- Department of Pediatric Surgery, Osaka City General Hospital, Osaka, Japan
| | - Ryota Souzaki
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mayumi Higashi
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kohei Sakai
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ken Takahashi
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Sugiura
- Department of Pediatrics, Toyohashi Municipal Hospital, Aichi, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Sacrococcygeal yolk sac tumor developing after teratoma: a clinicopathological study of pediatric sacrococcygeal germ cell tumors and a proposal of the pathogenesis of sacrococcygeal yolk sac tumors. J Pediatr Surg 2013; 48:776-81. [PMID: 23583133 DOI: 10.1016/j.jpedsurg.2012.08.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Revised: 08/22/2012] [Accepted: 08/23/2012] [Indexed: 11/22/2022]
Abstract
PURPOSE We evaluated the clinicopathological characteristics of pediatric sacrococcygeal germ cell tumors (SGCTs) and yolk sac tumors (YSTs) developing after sacrococcygeal teratoma (SCT) resection, and discussed the pathogenesis of sacrococcygeal YST. METHODS We retrospectively analyzed pediatric SGCT patients attending 10 Japanese institutions. RESULTS A total of 289 patients were eligible, of which 74.6% were girls. The mean age at surgery was 7.1months. There were 194 mature and 47 immature teratomas, and 48 YSTs. YST developed after SCT resection in 13 patients (5.4% of SCTs), and was detected between 5 and 30months after resection. At initial surgery, 9 of these 13 patients were neonates, 12 underwent gross complete resection with coccygectomy, and 9 had histologically mature teratoma without microscopic YST foci. Postoperative serum alpha-fetoprotein (AFP) levels were regularly examined in 11 patients. Intervals of AFP measurement≤4months helped to detect subclinical localized YSTs for resection. CONCLUSIONS The characteristics of SGCT in Japanese children were similar with those reported in Europe or the United States. YST developed after SCT resection not only in patients with previously reported risk factors. We recommend that patients undergo serum AFP monitoring every 3months for≥3years after SCT resection.
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Hager T, Sergi C, Hager J. Sacrococcygeal Teratoma – a single center study of 43 years (1968–2011) including follow-up data and histopathological reevaluation of specimens. Eur Surg 2012. [DOI: 10.1007/s10353-012-0098-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Berger M, Heinrich M, Lacher M, Hubertus J, Stehr M, von Schweinitz D. Postoperative bladder and rectal function in children with sacrococcygeal teratoma. Pediatr Blood Cancer 2011; 56:397-402. [PMID: 21061314 DOI: 10.1002/pbc.22887] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In patients with sacrococcygeal teratoma, the location of the tumor and surgical intervention affects bladder and rectal function. However, there are no clear guidelines for postoperative assessment of bladder function, and the literature on this subject is scarce especially for children requiring multiple surgical interventions. The aim of this study is to evaluate postoperative bladder and rectal function in children with sacrococcygeal teratoma. METHODS Retrospective analysis was performed of 25 patients (6 male, 19 female) with sacrococcygeal teratoma operated at our institution from 1998 to 2009. Functional assessment of the bladder and rectum was carried out by clinical follow-up, rectomanometry, and urodynamic studies. Data of 24 children were available for follow-up. RESULTS Of the 24 children, twelve had bladder dysfunction (50%). Ten children (42%) required more than one surgical intervention. Of the 14 children operated on only once, three developed bladder dysfunction (21%), compared to nine of the 10 children who underwent multiple surgical interventions (90%). All four Altman stages were represented, and bladder dysfunction was found for all tumor types. All children with clinical bladder dysfunction showed abnormalities on urodynamic studies, with seven cases of neurogenic bladder. In contrast, no rectal dysfunction was found. CONCLUSIONS Bladder dysfunction is a common risk of sacrococcygeal tumors. The risk increases particularly if multiple surgical interventions are needed in order to excise the tumor. Therefore, the need for meticulous and complete excision upon first intent is crucial in order to avoid bladder dysfunction.
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Affiliation(s)
- Michael Berger
- Department of Pediatric Surgery, Dr. von Hauner Childrens Hospital, Munich, Germany.
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Aniba K, Ghannane H, Lmejjati M, Ouali M, Jalal H, Ousehal A, Ait Benali S. [Benign sacrococcygeal teratoma in a child: a case report with a review of the literature]. Arch Pediatr 2009; 16:1467-9. [PMID: 19748243 DOI: 10.1016/j.arcped.2009.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Revised: 09/03/2008] [Accepted: 07/21/2009] [Indexed: 11/18/2022]
Abstract
Sacrococcygeal teratomas are rare congenital tumors, generally discovered at birth. These tumors are seldom observed in children. Radical resection must be performed to avoid potentially malignant recurrence even if the primary lesion is benign. We report a case in an 8-year-old girl who did not have a past medical history. Since the age of 2 years, she presented a progressive sacral tumefaction with no neurological deficit. The MRI showed a large sacrococcygeal cyst in hypointense-signal T1-weighted imaging with no contrast enhancement, and a hyperintense signal in T2-weighted imaging. At surgery, the tumor was totally removed. The intraoperative aspect was that of a viscous cyst. The histological study showed a sacrococcygeal teratoma.
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Affiliation(s)
- K Aniba
- Service de neurochirurgie, CHU Mohamed VI, poste Allal El Fassi, Marrakech, Morocco.
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Holcroft CJ, Blakemore KJ, Gurewitsch ED, Driggers RW, Northington FJ, Fischer AC. Large fetal sacrococcygeal teratomas: could early delivery improve outcome? Fetal Diagn Ther 2008; 24:55-60. [PMID: 18504383 DOI: 10.1159/000132408] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 04/02/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine if gestational age (GA) at delivery or tumor size impacts outcome in neonates with very large sacrococcygeal teratomas (SCTs). METHODS Retrospective chart review from 1990 to 2006 of live-born infants with very large SCTs, defined as diameters exceeding 10 cm. Data analyzed using the independent t test and Fisher's exact test, with p values <0.05 considered significant. RESULTS Nine infants with very large SCTs were identified. Six of the 9 infants survived, 4 of whom had evidence of early hydrops. Mean GA of survivors was 32.2 +/- 3.7 versus 31.7 +/- 0.6 weeks in nonsurvivors (p = 0.85). Infants with the largest SCTs did not survive. CONCLUSION Risks of preterm delivery must be weighed against complications from further enlargement of very large SCTs and against the risks of in utero intervention.
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Affiliation(s)
- Cynthia J Holcroft
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Bettaieb I, Bellil-Ben Haha S, Zemmel I, Braham E, Bellil K, Mekni A, Kchir N, Haouet S, Zitouna K. [Benign sacrococcygeal teratoma in an adult]. Neurochirurgie 2007; 53:299-302. [PMID: 17543350 DOI: 10.1016/j.neuchi.2007.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Accepted: 02/10/2007] [Indexed: 11/30/2022]
Abstract
Sacrococcygeal teratomas are rare congenital tumors generally discovered at birth. Exceptionally these tumors are observed in adults. Radical resection must be performed to avoid potentially malignant recurrence even if the primary lesion was benign. We report a case of a benign sacroccygeal teratoma diagnosed in a 25-year-old male and discuss clinical features, pathological considerations and treatment.
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Affiliation(s)
- I Bettaieb
- Service d'anatomie pathologique, hôpital La Rabta, 1007 Bab Saadoun, Tunis, Tunisie
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Ozkan KU, Bauer SB, Khoshbin S, Borer JG. Neurogenic Bladder Dysfunction After Sacrococcygeal Teratoma Resection. J Urol 2006; 175:292-6; discussion 296. [PMID: 16406929 DOI: 10.1016/s0022-5347(05)00012-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Indexed: 11/23/2022]
Abstract
PURPOSE SCT treatment in newborns consists of surgery and selective chemotherapy. Few reports document urological sequelae using this approach. This review focuses on the urological and neurourological findings following SCT treatment in the newborn period. MATERIALS AND METHODS We reviewed the records of all infants with SCT resected in early infancy who underwent urodynamic evaluation for bladder dysfunction between 1986 and 2004. The radiological, neurological and urodynamic findings, and postoperative incontinence management were analyzed. RESULTS We analyzed UDS of 14 patients who presented with urinary infection or incomplete bladder emptying after SCT resection. At the time of UDS an abnormal neurological examination was noted in 5 patients (36%). Detrusor overactivity was seen in 8 patients, underactivity in 2 and normal activity in 4. Abnormal urethral sphincter EMG potentials were observed in 7 of 13 patients (54%). Five of 13 patients (38%) had sphincter dyssynergia during voiding. Consequently, CIC was needed in 11 of the 14 patients (79%) to empty the bladder, of whom 5 also required anticholinergics to improve detrusor compliance and dryness. Only 3 patients voided spontaneously with normal bladder and sphincter function, of whom 2 were toilet trained. Hydronephrosis was seen in 6 patients and reflux was noted in 7 (including 5 of 6 with hydronephrosis). Antireflux surgery was performed in 6 patients, all of whom had up to grade 4 reflux due to recurrent urinary tract infection. One girl with grade 2 reflux had spontaneous resolution. CONCLUSIONS SCT and its treatment can produce neurourological dysfunction of the lower urinary tract with high grade reflux, and abnormal bladder and urethral function. Complete assessment, including urodynamic studies, is imperative preoperatively and postoperatively. Constant vigilance is required to maintain as near normal bladder function as possible and to prevent upper urinary tract injury.
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Affiliation(s)
- Keramettin Ugur Ozkan
- Department of Urology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts, USA
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Nieuwenhuijs JL, De Jong TPVM. Two cases of unusual urethral complications after resection of sacrococcygeal teratoma. J Pediatr Surg 2003; 38:E14-5. [PMID: 14614737 DOI: 10.1016/j.jpedsurg.2003.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This report describes 2 rare complications of a sacrococcygeal teratoma leading to urethral obstruction in 1 case and midurethral necrosis in the other. The anomalies appear to be based on pressure necrosis of the urethra by mechanical compression between the symphysis pubis and the teratoma.
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Affiliation(s)
- Jaap L Nieuwenhuijs
- Pediatric Renal Center, Wilhelmina Children's Hospital, UMC, Utrecht, The Netherlands
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Abstract
An extensive analysis of the existing literature concerning sacral tumors was conducted to characterize their clinical manifestations. Although certain specific manifestations can be attributed to some of the tumor types, a more general pattern of clinical presentation of an expansive sacral lesion can be elaborated. Local pain with or without pseudoradicular or radicular radiation is the most frequent initial symptom and is usually followed by the manifestation of a lumbosacral sensorimotor deficit; bladder/bowel and/or sexual dysfunction appear throughout the natural course of disease.
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Affiliation(s)
- Michael Payer
- Department of Neurosurgery, University Hopital of Geneva, Switzerland.
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Perrelli L, D'Urzo C, Manzoni C, Pintus C, De Santis M, Masini L, Noia G. Sacrococcygeal teratoma. Outcome and management. An analysis of 17 cases. J Perinat Med 2002; 30:179-84. [PMID: 12012641 DOI: 10.1515/jpm.2002.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS The authors compare their experience of 17 cases of sacrococcygeal teratoma (SCT) with the literature in an attempt to clarify the natural history of this tumor and to identify factors related to its prognosis and management. METHODS The obstetrical, neonatal and surgical data were analyzed for 17 cases of SCT observed between July 1985 and December 1998. RESULTS Three fetuses died in utero or shortly after birth. In the remaining 14, the tumors were removed. Twelve of the infants are currently tumor-free, with good sphincter control and lower-limb function. The remaining two died: one had a malignant tumor, and the other had a recurrence of an embryonal carcinoma. Recurrent tumors (mature histotypes) were also removed from two of the 12 patients who survived. CONCLUSIONS Benign SCTs generally have favorable prognosis. Negative prognostic factors for SCT include solid tumors, those detected early in pregnancy, malignant histotypes, polyhydramnios, placentomegaly, and fetal hydrops.
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Affiliation(s)
- Luigi Perrelli
- Division of Pediatric Surgery, Catholic University of The Sacred Heart, Rome, Italy
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GATTI JOHNM, PEREZ-BRAYFIELD MARCOS, KIRSCH ANDREWJ, SMITH EDWINA, MASSAD HALCSCHERZCHARLOTTEA, BROECKER BRUCEH. ACUTE URINARY RETENTION IN CHILDREN. J Urol 2001. [DOI: 10.1016/s0022-5347(05)66574-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- JOHN M. GATTI
- From the Division of Pediatric Urology, Emory University School of Medicine and Children’s Healthcare of Atlanta Hospitals, Atlanta, Georgia
| | - MARCOS PEREZ-BRAYFIELD
- From the Division of Pediatric Urology, Emory University School of Medicine and Children’s Healthcare of Atlanta Hospitals, Atlanta, Georgia
| | - ANDREW J. KIRSCH
- From the Division of Pediatric Urology, Emory University School of Medicine and Children’s Healthcare of Atlanta Hospitals, Atlanta, Georgia
| | - EDWIN A. SMITH
- From the Division of Pediatric Urology, Emory University School of Medicine and Children’s Healthcare of Atlanta Hospitals, Atlanta, Georgia
| | - HAL C. SCHERZ CHARLOTTE A. MASSAD
- From the Division of Pediatric Urology, Emory University School of Medicine and Children’s Healthcare of Atlanta Hospitals, Atlanta, Georgia
| | - BRUCE H. BROECKER
- From the Division of Pediatric Urology, Emory University School of Medicine and Children’s Healthcare of Atlanta Hospitals, Atlanta, Georgia
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