Intradural extramedullary mature cystic teratoma: not only a childhood disease

Long-Segment Intradural Extramedullary Teratoma of Dorsolumbar Spinal Cord in an Adolescent: A Rare Tumor with Review of Literature

Spinal intradural extramedullary teratomas are rare tumors arising from more than one germ cell layers and are more common in children than in older age groups. Teratomas are more commonly seen in intracranial compartment and are extremely rare in the spine. They are difficult to diagnose pre-operatively and the definitive diagnosis is usually done by histopathologic evaluation. Intraspinal teratomas should be considered in the differential diagnosis of any intradural extramedullary tumor of the spine. We reviewed the literature and reported a rare case of intradural extramedullary teratoma in an adolescent located in dorsolumbar spine without any history of prior spinal procedure.

Multiple Simultaneous Mature Teratomas of the Spinal Cord in an Adult

Teratomas of the spinal cord are rare tumors, particularly in adults, but there is an increasing body of literature documenting both their diagnosis and successful treatment with surgical resection. However, to date, the literature has largely characterized spinal teratomas as single solitary lesions. Here, we report on an adult patient who presented with signs of progressive lower extremity weakness. Imaging demonstrated two simultaneous lesions of the spine, an extramedullary lesion in the upper thoracic region and an intramedullary lesion in the mid-thoracic region. Both lesions were resected and pathologically determined to be mature spinal teratomas. To our knowledge, this is only the second report of this tumor presenting simultaneously at more than one location in the spine and the first time it has presented both as an intra-axial and extra-axial lesion. Our results suggest that the presence of more than one simultaneous lesion does not necessarily increase the risk of a more aggressive immature pathology.

Conus Medullaris Teratoma: Case Report and Literature Review

Teratomas are benign germ cell tumors that usually found out of their anatomical origin. Teratomas usually are found in sacrococcygeal area, gonads, mediastinum, cervicofacial region and intracranial fossa. Spinal teratomas are rare. In this study we describe a case of conus medullaris teratoma which was diagnosed based on imaging studies. The patient underwent surgery. We did bilateral laminectomy. The mass lesion had an obvious and rigid attachment to the conus medullaris. The wall of the lesion was resected as much as possible, but total resection of the lesion's wall could not be done due to changes in neural monitoring. Previous related studies are reviewed.

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.

Spinal Intradural Extramedullary Dermoid Cyst

BACKGROUND

Dermoid cysts are benign congenital tumors that develop early in life. These tumors are classified by the presence of all 3 germ layers. Spinal intradural extramedullary teratoma is a rare disease, which is more common in children under 5 years of age than in adults.

CASE DESCRIPTION

A 12-year-old girl with a dermoid cyst at the lower lumbar level presented with 2-month low back pain and intermittent lower extremity radicular symptoms on the right side. Magnetic resonance imaging scan of the spine revealed an intradural extramedullary mass lesion at L4-5. Surgical excision of the cyst was successfully performed. Surgical and histopathologic findings confirmed extramedullary ruptured matured teratoma. Postoperatively, the patient had remarkable clinical improvement.

CONCLUSIONS

Although dermoid cysts are uncommon, they should be considered in the differential diagnosis of spinal lesions in patients with lower back pain. It can be successfully treated with surgical excision.

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.

Adult Thoracic Intradural Exophytic Mature Teratoma: Case Report and Literature Review

Mature thoracic intraspinal teratomas are rare tumors in adults. In this case study, we present a case of intradural, extramedullary teratoma, which was surgically resected. A 50 year old man presented with progressive bilateral leg pain, severe myelopathy and weakness. Magnetic Resonance Imaging (MRI) revealed a cystic mass lesion in the T11-12 region region. Microsurgical resection of the tumor using CO² laser with neuromonitoring was performed. Postoperatively, the patient had a remarkable clinical improvement. Mature spinal teratomas are rare, slow growing spinal tumors. Surgical resection provides excellent recovery, and recurrence rates are low.

Totally cystic intradural schwannoma in thoracic region

Spinal schwannomas are benign intradural extramedullary tumors arising from spinal nerve root sheath. They are usually solid or heterogeneously solid. Totally cystic schwannomas are rare entities. Herein, we report a 60-year-old male presenting with backache radiating along the chest wall and weakness of both lower limbs. He had spastic paraparesis. Magnetic resonance imaging revealed a cystic mass in the thoracic region. At operation, the cystic mass was seen to be attached to D4 dorsal rootlets. It was excised in toto and histopathology confirmed it to be a schwannoma. The relevant literature is reviewed.

Upper Lumbar Mature Cystic Teratoma: A Case Report

BACKGROUND

Intradural extramedullary spinal teratoma (IEST) is a rare condition in adults, with a male predominance. It is commonly associated with spinal dysraphism, lumbar puncture, and previous spinal surgery. This case is a 37-year-old male diagnosed with a mature cystic IEST without dysraphism or previous surgical interventions.

CASE DESCRIPTION

The patient's symptoms included a lumbar backache that progressed to the toes, as well as the anterior region of both thighs. Subsequently, he could not walk for >3 minutes and experienced saddle paresthesias, heaviness, and numbness in both lower limbs. The teratoma was diagnosed by magnetic resonance imaging (MRI), which showed a mixed signal intensity mass with a fatty component in the conus medullaris at the L1-L2 level. The treatment strategy included total surgical excision of the teratoma, followed by histopathological examination, at which the mass was diagnosed as a mature cystic teratoma. On postoperative follow-up, the patient reported urinary and fecal incontinence. Neurologic examination of both the lower limbs revealed hyperreflexia of the left knee and atrophy of the left calf muscles, but no residual mass at the site of surgery.

CONCLUSIONS

MRI is a standard tool for diagnosing IEST, but the diagnosis is confirmed by histopathological examination. Total surgical excision is the treatment of choice, but when adhesions to the neural tissue are present, subtotal excision should be attempted. The patient should be followed up with serial clinical and radiologic examinations to ensure the absence of residual mass at the site of surgery.

Spinal intradural extramedullary mature cystic teratoma in an adult: A rare tumor with review of literature

Background:

Spinal intradural extramedullary teratoma is a rare condition, more common in children than in adults often with a history of spinal dysraphism.

Method:

We reviewed the literature and Pubmed advanced search showed nine results of intradural extramedullary teratoma in adults which included five independent case reports and three cases in a case series. We reported a rare case of intradural extramedullary teratoma in an adult located opposite L4 vertebra with neither spinal dysraphism nor any history of the prior spinal procedure.

Results:

The occurrence of teratomas in the spine is extremely rare. Further, spinal intradural extramedullary teratoma is more common in children but a rare entity in adults.

Conclusion:

Although uncommon, spinal cord neoplasm should be considered in the differential diagnosis of backache or radicular pain associated with neurological deficits even in absence of spinal dysraphism or any spinal procedure.

Subtotal resection of an intradural mature teratoma in an adult presenting with difficulty initiating micturition

Background:

Teratomas are tumors comprised of tissues from all three germ layers. Teratomas within the spine are exceedingly rare especially in the absence of either spinal dysraphism, congenital abnormalities of the spine, spinal surgery, or history of lumbar punctures. Virchow was the first to describe this occurrence in the spine in 1863 and since then, only a handful of cases have been reported.

Case description:

A 41-year-old male presented with a longstanding history of difficulty initiating micturition and lower back pain with recent onset of saddle paraesthesia and bilateral leg pain. He did not have a history suggestive of spinal trauma nor congenital abnormalities. Neurological examination was unremarkable. Magnetic resonance imaging (MRI) confirmed the presence of an intradural extra axial lesion in the region of the cauda equine. At surgery, the lesion was found to be densely adherent to the conus and a subtotal resection was performed. Histological examination confirmed the lesion to be a mature teratoma. Postoperatively, he made a good recovery and there is no evidence of recurrence at one year follow-up.

Conclusion:

This case demonstrates that a teratoma without immature elements can be subtotally excised to reduce the risk of neurological morbidity.

Mature teratoma of the spinal cord in adults: An unusual case

Intraspinal mature teratomas rarely occur in adults. The present study describes an unusual case of adult intradural mature teratoma, which was completely resected. A 22-year-old female presented with an intermittent pinching pain in the lower right shank that had lasted for three months. Magnetic resonance imaging (MRI) results indicated a multicystic mass extending from the T12 to L2 vertebrae, and the tumors were certified as teratomas by a histopathological examination. The level of pain experienced by the patient was improved following the surgery. The present study also compared the literature concerning adult intradural mature teratoma, summarized the basic clinical characteristics and theory of origin of adult intradural mature teratoma and reviewed the available treatments for this disease.

Intradural lumbar mature teratoma with neuronal and glial tissue component in an adult. Case report

A 23-year-old Chinese male patient presented with an extremely rare case of spinal teratoma with neuronal and glial tissue components manifesting as lower back pain and radiating pain to the leg. Subtotal excision of the tumor was conducted. Histological examination revealed a mature teratoma with neuronal and glial tissue components. Initial presentation of spinal teratoma in adulthood is rare. Teratomas show a wide array of organoid tissue differentiation, but neuronal tissue component is uncommon.

Spinal epidural teratoma: review of spinal teratoma with consideration on the pathogenesis: case report

BACKGROUND AND IMPORTANCE

Of the 170 cases of teratomas in the spinal canal reported in the English literature, only 13 were spinal epidural teratomas (SETs). We present a case of SET, review the characteristics of SETs in comparison with spinal intradural teratomas (SITs), and investigate the pathogenesis of spinal teratoma.

CLINICAL PRESENTATION

A 17-month-old boy visited our clinic with paraparesis. A multicystic mass was noted in the left epidural space from T8 to T10 and the left paraspinal area. Complete resection of the tumor, including the paraspinal portion, was accomplished by laminoplastic laminotomy. The tumor was well encapsulated and filled with heterogeneous contents. The tumor was suspected to originate from the left T9 root.

CONCLUSION

On histopathological examination, the tumor was found to be a mature teratoma. The clinical characteristics of SETs and SITs show similarities in age, male preponderance, location, associated anomalies, and pathology. SETs and SITs are probably 2 different types of a single disease entity. Pluripotent somatic cell from the Hensen's node and caudal cell mass is the probable origin of spinal teratoma. However, originating from misplaced primordial germ cell could not be excluded.

[A case of cervical intradural extramedullary mature cystic teratoma: diagnosis and management]

Spinal intradural extramedullary teratoma is a rare condition that develops more commonly in children than in adults. It may be associated with spinal dysraphism. We report an exceptional case of adult-onset intradural extramedullary teratoma of the cervical spinal cord and bulbomedullary junction with no evidence of spinal dysraphism and no history of previous spinal surgery and/or lumbar puncture. The patient was a 38-year-old woman whose chief complaint was progressive installation of a tetraparesis. Magnetic resonance imaging showed a cystic tumor on both sides of the foramen magnum compressing the bulbomedullary junction. The tumor was totally surgically resected. The histopathological diagnosis was a mature teratoma.

Spinal teratomas: a clinico-pathological study of 27 patients

BACKGROUND

Spinal cord teratomas are uncommon tumours. The diagnosis is rarely suspected before surgery and final diagnosis is invariably made at histopathological examination.

METHODS

We retrospectively analysed our neuropathology records for the last 20 years and all patients diagnosed as spinal teratomas were retrieved. The clinical and radiological features were noted. Slides were reviewed and the diagnosis was confirmed.

FINDINGS

During a period of 20 years, we found 27 examples of spinal teratomas. There was a wide age range and 37.3% presented in adulthood. Male predominance was observed both in children as well as adults. The dorso-lumbar location was common in children as well as in adults but an intramedullary location, in association with a myelomeningocele and split cord malformation, was more common in children. Twenty one patients had associated features of spinal dysraphism. Of the six who were not associated with this, five were adult patients. Radiologically mixed solid and cystic morphology, fat signal and areas of calcification were seen in one third of patients. All tumours except one showed benign (mature) components. Interestingly, two lesions contained mature renal tissue: one exhibited pulmonary differentiation and one had Wilm's tumour as a component of the teratoma. In five patients the initial sections showed epidermis with skin adenexal structures and a diagnosis of dermoid cyst was suspected but serial sectioning revealed other teratomatous components. All patients were treated with surgical excision.

CONCLUSION

Although there are no specific features on imaging, mixed solid and cystic morphology, fat signal and areas of calcification are helpful in the pre-operative diagnosis. Most of these lesions are diagnosed on histopathological examination after surgery and therefore thorough sampling and serial sectioning are mandatory to identify all components of the teratoma in order to avoid misdiagnosis.

Spinal intradural extramedullary mature cystic teratoma in an adult

Spinal intradural extramedullary teratoma is a rare condition that develops more commonly in children than in adults and may be associated with spinal dysraphism. We report a rare case of adult-onset intradural extramedullary teratoma in the thoracolumbar spinal cord with no evidence of spinal dysraphism and without the history of prior spinal surgery. The patient was a 38-year-old male whose chief complaint was urinary incontinence. X-ray images of the thoracolumbar spine showed the widening of the interpedicular distance and posterior marginal erosion of the vertebral bodies and pedicles at the T11, T12, and L1 level. Magnetic resonance imagings of the lumbar spine showed a lobulated inhomogeneous high signal intradural mass (87x29x20 mm) between T11 and L1 and a high signal fluid collection at the T11 level. Laminectomy of the T11-L1 region was performed, and the mass was subtotally excised. The resected tumor was histopathologically diagnosed as a mature cystic teratoma. The patient's symptom of urinary incontinence was improved following the surgery.