[Preoperative Diagnosis of Spinal Immature Teratoma Associated with Cerebrospinal Fluid Leakage from the Congenital Dermal Sinus Tract in a 0-Day-Old Infant:A Case Report]

We report the case of a patient with spinal immature teratoma and cerebrospinal fluid leakage from the congenital dermal sinus tract. A 0-day-old female infant presented with a subcutaneous soft mass with a dimple in the lumbosacral region at birth. Magnetic resonance imaging revealed a mixed low-intensity mass located in the extraspinal and intraspinal canal with a sinus tract. The reconstructed three-dimensional spinal computed tomography image showed spina bifida and ectopic ossification at the dorsal aspect of the sacrum. Urgent removal of the tumor and dermal sinus tract was then performed under evoked electromyography monitoring. The resected tumor was histopathologically diagnosed as immature teratoma.

[Internally situated sacrococcygeal teratomas, often invisible but not harmless]

A sacrococcygeal teratoma (SCT) may be completely concealed within the pelvis and therefore not be visible externally. Symptoms of such an SCT can be very aspecific. We present 4 patients with an intrapelvic SCT. The first patient, a newborn girl, had an antenatally-diagnosed cystic mass in her pelvis, which was a benign SCT. After removal she suffered from neurogenic bladder dysfunction. The second patient was a 2-year-old boy who after two incomplete resections of a benign intrapelvic SCT, developed a malignant SCT. The other 2 patients, 2 girls aged 4 and 15 years, both presented with constipation and abdominal pain and were diagnosed as having an SCT. Early detection and radical excision, including removal of the os coccygis, are necessary to prevent development of malignancy. Long-term functional sequelae can occur after excision.

Extragonadal teratomas presenting at birth and originating from 3 different sites--a report of 3 cases

Three cases of extragonadal teratomas presented at birth and all the cases arisen from three separate sites are reported in the present study. A huge sacrococcygeal teratoma is being reported and the other two retroperitoneal and nasopharyngeal teratomas, are reported for the rarity of their location in neonatal period. Teratomas of all three babies were mature benign on histopathology and surgical removal sufficed as mode of treatment. No recurrence was noted on follow-up.

Hereditary sacrococcygeal teratoma--not the same as its sporadic counterpart!

Sacrococcygeal teratoma (SCT) can be sporadic or familial and there appear to be different characteristics to these entities. It can be an isolated anomaly or occur as part of the Currarino triad, when it is associated with anorectal malformations and sacral anomalies. We present a case of familial sacrococcygeal teratoma and discuss its relationship to previously published reports, drawing conclusions regarding embryogenesis, diagnosis, screening and management.

Congenital Anomalies of the Spine

The complexity of the congenital anomalies of the spine can make the neuroradiologic diagnosis challenging. Knowledge of spinal embryology greatly helps in the understanding and classification of these anomalies. We use the classification devised by Tortori-Donati and Rossi and find it helpful from clinical and imaging standpoints. We believe that most patients who have known or suspected congenital spinal anomalies benefit from MR imaging.

Prognostic factors affecting urologic outcome after untethering surgery for lumbosacral lipoma

OBJECTS

The authors report results of preoperative and postoperative urodynamic studies (UDS) and prognostic factors of urologic outcome in cases of lumbosacral lipomas for which prolonged follow-up data were available.

MATERIALS AND METHODS

The present series includes 42 consecutive cases of lumbosacral lipoma in patients aged 2 months to 15 years who underwent untethering operation during the period from 1986 to 1997. All of them underwent preoperative and postoperative UDS. At the last follow-up (mean duration of follow-up 108 months, range 44 to 176 months), 26 cases maintained social continence with or without intermittent catheterization. Young age (< or =12 months) at operation, preoperative absence of urologic symptoms, and absence of neurologic abnormalities were significantly correlated with favorable urologic outcome.

CONCLUSION

UDS in cases with lumbosacral lipomas is a valuable tool for detecting neurourologic abnormalities as well as for monitoring the postoperative course and guiding management. History taking and neurologic examination are also proved to be important aspects in the evaluation of children with lumbosacral lipomas, predictive of urologic outcome. Better urologic results are anticipated if surgery is performed when the child is 12 months old or younger.

Spinal hamartoma associated with spinal dysraphism

OBJECTS

The aims of the study were (1) to review the pathological findings of spinal lipomatous masses associated with congenital spinal dysraphism and (2) to discuss the pathological diagnosis.

METHODS

The pathological records of 47 patients at our institution were reviewed, and three illustrative cases were presented.

CONCLUSION

Spinal tumorous lesions associated with spinal dysraphism have been traditionally described as lipoma since they are composed mostly of fatty tissue. However, they are different from lipomas arising in other part of the body in that they often contain various tissues of ecto- and mesodermal origin. In our study, we detected such heterotopic components in 24 out of 47 cases. Although they are also similar to teratoma, it is generally accepted that they are malformative lesions which lack neoplastic potential. We therefore should diagnose them as hamartoma rather than lipoma or teratoma.

Ruptured occipitocervical teratoma mimicking an upper cervical myelomeningocele. Case report

Occipitocervical teratoma is an extremely rare condition, and only a few cases have been reported. The authors report on a neonate who harbored a ruptured posterior midline occipitocervical lesion that mimicked an upper cervical myelomeningocele, although the pathological findings were diagnostic of teratoma.

[Extrathoracal pulmonary sequestration in the differential diagnosis of paravertebral tumors in the neonate]

BACKGROUND

Paravertebral masses of the fetus are often detected during routine prenatal ultrasonography. The most common differential diagnoses of these tumors are neuroblastoma, adrenal hemorrhage, schwannoma and germ cell tumors.

CASE REPORT

We report on a mature male newborn, who was diagnosed antenatally at 23 + 3 weeks of gestation with a tumor in the left paravertebral region. After birth the child was transferred to a neonatal unit. Tumor markers like urinary catecholamines were within normal limits, neuron-specific enolase was slightly elevated. MRI as well as ultrasonography confirmed a 3.2 x 2.2 x 1.6 cm large smoothed edged tumor in the left paravertebral region at the level of T10-T12. An open biopsy was performed, and the tumor which was located below the diaphragma was subtotally resected. Histopathology showed an extralobar pulmonary sequestration. Surgery as well as postoperative course was uneventful.

CONCLUSIONS

Extralobar pulmonary sequestrations represent rare congenital anomalies, which are usually asymptomatic. Clear differentiation between tumor and pulmonary sequestration is seldom possible despite high resolution imaging studies. Hence, a biopsy procedure should be done for diagnosis of paravertebral masses.

Lumbar teratoma presenting intradural and extramedullary extension in a neonate

BACKGROUND CONTEXT

The association of teratomas and spinal malformations such as spina bifida, partial sacral agenesis, hemivertebrae, and diastematomyelia has been described in the literature. Reported cases, however, are mainly presacral or sacrococcygeal with an extremely rare presentation of intradural extension.

PURPOSE

A case of lumbar teratoma with an intradural extension and extramedullary component and the clinical outcome following surgical treatment are reported.

STUDY DESIGN/SETTING

To our knowledge, among the reported teratoma cases with an intradural extension and extramedullary component, our case has a distinguishing feature regarding the involvement of the lumbar spine. It is also the first case, showing no neurological deficit during the postoperative period.

METHODS

A full-term, female infant presented with a 30 x 30 x 10 mm lumbar mass covered with normal skin. The mass contained an irregular, bone-like, hard and mobile material accompanying cystic components. Magnetic resonance imaging revealed a total closure defect of the first and second lumbar laminae and a subcutaneous mass with intradural extension. The lesion was found to penetrate the dural sac through an extended exposure from T12 to L3. There was no firm attachment of the intradural, extramedullary component of the lesion. Total removal of the tumor was achieved.

RESULTS

The patient was discharged on day 7 without any neurological deficit or sign of hydrocephalus. The pathological examination showed a benign teratoma containing mature cartilage, muscle, adipose tissue, and glandular tissue. Follow-up at 2 years showed no recurrence or neurological deficit and a normal sphincter tone. Urodynamic evaluation was within normal limits.

CONCLUSION

Accompanying a spinal dysraphic state, the mature teratoma in our case may support the idea of a tumor actually arising from a dysraphism and growing outward to produce the mass.

A case of type III cystic sacrococcygeal teratoma

We report a rare case of congenital type III cystic teratoma that may be falsely diagnosed as an anterior sacral meningocele. A female newborn baby presented with a long, white-colored 4 x 1 cm coccygeal cyst posterior to the anus. Magnetic resonance imaging (MRI) demonstrated that a 10 x 4 cm elliptical intrapelvic and -abdominal mass anterior to the sacrum and coccyx extended inferiorly to the retrorectal space. We intraoperatively found that the cyst consisted of a mostly thin, white wall, but also with small posterior narrow nodules. We suggest that all cysts in the sacrococcygeal area should be excluded from teratoma carefully, with MRI.

[Fetal surgery]

Fetal surgery is a newly evolving multidisciplinary medical field, being performed in specialized centers. It deals with the treatment of selected fetuses with congenital anomalies that cause high morbidity and mortality. The aim of the surgical treatment is to avoid the development of progressive and eventually irreversible damage at birth. Examples of entities treated are obstructive uropathy leading to renal insufficiency, lung hypoplasia in severe congenital diaphragmatic hernia, severe congenital cystic adenomatoid malformation of the lung, and sacrococcygeal teratoma. This review describes principles of fetal surgery, physiopathologic processes of some of the anomalies treated in this way, and diagnostic and therapeutic approaches. Recently published results are presented and discussed.

Congenital teratoma: a clinicopathologic study of 22 fetal and neonatal tumors

Extragonadal teratoma is the most common congenital tumor. The prognostic significance of the grade of immaturity and the presence of small foci of conventional yolk sac tumor (YST) in fetal and neonatal teratomas have not been determined. We report detailed histologic studies of 22 congenital teratomas, including eight tumors resected in utero for developing hydrops, and correlate the histologic features with initial serum alpha-fetoprotein (AFP) levels and clinical outcome. All fetal tumors that required in utero intervention were grade 3 immature teratomas, with admixed conventional YST in 44%. Among tumors resected postnatally, those presenting in utero were more commonly immature (71% vs. 50%). All initial post-surgical serum AFP levels were high, as expected in a neonate. No correlation was found between AFP elevation above the mean for gestational age and the presence of YST, hepatic differentiation, or immature endodermal glands in the tumor. Among 15 survivors with follow-up, 5 patients had malignant mixed germ cell tumors (immature teratoma with foci of conventional YST) and 5 had immature teratomas with foci of hepatic differentiation or immature endodermal glands with subnuclear vacuoles (so-called "well-differentiated YST"). No patient has developed recurrent or metastatic disease after treatment by complete surgical excision alone (mean follow-up, 37.6 months). The clinical behavior of congenital teratomas is determined predominantly by whether or not the tumor can be completely resected and in our study did not correlate with the grade of the teratoma or with the presence or absence of foci of hepatic tissue, immature intestinal glands, or foci of conventional YST.

Spinal Arachnoid Cyst Containing Nevus Cells in a Patient with a Large Congenital Melanocytic Nevus: Case Report

OBJECTIVE AND IMPORTANCE:

Spinal arachnoid cysts are rare, and their cause and pathogenesis remain controversial. We experienced a rare case with a large congenital melanocytic nevus in which a spinal arachnoid cyst contained nevus cells, suggesting the congenital nature of a spinal arachnoid cyst.

CLINICAL PRESENTATION:

A 37-year-old Japanese man had been born with a large melanocytic nevus on his back. He experienced intermittent pain radiating to both thighs and to the lower back and waist. A magnetic resonance imaging study disclosed the presence of a posterior intradural extramedullary arachnoid cyst extending from T10 through T12. His spinal cord was displaced anteriorly and flattened.

INTERVENTION:

An osteoplastic laminoplasty was performed, and the arachnoid cyst was totally removed. The cyst membrane exhibited many foci of brown deposits, and histological examination disclosed the presence of melanin-containing cells in the cyst membrane. Morphologically and immunohistochemically, the melanin-containing cells in the cyst membrane were similar to nevus cells in the dermis.

CONCLUSION:

The histological findings of our case suggest that the patient's spinal arachnoid cyst was formed at the same stage of development as the melanocytic nevus.

[Posteromedial bowing of the lower leg and neuroblastoma with possible neurofibromatosis type I: a case report and literature review]

BACKGROUND

The posteromedial bowing of the tibia is a rare condition that is not yet known to be related to neurofibromatosis. The case of a three month-old boy with the tentative diagnosis of neurofibromatosis is described. He developed paraplegia due to an abdominal neuroblastoma at the age of 9 months. This led us to a review of the literature.

METHOD

122 cases of posteromedial bowing of the tibia in 20 publications of the years 1949 - 2000 were analysed under special respect to gender, side of affection, shortening of the lower leg, treatment and possible cause.

RESULTS

The posteromedial bowing of the lower leg seems to affect more boys as well as the left side. As far as described in all but one case it was the first delivery. Regularly, a limb shortening and pes calcaneovalgus is to be found. 99 children were treated conservatively, 21 got an operation of the affected side. In 19 performed osteotomies no pseudarthrosis occurred. One case of a fracture due to an adequate trauma without healing problems is described.

Conservative Management of Asymptomatic Spinal Lipomas of the Conus

OBJECTIVE

The natural history of spinal lipomas of the conus (SLCs) has not been well studied. Because of disappointing long-term results with early surgical treatment of asymptomatic children with SLCs, we have followed a protocol of conservative management for these patients. The results are presented in this report.

METHODS

Since 1994, all asymptomatic children with SLCs who were examined at Necker-Enfants Malades Hospital were subject to a protocol of conservative management. The records for those patients were reviewed, to determine the incidence and timing of neurological deterioration. The findings were compared with those for a previously reported historical cohort of asymptomatic patients who underwent early surgery at our institution.

RESULTS

Fifty-three asymptomatic children (35 girls and 18 boys) with SLCs were monitored, with conservative management. During a mean follow-up period of 4.4 years (range, 12 mo to 9 yr), 13 patients (25%) exhibited neurological deterioration. At 9 years, the actuarial risks of deterioration, as determined with the Kaplan-Meier method, were 33% for the conservatively treated patients and 46% for the surgically treated patients. With a Cox proportional-hazards model, there was no significant difference in the risks of neurological deterioration for patients who were treated conservatively and those who underwent early surgery.

CONCLUSION

The incidences and patterns of neurological deterioration seemed to be very similar, regardless of whether early surgery was performed. These results suggest that conservative treatment of asymptomatic patients is a reasonable option. A more definitive randomized study will be required to clarify the relative efficacy of early surgery for SLCs among asymptomatic patients.

Congenital disseminated malignant rhabdoid tumor and cerebellar tumor mimicking medulloblastoma in monozygotic twins: pathologic and molecular diagnosis

Malignant rhabdoid tumors are highly aggressive childhood tumors. Recently, all of the malignant rhabdoid tumors, whatever their location, have been related to the inactivation of the hSNF5/INI1 gene. A subset of cerebral tumors, associated with malignant rhabdoid tumors or isolated ones arising in siblings, showed similar molecular alterations. We report for the first time in monozygotic twins a congenital disseminated malignant rhabdoid tumor in one twin and a cerebellar tumor mimicking a medulloblastoma in the other. Molecular analysis revealed similar alterations for both tumors: a deletion of exon 7 of the hSNF5/INI1 gene in one allele, and a point mutation in the same exon in the other, suggesting a common genetic pathway. Analysis of constitutional DNA revealed a germline mutation. These findings are in favor of a common etiology for rhabdoid tumor and a subset of brain tumors developing in infancy.

The human tail associated with intraspinal lipoma: case report

A case of a tail in a 9-month-old baby is reported. Computed tomography and magnetic resonance imaging clearly demonstrated the presence of spina bifida and lipoma continuous from the tail to the spinal canal. A few medical-historical aspects are discussed. The human tail may be related to spinal dysraphism and requires detailed neuroimaging investigation and microsurgery.

[Sacrococcygeal teratoma in obstetrics]

MATERIALS/METHODS

5 fetuses with prenatally diagnosed sacrococcygeal teratoma at the Department of Prenatal Diagnosis and Therapy during a 30-month period. Modified splint technique according to Duzin, following a Pfannenstiel's incision in 4 cases.

RESULTS

4 infants with uninjured tumor could be transferred to pediatric surgery for treatment.

CONCLUSIONS

The modified splint technique according to Duzin can be applied particularly in the case of a big tumor.

Prenatal diagnosis and perinatal management of fetal sacrococcygeal teratoma

Sacrococcygeal teratoma is the most common fetal neoplasm, with an incidence of 1 in 40,000 births. Fetuses with this malformation are at risk for significant perinatal morbidity and mortality. We identified nine fetuses with sacrococcygeal teratomas that were diagnosed antenatally and managed at the University of North Carolina Hospitals over a 7-year period. We retrospectively reviewed the charts of mothers and infants and recorded data concerning perinatal and surgical management. Six infants survived the neonatal period. All infants diagnosed after 20 weeks' gestation survived. Fetal hydrops developed in three fetuses, all of whom died. Inadequate ventilation secondary to prematurity was a contributing factor in each lethal case. Diagnosis at an early gestational age, development of fetal hydrops, and premature delivery predicted a poor prognosis. When possible, we recommend that delivery be delayed to allow for fetal development. Stabilization of the infant should be attempted before resection of the teratoma.

Prenatal diagnosis and perinatal management of fetal sacrococcygeal teratoma

Sacrococcygeal teratoma is the most common fetal neoplasm, with an incidence of 1 in 40,000 births. Fetuses with this malformation are at risk for significant perinatal morbidity and mortality. We identified nine fetuses with sacrococcygeal teratomas that were diagnosed antenatally and managed at the University of North Carolina Hospitals over a 7-year period. We retrospectively reviewed the charts of mothers and infants and recorded data concerning perinatal and surgical management. Six infants survived the neonatal period. All infants diagnosed after 20 weeks' gestation survived. Fetal hydrops developed in three fetuses, all of whom died. Inadequate ventilation secondary to prematurity was a contributing factor in each lethal case. Diagnosis at an early gestational age, development of fetal hydrops, and premature delivery predicted a poor prognosis. When possible, we recommend that delivery be delayed to allow for fetal development. Stabilization of the infant should be attempted before resection of the teratoma.

Adult sacrococcygeal teratomas

We report a rare case of a benign adult sacrococcygeal teratoma discovered during pregnancy. The cystic mass was confirmed on CT scan and magnetic resonance imaging. In the fifth postpartum month, three cysts (1, 2.5, and 6 cm) were excised. Pathologically, the specimens contained differentiated tissue from all three germ layers, including endocrine tissue within the ectopic exocrine pancreas.

MR imaging of congenital anomalies of the pediatric spine

Congenital anomalies of the pediatric spine are ideally evaluated with MR imaging. The wide spectrum of pathology in this category of disease is dramatically displaced for both diagnosis and treatment planning for the neurosurgeon. An understanding of embryology and knowledge of the clinical presentation combined with the MR imaging findings allows the radiologist to play a key role in the evaluation of these complex anomalies.

A case of incomplete Currarino triad with malignant transformation

A case of an incomplete Currarino triad is reported. The baby underwent an emergency laparotomy due to a life-threatening intestinal obstruction caused by severe rectal stenosis. During the posterosagittal anorectoplasty (PSARP), a presacral teratoma was identified and resected. The tumor recurred three times; she initially responded to chemotherapy, but nonetheless died at the age of 4 years. In cases with evidence of anorectal stenosis, a presacral mass should be suspected. PSARP is the best choice of treatment for both the anorectal anomaly and excision of the presacral mass. The presacral region should be followed up closely for recurrence of the tumor.

[Significance of prenatal diagnosis in interdisciplinary treatment of sacrococcygeal teratoma]

The perinatal treatment of 23 infants with sacrococcygeal teratomas was recorded prospectively from 1990 to 1997, during which period 14 children (teratomas 6.9-18 cm) could be followed throughout the whole pregnancy at our own perinatal department. There were three prenatal deaths (21 h-27 week of gestation) and two peripartal deaths (1 hydrops and 1 ruptured teratoma). Prenatal Doppler sonography allows appropriate selection of high-risk fetuses. The vital prognostic sign was developing fetal hydrops with associated umbilical vein pulsations, increased aortal flow and an increasing pulsatility index in der venous duct.

[Perinatal and perianesthetic management of the sacrococcygeal teratoma in a neonate]

We report perinatal and perianesthetic management of a female infant with sacrococcygeal teratoma who underwent fetal bladder puncture and postnatal tumor resection. At 33 weeks' gestation, fetal ultrasonography revealed an intrapelvic mass, oligohydramnios and the dilatation of the bladder. At 34 weeks' gestation, bladder puncture was performed in utero to relieve urinary obstruction by the mass. And it served to reserve the renal function but caused remarkable ascites at birth due to urine leakage to the peritoneum through the puncture site. After the delivery by cesarean section, the patient underwent the tumor extirpation at 2 days of life. The operation and anesthesia proceeded uneventfully. In previous reports, several mortalities due to exsanguinating hemorrhage during surgery have been reported. In addition, sacrococcygeal teratoma is occasionally accompanied by coagulopathy and high output cardiac failure caused by arteriovenous fistulae. Therefore it is important for good patient outcomes to evaluate preoperatively the risks mentioned above.

Prenatal diagnosis and perinatal management of fetal sacrococcygeal teratoma

Sacrococcygeal teratoma is the most common fetal neoplasm, with an incidence of 1 in 40,000 births. Fetuses with this malformation are at risk for significant perinatal morbidity and mortality. We identified nine fetuses with sacrococcygeal teratomas that were diagnosed antenatally and managed at the University of North Carolina Hospitals over a 7-year period. We reviewed retrospectively the charts of mothers and infants and recorded data concerning perinatal and surgical management. Six infants survived the neonatal period. All infants diagnosed after 20 weeks' gestation survived. Fetal hydrops developed in three fetuses, all of whom died. Inadequate ventilation secondary to prematurity was a contributing factor in each lethal case. Diagnosis at an early gestational age, development of fetal hydrops, and premature delivery predicted a poor prognosis. When possible, we recommend that delivery be delayed to allow for fetal development. Stabilization of the infant should be attempted before resection of the teratoma.

Spinal canal involvement in infantile myofibromatosis: case report and review of the literature

PURPOSE

An unusual case of infantile myofibromatosis with spinal canal involvement is reported and the literature is reviewed.

PATIENT AND METHODS

A female neonate had bladder and bowel dysfunction and paresis of the lower extremities.

RESULTS

Intrapelvic and paravertebral masses with extension into the spinal canal were detected by imaging studies. In addition, radiologic examination showed multiple metaphyseal radiolucent lesions of the long bones and pathologic fracture of the left femur. The histopathologic diagnosis of the paravertebral tumor and bone lesions was infantile myofibromatosis. Surgical resection of the paravertebral and intrapelvic masses was performed to improve her neurologic impairments. Paresis of the lower limbs gradually improved, whereas bladder and bowel dysfunction remained unchanged.

CONCLUSIONS

Only six cases of infantile myofibromatosis associated with spinal canal involvement have been reported. Three patients with flaccid paresis of extremities and respiratory distress died in the newborn period. The other three patients showed improvement of the paresis. The prognosis of infantile myofibromatosis without visceral complication is generally good, but neurologic impairment may occur at birth if the spinal cord is compressed.

A case of congenital intraspinal neuroblastoma

A case of congenital intraspinal neuroblastoma with paraplegia in a newborn is described, and a review of previously reported cases is presented. Calcification within the spinal canal and abdominal mass was noted. At age 75 days, the patient underwent a resection of almost the entire retroperitonial tumor. A magnetic resonance scan showed hepatic metastasis, and chemotherapy was changed to a more intensive regimen. The liver metastasis disappeared; however, neurological signs persisted. A literature review of 38 cases showed 26 patients had a laminectomy and 12 patients did not. Treatment with or without laminectomy was associated with a poor prognosis for neurological recovery, suggesting cord compression must occur antenatally, and irreversible damage occurs before birth. Congenital intraspinal neuroblastoma has a relatively good prognosis (survival rate, 91.9%), although complete neurological recovery is highly unusual. Based on these findings, the authors conclude that a laminectomy is not indicated for those patients.

[Delivery following surgically treated sacrococcygeal teratoma in the mother]

The delivery of a 23 para I who was born herself with a sacrococcygeal teratoma of the type II is reported. After the extirpation of the tumor and of the coccyx an anomaly of the pelvis is found in the sense of a pygopagic pelvis (stretching and bending of the sacrum towards the dorsum). This anomaly and the scars in the way of a maternal soft tissue dystocia seem to be the reasons for the insufficient progression of labour. The delivery had to be done by caesarean section. A historical review concerning the surgery of sacrococcygeal teratomas is given.

[Prenatal diagnosis of an intraspinal lipoma. A case report]

This report describes a prenatal diagnosis of intraspinal lipoma. This pathology, not well known by obstetricians, forms a part of neural tube defects. Echographic aspect, embryologic origin, differential diagnosis, neurosurgical prognosis and treatment are reviewed and discussed.

Oncoproteins and tumor suppressor proteins in congenital sacrococcygeal teratomas

Congenital sacrococcygeal teratoma (SCT) is the most common germ cell tumor of infancy and childhood with a female preponderance. Most SCTs are diagnosed at birth, are benign, and consist of fully differentiated, mature tissues. Tumorigenesis of SCTs remains poorly understood. Almost nothing is known about possible oncogene activation or tumor suppressor inactivation in these rare tumors. We describe the presence of various oncoproteins and tumor suppressor proteins in eight cases of congenital SCT. The following oncogenes were examined: ras family (c-H-, c-N-, and c-K-ras), early genes (fos, jun), and tumor suppressor genes (p53 and nm23-H-I). There was no relationship between the intensity of expression of these oncoproteins and tumor suppressor genes and the following parameters: tumor size, age, and survival of the patients. We did not observe any difference, however, between the expression of the examined oncogenes and tumor suppressor genes nm23 and p53 in immature and mature teratomas. Our findings suggest that the ras family of oncogenes, fos and jun oncogenes, and nm23 and p53 tumor suppressor genes are present in congenital SCT, indicating a possible role in genesis and development of these tumors.

Resection of a massive sacrococcygeal teratoma using hypothermic hypoperfusion: a novel use of extracorporeal membrane oxygenation

A 33-week-gestation infant with a massive sacrococcygeal teratoma weighted 4,000 g, but the actual weight of the infant was approximately 1,500 g. With the potential for massive blood loss and impaired lung compliance during resection, some type of cardiopulmonary support was necessary. Resection was undertaken with the assistance of venoarterial extracorporeal membrane oxygenation (ECMO) and hypothermic hypoperfusion. Immediately after removal of the tumor, which weighted 2,420 g, the infant was decannulated from ECMO, and the carotid artery was primarily reconstructed end-to-end. The amount of intraoperative blood loss was 550 mL Postoperatively, the child weighted 1,580 g. Follow-up head ultrasound results were normal, and the patient has done well. This is the first reported case in which ECMO with hypothermic hypoperfusion was used for resection of a massive tumor. This experience shows that ECMO is both useful and safe as a means of temporary cardiopulmonary support for resection of massive tumors in infants.

[The MRI in pre- and postnatal diagnosis of congenital sacrococcygeal teratoma]

INTRODUCTION

The main tasks of imaging methods on the evaluation of relatively rare and potentially malignant connatal sacrococcygeal teratomas (SCT) are to depict the extent, structure and relationship to surrounding systems.

METHODS

Two cases with SCT were studied with pre- and postnatal MRI and findings were compared with the ultrasound and clinical data.

RESULTS

Before delivery, MRI permits depiction of the size and structure of teratomas and the integrity of the serum. After delivery, evaluation of the rectum, urinary tract and levator muscles is important to facilitate surgical reconstruction.

[Sacrococcygeal teratomas. Apropos of a case of teratoma weighing 4200 g]

We report a clinical case of a large sacro-coccygeal teratoma diagnosed antenatally by ultra-sound at 35 weeks gestation. A review of the literature shows that their outcome depends upon the size of the tumor, its degree of maturity, whether its location is pelvic or not, the presence of any associated malformations, prematurity, atraumatic delivery and upon prompt and complete removal of the tumor.

Human tail associated with lipomeningocele--case report

A 3-month-old boy presented with a tail associated with lipomeningocele. Computed tomography and magnetic resonance imaging clearly demonstrated the presence of spina bifida and lipoma continuous from the tail to the thickened conus medullaris. The human tail may be related to spinal dysraphism and requires detailed neuroimaging investigation, and possibly microsurgery to prevent the tethered cord syndrome.

Effect of surgical repair on the neurologic function in infants with lipomeningocele

Eighteen children under the age of 1 year underwent surgery for lipomeningocele at our institution between 1983 and 1991. All the patients had neurologic exams and urodynamic studies (UDS) including a cystometrogram and electromyography of the external urethral sphincter pre- and postoperatively. The surgical procedure performed included an untethering of the spinal cord, laser debulking of the lipoma and placement of a dural graft. All the infants presented with a lesion on their back. Two of 10 infants with a normal neurological exam had abnormal UDS preoperatively. Early surgery normalized abnormal preoperative UDS in 5 of 6 (83%) infants with abnormal UDS. Moreover, 3 of 8 (38%) infants with an abnormal neurological exam preoperatively improved after surgery and none worsened. These observations suggest that abnormal urinary tract function in infants with lipomeningocele may be reversible with early prophylactic surgery.

Tailgut remnant--or teratoma?

The tailgut is the distalmost portion of the embryonic gut, located caudal to the cloacal membrane. Up to the sixth week of development, it is in close proximity to the distal end of the notochord and the neural tube. It completely regresses by the seventh week, but some caudal duplication-like cysts have been attributed to its remnants. We report a full-term male born with a large heterogeneous sacral mass. Severe bony abnormalities of the coccyx, sacrum and lower lumbar vertebrae were present, but the infant was neurologically intact. At surgery, the upper cystic structures within the mass were found to communicate with the dura, while the solid component, whose surface resembled intestinal mucosal folds, was closely related to the perirectal tissues. The mass was completely resected and the dura oversewn. Since this complex mass contained all three cell lines in an aberrant location, it satisfies the definition of a sacrococcygeal teratoma. However, its unique architecture suggests a malformative, rather than tumoral origin. The macroscopic appearance of this lesion reflects the embryonic relationship between the tailgut, the neural tube and the notochord.

Fetal sacrococcygeal teratoma

The fetus with sacrococcygeal teratoma (SCT) is at high risk for prenatal and perinatal complications. The natural history and pathophysiology of fetal SCT is different than that of postnatally diagnosed SCT, and has only recently been defined. Survival of fetuses with SCT is dependent on anticipation and recognition of pathophysiologic events, and optimal obstetric and surgical management. In a subset of fetuses with SCT, fetal resection of tumor may offer the only hope for survival.