Life-threatening respiratory distress caused by a mediastinal teratoma in a newborn

Fetal Presentation of Mediastinal Immature Teratoma: Ultrasound, Autopsy and Cytogenetic Findings

Teratomas are the most common congenital tumors, occurring along the midline or paraxial sites, or uncommonly, the mediastinum. Teratomas are classified as mature, containing only differentiated tissues from the three germinal layers; and immature, which also present with neuroectodermal elements, ependymal rosettes, and immature mesenchyme. Herein, we describe a new case of fetal mediastinal immature teratoma detected at 21 weeks of gestational age (wga) + 1 day with thorough cytogenetic analysis. Ultrasound (US) showed a solid and cystic mass located in the anterior mediastinum, measuring 1.8 × 1.3 cm with no signs of hydrops. At 22 wga, US showed a mass of 2.4 cm in diameter and moderate pericardial effusions. Although the prenatal risks and available therapeutic strategies were explained to the parents, they opted for termination of pregnancy. Histology showed an immature teratoma, Norris grade 2. Karyotype on the fetus and tumor exhibited a chromosomal asset of 46,XX. The fetal outcome in the case of mediastinal teratoma relies on the development of hydrops due to mass compression of vessels and heart failure. Prenatal US diagnosis and close fetal monitoring are paramount in planning adequate treatment, such as in utero surgery, ex utero intrapartum therapy (EXIT) procedure, and surgical excision after birth.

Mediastinal teratoma in a neonate with acute respiratory failure

Background: While teratomas account for the leading cause of germ cell tumors, the mediastinal teratomas represent one of the infrequent types of congenital germ cell tumors. Neonates with large mediastinal teratomas generally show severe respiratory distress, and the immediate surgical treatment is needed to alleviate their problems.

Objectives: Report clinical symptoms, diagnostic procedures, treatment option, and outcomes after the treatment for a neonate with a large mediastinal teratoma.

Methods: A 2-day-old female infant presented with acute respiratory failure diagnosed as mediastinal teratoma. It was followed with surgical treatment. The removed tissues were examined pathologically.

Results: The girl suffered an acute respiratory failure two days after birth. The chest radiography, echocardiography, and chest computerized tomography results showed the considerable size of the mediastinal teratoma. A median sternotomy was performed on the third day of infant life to remove the tumor without rupturing the capsule. Pathological diagnosis was germ cell tumor. Clinical follow-ups reported no complication.

Conclusion: The successful management of a neonate with large mediastinal teratomas was presented. Immediate detection and proper treatment of the large mediastinal teratoma in a neonate was most important to decrease the morbidity and mortality of the infant.

Mediastinal teratoma with hydrops fetalis in a newborn and development of chronic respiratory insufficiency

BACKGROUND

Mediastinal fetal teratoma can be detected as a mass in the chest during a routine prenatal ultra-sound screening. Because of the pressure on mediastinal structures it can be the cause of non-immune hydrops fetalis and polyhydramnion. The development of hydrops fetalis leads to fetal death or premature delivery in most reported cases. Early surgical removal is important, but, the result of treatment depends on the stage of development of mediastinal organs and complications in the postoperative period.

CASE REPORT

A 31-year-old gravida carrying twins, with spontaneous membrane rupture at 32 weeks gestation underwent urgent caesarean section after antenatal ultrasound revealed severe polyhydramnion and hydrops fetalis in geminus A. The child was intubated immediately after birth due to severe respiratory distress. Ultrasound and X-ray revealed a tumour mass in the right hemithorax. Tumour resection was performed at the age of 7 days. Histology examination revealed an encapsulated immature teratoma. The postoperative course was complicated with respiratory insufficiency which turned into chronic at the age of eight months.

CONCLUSION

This is the fifth reported child with fetal mediastinal teratoma and severe hydrops fetalis that survived the neonatal period. Additional diagnostic search revealed abnormal course of both pulmonary arteries, which was probably one of the main causes of respiratory insufficiency.

Perinatal (fetal and neonatal) germ cell tumors

BACKGROUND/PURPOSE

Germ cell tumors are relatively common in the fetus and neonate and are the leading neoplasms in some perinatal reviews. The purpose of this study is to focus on the fetus and neonate in an attempt to determine the various ways germ cell tumors differ clinically and morphologically from those occurring in the older child and adult and to show that certain types of tumors have a better prognosis than others.

METHODS

The author conducted a retrospective review of perinatal teratomas and other germ cell tumors reported in the literature and of patients treated and followed up at Children's Hospital San Diego and Children's Hospital Los Angeles. Only fetuses and infants less than 2 months of age with adequate clinical and pathologic data were accepted for review.

RESULTS

Five hundred thirty-four fetuses and neonates presented with teratomas diagnosed prenatally (n = 226) and at birth (n = 309). The most common initial finding was a mass, noted either by antenatal sonography or by physical examination during the neonatal period, with signs and symptoms referable to the site of origin. Overall polyhydramnios was next followed by respiratory distress and stillbirth. The number of mature and immature teratomas was approximately the same. The incidence of teratoma with yolk sac tumor either at presentation or at recurrence was 5.8%, and the survival rate was 39%. Sacrococcygeal teratomas had the highest incidence of yolk sac tumor at 10%. Recurrent disease in the form of either teratoma or yolk sac tumor developed in 5% of patients. All individuals with teratomas who survived received surgical resection.

CONCLUSIONS

Some germ cell tumors of the fetus and neonate have a better prognosis than others. Neonates with gastric teratomas have the best survival rates, and those with intracranial germ cell tumors the worst. Fetuses with teratomas detected antenatally have 3 times the mortality rate compared with postnatally diagnosed neonates. Although perinatal teratomas have a relatively low recurrence rate of 5%, close follow-up with imaging studies and serum alpha-fetoprotein determinations is is strongly recommended. Surgical resection alone may be adequate therapy for teratomas with nonmetastatic, microscopic foci of yolk sac tumor. In the nonteratoma group, patients with pure yolk sac tumor and gonadoblastoma have a much better outcome than those with choriocarcinoma, which has a very low survival of rate of 12%. Currently, the use of platinum-based combination chemotherapy has significantly improved the survival rate of infants with advanced malignant germ cell tumor disease.

Acute respiratory failure associated with intrathoracic masses in neonates

BACKGROUND

Intrathoracic masses are uncommon in children. Occasionally, they present with acute respiratory failure in the neonatal period. Although emergency resection usually is the treatment of choice, other modalities are sometimes necessary to stabilize the patient.

METHODS

Seven neonates with intrathoracic masses were treated. Five had congenital cystic adenomatoid malformations (CCAM), 1 had a mediastinal teratoma, and 1 had a pneumatocele. These cases were reviewed retrospectively.

RESULTS

Four of the 7 infants had respiratory failure in the neonatal period. A patient with a large mediastinal teratoma and 1 with a CCAM that increased rapidly after presentation underwent emergency operation, relieving respiratory distress. The other 2 large CCAMs presented with severe respiratory distress immediately after birth because of pulmonary hypoplasia. One neonate with a Stocker-I CCAM died after emergency resection. One more recent patient with a Stocker-III CCAM survived after successful treatment with delayed resection, performed 3 days after birth. Nitric oxide (NO), and extracorporeal membrane oxygenation (ECMO) were instituted as supportive care because of profound persistent fetal circulation (PFC).

CONCLUSIONS

Acute respiratory failure associated with intrathoracic masses in neonates may be managed in 1 of 2 ways. A small mass that increases rapidly should be resected soon after presentation. In neonates with large masses with associated PFC, surgery can be delayed until the patient is stable. ECMO, NO, and high-frequency oscillation (HFO) can be used aggressively for stabilizing such neonates.