Congenital cervical teratomas

Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses

PURPOSE

To investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes.

STUDY DESIGN

A retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed.

RESULTS

Antenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d - 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients.

CONCLUSION

This series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.

Multidisciplinary management of congenital giant head and neck masses: Our experience and review of the literature

BACKGROUND

Large fetal head and neck (HN) masses can be life-threatening at birth and postnatally owing to airway obstruction. The two most frequent congenital masses that may obstruct the airway are lymphatic malformation (LM) and teratoma. The aim of this paper was to evaluate the results of our experience in the management of giant congenital HN masses and to conduct a literature review.

METHODS

The study involved a consecutive series of 13 newborns (7 females) affected by giant HN masses. Prenatal diagnosis was achieved by means of ultrasound (US) and fetal magnetic resonance imaging (MRI). Delivery was performed by means of EXIT procedure in case of radiological evidence of airway obstruction. In the postnatal period all feasible therapeutic options (surgery, sclerotherapy, medical therapy) were discussed and adopted by a multidisciplinary team. Twelve patients underwent surgery and one received Rapamycin for one month, with consequent surgical resection owing to increasing size of the mass.

RESULTS

The histopathological diagnosis was LM in 11 cases and teratoma in 2 cases. Airway obstruction was solved in 11 cases; 2 LM patients required a tracheotomy because of persistent airway obstruction. Major complications were flap necrosis (one patient) and facial nerve palsy (2 cases). Recurrence occurred in 5 patients.

CONCLUSIONS

The management of congenital HN masses is always challenging and necessarily requires an interdisciplinary approach. Current therapeutic options include surgery, sclerotherapy, medical therapy or a combination of them. When they are large enough to obstruct the airway, a patient-centered approach should guide timing and modality of treatment.

LEVEL OF EVIDENCE

IV.

Huge Neck Masses Causing Respiratory Distress in Neonates: Two Cases of Congenital Cervical Teratoma

Congenital cervical teratomas are rare and usually large enough to cause respiratory distress in the neonatal period. We present two cases of congenital huge cystic neck masses in which distinguishing cervical cystic hygroma and congenital cystic teratoma was not possible through radiologic imaging techniques. Experience with the first case, which was initially diagnosed and treated as cystic hygroma by injection sclerotherapy, led to early suspicion and surgery in the second case. The masses were excised completely and histopathologic diagnoses were congenital teratoma in both patients. Our aim is to review congenital huge neck masses causing respiratory distress in early neonatal life to highlight this dilemma briefly with these interesting cases.

Case Report: Severe acute respiratory distress by tracheal obstruction due to a congenital thyroid teratoma

Congenital teratoma is a rare condition and is a germ cell tumor composed of elements from one or more of the embryonic germ layers and contain tissues usually foreign to the anatomic site of origin. We report a case of a neck tumor diagnosed during pregnancy, initially thought to be a goiter. After birth the neck mass kept growing until it compressed the trachea and produced respiratory failure. The infant had a difficult tracheal intubation because of the compressing mass. The staff decided to surgically remove the neck mass. After that, the infant became eupneic. The histological analysis showed a mature teratoma with no atypias.

Retroperitoneal cystic immature teratoma: A case report

Retroperitoneal cystic immature teratoma (RCIT) is a rare disease. RCITs manifest as solid and cystic masses. In pathological sections, cysts of various sizes, with internal hemorrhage and necrosis, are observed. Components of all germ layer tissue are also observed, the majority of which is located within the endoderm. As the tumor contains undifferentiated immature tissue components, RCITs are also termed malignant teratomas. Immature teratomas grow rapidly, often invading adjacent tissue to cause serious symptoms, and transfer through the blood and lymph vessels, often resulting in glandular cancer. The present study reports the case of an infant with RCIT. The female patient, aged six months and six days, was hospitalized due to an abdominal mass. Physical examination revealed a large mass (10×8 cm) below the xiphoid in the epigastrium. The mass, which ranged from the xiphoid to the umbilical region, was friable, and possessed a smooth surface, clear boundaries and poor activity, without tenderness. Upper abdominal computed tomography (CT) revealed a large, solid, cystic mass in the left, middle and lower retroperitoneum. The patient was admitted to the Yantai Yuhuangding Hospital for surgery. The pre-operative examination was improved following admission by documenting parameters that included the results from routine blood tests, bleeding and clotting times and cardiography. Retroperitoneal tumor resection was then performed. During resection, the tumor was found to originate from the retroperitoneum. As the tumor involved the gastric wall, a section of the gastric wall was resected, in addition to the tumor. The resection surface was yellow and friable. Pathological examination of tumor tissue sections revealed the involvement of immature nerves and mesenchymal components, confirming the diagnosis of a grade II immature teratoma. Subsequent to six months of outpatient follow-up, the patient had recovered well, without recurrence. RCIT is a clinically rare disease, and the present study adds to the current understanding of this rare condition in infants.

Malignant fat-forming solitary fibrous tumor (lipomatous hemangiopericytoma) in the neck: Imaging and histopathological findings of a case

Fat-forming solitary fibrous tumor (SFT) is a rare variant of solitary fibrous tumor, a mesenchymal fibroblastic neoplasia with a particular branching hypervascular pattern. This tumor is usually classified as benign and only very few fat-forming SFTs with malignant histologic features have been reported. We report a histologically malignant fat-forming solitary fibrous tumor in a 61-year-old man, located in his neck. Ultrasonography examination was first performed showing a heterogeneous lesion, predominantly hyperechoic, with sound beam attenuation, containing two hypoechoic solid nodules. Magnetic resonance imaging and computed tomography examinations demonstrated a heterogeneous and predominantly adipose mass, containing post contrast enhancing solid nodules and thin septations. Treatment consisted of total removal of the lesion. Histologically, the tumor showed hypercellularity, numerous mitoses and cytological atypia, fulfilling the criteria for malignancy. The patient had no metastasis. This rare tumor may be confused with other fat-containing lesions on imaging examinations, mainly liposarcoma.

An unusual case of Cat-Eye syndrome phenotype and extragonadal mature teratoma: review of the literature

BACKGROUND Cat-Eye syndrome (CES) with teratoma has not been previously reported. We present the clinical and molecular findings of a 9-month-old girl with features of CES and also a palpable midline neck mass proved to be an extragonadal mature teratoma, additionally characterized by array comparative genomic hybridization (aCGH). RESULTS High resolution oligonucleotide-based aCGH confirmed that the supernumerary marker chromosome (SMC) derived from chromosome 22, as was indicated by molecular cytogenetic analysis with fluorescence in situ hybridization (FISH). Additionally, aCGH clarified the size, breakpoints, and gene content of the duplication (dup 22q11.1q11.21; size:1.6 Mb; breakpoints: 15,438,946-17,041,773; hg18). The teratoma tissue was also tested with aCGH, in which the CES duplication was not found, but the analysis revealed three aberrations: del Xp22.3 (108,864-2788,689; 2.7 Mb hg18), dup Yp11.2 (6688,491-7340,982; 0.65 Mb, hg18), and dup Yq11.2q11.23 (12,570,853-27,177,133; 14.61 Mb, hg18). These results indicated 46 XY (male) karyotype of the teratoma tissue, making this the second report of mature extragonadal teratoma in a female neonate, probably deriving from an included dizygotic twin of opposite sex (fetus in fetu). CONCLUSIONS Our findings extend the phenotypic spectrum of CES syndrome, a disorder with clinical variability, pointing out specific dosage-sensitive genes that might contribute to specific phenotypic features.

Giant craniofacial immature teratoma with primary intracranial lesions

Teratomas can occur in almost any region of the body and are the most common extragonadal germ cell childhood tumors. Immature teratomas in the head and neck region cause severe deformity and threat life because of several reasons. Imaging investigation (ultrasonography, computed tomography, magnetic resonance imaging) is of outmost importance for the diagnosis and preoperative planning, considering that the total surgical resection of the teratoma constitutes the treatment of choice. Untreated teratomas have mortality rates of 80% to 100%. In this study, a giant craniofacial immature teratoma having both intracranial and extracranial primary lesions is reported. As a conclusion, intracranial primary lesions should be kept in mind in extracranial head and neck immature teratoma cases.

Early resection and reconstruction of head and neck masses in infants with upper airway obstruction

OBJECTIVE

Congenital airway obstruction can be caused by tumors or lesions arising from the neck, tongue and oral cavity. Neonates may require prolonged intubation or tracheostomy before curative resection and reconstruction. The aim of the study was to carry out surgical resection and reconstruction with locoregional flap and free bone graft in the neonatal and early infantile period for definitive management of head and neck masses and treatment of potential airway obstruction.

METHODS

Newborns with obstructive head and neck masses in Queen Mary Hospital, University of Hong Kong Medical Centre between 2006 and 2009 were operated on in the neonatal period.

RESULTS

There were one obstructive neck teratoma, two intraoral teratomas and one neuroglial heterotopia. All tumors were resected within the first 3 months of life without major complication. A local cervical cutaneous flap was first used to reconstruct the lateral pharyngeal wall defect in a neonate with a huge neck teratoma, followed by another infant with a neuroglial heterotopia. A piece of cranial bone was used for reconstruction of the skull base defect. None of them required tracheostomy or prolonged intubation. Oral feeding was resumed in the early postoperative period.

CONCLUSION

Surgical resection and reconstruction with locoregional flap and bone graft can be performed safely in neonatal and early infantile period as management of head and neck masses and treatment of upper airway obstruction.

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.

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.

[Neonatal cervical teratoma: case report]

Cervical teratomas are extremely rare tumours. Surgery of these mostly benign malformations is very challenging for a multidisciplinary team. A single case of a newborn, who was imminently prenatally diagnosed with a neck mass, is presented. After delivery the patient was transferred to neonatal intensive care unit and intubation was performed. A rapid growth of the mass required early surgery and removal of the neck mass was performed on the third day post delivery. Histological investigation showed an immature teratoma. The postoperative period was complicated by hypothyroidism. Due to severe laryngo-tracheomalacia tracheostomy was required when the baby was 2 weeks old. Further development has been without any sign of recurrence (12 months). On the basis of this case differential diagnosis, therapy and outcome is discussed.

Congenital cervical teratomas: diagnostic, management and postoperative variability

OBJECTIVE

To review the diagnosis, management and outcomes of congenital cervical teratomas presenting to a tertiary referral centre.

METHODS

Retrospective chart review of three cases presenting within an 18-month period.

RESULTS

Of the three patients in this series, one was diagnosed antenatally. The remaining cases were diagnosed at birth. The antenatally diagnosed patient underwent an EXIT procedure whereby the airway was secured by tracheostomy. This patient subsequently died 30 min after separation from the materno-foetal circulation. Neither of the other two cases had any neonatal respiratory distress, despite having large tumours. Both patients had neonatal surgical excision of the teratomas performed. Both patients had postoperative respiratory distress, requiring intervention. Both patients made a full recovery. No recurrence has been reported.

CONCLUSION

The antenatal diagnosis of large congenital cervical teratomas allows for planned intervention by experienced personnel. A successful outcome may not be obtained. All patients that undergo surgical excision of these tumours must be closely observed for post-operative respiratory distress, even in the absence of pre-operative symptoms.