Variability in Surveillance Strategies Following Resection of Sacrococcygeal Teratoma

INTRODUCTION

Surveillance following sacrococcygeal teratoma (SCT) resection varies. The purpose of this study was to describe the clinical characteristics and outcomes of patients undergoing SCT resection and examine current institutional practices to detect recurrence.

METHODS

A single-institution retrospective review of children who underwent resection of an SCT from January 1, 2010 to December 31, 2020 was performed. Data were summarized and surveillance strategies compared between histopathologic subtypes using nonparametric methods.

RESULTS

Thirty six patients (75.0% female) underwent SCT removal at a median age of 8 d. Histopathology revealed 27 mature teratomas (75.0%), eight immature teratomas (22.2%), and one malignant germ cell tumor (2.8%). Median postoperative follow-up was 3.17 y (interquartile range [IQR]: 2.31-4.38 y). Patients had a median of 2.32 clinic visits per year (IQR: 2.00-2.70), alpha-fetoprotein levels were obtained at a median of 2.01 times per year (IQR: 0-1.66), and surveillance imaging was performed at a median of 2.31 times per year (IQR: 0-2.84). Patients with immature teratomas had alpha-fetoprotein laboratories obtained more frequently than patients with mature teratomas (3.10 times/year versus 0.93 times/year, P = 0.001). There was no significant difference in the number of imaging studies obtained between groups. Two patients (5.6%) developed recurrence, which were identified on magnetic resonance imaging at 191 and 104 d postresection, respectively.

CONCLUSIONS

Postoperative surveillance practices varied widely. Recurrence was noted in a single malignant case in the first year following resection. Multi-institutional studies are needed to determine the optimal surveillance strategy to detect recurrence of SCT.

Endoscope-assisted microsurgical resection of a third ventricular immature teratoma

BACKGROUND

Reaching a tumor within the third ventricle is challenging, and planning an accessible trajectory is crucial without injuring the surrounding structures. We report a 5-year-old boy presented with headache and a seizure where sequential MRI brain studies in a short time period revealed a rapid growing immature teratoma within the third ventricle with hydrocephalic changes. Several management procedures were performed for CSF diversion and medical treatment of the tumor with chemotherapy and stem cell therapy. The tumor was rapidly growing, and surgical excision was decided. Total resection was achieved via endoscope-assisted microsurgical transcallosal approach. Seven years after surgery, the patient experienced no recurrence of the tumor with a favorable clinical condition.

CONCLUSION

We report a rare case of posterior third ventricular immature teratoma where the endoscope-assisted microsurgical technique was implemented with favorable long-term postoperative outcome.

Primary immature teratoma of the liver in an adult: Case report

Teratoma is an uncommon germ cell tumor and develops from at least 2 of the 3 germ cell layers: ectoderm, mesoderm, and endoderm. The origin of teratoma is primordial germ cells that migrate from the allantois to the gonadal ridges during embryogenesis. The teratomas can be intragonadal or extragonadal. Primary extragonadal teratoma is defined as if there is no evidence of a primary tumor in the testicles or ovaries. Common extragonadal sites include the anterior mediastinum, retroperitoneum, sacral region, and intracranial cavity. Primary intrahepatic teratomas are extremely rare, accounting for less than 1% of all teratoma cases. Hepatic teratomas are more common in children than in adults. We present a case of an immature primary hepatic teratoma in an adult woman.

Evaluation of calcification distribution by CT-based textural analysis for discrimination of immature teratoma

BACKGROUND

Mature and immature teratomas are differentiated based on tumor markers and calcification or fat distribution. However, no study has objectively quantified the differences in calcification and fat distributions between these tumors. This study aimed to evaluate the diagnostic potential of CT-based textural analysis in differentiating between mature and immature teratomas in patients aged < 20 years.

MATERIALS AND METHODS

Thirty-two patients with pathologically proven mature cystic (n = 28) and immature teratomas (n = 4) underwent transabdominal ultrasound and/or abdominal and pelvic CT before surgery. The diagnostic performance of CT for assessing imaging features, including subjective manual measurement and objective textural analysis of fat and calcification distributions in the tumors, was evaluated by two experienced readers. The histopathological results were used as the gold standard. The Mann-Whitney U test was used for statistical analysis.

RESULTS

We evaluated 32 patients (mean age, 14.5 years; age range, 6-19 years). The mean maximum diameter and number of calcifications of immature teratomas were significantly larger than those of mature cystic teratomas (p < 0.01). The mean number of fats of immature teratomas was significantly larger than that of mature cystic teratomas (p < 0.01); however, no significant difference in the maximum diameter of fats was observed. CT textural features for calcification distribution in the tumors showed that mature cystic teratomas had higher homogeneity and energy than immature teratomas. However, immature teratomas showed higher correlation, entropy, and dissimilarity than mature cystic teratomas among features derived from the gray-level co-occurrence matrix (GLCM) (p < 0.05). No significant differences were observed in the CT features of fats derived from GLCM.

CONCLUSION

Our results demonstrate that calcification distribution on CT is a potential diagnostic biomarker to discriminate mature from immature teratomas, thus enabling optimal therapeutic selection for patients aged < 20 years.

Treatment of Immature Teratoma Associated with Ovarian Endometrioma: A Case Report

Background

Mature teratoma is a benign neoplasm, mostly composed of well-differentiated derivations of almost two or three germ cell layers, while immature teratoma is a malignant neoplasm composed of immature neural and embryonic tissue. Immature teratoma in the context of ovarian endometrioma has not been reported yet.

Case Presentation

A 34-year-old woman with primary infertility is reported in this study who suffered from immature teratoma associated with ovarian endometrioma. After several rounds of fertility treatment, the patient was referred for severe abdominal pain and underwent emergency surgery for the rupture of ovarian endometrioma. To preserve the ovary, the cyst was not resected in areas attached to the ovary. Some months later, the patient noticed a progressive abdominal enlargement. The sonographic evaluation revealed multiple solid-cystic lobulated masses on the abdominal wall and throughout the pelvic cavity. The histologic diagnosis was consistent with immature teratoma. The patient was treated with high-dose neoadjuvant chemotherapy and fertility-sparing surgery (FSS). The histologic evaluation of the extracted masses revealed teratoma maturation.

Conclusion

This study reveals the importance of complete removal of endometrioma and highlights the role of neoadjuvant chemotherapy in fertility-sparing surgery and potentiating teratoma maturation.

Germ cell cancer in pregnancy - Successfully treated with chemotherapy and surgery

A 31-year-old primigravida, with spontaneous singleton pregnancy, presented in 21 weeks of gestation with abdominal pain. Abdominal ultrasound (USS) and Magnetic Resonance Imaging (MRI) showed a 12 × 14cm large complex lesion arising from the right ovary suspicious for an ovarian malignancy. The radiological staging demonstrated no further metastatic disease; however, it also revealed a 6 cm lesion in the contralateral ovary, consistent with a dermoid cyst. After tumour board discussion the patient underwent a mid-line laparotomy with right oophorectomy, cytology, and peritoneal and omental staging, under oral tocolysis with indomethacin. The left presumed ovarian dermoid was left in situ to avoid additional surgical and obstetrical morbidity. Histology confirmed a grade 3 immature teratoma with primitive neuroepithelium focally present on the capsular surface and atypical cells in the cytology amounting to a stage 1 C2 disease at least. Due to high-risk disease, she was offered adjuvant treatment. The patient received one cycle of intravenous paclitaxel, etoposide, and cisplatin chemotherapy, in an adjuvant setting. She underwent an elective caesarean section at 36 weeks, with the safe delivery of a healthy baby girl. After 6 weeks of her delivery, she received three further cycles of etoposide, and cisplatin to complete her course of adjuvant chemotherapy. Three months after the last chemotherapy cycle, she underwent a laparoscopic removal of the left ovarian dermoid that had increased in size to 8 cm. Final histology revealed no immature elements. To this point, 2 years after initial diagnosis, both mother and child are healthy with no long-term complications. The patient has resumed her normal menstrual cycle and being in remission, she wishes soon to try for a second child. To our knowledge, this is the only reported case of ovarian immature teratoma in pregnancy treated successfully with surgery and adjuvant iv paclitaxel, etoposide, and cisplatin chemotherapy regime.

Mature and immature ovarian teratomas share methylation profiles of imprinted genes: a MS-MLPA analysis

Immature teratomas are a subset of ovarian teratomas, and the pathogenic relationship between mature and immature ovarian teratomas is unclear. Mature ovarian teratomas are parthenogenetic tumors that arise from a single oocyte/ovum, whereas the origin of immature ovarian teratomas has not been extensively investigated. Since parthenogenetic tumors contain only maternal genomes, genome imprinting in these tumors usually follows a maternal pattern. DNA methylation is among the most important mechanisms of genome imprinting. Therefore, we analyzed the methylation profile of imprinted genes by performing methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) of 25 imprinting control regions (ICRs) in 10 imprinted genes/gene clusters from formalin-fixed, paraffin-embedded samples obtained from 4 immature ovarian teratomas, 8 mature ovarian teratomas, and 4 ovarian yolk sac tumors (YSTs). Both the immature and mature components showed similar methylation levels in each ICR in immature teratomas. Overall, immature ovarian teratomas showed maternal methylation patterns of imprinted genes in concordance with their parthenogenetic origin. However, they also showed aberrant methylation levels in a few imprinted genes, suggesting that genome imprinting in immature teratomas may partially differ from that in mature teratomas. Microscopic foci of YST were seen in one immature teratoma; the YST component also showed a maternal methylation pattern, unlike the pure YSTs that showed irregular patterns. Thus, teratoma-associated YST and pure YST may have different pathogenic mechanisms.

Nephrogenic rest vs immature teratoma associated with lumbosacral lipomyelomeningocele: a case report and review of the literature

BACKGROUND

Lipomyelomeningoceles (LMMs) are subcutaneous lipomas with dural penetration that often present with spinal cord tethering and may lead to neurological deterioration if untreated. This report describes a rare case of an LMM associated with immature nephroblastic tissue, representing a nephrogenic rest (NR) or, less likely, an immature teratoma.

CLINICAL PRESENTATION

An 8-day-old infant girl presented to the clinic with a sacral dimple. Imaging demonstrated a tethered spinal cord with low-lying conus medullaris and an LMM. A firm mass was noted in the subcutaneous lipoma. Detethering surgery and removal of the lipoma and mass were performed at the age of 6 months. Pathological examination identified the mass as cartilage, fat, and immature nephroblastic tissue consistent with NR tissue or, less likely, a teratoma with renal differentiation.

CONCLUSION

This presentation of an LMM associated with an immature teratoma or NR poses a risk of malignant transformation in patients. As a result, careful surgical dissection, resection, and close clinical follow-up are recommended for these patients.

Large Retroperitoneal Teratoma Presenting with Unilateral Hydronephrosis in an Infant: A Case Report and Review of the Literature

Teratoma is a type of germ cell tumor layer that appears in the gonadal, sacrococcygeal, mediastinal, and retroperitoneal regions. Primary retroperitoneal teratoma is rare and asymptomatic but can present with symptoms due to a mass effect on neighboring organs. These tumors have to be considered in the differential diagnosis of a mass in the abdominal cavity of children to distinguish between Wilms' tumor, neuroblastoma, and other intra-abdominal lesions. We presented an infant boy with protrusion of the left upper quadrant of the abdomen and a palpable abdominal mass that had progressively enlarged. An abdominal computed tomography scan revealed a large retroperitoneal cystic, solid mass on the left side of the abdominal cavity, causing pressure on the left ureter. Also, hydronephrosis of the left kidney was seen with a decreased enhancement of the left kidney due to obstruction uropathy. The mass was suspicious on imaging for a retroperitoneal teratoma. The patient underwent laparotomy, and excision of the huge retroperitoneal mass was done. The final diagnosis was an immature teratoma grade 3, and the patient was discharged in good condition. Retroperitoneal teratomas are rare tumors in infants. These tumors would be an incident diagnosis or diagnosed by the mass effect of giant tumors on other organs. They must be considered in the differential diagnosis of intra-abdominal tumors in children. Hydronephrosis and obstructive uropathy can be rare consequences of the mass effects of these tumors.

Ganglioneuroblastoma arising in a Mature Cystic Teratoma of Ovary: Report and Literature review of an uncommon neoplasm

•Somatic neoplasms in Mature Cystic Teratoma are uncommon; Ganglioneuroblastoma is rare, this is 2nd reported case.•Due to rarity, it can pose a diagnostic challenge for Pathologists, and management and staging conundrum for Gynecologists.•Morphological differentials include immature teratoma, glial neoplasms arising in teratoma, and carcinoid.

UNDIFFERENTIATED SARCOMA ARISING IN AN IMMATURE TERATOMA OF THE OVARY: A case report

INTRODUCTION

The immature teratomas present less than 1 % of ovarian cancers and affect preferentially young women (1). We report a rare case of an ovarian teratoma harboring undifferentiated sarcoma highlighting the clinical and pathological characteristics.

CASE PRESENTATION

The patient was a 24-year-old female who consulted for an abdominal mass. Pelvic ultrasound and magnetic resonance imaging (MRI) revealed an ovarian teratoma measuring 22 cm with no evidence of malignancy. She underwent an exploratory laparotomy. She had a unilateral adnexectomy as the ovarian parenchyma was damaged and the fallopian tube was involved in the mass. The final anatomopathological examination revealed the presence of a teratoma with a predominant component of undifferentiated sarcomatous. This component made the prognosis worse and led to a rapid unfavorable evolution with numerous metastases (lung, liver, and peritoneum). She refused all treatment and died within a week of diagnosis.

DISCUSSION

Immature teratoma is a malignant tumor composed of tissues derived from the three embryonic cell lineages at different stages of maturation. This fact makes the determination of its histologic grade by radiologic examination very difficult (1) and consequently raises a challenge in the workup as the prognosis of immature teratomas is closely related to their histologic grade (16). Improved chemotherapy after surgery has increased the 5-year survival rate for these malignancies from 90 % to 100 % (18).

CONCLUSION

Young women are most commonly affected by immature teratomas. The prognosis and histologic grade are interrelated. To protect fertility, the trend now is treat them more frequently with conservative surgery.

Rapid-Growing Intracranial Immature Teratoma Presenting Obstructive Hydrocephalus and Abducens Nerve Palsy: A Case Report and Literature Review

Intracranial immature teratoma is an extremely rare disease with poor prognosis and requires complicated treatment. Owing to the deep midline location of the tumor, total surgical resection of the tumor is challenging. We present our experience with a fast-growing pineal gland immature teratoma in a 4-year-old boy, who presented with obstructive hydrocephalus and abducens nerve palsy, which was treated with total surgical resection of the tumor. In addition, we aimed to determine the appropriate treatment modality for intracranial immature teratomas by reviewing the literature and investigating the prognosis.

A Rare Neonatal Intramedullary Immature Teratoma Undiagnosed in utero: A Case Report

BACKGROUND AND IMPORTANCE

Immature teratoma is a known pediatric tumor. However, spinal variants are rare and can present both a diagnostic and therapeutic challenge, particularly regarding aggression as it pertains to extent of resection, likelihood of recurrence and concordant prognosis, and the need and efficacy of adjuvant therapies.

CLINICAL PRESENTATION

The patient is a 27-day-old female who presented with 10 days of poor feeding, irritability, and progressive hypotonia. Although upon immediate presentation emergency providers' differential diagnoses included meningitis, inborn error of metabolism, and genetic neurodegenerative disease, a subsequent magnetic resonance (MR) imaging of the total spine revealed a large intradural intramedullary mass extending from the medulla to the thoracic cord at T12. The patient underwent multilevel cervical and thoracic laminectomies/laminoplasty for maximal safe resection. Histopathology revealed mostly mature tissue elements originating from all 3 germ layers, interspersed with foci of immature neuroepithelium, consistent with grade 1 immature teratoma. Following surgical intervention, the patient regained strength and spontaneous movement and underwent physical therapy. Follow-up MR imaging of the total spine was obtained every 3 months, and at 9 months, recurrence was demonstrated, which was successfully treated with chemotherapy. Further surveillance MR imaging of the total spine has demonstrated cystic myelomalacia changes without definite tumor recurrence, at 5-year follow-up. Clinically, the patient has developed scoliosis without weakness, pain, or urinary symptoms.

CONCLUSION

This case demonstrates an exceptionally rare and unusual variant neoplasm in a neonate and highlights the difficulty of diagnosis and the important role of MR imaging. It also illustrates the importance of gross total resection, the risk of recurrence, and the need for close radiographic follow-up of these lesions. It also provides a useful example of the efficacy of adjuvant chemotherapy in treating recurrence.

Cisplatin induces differentiation in teratomas derived from pluripotent stem cells

Introduction

Currently, embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs) can be induced to differentiate at the cellular level but not to form mature tissues or organs suitable for transplantation. ESCs/iPSCs form immature teratomas after injection into immunodeficient mice. In humans, immature teratomas often transform into fully differentiated mature teratomas after administration of anticancer agents.

Methods

We first investigated the ability of cisplatin to induce changes in mouse ESCs/iPSCs in vitro. Next, we designed experiments to analyze ESC/iPSC-derived immature teratoma tissue in vivo after treatment of cisplatin. Groups of six mice carrying ESC- or iPSC-derived teratomas were given either low or high dose intraperitoneal injection of cisplatin, while the control group received saline for 4 weeks.

Results

Treatment of ESC/iPSC cultures with cisplatin for 3 days caused a dose-related decrease in cell numbers without inducing any morphological changes to the cells. ESC/iPSC-derived teratomas showed lower growth rates with a significantly higher mature components ratio in a concentration dependent manner after cisplatin treatment (P < 0.05); however, immunohistochemical analyses demonstrated a significantly reduced PCNA labelling index and an increase in an apoptosis marker on immature neural components (P < 0.05) along with emergence of h-Caldesmon⁺ mature smooth muscle cells in treated mice. Moreover, newly differentiated components not found in the control group, such as mature adipose tissue, cartilage, and pancreas, as well as striated muscle, salivary glands, gastric mucosa with fundic glands, and hair follicles emerged. The identities of these components were confirmed by immunostaining for specific markers.

Conclusions

Cisplatin has the ability to reduce immature components in ESC/iPSC-derived teratomas, presumably through apoptosis, and also to induce them to differentiate.

•

Transformation of immature to mature teratoma after chemotherapy was verified.

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Mice bearing ESC/iPSC-derived immature teratomas were used.

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Mice were treated with intraperitoneal injection of cisplatin for 4 weeks.

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Newly differentiated structures were found only in the tumors of treated mice.

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Cisplatin can induce differentiation in ESC/iPSC-derived immature teratomas.

Massive primary retroperitoneal immature teratoma in an adult: A case report

INTRODUCTION AND IMPORTANCE

Teratoma is a rare clinical entity in adults and commonly arises from gonads. Being rare, retroperitoneal teratomas account for 4 % of all primary teratomas. A teratoma can be mature or immature, of which mature is more common in adults and immature is more common in neonates or children. It is labeled immature if at least one from the three germ layers lacks differentiation. To the best of our knowledge, this is the first case of primary retroperitoneal 'immature' teratoma in a male adult.

CASE DESCRIPTION

A 53-year-old male, following a road traffic accident, was investigated for the same and was incidentally detected with a retroperitoneal mass based on Chest X-ray, USG abdomen, and CT scan reports.

CLINICAL FINDINGS AND INVESTIGATIONS

A painless palpable mass was identified on examination after the patient was referred to our tertiary care hospital for surgical benefit. AFP, HCG and LDH were tested and reported normal.

INTERVENTIONS AND OUTCOMES

An exploratory laparotomy was done and the mass was surgically removed and sent for histopathological examination, which revealed an 'immature' retroperitoneal teratoma. After resection, a rent was identified in the IVC, following which the IVC was clamped. On follow-up, the patient has been compliant and the prognosis is good.

CONCLUSION

Retroperitoneal teratoma is a very rare clinical entity in adults. Being such massive, it can remain asymptomatic to be detected incidentally. Diagnosis is made with help of radiological findings and can be confirmed after surgical resection and histopathological examination. Surgery remains the mainstay of treatment.

Recurrent High-grade Ovarian Immature Teratoma with Peritoneal Dissemination

BACKGROUND

Peritoneal dissemination of ovarian immature teratoma in children is a rare entity and is associated with a poor prognosis. There are no guidelines on the optimal management of these patients with regard to surgery and systemic treatments.

CASE

This is the case of a 16-year-old patient who experienced an early recurrence of immature teratoma with peritoneal dissemination after surgery and systemic chemotherapy failure, and was treated with an aggressive salvage cytoreductive surgery. She was still disease-free 6 months after her second surgery.

SUMMARY AND CONCLUSION

Upfront aggressive surgical management with complete cytoreductive surgery is recommended when patients present with disease recurrence and peritoneal dissemination of ovarian immature teratoma. Such cases should be managed in centers with local expertise in the treatment of peritoneal surface malignancies.

Pediatric ovarian immature teratoma: Histological grading and clinical characteristics

BACKGROUND

Ovarian immature teratomas (ITs) are relatively rare among all pediatric ovarian tumors. The histological grading for ovarian ITs, which ranges from 1 to 3, is based on the proportion of immature neuroepithelial component. Higher-grade ITs in adults are treated as malignant neoplasms and require adjuvant chemotherapy. However, there is no consensus on the therapeutic management of pediatric ovarian ITs. The aim of our study was to analyze the histological grades and clinical characteristics of ovarian ITs in pediatric patients.

METHODS

This retrospective chart review consisted of seven patients, including one, three, and three patients with histological grade 1, 2, and 3 pediatric ovarian ITs, respectively, who were treated at our institute between 2000 and 2016. Collected data comprised age, alpha-fetoprotein (AFP) level, clinical stage, tumor size, treatment, and prognosis.

RESULTS

The median age and AFP levels of patients with grade 1, 2, and 3 ovarian ITs were 8, 7, and 10 years and 37, 112, and 221 ng/ml, respectively. All cases were Children Oncology Group (COG) stage I and International Federation of Gynecology and Obstetrics (FIGO) stage IA. All patients had unilateral tumors in the right ovary. The median tumor sizes of the grade 1, 2, and 3 IT patients were 104, 160, and 100 cm², respectively. All patients underwent primary open surgery alone. Two patients, including one patient each with grade 2 and 3 ITs, underwent tumor enucleation as ovary-sparing surgery, whereas the remaining five patients underwent unilateral salpingo-oophorectomy. The median follow-up was seven years, and all cases achieved event-free survival.

CONCLUSIONS

Clinical characteristics of patients with grade 3 ovarian ITs were relatively older and had higher AFP levels than those with lower-grade ITs. According to our patient's clinical course and prognosis, COG stage I pediatric ITs should be treated by surgery alone and that postoperative chemotherapy is unnecessary even for those with grade 3 ITs as well as patients with rather low AFP levels.

LEVEL OF EVIDENCE

IV.

Diagnosis and management of growing teratoma syndrome after ovarian immature teratoma: A single center experience

OBJECTIVES

To evaluate the diagnostic, surgical, and oncological outcomes of patients with growing teratoma syndrome (GTS).

METHODS

Patients diagnosed with ovarian immature teratoma (IMT) between 1980 and 2018 at Peking Union Medical College Hospital (PUMCH) were evaluated for the development of GTS. Their clinical characteristics, surgical and pathological data, and oncological outcomes were collected.

RESULTS

Between 1980 and 2018, 175 cases of IMT were referred to PUMCH. Thirty-five patients subsequently developed GTS with a crude rate of approximately 20%. The median interval between the initial diagnosis of IMT and the first occurrence of GTS was 18.5 months (range, 6-78 months). Residual disease (P < 0.001) and gliomatosis peritonei (GP) at initial surgery (P = 0.023) were independent risk factors for GTS development. Fertility-sparing surgery for GTS was performed in 27 patients and four patients achieved five singleton pregnancies. The median follow-up time was 73 months (range, 11-401 months). Eleven patients developed at least one recurrence. Residual disease after GTS surgery was associated with GTS recurrence (P = 0.001). By the end of follow-up, 27 patients were alive without disease and the other eight patients were alive with disease.

CONCLUSION

The presence of residual disease and GP at initial surgery are risk factors for GTS. Complete surgical resection is the cornerstone for treatment of GTS. The presence of residual disease after surgery for GTS is a risk factor for GTS recurrence. Fertility-sparing surgery should be performed because spontaneous pregnancy is possible. The overall prognosis of GTS is excellent.

Ovarian germ cell tumour classification: views from the testis

The classification of ovarian germ cell tumours has remained unchanged for many years, while there have been considerable changes in the testicular classification. In recent years there has been concern about the overtreatment of clinical stage 1 testicular germ cell tumours with increasing use of surveillance for low-risk disease. We outline here the current classification of germ cell tumours of the ovary with particular regard to treatment and outcome and highlight some areas which may cause confusion, particularly pertaining to immature teratomas and mixed germ cell tumours. We suggest that some minor changes to the classification, evidenced by a recent retrospective series by some of the authors, may lead to less adjuvant chemotherapy for immature teratomas and may obviate the need for the grading of immature teratomas, by aligning with testicular experience in pure post-pubertal teratomas. Adoption of this will require retrospective and prospective re-evaluation, but may avoid long-term patient morbidity.

Primary and Recurrent Growing Teratoma Syndrome in Central Nervous System Nongerminomatous Germ Cell Tumors: Case Series and Review of the Literature

BACKGROUND

The term "growing teratoma syndrome (GTS)" has been used as follows: patients with germ cell tumor (GCT) who present with enlarging original/metastatic masses during or after appropriate systemic chemotherapy despite normalized serum markers. In other words, the definition of the term GTS is not fully established. We analyzed and reviewed our case series regarding GTS that developed after the treatment of central nervous system (CNS) nongerminoatous germ cell tumors (NGGCTs).

METHODS

Our institutional review board approved this retrospective study. Between 2003 and 2018, we treated 16 patients (16 males; age ranging from 5.4 to 51.9 years, median 13.8) with CNS-NGGCT at our institution. We reviewed those patients and also reviewed the literature about GTS of CNS. We defined primary GTS (p-GTS) as the enlargement of cyst size and/or solid tumor occurred during treatment in the absence of marker elevation, and recurrent GTS (r-GTS) as the enlargement of teratoma after complete response of initial tumors.

RESULTS

Among 16 patients with CNS-NGGCT, we surgically confirmed mature/immature teratoma components in 15 patients. Two patients underwent surgical removal of tumor before neoadjuvant therapy, and among the rest 14 patients, 6 developed p-GTS, and 2 patients underwent salvage surgery during chemo-/chemoradiotherapy. Those with histologic diagnosis of immature teratoma during salvage surgery had a shorter interval from the initiation of chemoradiotherapy compared with mature teratoma (P < 0.05). One patient developed r-GTS. In the literature review, most of the p-GTS consisted of enlargement with the multicystic component. Histologic diagnosis of immature teratoma during salvage surgery was observed in earlier stages of chemoradiotherapy (P < 0.05, log-rank test). Previous history of p-GTS might be a risk factor of r-GTS.

CONCLUSIONS

The incidence of p-GTS, enlargement of the cystic component during treatment, is not rare. Physicians need to be aware of this important phenomenon.

Immature teratoma of the posterior fossa in an infant: case report

Teratoma is a rare tumor of the central nervous system that belongs to intracranial germ cell tumors. We report a 2-month-old male child with an immature teratoma of the posterior fossa. Physical and laboratory examinations were normal. Though a radiologic examination was characteristic for this neoplasm, it was insufficient to make a definite diagnosis. Combining the radiologic findings with a histopathologic examination contributed to diagnosing immature teratoma and differentiating it from other subtypes of intracranial germ cell tumors. Our aim was to provide a greater understanding of immature teratoma by reporting this case.

A multicentre retrospective cohort study of ovarian germ cell tumours: Evidence for chemotherapy de-escalation and alignment of paediatric and adult practice

BACKGROUND

Adult guidelines recommend BEP (bleomycin, etoposide, cisplatin) for all ovarian germ cell tumours, causing debilitating toxicities in young patients who will survive long term. Paediatricians successfully reduce toxicities by using lower bleomycin doses and substituting carboplatin for cisplatin, while testicular and paediatric immature teratomas (ITs) are safely managed with surgery alone.

AIM

The aim was to determine whether reduced-toxicity treatment could rationally be extended to patients older than 18 years.

METHODS

Multicentre cohort study was carried out in four large UK cancer centres over 12 years.

RESULTS

One hundred thirty-eight patients were enrolled. Overall survival was 93%, and event-free survival (EFS) was 72%. Neoadjuvant/adjuvant chemotherapy (82% BEP) caused 27 potentially chronic toxicities, and one patient subsequently died from acute lymphoblastic leukaemia. There was no difference in histology, stage or grade in patients ≤/>18 years, and EFS was not different in these age groups (≤18:28% and >18:28%; log-rank P = 0.96). Histological subtype powerfully predicted EFS (log-rank P = 4.9 × 10-7). Neoadjuvant/adjuvant chemotherapy reduced future relapse/progression in dysgerminoma (n = 37, chemo:0% vs. no chemo:20%), yolk sac tumour (n = 23, 26.3% vs.75%) and mixed germ cell tumour (n = 32, 40%vs.70%) but not in IT (n = 42, 33% vs.15%). Additionally, we observed no radiological responses to chemotherapy in ITs, pathological IT grade did not predict EFS (univariate hazard ratio 0.82, 95% confidence interval: 0.57-1.19, P = 0.94) and there were no deaths in this subtype.

CONCLUSION

Survival was excellent but chemotherapy toxicities were severe, implying significant overtreatment. Our data support the extension of reduced-toxicity, paediatric regimens to adults. Our practice-changing findings that IT was chemotherapy resistant and pathological grade uninformative strongly endorse exclusive surgical management of ovarian ITs at all ages.

Ovarian Cancer Immature Teratoma Type in Pregnancy: Management and Feto-Maternal Outcomes

BACKGROUND

Immature teratoma is malignant ovarian germ cell tumours (MOGCTs). The case in pregnancy is very rare which less than 1% of all ovarian teratoma cases. The aim is to reach optimal and comprehensive management for immature ovarian teratoma in pregnancy to gain the healthiest maternal and fetal outcomes.

CASE PRESENTATION

Thirty-one years old female G2P1A0, 8 weeks 1-day pregnancy, with left ovarian solid tumour 15 x 15 x 15 cm in size. At gestational age (GA) of 19 weeks 5 days, the size of the tumour was increasing rapidly to 30 x 30 x 30 cm. Alfa-fetoprotein raised to 699.9 IU/mL and LDH 579 U/L. The patient had gone primary conservative left oophorectomy, omentectomy, and ascites fluid cytology with histopathological conclusion grade II immature teratoma of left ovary containing the immature neuroepithelial and fat component: magnetic resonance imaging (MRI) at 25 weeks 3 days GA, no spreading. Amniocentesis performed at 27 weeks 2 days GA, the fetus had normal 46 chromosomes and sex XX without major structural abnormality. The patient had BEP chemotherapy start at 27 weeks 2 days GA. Patient in labour at 40 weeks 2 days GA. The female baby had spontaneous delivery with 2700 grams in body weight without congenital abnormality. Complete surgical staging performed at 58th days postpartum and histopathological result there was no malignant cell anymore, but post-chemotherapy ovarian atrophy feature had found on the contralateral ovary. The patient showed psychosocial problem including post-chemotherapy depression and premature ovarian failure (POF). Immunohistochemistry (IHC) ER and PR of teratoma tissue showed immature component had ER (-) and PR (+). Follow up of the baby was in good condition.

CONCLUSION

BEP chemotherapy become regimen choice for this case with fetal outcomes was good, but there was a POF sign on the mother. Survival of patient on this case is 62%, free recurrence survival post-BEP 84% and progressivity post complete surgical staging 8% without delay the chemotherapy.

An autopsy case of epignathus (immature teratoma of the soft palate) with intracranial extension but without brain invasion: case report and literature review

Background

Epignathus is a rare congenital orofacial teratoma infrequently associated with intracranial extension. Intracranial extension of an epignathus indicates a poor prognosis; however, only a small number of such cases have been reported. While there have been some studies reporting cases of epignathus expanding directly into the cranium, others have reported no communication between an epignathus and an intracranial tumor.

Case presentation

A fetus at gestational week 27 was suspected of having an epignathus with intracranial tumor as shown by ultrasonographic and magnetic resonance imaging. The fetus was stillborn and an autopsy was performed. An epignathus measuring 12 × 6 × 6 cm and weighing 270 g protruded from the mouth, with its base on the soft palate. An intracranial tumor weighing 14 g was located at the middle intracranial fossa and connected to the epignathus through the right side of the sella turcica. The intracranial tumor was encapsulated, and there was no invasion into the brain. Histologically, both the epignathus and intracranial tumor were immature teratomas, with neural and pulmonary components that were especially immature as compared to those of the internal organs and brain tissues of the fetus.

Conclusion

There have been several reports of epignathus and intracranial tumors that did not communicate; therefore, careful evaluation is needed when a fetus is suspected of having an epignathus extending into an intracranial lesion. Our case supports the findings that an epignathus can directly expand into the cranium. Moreover, this is a rare case of an epignathus in which the intracranial lesion was encapsulated and did not invade the brain. These rare but important findings will provide additional, potential therapeutic strategies for gynecologists, neurosurgeons, and pathologists.

Immature Teratoma of Nasal Septum: A Case Report

INTRODUCTION

Teratomas are neoplastic tumors derived from totipotent germ cells containing a wide assortment of tissues originating from all three germ cell layers. Teratomas can be mature or immature depending on the presence of immature tissues; typically neuroepithelial tissue. Immature teratomas can be oncologically benign or malignant, and can be divided into three grades with increasingly aggressive biological behavior. The most common site for this tumor is the sacrococcygeal region. The nasal septum is an exceptionally rare site for immature teratomas, with very few cases reported.

CASE REPORT

We discuss a 14-year-old male patient with a left nasal mass which, on histopathological examination, turned out to be a Grade-3 immature teratoma. Imaging revealed the mass to be confined in the left nasal cavity with erosion of the anterior skull base. During endoscopic excision, the tumor was seen extending intracranially but remaining extradurally. Complete resection was achieved, albeit with mild cerebrospinal fluid (CSF) leakage, which was closed successfully. The patient was subjected to adjuvant chemotherapy. A regular follow-up of 2 years showed no recurrence.

CONCLUSION

The purpose of this report is to document the first case of a high-grade immature teratoma arising from the nasal septum with intracranial extension, as well as the efficacy of combined endoscopic resection and adjuvant chemotherapy for this pathology.

Clinicopathological spectrum of teratomas: An 8-year retrospective study from a tertiary care institute

BACKGROUND

Teratomas are tumors that contain tissues derived from three different germ cell layers and having a wider range of differentiation with different site and age at presentation. The aim of the present study was to know the frequency of teratomas in various sites and to analyze their clinicomorphological features.

MATERIALS AND METHODS

The present study is a retrospective study conducted in tertiary care hospital of Central India. All the cases diagnosed as teratoma in the period of 8 years were included and studied with reference to age, sex, site, size, gross, and microscopic features.

RESULTS

A total of 92 cases were retrieved. The most common teratoma was ovarian (78.26%) followed by intracranial/intraspinal and sacrococcygeal in frequency of 7.61% each. Out of 92 cases, 89 were mature and benign, 2 cases were immature teratoma each in ovary and in sacrococcyx, and 1 case of teratocarcinoma in testis.

CONCLUSION

Teratomas have much diversity in their age at presentation, location, gross features, and in degree of differentiation. The prognosis and treatment also depends on the histological grading of teratomas. Thus, pathologists have an important role in establishing a reliable prognostic profile.

Immature teratoma mimicking pulmonary stenosis: a case report

Background

Immature teratoma in a mediastinal location is a rare disease that might present as a valve pathology. Germ cell tumors with mediastinal locations account for up to 6% of immature teratoma cases. We present a case of an immature teratoma located primarily in the anterior mediastinum that manifested solely through symptoms of pulmonary stenosis.

Case presentation

We report a case of a 20-year-old white man with an immature teratoma who presented with progressive exertional dyspnea. During a cardiac examination, an ejection systolic murmur was observed, and echocardiography findings at an Emergency Centre revealed high velocity flow at the level of the pulmonary artery, indicating pulmonary stenosis. He was hospitalized in our Cardiology Department for further investigation. A chest X-ray revealed a mediastinal mass, and repeated echocardiography indicated the presence of a large mediastinal mass compressing his main pulmonary artery. Magnetic resonance imaging confirmed the tumor in the mediastinum, and a histopathological diagnosis of immature teratoma was established following biopsy.

Conclusion

Immature teratoma causing cardiac-related complaints might shift the diagnosis toward cardiovascular diseases, thus requiring prompt examination by standard and sophisticated methods to clarify the diagnosis.

Orbital immature teratoma: A rare entity with diagnostic challenges

Childhood orbital teratomas are congenital lesions that presents most often at birth with progressive, severe unilateral proptosis. Due to the rarity of such tumors, the diagnosis is often missed with delay in the patient's management. We are presenting a unique case of an immature right orbital teratoma with extensive growth in a full-term newly born baby boy. In this case report, we provide description of the clinical findings, initial misdiagnosis and the eventual management with review of similar reported cases.

Third Ventricle Germ Cell Tumor Originating from the Infundibulum with Rapidly Expansive Enlargement

We present a pediatric case of a rapidly expanding third ventricle germ cell tumor (GCT). A 14-year-old boy suffered from gradual-onset central diabetes insipidus (DI) and received desmopressin treatment. Magnetic resonance imaging (MRI) showed nonspecific findings of the pituitary-hypothalamic axis. Nine months after the initial DI diagnosis, he developed progressively worsening headache. MRI demonstrated a third ventricle tumor causing noncommunicating hydrocephalus, although an MRI 16 weeks before admission did not show the lesion. We performed gross total resection (GTR) of the tumor in 2 stages: a translamina terminalis approach and an extended transsphenoidal approach. The lesion was histologically diagnosed as immature teratoma with some germinoma. His noncommunicating hydrocephalus resolved after surgery. Through postoperative radiochemotherapy (whole ventricle: 23.4 Gy/13 fractions, tumor bed: 27.0 Gy/15 fractions, and 3 courses of carboplatin-etoposide), he has was in complete remission at the 3-year follow-up and has continued his high school program. This case suggests the following: (1) a mixed GCT originating from the neurohypophysis/infundibulum can show rapidly expansive growth in a child with central DI; (2) GTR and adjuvant radiochemotherapy can result in a good therapeutic outcome in rapidly expanding GCT; and (3) the extended transsphenoidal approach is a complementary approach to transcranial resection of anterior third ventricle GCTs.

Hepatoduodenal ligament teratoma with immature elements

Pediatric germ cell tumors comprise 1-3% of all malignant pediatric tumors and are found in variable locations. We present the case of a term 3.7 kg neonate who was found to have a giant liver mass at birth, later determined to be an immature teratoma arising from the hepatoduodenal ligament. This case report and images add to the limited literature a very rare presentation of a teratoma.

A case of ovarian growing teratoma syndrome treated by cytoreductive surgery

Ovarian growing teratoma syndrome (GTS) is a rare disease characterized by growth of a benign tumor during or after chemotherapy, following the removal of germ cell gonadal cancers. Although benign, GTS tumors grow gradually and may compress surrounding organs. In addition, up to 3% of GTS cases can undergo malignant transformation. It is, therefore, needed to treat GTS. No standardized management protocol has been established to treat GTS; however, surgical resection is likely the only effective treatment because tumors in GTS are resistant to chemotherapy and radiation therapy. However, complete resection with conventional procedures is sometimes difficult when peritoneal metastasis is widespread. We report a rare case of ovarian GTS with widespread peritoneal metastases, which was totally resected by peritonectomy procedures. A 45-year-old Japanese woman was initially diagnosed with an immature teratoma grade 3, which was treated by hysterectomy and bilateral salpingo-oophorectomy. Adjuvant chemotherapy was performed after surgery with bleomycin, etoposide, cisplatin, and other chemotherapies. Due to recurrence of a chemoresistant tumor and normalization of tumor markers, GTS was suspected. She was referred to our institute, and complete cytoreductive surgery was performed using peritonectomy procedures, including parietal peritoneal resection, greater omentectomy, lesser omentectomy, rectosigmoid colectomy, diaphragm dissection, and cholecystectomy. A complete cytoreduction with no visible residual tumor tissue was achieved.

A fetus with a mass in the oral cavity: a rare case of oral immature teratoma

Teratomas are congenital germ cell tumors composed of diverse tissues of ectodermal, mesodermal, and endodermal origin with variable levels of maturity. Immature teratoma is an uncommon prenatal finding, which was rarely reported in the oral region. We herein report a unique case of a male neonate with a mass arising in his oral cavity. Ultrasonic studies diagnosed it as fetus-in-fetus or teratoma and pathological studies of the resected mass provided supportive evidence for the case of an oral immature teratoma. To our knowledge, there are few cases of oral immature teratoma arising in the fetus reviewing the literature.

Fertility sparing approach as the standard of care in young patients with immature teratomas

Immature teratomas are quite rare tumors arising in young women. They are usually diagnosed in early stage and grade and have a good prognosis. In these young patients, fertility-sparing management is suggested as the standard of care. Bilateral immature teratoma is a rare condition with an incidence of 10%, with a five-year survival rate of 80%. The majority of patients received fertility-sparing treatment followed by adjuvant chemotherapy in 78%. Older age, advanced stage, and high grade are negative prognostic factors. The surgery-only, watch-and-wait approach was evaluated; however, after a median follow-up time of 42 months, 50% of patients experienced recurrence, but they were successfully salvaged with chemotherapy. In a retrospective study, 12 out of 27 patients tried to conceive, resulting in 10 pregnancies (8 after chemotherapy). We present a narrative review of the current literature regarding the essential multidisciplinary approach of such patients in order to achieve the best oncologic and fertility-sparing outcome.

Wilms' tumor of the ovary

Extrarenal Wilms' tumor of the ovary is a very rare tumor likely derived from embryonic mesonephros. We present the first reported case of a teratoid extrarenal Wilms' tumor of the ovary with a short review of the existing literature. In the case, a 26-year-old woman presented with back pain and was found to have a dermoid cyst; three years later, she presented again, now pregnant, with severe abdominal pain. She was diagnosed with an immature teratoma consisting of a Wilms' tumor (immature component) arising within a mature teratoma and treated exclusively with surgery and surveillance. The recovery from surgery was uneventful and the patient remains without evidence of disease with eleven months of follow-up.

Ovarian cystectomy in the treatment of apparent early-stage immature teratoma

Objective

To investigate the role of ovarian cystectomy in patients with early-stage immature teratoma.

Methods

A retrospective review was undertaken on patients diagnosed pathologically with immature teratoma and with malignant lesions confined to the ovary. Patients were included if they had been treated between January 1997 and December 2015 at the Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China. Relevant demographic and clinical data were retrieved from the medical records.

Results

Forty-three patients were included in the study; 14 underwent ovarian cystectomy (group 1) and 29 underwent unilateral salpingo-oophorectomy (USO; group 2). Three of the patients who underwent USO relapsed and required a second surgical intervention. The 5-year disease-free survival rates were 100% and 88%for groups 1 and 2, respectively. There were no significant differences between the two groups in terms of survival or postoperative fertility outcomes. Univariate and multivariate analysis further revealed that ovarian cystectomy was not a poor prognostic indicator for disease-free survival.

Conclusion

These current data suggest that ovarian cystectomy can be considered for patients with apparent early-stage immature teratoma as it preserves fertility as much as possible without adversely impacting upon survival.

Diagnostic Significance of Cellular Neuroglial Tissue in Ovarian Immature Teratoma

Background

Immature teratoma (IT) is a tumor containing immature neuroectodermal tissue, primarily in the form of neuroepithelial tubules. However, the diagnosis of tumors containing only cellular neuroglial tissue (CNT) without distinct neuroepithelial tubules is often difficult, since the histological characteristics of immature neuroectodermal tissues remain unclear. Here, we examined the significance of CNT and tried to define immature neuroectodermal tissues by comparing the histological features of neuroglial tissues between mature teratoma (MT) and IT.

Methods

The histological features of neuroglial tissue, including the cellularity, border between the neuroglial and adjacent tissues, cellular composition, mitotic index, Ki-67 proliferation rate, presence or absence of tissue necrosis, vascularity, and endothelial hyperplasia, were compared between 91 MT and 35 IT cases.

Results

CNTs with a cellularity grade of ≥ 2 were observed in 96% of IT cases and 4% of MT cases (p < .001); however, CNT with a cellularity grade of 3 in MT cases was confined to the histologically distinct granular layer of mature cerebellar tissue. Moreover, CNT in IT exhibited significantly higher rates of Ki-67 proliferation, mitoses, and necrosis than those in MT (p < .001). Furthermore, an infiltrative border of neuroglial tissue and glomeruloid endothelial hyperplasia were significantly more frequent in IT cases than in MT cases (p < .001).

Conclusions

Our results suggest that if CNT with a cellularity grade of ≥ 2 is not a component of cerebellar tissue, such cases should be diagnosed as IT containing immature neuroectodermal tissue, particularly if they exhibit an infiltrative border, mitoses, necrosis, and increased Ki-67 proliferation.

The influence of age and other prognostic factors associated with survival of ovarian immature teratoma - A study of 1307 patients

OBJECTIVE

To determine impact of age and other prognostic factors on the survival of ovarian immature teratoma (IT) patients.

METHODS

Data obtained from the SEER database between 1973 and 2012. Kaplan-Meier methods and multivariate Cox regression models were used for statistical analyses.

RESULTS

Of 1307 patients (median: 24years; range: 0-93), 78%, 5%, 13%, 4% were stages I, II, III and IV, respectively. 25%, 35%, and 40% had grades 1, 2, and 3. Whites were less likely to be diagnosed, and Asians had a nearly 3-fold higher proportion of IT compared to the proportion of Asians in the U.S. census. The 5-year disease-specific survival (DSS) was 91.2%. Those with stages I, II, III and IV disease had survivals of 99.7%, 95%, 81%, and 71.8% (p<0.001) and grades 1, 2, and 3 had DSS of 98.7%, 95.8%, and 91% (p<0.001), respectively. Of those who underwent fertility-preserving surgery, the DSS was 98.8%. Over time from 1973 to 1986, to 1987-1999, to 2000-2012, the survivals were 76.4%, 92.8%, and 94.7% (p<0.001). Of stage I patients, no patient <18years (n=214, used as adult cutoff) and 2 of 283 patients >18years died of cancer, with corresponding 5years DSS of 100% vs. 99.6% (p>0.05). Older age (by year, HR: 1.05; 95% CI: 1.04-1.06; p<0.0001) and higher stage (HR: 11.52; 95% CI: 4.08-32.48; p<0.0001) were independent factors indicating poorer survival.

CONCLUSION

The outcome of patients with stage I disease was excellent at 99.7%, with children and adults having corresponding survivals of 100% and 99.6%.

Characteristics, treatment and outcomes of women with immature ovarian teratoma, 1998-2012

OBJECTIVE

To explore the presentation, management and outcomes of adult women diagnosed with immature ovarian teratoma.

METHODS

The National Cancer Database (NCDB) was used to identify women≥18years of age diagnosed with an immature teratoma from 1998 to 2012. We analyzed demographic, clinical and tumor characteristics, and treatment trends. Multivariable models were employed to examine predictors of adjuvant chemotherapy use and survival.

RESULTS

We identified a total of 1045 adult women with immature teratoma. The median age of diagnosis was 27years and most were diagnosed between ages 18 and 39 (88.9%). The majority presented with early-stage (I/II) disease (76.0%), underwent unilateral salpingo-oophorectomy (52.5%) and received adjuvant chemotherapy (56.8%). The probability of receiving chemotherapy increased with stage, grade, and treatment at academic compared to community based centers (P<0.05.). Older age, advanced stage, and grade III histology were associated with worse survival (P<0.05). Five-year survival rates were: 98.3% (95% CI 96.8-99.1), 93.2% (95% CI 82.8-97.4), 82.7% (95% CI 74.3-88.5), and 72.0% (95% CI 50.1-85.5) for stages I, II, III, and IV disease, respectively.

CONCLUSIONS

The incidence of immature teratoma is highest in young adults aged 18 to 39. Most patients present with early-stage disease, are managed with fertility sparing surgery and chemotherapy and have an excellent prognosis. Later age at diagnosis, advanced stage, and high-grade histology confer a worse prognosis.

Prenatally Diagnosed Aggressive Intracranial Immature Teratoma-Clinicopathological Correlation

OBJECTIVE

To describe clinicopathological correlation of congenital intracranial immature teratoma.

METHODS

A retrospective case analysis from a tertiary medical center.

RESULTS

We report a case of an intracranial immature teratoma detected prenatally at 35 weeks of gestation. The tumor showed rapid growth, causing acute hydrocephalus requiring subsequent ventriculoperitoneal shunting. Resective surgery was performed within 2 weeks after birth. The infant died at day of life 29. Histological examination revealed an immature teratoma, with high MIB1/Ki-67 proliferation index.

CONCLUSION/IMPLICATIONS

Intracranial immature teratoma with high MIB1/Ki-67 proliferation index may serve as an independent poor prognostic factor.

Portal Hypertension Caused by Immature Teratoma in an Adolescent Female

BACKGROUND

Tumor compression is a cause of portal hypertension. In adolescents, most tumors are germ cell tumors.

CASE

We report the case of a 17-year-old female patient with progressive abdominal distention. Portal hypertension with ascites and esophageal varices were identified. A computed tomography scan showed a large ovarian mass that was consistent with a teratoma. After laparotomy, the portal hypertension was resolved.

SUMMARY AND CONCLUSION

Venous compression by an immature teratoma should be considered a cause of portal hypertension in adolescents.

Immature teratoma of ovary--outcome following primary and secondary surgery: study of a single institution cohort

OBJECTIVE

To analyse the clinical presentation, treatment - primary and secondary debulking and outcomes with focus on recurrences in ovarian immature teratoma.

STUDY DESIGN

This is a single institution, retrospective analysis of 24 women who presented to a gynecologic oncology unit from 1999 to 2011 with ovarian immature teratoma. Patient's clinical presentation, operative and chemotherapy details were included in a database. Follow up details regarding recurrence and management and future outcomes were also noted. Overall survival was calculated from the date of registration to last follow up or date of death. Survival curve was constructed by Kaplan-Meier method.

RESULTS

Immature teratoma accounted for 11% of 218 malignant germ cell tumors. Of the 24 patients, pain was the predominant symptom and abdominal mass was the commonest clinical presentation. Sixteen out of 24 patients presented in Stage I and grade 3 tumors were found in 43% of patients. Six patients had only unilateral salpingo oophorectomy and no staging procedure. Twelve patients underwent staging, with omentectomy being the commonest procedure. All but one, had cisplatin based combination chemotherapy. Six patients underwent secondary debulking of recurrence. Most recurrences were recorded in Stage III, higher grade tumors. With secondary cytoreduction and platinum based chemotherapy, it was possible to salvage most recurrences as well. Overall survival after a mean follow-up of 39 months was 91.6%.

CONCLUSION

Majority of the patients did well with conservative surgery in terms of survival, menstrual and reproductive function. Platinum based chemotherapy was indicated in higher grade and higher stage tumors as recurrences commonly occurred in this subgroup of patients. Recurrences could be salvaged with selected secondary cytoreduction and platinum based chemotherapy.

A rare case of postmenopausal immature teratoma with a recurrent grave course

Immature teratoma is quite uncommon older women, particular in postmenopausal period. Only a few cases of postmenopausal immature teratoma of the genital tract have been reported. This report describes a postmenopausal aggressive pelvic immature teratoma case with a grave course despite treatment. A 67-year-old woman being in menopause for the past 16 years was diagnosed with immature teratoma in the pelvic cavity. The mass was removed completely and hysterectomy plus bilateral salpingo-oophorectomy was done. Histopathological diagnosis was grade 2 immature teratoma. The patient had a grave course with recurrences despite therapy and died within one year after initial diagnosis. In teratomas diagnosed over 45 years of age, the possibility of malignant teratoma should also be borne in mind.

Gastric teratoma-unusual cause of neonatal obstructive jaundice: a case report

The gastric teratoma is a very rare tumour that usually presents as an abdominal mass, gastrointestinal bleeding with/without features of gastric outlet obstruction. We report a rare case of immature gastric teratoma in a two months old female child who presented with abdominal lump and jaundice. The presentation was a diagnostic challenge and a dilemma, added by the fine needle aspiration cytology (FNAC) suggestive of small round cell tumor, favouring diagnosis of Wilms tumor over Neuroblastoma. Intra-operatively the tumor was found compressing upon the common bile duct (CBD). Final histopathological examination (HPE) revealed immature gastric teratoma Grade III. We wish to highlight this unusual presentation of gastric teratoma manifesting with obstructive jaundice and fallacy of FNAC in the diagnosis of teratomas.

Peritoneal and nodal gliomatosis with endometriosis, accompanied with ovarian immature teratoma: a case study and literature review

Gliomatosis peritonei (GP) indicates the peritoneal implantation of mature neuroglial tissue and is usually accompanied by ovarian mature or immature teratoma. Here, we report a case of ovarian immature teratoma associated with gliomatosis involving the peritoneum, lymph nodes and Douglas' pouch, where gliomatosis coexisted with endometriosis. As far as we know, only seven cases of GP have been reported as coexisting with endometriosis. Eight cases with mature glial tissue in the lymph nodes, i.e., nodal gliomatosis, have been published either in association with GP or in its absence. Metaplasia of pluripotent coelomic stem cells has been suggested to be responsible for the pathogenesis of endometriosis and GP rather than implantation metastases of ovarian teratomatous tumor with varying maturation. This theory is also applied to GP independently of ovarian teratomatous tumors. To the best of our knowledge, nodal gliomatosis coexisting with GP and also involving endometriosis has not yet been reported.

Growing teratoma syndrome of the ovary showing three patterns of metastasis: a case report

Growing teratoma syndrome (GTS) is defined as metastatic masses during or after chemotherapy for germ cell tumors, which contain only mature teratoma components. The peritoneum of the pelvis and abdomen and the retroperitoneum are the most frequent sites of metastasis. We report a case of GTS of the ovary showing three patterns of metastasis: dissemination, lymphogenous metastasis, and hematogenous metastasis. The patient initially presented 5 years ago with a mixed germ cell tumor of the left ovary and positive cytology of ascites. After surgery and chemotherapy, mature teratomas recurred as pelvic peritoneal dissemination, a para-aortic lymph node mass, and a lung mass. Our case highlights the importance of long-term follow-up and a whole-body search. We think that our case is suggestive regarding the mechanism of critical GTS.

Interferon-α Treatment for Growing Teratoma Syndrome of the Testis

A 23-year-old man with a right scrotal mass and back pain was referred for further treatment after right radical orchiectomy for testicular cancer. CT scans brought by the patient showed extensive metastasis to the retroperitoneal lymph nodes with no lung involvement. α-Fetoprotein and human chorionic gonadotropin were elevated preoperatively (384 ng/ml and 112 mIU/ml, respectively). Confirmation of the histopathologic examination revealed a mixed germ cell tumor (95% immature teratoma and 5% embryonal carcinoma). We started the patient on chemotherapy with bleomycin, etoposide, and cisplatin (BEP). After a single course, tumor markers began to normalize, but there was radiologic evidence of continued growth of the retroperitoneal mass and new metastases in the lung. The patient was given 2 courses of salvage chemotherapy with etoposide, ifosfamide, and cisplatin (VIP). However, the mass and lung metastases continued to progress, and the patient was growing rapidly intolerant of the side effects of treatment (i.e., nausea, appetite loss, and pancytopenia). After thorough discussion with the patient and his family, we decided to start the patient on interferon (IFN)-α therapy. Natural, nonrecombinant IFN-α (OIF, Otsuka, Japan) 5,000,000 IU was administered twice weekly with approval of the ethics committee of our institution. The patient responded moderately with marked deceleration of tumor growth and stabilization of the lung metastases. He is alive and well at 16 months on IFN-α therapy.

Successful infertility treatment following fertility-sparing surgery and chemotherapy for ovarian immature teratoma: a case report and a literature review

Introduction

Malignant ovarian germ cell tumors (MOGCTs) are highly chemosensitive tumors most commonly found in adolescent girls and young women. However, patients with advanced disease can now be successfully cured with fertility-sparing surgery and adjuvant chemotherapy, resulting in childbearing.

Case

A 24-year-old nulliparous Japanese woman was diagnosed as having a stage IIIc immature teratoma. After fertility-sparing surgery, she received four cycles of chemotherapy consisting of cisplatin, etoposide, and pepleomycin. She married at the age of 34, but did not conceive due to sexual dysfunction of her husband. At the age of 38, intrauterine insemination was performed following ovulation induction with clomid and human menopausal gonadotrophin, which resulted in a singleton pregnancy. A healthy female infant was delivered at 38 weeks' gestation.

Conclusion

Treatment might sometimes be needed for infertile women with a history of MOGCTs, but further studies are needed to determine whether infertility treatment, including ovulation induction, is appropriate.

Immature gastric teratoma: a rare tumour

Gastric teratomas are very rare tumours in children. They usually present with a palpable mass in the upper abdomen. We report a case of gastric teratoma in one and half month old male infant who presented with a palpable mass in abdomen, extending from epigastrium to the pelvis. Ultrasound of abdomen revealed a huge mass with solid and cystic components. CT scan delineated calcifications in the mass. The preoperative diagnosis was a teratoma but not specifically gastric one. The mass was excised completely with seromuscular layer of the stomach wall. The histopathology confirmed it to be grade-3 immature gastric teratoma. The rarity of the origin of teratoma in addition to its immature variety prompted us to report the case.

Huge immature teratoma of the liver in an adult: a case report and review of the literature

Teratoma tumors are tumors of childhood and, to the best of our knowledge, only 9 cases of hepatic teratoma and 1 case of immature teratoma of the liver had been reported in adults in the English literature. We present the second case of immature liver teratoma in a 22-year-old woman who presented with a 4-month history of abdominal pain and fullness sensation. A computed tomography (CT) scan of the abdomen and pelvis showed a huge well-defined heterogeneous mass in the right lobe of the liver containing fat, calcification, and cystic and solid parts, all suggestive of a teratoma. A right hepatectomy and an omentectomy were performed. The pathology report showed a 27 cm mass composed of ectodermal, mesodermal and endodermal components with minimal atypia and foci of immature components suggestive of immature teratoma, which is the largest liver teratoma to be reported. The patient was discharged in good health. During 8 months of follow-up, a CT scan and α-fetoprotein levels were both normal, and the patient is still alive.