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Teratoma

Teratoma
Micrograph of a teratoma showing tissue from all three germ layers: mesoderm (immature cartilage - left-upper corner of image), endoderm (gastrointestinal glands - center-bottom of image) and ectoderm (epidermis - right of image).
H&E stain.
Classification and external resources
Specialty Gynecology, oncology
ICD-10 C62.9 (ILDS C62.930)
ICD-O 9080
DiseasesDB

3604 12952

12966
eMedicine med/3449
MeSH D013724

A teratoma is a eyes,[1][2] torso,[3][4] and hands, feet, or other limbs.[5]

Usually, a teratoma will contain no organs but rather one or more tissues normally found in organs such as the brain, thyroid, liver, and lung. Sometimes, the teratoma has within its capsule one or more fluid-filled cysts; when a large cyst occurs, there is a potential for the teratoma to produce a structure within the cyst that resembles a fetus. Because they are encapsulated, teratomas are usually benign, although several forms of malignant teratoma are known and some of these are common forms of teratoma. A mature teratoma is typically benign and found more commonly in women, while an immature teratoma is typically malignant and is more often found in men.

Teratomas are thought to be present at birth (congenital), but small ones often remain undiscovered until much later in life.

Definitive medical diagnosis of a teratoma is based on its histology.

Contents

  • Terminology 1
  • Signs and symptoms 2
    • Complications 2.1
  • Pathophysiology 3
    • Hypotheses of origin 3.1
    • Mature teratoma 3.2
    • Dermoid cyst 3.3
    • Fetus in fetu and fetiform teratoma 3.4
    • Struma ovarii 3.5
  • Diagnosis 4
    • Classification 4.1
      • Malignant transformation 4.1.1
      • Extraspinal ependymoma 4.1.2
  • Treatment 5
    • Surgery 5.1
    • Chemotherapy 5.2
    • Follow-up 5.3
  • Epidemiology 6
  • Research 7
  • Other animals 8
  • See also 9
  • References 10
  • External links 11

Terminology

As is true throughout

 This article incorporates public domain material from the U.S. National Cancer Institute document "Dictionary of Cancer Terms".

  • humpath pathology images #2657 (Teratomas), #4541 (Mature teratoma), #5350 (Immature teratoma)
  • cystic teratoma at eMedicine (also teratomasearch EMedicine for all articles containing the word )
  • Monster Tumors Show Scientific Potential in War Against Cancer article in the NYTimes
  • Mature teratoma entry in the public domain NCI Dictionary of Cancer Terms
  • Mystery illness - ovarian teratoma associated encephalitis (audio report)

External links

  1. ^ Chi JG, Lee YS, Park YS, Chang KY (July 1984). "Fetus-in-fetu: report of a case". American Journal of Clinical Pathology 82 (1): 115–9.  
  2. ^ Sergi C, Ehemann V, Beedgen B, Linderkamp O, Otto HF (1999). "Huge fetal sacrococcygeal teratoma with a completely formed eye and intratumoral DNA ploidy heterogeneity". Pediatric and Developmental Pathology : the Official Journal of the Society for Pediatric Pathology and the Paediatric Pathology Society 2 (1): 50–7.  
  3. ^ Kuno N, Kadomatsu K, Nakamura M, Miwa-Fukuchi T, Hirabayashi N, Ishizuka T (January 2004). "Mature ovarian cystic teratoma with a highly differentiated homunculus: a case report". Birth Defects Research. Part a, Clinical and Molecular Teratology 70 (1): 40–6.  
  4. ^ Arlikar JD, Mane SB, Dhende NP, Sanghavi Y, Valand AG, Butale PR (March 2009). "Fetus in fetu: two case reports and review of literature". Pediatric Surgery International 25 (3): 289–92.  
  5. ^ "Tumor in baby’s brain contained tiny foot". msnbc.msn.com. December 18, 2008. Retrieved 2008-12-19. 
  6. ^  
  7. ^ Harding MJ, Paul J, Gillis CR, Kaye SB (April 1993). "Management of malignant teratoma: does referral to a specialist unit matter?". Lancet 341 (8851): 999–1002.  
  8. ^ Danzer E, Hubbard AM, Hedrick HL, et al. (2006). "Diagnosis and characterization of fetal sacrococcygeal teratoma with prenatal MRI". AJR Am J Roentgenol 187 (4): W350–6.  
  9. ^ Kocaoglu M, Frush DP (2006). "Pediatric presacral masses". Radiographics 26 (3): 833–57.  
  10. ^ Choi, K. W.; Jeon, W. J.; Chae, H. B.; Park, S. M.; Youn, S. J.; Shin, H. M.; Sung, R. H.; Lee, S. J. (September 2003). "A recurred case of a mature ovarian teratoma presenting as a rectal mass" (PDF). The Korean Journal of Gastroenterology (in Korean) 42 (3): 242–245.  
  11. ^ a b c d Gonzalez-Crussi, F. (1982) Extragonadal Teratomas. Atlas of Tumor Pathology, Second Series, Fascicle 18. Armed Forces Institute of Pathology, Washington D.C.
  12. ^ Abbott TM, Hermann WJ, Scully RE (1984). "Ovarian fetiform teratoma (homunculus) in a 9-year-old girl". International Journal of Gynecological Pathology : Official Journal of the International Society of Gynecological Pathologists 2 (4): 392–402.  
  13. ^ Saito K, Katsumata Y, Hirabuki T, Kato K, Yamanaka M (2007). "Fetus-in-fetu: parasite or neoplasm? A study of two cases". Fetal. Diagn. Ther. 22 (5): 383–8.  
  14. ^ Kajbafzadeh AM, Baharnoori M (2006). "Fetus in fetu". Can J Urol 13 (5): 3277–8.  
  15. ^ Chua JH, Chui CH, Sai Prasad TR, Jabcobsen AS, Meenakshi A, Hwang WS (2005). "Fetus-in-fetu in the pelvis: report of a case and literature review" (PDF). Ann. Acad. Med. Singap. 34 (10): 646–9.  
  16. ^ Lee, Y. H.; Kim, S. G.; Choi, S. H.; Kim, I. S.; Kim, S. H. (December 2003). "Ovarian mature cystic teratoma containing homunculus: A case report" (PDF). Journal of Korean Medical Science 18 (6): 905–907.  
  17. ^ Kazez A, Ozercan IH, Erol FS, Faik Ozveren M, Parmaksiz E (2002). "Sacrococcygeal heart: a very rare differentiation in teratoma". European Journal of Pediatric Surgery 12 (4): 278–80.  
  18. ^ Dalmau J, Lancaster E, Martinez-Hernandez E, Rosenfeld MR, Balice-Gordon R (January 2011). "Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis". Lancet Neurol 10 (1): 63–74.  
  19. ^ a b Harms D, Zahn S, Göbel U, Schneider DT (2006). "Pathology and molecular biology of teratomas in childhood and adolescence". Klinische Pädiatrie 218 (6): 296–302.  
  20. ^ Ohno Y, Kanematsu T (1998). "An endodermal sinus tumor arising from a mature cystic teratoma in the retroperitoneum in a child: is a mature teratoma a premalignant condition?". Hum. Pathol. 29 (10): 1167–9.  
  21. ^ Utsuki S, Oka H, Sagiuchi T, Shimizu S, Suzuki S, Fujii K (Jun 2007). "Malignant transformation of intracranial mature teratoma to yolk sac tumor after late relapse. Case report". J. Neurosurg. 106 (6): 1067–9.  
  22. ^ Chen YH, Chang CH, Chen KC, Diau GY, Loh IW, Chu CC (2007). "Malignant transformation of a well-organized sacrococcygeal fetiform teratoma in a newborn male". J. Formos. Med. Assoc. 106 (5): 400–2.  
  23. ^ Hopkins KL, Dickson PK, Ball TI, Ricketts RR, O'Shea PA, Abramowsky CR (1997). "Fetus-in-fetu with malignant recurrence". J. Pediatr. Surg. 32 (10): 1476–9.  
  24. ^ Arioz DT, Tokyol C, Sahin FK, et al. (2008). "Squamous cell carcinoma arising in a mature cystic teratoma of the ovary in young patient with elevated carbohydrate antigen 19-9". Eur. J. Gynaecol. Oncol. 29 (3): 282–4.  
  25. ^ Muscatello L, Giudice M, Feltri M (2005). "Malignant cervical teratoma: report of a case in a newborn". European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 262 (11): 899–904.  
  26. ^ Ukiyama E, Endo M, Yoshida F, Tezuka T, Kudo K, Sato S, Akatsuka S, Hata J (2005). "Recurrent yolk sac tumor following resection of a neonatal immature gastric teratoma". Pediatr. Surg. Int. 21 (7): 585–8.  
  27. ^ Bilik R, Shandling B, Pope M, Thorner P, Weitzman S, Ein SH (1993). "Malignant benign neonatal sacrococcygeal teratoma". J. Pediatr. Surg. 28 (9): 1158–60.  
  28. ^ Hawkins E, Issacs H, Cushing B, Rogers P (1993). "Occult malignancy in neonatal sacrococcygeal teratomas. A report from a Combined Pediatric Oncology Group and Children's Cancer Group study". The American journal of pediatric hematology/oncology 15 (4): 406–9.  
  29. ^ Ramalingam P, Teague D, Reid-Nicholson M (Jul 2008). "Imprint cytology of high-grade immature ovarian teratoma: A case report, literature review, and distinction from other ovarian small round cell tumors". Diagn. Cytopathol. 36 (8): 595–9.  
  30. ^ Biskup W, Calaminus G, Schneider DT, Leuschner I, Göbel U (2006). "Teratoma with malignant transformation: experiences of the cooperative GPOH protocols MAKEI 83/86/89/96". Klinische Pädiatrie 218 (6): 303–8.  
  31. ^ Aktuğ T, Hakgüder G, Sarioğlu S, Akgür FM, Olguner M, Pabuçcuoğlu U (2000). "Sacrococcygeal extraspinal ependymomas: the role of coccygectomy". J. Pediatr. Surg. 35 (3): 515–8.  
  32. ^ Tapper D, Lack EE (1983). "Teratomas in infancy and childhood. A 54-year experience at the Children's Hospital Medical Center" (PDF). Ann. Surg. 198 (3): 398–410.  
  33. ^ Göbel, U.; Schneider, D. T.; Calaminus, G.; Haas, R. J.; Schmidt, P.; Harms, D. (March 2000). "Germ-cell tumors in childhood and adolescence." (PDF). Annals of Oncology 11 (3): 263–271.  
  34. ^ Mann JR, Gray ES, Thornton C, Raafat F, Robinson K, Collins GS, Gornall P, Huddart SN, Hale JP, Oakhill A (July 2008). "Mature and immature extracranial teratomas in children: the UK Children's Cancer Study Group Experience". Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology 26 (21): 3590–7.  
  35. ^ Lo Curto M, D'Angelo P, Cecchetto G, Klersy C, Dall'Igna P, Federico A, Siracusa F, Alaggio R, Bernini G, Conte M, De Laurentis T, Di Cataldo A, Inserra A, Santoro N, Tamaro P, Indolfi P (April 2007). "Mature and immature teratomas: results of the first paediatric Italian study". Pediatric Surgery International 23 (4): 315–22.  
  36. ^ Marina NM, Cushing B, Giller R, Cohen L, Lauer SJ, Ablin A, Weetman R, Cullen J, Rogers P, Vinocur C, Stolar C, Rescorla F, Hawkins E, Heifetz S, Rao PV, Krailo M, Castleberry RP (1999). "Complete surgical excision is effective treatment for children with immature teratomas with or without malignant elements: A Pediatric Oncology Group/Children's Cancer Group Intergroup Study". J. Clin. Oncol. 17 (7): 2137–43.  
  37. ^ Cushing B, Giller R, Ablin A, Cohen L, Cullen J, Hawkins E, Heifetz SA, Krailo M, Lauer SJ, Marina N, Rao PV, Rescorla F, Vinocur CD, Weetman RM, Castleberry RP (1999). "Surgical resection alone is effective treatment for ovarian immature teratoma in children and adolescents: a report of the pediatric oncology group and the children's cancer group". Am. J. Obstet. Gynecol. 181 (2): 353–8.  
  38. ^ Orbital dermoid cyst at eMedicine
  39. ^ Catone G, Marino G, Mancuso R, Zanghì A (April 2004). "Clinicopathological features of an equine ovarian teratoma". Reprod. Domest. Anim. 39 (2): 65–9.  
  40. ^ Lefebvre R, Theoret C, Doré M, Girard C, Laverty S, Vaillancourt D (November 2005). "Ovarian teratoma and endometritis in a mare". Can. Vet. J. 46 (11): 1029–33.  
  41. ^ López RM, Múrcia DB (Aug 2008). "First description of malignant retrobulbar and intracranial teratoma in a lesser kestrel (Falco naumanni)". Avian Pathol. 37 (4): 413–4.  

References

See also

Ovarian teratomas have been reported in mares[39][40] and in canines. Teratomas also occur, rarely, in other species.[41]

Other animals

In light of the ethical issues surrounding the source of human stem cells, teratomas are being looked at as an alternative source for research because they lack the potential to grow into functional human beings.

Research

Teratoma qualifies as a rare disease, but is not extremely rare. Sacrococcygeal teratoma alone is diagnosed at birth in one out of 40,000 humans. Given the current human population and birth-rate, this equals five per day or 1800 per year. Add to that number sacrococcygeal teratomas diagnosed later in life, and teratomas in other locales, and the incidence approaches ten thousand new diagnoses of teratoma per year.

Of teratomas on the skull sutures, approximately 50% are found in or adjacent to the orbit.[38] Limbal dermoid is a choristoma, not a teratoma.

Embryonal teratomas most commonly occur in the sacrococcygeal region: sacrococcygeal teratoma is the single most common tumor found in newly born humans.

Epidemiology

Adequate follow-up requires close observation, involving repeated physical examination, scanning (ultrasound, MRI, or CT), and measurement of AFP and/or βhCG.[36][37]

Depending on which tissue(s) it contains, a teratoma may secrete a variety of chemicals with systemic effects. Some teratomas secrete the "pregnancy hormone" human chorionic gonadotropin (βhCG), which can be used in clinical practice to monitor the successful treatment or relapse in patients with a known HCG-secreting teratoma. This hormone is not recommended as a diagnostic marker, because most teratomas do not secrete it. Some teratomas secrete thyroxine, in some cases to such a degree that it can lead to clinical hyperthyroidism in the patient. Of special concern is the secretion of alpha-fetoprotein (AFP); under some circumstances AFP can be used as a diagnostic marker specific for the presence of yolk sac cells within the teratoma. These cells can develop into a frankly malignant tumor known as yolk sac tumor or endodermal sinus tumor.

Although often described as benign, a teratoma does have malignant potential. In a UK study of 351 infants and children diagnosed with "benign" teratoma reported 227 with MT, 124 with IT. Five years after surgery, event-free survival was 92.2% and 85.9%, respectively, and overall survival was 99% and 95.1%.[34] A similar study in Italy reported on 183 infants and children diagnosed with teratoma. At 10 years after surgery, event free and overall survival were 90.4% and 98%, respectively.[35]

Follow-up

Teratomas that are in surgically inaccessible locations, or are very complex, or are likely to be malignant (due to late discovery and/or treatment) sometimes are treated first with chemotherapy.

For malignant teratomas, usually, surgery is followed by chemotherapy.

Chemotherapy

Prevention of recurrence does not require en bloc resection of surrounding tissues.

The treatment of choice is complete surgical removal (i.e., complete resection).[32][33] Teratomas are normally well-encapsulated and non-invasive of surrounding tissues, hence they are relatively easy to resect from surrounding tissues. Exceptions include teratomas in the brain, and very large, complex teratomas that have pushed into and become interlaced with adjacent muscles and other structures.

Surgery

Treatment

Extraspinal ependymoma, usually considered to be a glioma (a type of non-germ cell tumor), may be an unusual form of mature teratoma.[31]

Extraspinal ependymoma

A teratoma with malignant transformation (TMT) is a very rare form of teratoma that may contain elements of somatic (non germ cell) malignant tumors such as leukemia, carcinoma or sarcoma.[19] Of 641 children with pure teratoma, nine developed TMT:[30] five carcinoma, two glioma, and two embryonal carcinoma (here, these last are classified among germ cell tumors).

A grade 1 immature teratoma that appears to be benign (e.g., because AFP is not elevated) has a much higher risk of malignancy, and requires adequate follow-up.[25][26][27][28] This grade of teratoma also may be difficult to diagnose correctly. It can be confused with other small round cell neoplasms such as neuroblastoma, small cell carcinoma of hypercalcemic type, primitive neuroectodermal tumor, Wilm's tumor, desmoplastic small round cell tumor, and non-Hodgkin lymphoma.[29]

A "benign" grade 0 (mature) teratoma nonetheless has a risk of malignancy. Recurrence with malignant endodermal sinus tumor has been reported in cases of formerly benign mature teratoma,[20][21] even in fetiform teratoma and fetus in fetu.[22][23] Squamous cell carcinoma has been found in a mature cystic teratoma at the time of initial surgery.[24]

Malignant transformation

Grade 0, 1 and 2 pure teratomas have the potential to become malignant (grade 3), and malignant pure teratomas have the potential to metastasize. These rare forms of teratoma with malignant transformation may contain elements of somatic (non germ cell) malignancy such as leukemia, carcinoma or sarcoma.[19] A teratoma may contain elements of other germ cell tumors, in which case it is not a pure teratoma but rather is a mixed germ cell tumor and is malignant. In infants and young children, these elements usually are endodermal sinus tumor, followed by choriocarcinoma. Finally, a teratoma can be pure and not malignant yet highly aggressive: this is exemplified by growing teratoma syndrome, in which chemotherapy eliminates the malignant elements of a mixed tumor, leaving pure teratoma which paradoxically begins to grow very rapidly.

Teratomas are also classified by their content: a solid teratoma contains only tissues (perhaps including more complex structures); a cystic teratoma contains only pockets of fluid or semi-fluid such as cerebrospinal fluid, sebum, or fat; a mixed teratoma contains both solid and cystic parts. Cystic teratomas usually are grade 0 and, conversely, grade 0 teratomas usually are cystic.

Regardless of location in the body, a teratoma is classified according to a cancer staging system. This indicates whether chemotherapy or radiation therapy may be needed in addition to surgery. Teratomas commonly are classified using the Gonzalez-Crussi[11] grading system: 0 or mature (benign); 1 or immature, probably benign; 2 or immature, possibly malignant (cancerous); and 3 or frankly malignant. If frankly malignant, the tumor is a cancer for which additional cancer staging applies.

Classification

Some teratomas contain yolk sac elements, which secrete alpha-fetoprotein (AFP). Detection of AFP may help to confirm the diagnosis and is often used as a marker for recurrence or treatment efficacy, but is rarely the method of initial diagnosis. (Maternal serum alpha-fetoprotein, or MSAFP, is a useful screening test for other fetal conditions, including Down syndrome, spina bifida and abdominal wall defects such as gastroschisis).

Beyond the newborn period, symptoms of a teratoma depend on its location and organ of origin. Ovarian teratomas often present with abdominal or pelvic pain, caused by torsion of the ovary or irritation of its ligaments. A recently discovered condition where ovarian teratomas cause encephalitis associated with antibodies against the N-methyl-D-aspartate receptor (NMDAR) - often simply referred to as "Anti-NMDA receptor encephalitis", was identified as a serious complication. Patients develop a multistage illness that progresses from psychosis, memory deficits, seizures, and language disintegration into a state of unresponsiveness with catatonic features often associated with abnormal movements, and autonomic and breathing instability.[18] Testicular teratomas present as a palpable mass in the testis; mediastinal teratomas often cause compression of the lungs or the airways and may present with chest pain and/or respiratory symptoms.

Teratomas are thought to be present since birth, or even before birth, and therefore can be considered congenital tumors. Many teratomas are not diagnosed until much later in childhood or in adulthood. Large tumors are more likely to be diagnosed early on. Sacrococcygeal and cervical teratomas are often detected by prenatal ultrasound. Additional diagnostic methods may include prenatal MRI. In rare circumstances, the tumor is so large that the fetus may be damaged or die. In the case of large sacrococcygeal teratomas, a significant portion of the fetus' blood flow is redirected toward the teratoma (a phenomenon called steal syndrome), causing heart failure, or hydrops, of the fetus. In certain cases, fetal surgery may be indicated.

CT showing a teratoma of the ovary: fatty formation with a smooth boundary, with a dense part, possibly a tooth.

Diagnosis

A struma ovarii (literally: goitre of the ovary) is a rare form of mature teratoma that contains mostly thyroid tissue.

Struma ovarii

Regardless of whether fetus in fetu and fetiform teratoma are one entity or two, they are distinct from and not to be confused with ectopic pregnancy.

Most authorities agree that fetiform teratomas are highly developed mature teratomas; the natural history of fetus in fetu is controversial.[11] There also may be a cultural difference, with fetiform teratoma being reported more often in ovarian teratomas (by gynecologists) and fetus in fetu being reported more often in retroperitoneal teratomas (by general surgeons). cranial bones, long bones and a rudimentary beating heart.[16][17]

spine and bilateral symmetry.[11]

Fetus in fetu and fetiform teratoma

A dermoid cyst is a mature cystic teratoma containing hair (sometimes very abundant) and other structures characteristic of normal skin and other tissues derived from the ectoderm. The term is most often applied to teratoma on the skull sutures and in the ovaries of females.

A small (4 cm) dermoid cyst of an ovary, discovered during a C-section

Dermoid cyst

A mature teratoma is a grade 0 teratoma. Mature teratomas are highly variable in form and histology, and may be solid, cystic, or a combination of solid and cystic. A mature teratoma often contains several different types of tissue such as skin, muscle, and bone. Skin may surround a cyst and grow abundant hair (see Dermoid cyst). Mature teratomas generally are benign; malignant mature teratomas are of several distinct types.

Mature teratoma of the mediastinum. A horizontal slice of the resected tumor reveals fibrofatty tissue, calcified areas, and a few cystic spaces lined with smooth membrane and containing a hair. In the left lower corner, the involved B5 bronchus is evident.

Mature teratoma

Concerning the origin of teratomas, there exist numerous hypotheses.[11] These hypotheses are not to be confused with the unrelated hypothesis that fetus in fetu (see below) is not a teratoma at all but rather a parasitic twin.

Hypotheses of origin

Teratomas derived from germ cells occur in the skull sutures.

Teratomas belong to a class of tumors known as nonseminomatous germ cell tumor (N.S.G.C.T.). All tumors of this class are the result of abnormal development of pluripotent cells: germ cells and embryonal cells. Teratomas of embryonic origin are congenital; teratomas of germ cell origin may or may not be congenital (this is not known). The kind of pluripotent cell appears to be unimportant, apart from constraining the location of the teratoma in the body.

Pathophysiology

After surgery, there is a risk of regrowth in place, or in nearby organs.[10]

Teratomas are not dangerous for the fetus unless there is either a echocardiography.

Complications

The most commonly diagnosed fetal teratomas are sacrococcygeal teratoma (Altman types I, II, and III) and cervical (neck) teratoma. Because these teratomas project from the fetal body into the surrounding amniotic fluid, they can be seen during routine prenatal ultrasound exams. Teratomas within the fetal body are less easily seen with ultrasound; for these, MRI of the pregnant uterus is more informative.[8][9]

Teratomas of germ cell origin usually are found (i.e., present) in adult men and women, but they may also be found in children and infants. Teratomas of embryonal origin are most often found in babies at birth, in young children, and, since the advent of ultrasound imaging, in fetuses.

Signs and symptoms

The term "malignant teratoma" has sometimes been used as a synonym for nonseminomatous germ cell tumor.[7]

The words "teratoma" and "mature teratoma" both have been used to refer to a benign growth, while the word "teratoma" may also refer to "immature teratoma", a cancerous growth. Avoiding misunderstanding due to such polysemy is part of why tumor nomenclature changes over decades. The nomenclatural changes are voluntary, based on scientists agreeing or debating in the literature regarding what to call particular neoplastic entities (types of tumors).

[6]

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