DOI: 10.1148/radiol.2252010498
(Radiology 2002;225:497-499.)
© RSNA, 2002
Case 52: Gastric Teratoma1
Margaret D. Gore, MD and
Sandra K. Fernbach, MD
1 From the Department of Radiology, Evanston Northwestern Healthcare, 2650 Ridge Ave, Evanston, IL 60201. Received February 13, 2001; revision requested April 3; revision received May 22; accepted June 5. Address correspondence to M.D.G. (e-mail: mgore@enh.org).
Index terms: Diagnosis Please • Infants, newborn, gastrointestinal tract, 72.3129 • Stomach, CT, 72.1211 • Teratoma, 72.3129 • Ultrasound (US), in infants and children, 72.1298
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HISTORY
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This male child was born at term and had a normal prenatal history and birth. On the 1st day of life, he began to vomit blood-tinged secretions and breast milk. Results of all laboratory values were normal. He had had several normal bowel movements. Sequential radiographs (Fig 1) were obtained during an upper gastrointestinal series performed on the 1st day of life. The results of this study and the fact that the left side of his abdomen felt full prompted us to obtain an abdominal sonogram (Fig 2) on the following day.
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Figure 1a. Sequential radiographs obtained in a 1-day-old male infant during an upper gastrointestinal series. (a) Radiograph shows the presence of barium; this presence demonstrates that the stomach is distended because of a mass. Crescentic collections of barium (arrows) outline the lobulations of the mass. Contrast material in the duodenum documents the normal position of the duodenojejunal junction. (b) Radiograph obtained after the introduction of more barium more clearly shows the size and contour of the intragastric mass (arrows). When the child was moved into various positions, the mass could not be displaced; the filling defects thus did not represent gas collections.
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Figure 1b. Sequential radiographs obtained in a 1-day-old male infant during an upper gastrointestinal series. (a) Radiograph shows the presence of barium; this presence demonstrates that the stomach is distended because of a mass. Crescentic collections of barium (arrows) outline the lobulations of the mass. Contrast material in the duodenum documents the normal position of the duodenojejunal junction. (b) Radiograph obtained after the introduction of more barium more clearly shows the size and contour of the intragastric mass (arrows). When the child was moved into various positions, the mass could not be displaced; the filling defects thus did not represent gas collections.
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Figure 2. Transverse sonogram of the left upper quadrant obtained in the same infant shows a mass. Anteriorly and to the right are the liver (L) and gallbladder. Several cysts within the mass project anterior to the spine.
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IMAGING FINDINGS
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The intraluminal contrast material (Fig 1) was displaced around a large intragastric mass. Some contrast material collected along the lobulations of the mass. Sonography was performed to determine the origin, composition, and size of the mass.
The transverse sonogram of the left upper quadrant (Fig 2) demonstrated a mass of mixed echogenicity interposed between the kidney and the spleen. Multiple cysts were present within the mass, and a few punctate regions of calcification that were not visible on conventional radiographs produced shadowing. The left kidney was displaced caudally.
On the 3rd day of life, abdominal computed tomography (CT) was performed without any contrast material; the child was in the supine position. An 8.0 x 3.5 x 3.0-cm mass with both solid and cystic components, as well as calcifications, filled the gastric lumen (Fig 3a). Anteriorly, it was outlined with air, but posteriorly, it could not be distinguished from the gastric wall. The complex mass extended into the retrogastric tissues and displaced the left kidney inferiorly. Scans with the child in the prone position were obtained a few minutes later (Fig 3b) and indicated that air did not dissect around the posterior aspect of the mass. The mass was growing posterior to the gastric wall and anteriorly into the gastric lumen (Fig 3b). The entire mass measured 13.0 x 3.5 x 3.5 cm.
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Figure 3a. Transverse abdominal nonenhanced helical CT scan (7-mm collimation) obtained in the same infant. (a) Scan through the left upper quadrant obtained with the infant in the supine position demonstrates the lobulated mass (white arrows) filling and distending the stomach. The complex nature of the mass (ie, solid, cystic, calcified) is well seen. The posterior gastric wall cannot be distinguished from the mass. Anteriorly, the mass is adjacent to gastric air, indicating that a portion of the gastric wall is free of tumor. A small amount of residual contrast material (black arrow) pooled along the lateral aspect of the mass. (b) Scan obtained a few minutes after a with the infant in the prone position. This section is at approximately the same level as that depicted in the sonogram in Figure 2. Air cannot dissect around the posterior aspect of the mass, and this finding indicates that it is in continuity with the gastric wall. The large retrogastric component of the mass (arrows) contains multiple cysts and calcifications. The previously noted intraluminal contrast material produced a thin dense line around the mass.
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Figure 3b. Transverse abdominal nonenhanced helical CT scan (7-mm collimation) obtained in the same infant. (a) Scan through the left upper quadrant obtained with the infant in the supine position demonstrates the lobulated mass (white arrows) filling and distending the stomach. The complex nature of the mass (ie, solid, cystic, calcified) is well seen. The posterior gastric wall cannot be distinguished from the mass. Anteriorly, the mass is adjacent to gastric air, indicating that a portion of the gastric wall is free of tumor. A small amount of residual contrast material (black arrow) pooled along the lateral aspect of the mass. (b) Scan obtained a few minutes after a with the infant in the prone position. This section is at approximately the same level as that depicted in the sonogram in Figure 2. Air cannot dissect around the posterior aspect of the mass, and this finding indicates that it is in continuity with the gastric wall. The large retrogastric component of the mass (arrows) contains multiple cysts and calcifications. The previously noted intraluminal contrast material produced a thin dense line around the mass.
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DISCUSSION
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The child underwent resection of the mass and a portion of the posterior gastric wall. Pathologic analysis of the specimen revealed a benign gastric teratoma with elements derived from all three germ layers. Immature neuroectodermal components were identified within it, but these, according to the literature, do not change the benign behavior of the tumor (1). The cysts were lined with endodermal derivatives: gastrointestinal, respiratory, and transitional epithelium. The child has been eating and growing normally since resection of the mass. Findings of a follow-up upper gastrointestinal series indicated no recurrence of the tumor.
The finding of an intragastric defect during an upper gastrointestinal series in a neonate evokes a differential diagnosis of intraluminal debris, such as a large organized blood clot or, less likely, a lactobezoar, especially if these findings occur within the immediate perinatal period. With sonography, the diagnosis of a blood clot or a lactobezoar was excluded in two ways. Findings at sonography demonstrated that the mass was not mobile; a blood clot and a lactobezoar generally are. Findings at sonography also showed that the mass was complex, contained calcifications, and extended beyond the gastric lumen, and these characteristics are absent in patients with blood clots and lactobezoars. Gastric teratoma is an uncommon lesion, and it frequently projects into the lumen and includes calcifications in about 35%–60% of children (1).
The differential diagnosis of a calcified mass in the left upper quadrant in a neonate would include mesoblastic nephroma, congenital neuroblastoma, and teratoma. In this neonate, because the kidney was normal at sonography, mesoblastic nephroma was easily excluded. Neuroblastoma occurs more often in the neonate than in the older child. The uncommon cystic variant is more frequently seen in neonates, but even in this age group, neuroblastoma tends to be solid. In the neonate, liver involvement is a more common manifestation of neuroblastoma than is a focal abdominal mass. With CT, calcifications are seen in about 85% of neuroblastomas, but intragastric extension of a congenital neuroblastoma is exceedingly rare (2). In one child with diffuse metastatic neuroblastoma from the skull to the inguinal lymph nodes, involvement of the gastric wall was present; this was not detected by using imaging but by inspection at the time of exploratory laparotomy (3).
The presence of solid, cystic, and calcified tissues in the left suprarenal location suggested two diagnoses: congenital neuroblastoma and gastric teratoma. The intragastric location of the mass increased the likelihood that the mass was a gastric teratoma.
Gastric teratomas occur in neonates and infants, with approximately 90% of cases reported in boys (1,4–6). Cases in fewer than a dozen female children with gastric teratoma have been reported (4–6). Gastric obstruction by the mass may produce polyhydramnios prenatally, premature labor or dystocia, or feeding problems after birth. Postnatal detection of the mass often is established with palpation, as is true for detection of many pediatric gastrointestinal tumors (1,4–6). Gastrointestinal bleeding, as in this infant, is a rare symptom of teratoma at presentation and may be caused by ulceration of the tumor (4,5,7). In virtually all cases, gastric teratoma is an isolated finding and is not associated with other tumors or malformations.
Gastric teratomas account for approximately 1% of pediatric teratomas (6). In the neonate, teratomas are most frequently seen in the sacrococcygeal region. Throughout childhood, these tumors also are seen in the mediastinum, the gonads (both the ovaries and the testes), the retroperitoneum, and the neck.
Although gastric teratomas usually are benign, they may contain immature neuroepithelial tissue that appears malignant histologically (1,4,8). Patients with gastric teratomas, even those with malignant histologic features or exophytic extension into adjacent organs and tissues, have an excellent prognosis (1,4,8,9). Surgical resection of the entire mass usually is curative; incomplete resection may result in recurrence. Additional therapies (ie, chemotherapy and radiation therapy) are not needed. One case report of a gastric teratoma with both primitive neuroglial elements and a focus of endodermal sinus tumor, a more malignant germ cell tumor, has been reported (8). This, too, responded to surgical excision without adjunctive therapy.
Diagnosis of teratoma is confidently made when the tumor contains derivatives of all three germ layers. Some pathologists will make the diagnosis of teratoma in tumors exhibiting only two germ layer derivatives, but such tumors are more correctly termed dermoids (1). Tissues derived from the epithelium of teratomas frequently develop into the classically visualized elements of teeth, fat, and hair.
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FOOTNOTES
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Part 1 of this case appeared 4 months previously and may contain larger images.
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REFERENCES
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- Bowen B, Ros PR, McCarthy MJ, Olmsted WW, Hjermstad BM. Gastrointestinal teratomas: CT and US appearance and pathologic correlation. Radiology 1987; 162:431-433.[Abstract/Free Full Text]
- Bousvaros A, Kirks DR, Grossman H. Imaging of neuroblastoma: an overview. Pediatr Radiol 1986; 16:89-106.[Medline]
- Sandoval C, Oiseth S, Slim M, et al. Gastric ganglioneuroblastoma: a rare finding in an infant with multifocal ganglioneuroblastoma. J Pediatr Hematol Oncol 1996; 18:409-412.[CrossRef][Medline]
- Gupta DK, Srinivas M, Dave S, Agarwala S, Bajpai M, Mitra DK. Gastric teratoma in children. Pediatr Surg Int 2000; 16:329-332.[CrossRef][Medline]
- Skinner MA, Plumley DA, Grosfeld JL, Rescorla FJ, West KW, Scherer LR. Gastrointestinal tumors in children: an analysis of 39 cases. Ann Surg Oncol 1994; 1:283-289.[Abstract]
- Gengler JS, Ashcraft KW, Slattery P. Gastric teratoma: the sixth reported case in a female infant. J Pediatr Surg 1996; 30:889-890.[CrossRef]
- Haley T, Dimler M, Hollier P. Gastric teratoma with gastrointestinal bleeding. J Pediatr Surg 1986; 21:949-950.[Medline]
- Bourke CJ, Mackay AJ, Payton D. Malignant gastric teratoma: case report. Pediatr Surg Int 1997; 12:192-193.[Medline]
- Dunlap JP, James CA, Maxson RT, Bell JM, Wagner CW. Gastric teratoma with intramural extension. Pediatr Radiol 1995; 25:383-384.[CrossRef][Medline]
Congratulations to the 42 individuals who submitted the most likely diagnosis (Gastric Teratoma) for Diagnosis Please, Case 52. The names and locations of the individuals, as submitted are as follows:
- Gholamali Afshang, MD, Tinley Park, Ill
- Edward L. Baker, MD, San Francisco, Calif
- Ken Baliga, Rockford, Ill
- Richard A. Barth, MD, Stanford, Calif
- Dr Adrian Brady, Cork, Ireland
- Bharath Chinta, Pontiac, Mich
- Federico Dalla Torre, MD, Cipolletti, Rio Negro, Argentina
- J. F. K. de Villiers, MB, ChB, MMed (RadD), Gisborne, New Zealand
- Mustafa Kemal Demir, MD, Ataköy, Istanbul, Turkey
- Frederique Dugougeat, MD, Lyon, Debrousse, France
- Shella Farooki, MD, Dublin, Ohio
- Arie Franco, MD, PhD, Livingston, NJ
- Christine M. Glastonbury, MD, San Francisco, Calif
- Mark Goldshein, MD, Andover, Mass
- Waleed Ibrahim, MD, Detroit, Mich
- Vinay Jain, Pontiac, Mich
- Hirotsugu Kado, Fukui, Echizen, Japan
- Eric Kinder, MD, Seattle, Wash
- Ravishankar S. Konchada, Seattle, Wash
- Jeff Kuo, Silver Spring, Md
- Tony Lamont, South Brisbane, Australia
- Mark E. Lockhart, MD, Birmingham, Ala
- R. Madan, Lucknow, India
- N. B. S. Mani, MD, Nassau, Bahamas
- Tuan D. Nguyen, MD, Kongsberg, Norway
- Giuseppe Riboni, MD, Milan, Italy
- Gaurav Saigal, Miami, Fla
- Pierre Schmit, MD, L’Hay-les-Roses, France
- Matt Shapiro, MD, Lowell, Mass
- Taro Shimono, MD, Osaka, Japan
- Wing H. Tam, MD, Windsor, Ontario, Canada
- Ann Tate, Suffolk, England
- Douglas L. Teich, MD, Brookline, Mass
- D. Dean Thornton, MD, Birmingham, Ala
- Herminia Tyminski Al-Saffar, MD, Manama, Bahrain
- Christopher Vittore, MD, Rockford, Ill
- Zhen Jane Wang, MD, San Francisco, Calif
- Jeff West, MD, Jacksonville, Fla
- David J. Wright, MD, Lake Oswego, Ore
- Benjamin M. Yeh, MD, San Francisco, Calif
- Joe Yut, Olathe, Kan
- Dr Adriana Zatti Lima, Belo Horizonte, Brazil
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TOP
HISTORY
IMAGING FINDINGS
