A Huge Immature Cervical Teratoma; Antenatal Diagnosis, and its Management – An Unusual Entity
A 26-years-old second gravida female reported at 37th week with antenatal ultrasound of the fetus showing well-defined and hyperechoic solid mass of size of 5.5 × 6 centimeters in the anterior aspect of neck []. Associated findings included mild polyhydromnios and vertical lie. Guarded prognosis with conservative management till the birth of the fetus was advised. Mode of the delivery was to be decided by obstetric indications. Finally, the baby was born by cesarean section and had huge cervical mass. Baby cried immediately after birth and had respiratory distress of mild nature apparent only in supine position when the compression effect was maximum. The distress was relieved in lateral position, and baby was maintaining saturation with minimal oxygen support.\nOn initial assessment, the vitals of the baby were stable. Examination of respiratory system revealed equal air entry on both the side with mild conducted sounds and inspiratory stridor. Rests of the systemic examinations were within normal limits. On local examination, there was a neck mass which was solitary, oval, of size about 9 × 5 × 6 cms in midline anteriorly having firm consistency with moderate mobility in all the directions []. Swelling was non-pulsatile, and there were no skin changes.\nInitial imaging was done by X-ray neck and ultrasound. These were stipulated calcifications within the mass as shown by X-ray. Ultrasound showed the mass to be consisting of solid matrix with occasional cystic areas filled with hemorrhagic fluid having freckles of calcifications and well-defined capsules all around with neck vessels pushed laterally and some degree of tracheal displacement suggestive of the teratoma with mass effect. Computed tomographic scan was obtained to further rule out the organ of origin, vascular involvement, and thoracic extension of the mass lesion. CT showed the mass to be of size 8 × 6 × 5 cms and heterogeneous with scattered, nodular calcification extending superiorly into sub-mandibular and inferiorly up to supraclavicular region []. Invasive investigations like fine needle biopsy were not attempted due to the fear of hemorrhage within the tumor leading to further aggravation of respiratory distress and complicating the pre-operative clinical scenario. Corroborative evidences of the mass to be teratoma were obtained by means of tumor marker studies like estimation of alpha-fetoprotein and beta human chorionic gonadotropins. Alpha-fetoprotein level was significantly high in the range of 83,000 ng/ml though there was no rise in beta HCG. As the neck teratomas mostly arise from and completely replace the thyroid tissue, thyroid function test was also obtained, but T3, T4, and thyroid-stimulating hormone levels were within normal range.\nAfter pre-operative stabilization and investigations, patient was taken up for the surgical excision of the mass. General anesthesia with endotracheal intubation was done though securing the airway was difficult. Transverse incision directly over the mass was given. Below the platysma muscles, the well-encapsulated mass was lying above the strap muscles of the neck, attached only with the fibrous bands and few small caliber vessels feeding the mass. Complete enucleation of the mass without capsule rupture was attained, and specimen was sent for histopathological examinations. No ventilatory support was needed in post-operative period. Feeds were allowed in 2nd post-operative day, and patient was discharged on 4th day. Repeat alpha-fetoprotein and beta HCG at the end of 1 month, 3 months, and 1 year were within normal range.\nHistopathology report came out as lobulated grey-white mass predominantly solid with areas of cystic changes. Cysts were ranging from 1 mm to 1 cm and filled with mucinous material. The solid parts consisted of cartilages and bony spicules. Multiple sections studied from tumor showed mature as well as immature elements derived from all 3 germ layers. Mature elements comprised of nests of squamous cells, glands, mature cartilage, occasional bony tissue, neural tissue, and smooth muscle tissue. Immature elements included neuroepithelial elements, occasional group of blastemal cells, and immature cartilage in myxoid stroma. Mitosis was in the range of 2/10 HPF. Normal thyroid tissue was not seen in the section studied. Final diagnosis was immature cervical teratoma; grade II.