Immature gastric teratoma (case report of a rare neoplasm)

History

• Patient Name Zain Sajjad• Age 3 months• Sex male• Address Rahim Yar Khan• Weight 5 kg

Presentation

Abdominal distension- 15 daysMass abdomen- 15 days

Examination A healthy-looking male infant

with stable vital signs and no respiratory distress.

The abdomen of infant was moderately distended more on the left side. There was a mass palpable on left side abdomen occupying left hypochondrium and left lumbar region.

The mass was hard in consistency, measuring about 12*15 cm in the left abdomen, not adherent to the abdominal walls and other viscera.

Based on history and clinical examination our suspician was neuroblastoma of left adrenal gland.

Investigations•CBC showed Hb 13g/dl, TLC 8500

with normal neutrophill and lymphocyte count and ESR.• HBsAg & AntiHCV- negative• LFTs,RFTs,S/E & bleeding profile-

normal.

Abdominal X-rays showed a large soft tissue mass with calcifications occupying central abdomen and displacement of gut loops. There were no signs of intestinal obstruction.

CT scan was planned but not done (Parents were not willing).

TreatmentAfter arrangement of blood patient

was explored. Per-operatively there was an exophytic hard mass with some cystic areas measuring 12*15cm, originating from the gastric wall, with no attachment to other viscera. Rest of the viscera were normal. No L/N were identified

•Mass was completely excised with 2cm resection margins, gastric wall repaired and abdomen closed.

In post-op period patient remained well and made uneventful recovery. Histopathology sent. Patient was discharged on 5th post-op day and called for follow-up after one week.

Histopathology reportMalignant neoplasm composed of ectodermal,

endodremal and mesodermal structures. Glial tissue, cartilage, bone, primitive glandular structures are seen. Scattered foci of neuroepithelium and loose mesenchyme are also identified. Individual tumour cells are immature with high nuclear cytoplasmic ratio, hyperchromasia and dispersed chromatin are identified.

H/P cont….

• Tumour at resection margins not identified.• Distance of tumour from closest marging

was 1mm.• Children oncology group staging for any

malignant extragonadal germ cell tumour. Stage 1: complete resection at any site; negative margins.

Discussion• Primary gastric tumors are very rare in infants

and children. • Gastric Teratomas are extremely rare (< 1% all

Teratomas)• Teratomas have origin from all 03 layers

(endoderm, ectoderm and mesoderm)• Gastric teratoma occur in male neonates and

infants (90%).

• First case was reported in 1922.• Only 66 cases were reported up till

now.• Mature teratomas are benign where

malignant potential is present in immature teratomas.• 60% are exophytic growths, 30%-

endophytic, 10% mixed exophytic and endophytic.

Majority of tumours present with abdominal distension and palpable abdominal mass, whereas a minority may present with hematemesis.

Majority arise from greater curvature and posterior wall. Other less common sites are lesser curvature, antrum and fundus. Some of these tumours are pedunculated.

• Pre-op diagnosis of gastric tumours is difficult.• Abdominal X-rays, USG, CT scan, MRI

abdomen and endoscopy are important diagnostic tools.

• Plain films show soft tissue mass with or without calcification.• USG abdomen demonstrate a

heterogenous mass with mixed echogenicity.

CT scan demonstrates a mass with solid and cystic components and internal calcifications and fat. CT scan is modality of choice. When combined with oral and I/V contrast they can detect the origin of the tumour, its relation with GIT, blood vessels and other viscera.

Modalities like Barium and gastroscopy have a limited role in the diagnosis of gastric teratoma.

• Surgical excision is treatment of choice. • Depending on location and extent of

tumor partial, subtotal and total gasterectomy have been done.

PrognosisFollowing surgical excision has been excellent with report of one case of recurrence.

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