Benign Mature Cystic Teratoma of the Anterior Mediastinum Leading to Heart Failure: Report of a Case

A 12-year-old male child was referred to our clinic for the surgical treatment of an anterior mediastinal mass, suspected to be a thymic cyst, which was considered to potentially lead to cardiac failure. The mass was resected completely with a median sternotomy. The postoperative course was uneventful. A pathological examination revealed a mature cystic teratoma of anterior mediastinum which is a very rare cystic tumor at this location. The incidence, diagnostic procedures, complications, and treatment of mediastinal teratomas are discussed along with a review of the literature.     

Mature cystic teratoma with malignant transformation to adenocarcinoma

An anterior mediastinal tumor had been found in a 65-year-old woman 10 years previously, and she had been followed-up under the diagnosis of a mature cystic teratoma. Changes in the structure of the inside of the mediastinal cystic tumor were observed on a chest computed tomography image, and she was referred to our hospital for surgical intervention. The tumor was removed and was determined to be a mature teratoma. An adenocarcinoma was also observed in part of this cystic lesion. From these findings, the lesion was diagnosed as a malignant change in a mediastinal mature teratoma. Because few if any changes tend to be observed in the cystic wall of such cases, an aggressive resection of such mature cystic teratomas is therefore recommended.     

Matured mediastinal teratoma extending into the cervical neck of an adult

Teratomas have been reported to occur in various sites and organs. Cervical neck teratomas are relatively rare in adulthood, and mediastinal teratomas that extend into the cervical neck are also rare. Therefore, we report a case of a matured teratoma found in the cervical tumor of an adult. A 27-year-old woman was admitted with a cervical soft tumor. Preoperative examination revealed a cystic mass in the upper mediastinum that extended to the thyroid. We diagnosed this as a thymic or foregut cyst and removed the tumor via a collar incision. Histological examination revealed a benign mature teratoma.     

Mature teratome of the mediastinum

STUDY AIM: The aim of this retrospective study was to report a series of 12 cases of mature teratoma of the mediastinum operated during a 10-year period in the same center. PATIENTS AND METHOD: From 1990 to 2000, 12 patients (7 females and 5 males with a mean age of 32 years) were operated for mature mediastinal teratoma. Chest pain was present in 10 cases; cough, dyspnea and septic episodes were present in 5 cases and X-ray detected the mediastinal tumor in 10 cases. CT scan showed a tumor with liquid and fatty components and calcifications in 5 out of 9 cases. Tumors were resected via a posterolateral thoracotomy in 11 cases and an anterior thoracotomy in one case, associated with pneumonectomy in 1 case, basal segmentectomy in 1 case and thymectomy in 1 case. RESULTS: There were no postoperative deaths. Morbidity included 2 phrenic nerve palsies, 1 pyothorax after pneumonectomy, 1 case of bleeding and 1 pleural effusion. No recurrences have been observed with a follow-up of 5 to 87 months. Nine of the 10 tumors reviewed by pathologist contained multiple tissue components and one only contained a single tissue. CONCLUSION: Mature teratomas are usually detected in young patients: they are usually located in the middle part of the anterior mediastinum and are only diagnosed by pathologic examination of the specimen. They have an excellent prognosis when tumor resection is complete and in the absence of immature tissue in the tumor.     

Mediastinal mature teratoma with rupture into pleural cavity due to blunt trauma

We report a rare case of mediastinal mature teratoma with rupture due to blunt trauma. A 15-year-old boy had received a strong head-butt in the left upper chest wall and was admitted with the sudden onset of left-sided severe chest pain and dyspnea. Chest computed tomography (CT) scan on admission revealed a heterogeneous mass lesion in the anterior mediastinum. The contrast-enhanced CT scans obtained 2 days after admission showed not only mediastinal mass lesion but also left pleural effusion. On the radiologic finding at 5 months later, the lesion became larger and was thought to be a typical mediastinal mature teratoma. The patient underwent extirpation of the tumor. Microscopically, the tumor was typically composed of adult-type tissues and was confirmed to be mature teratoma.     

Mediastinal mature teratoma perforated into the pericardial sac: a case report

Mature teratomas occasionally rupture into adjacent organs such as lung, bronchus, mediastinum and pericardial sac. However, perforation into the pericardial sac is rare. We experienced a case of mediastinal mature teratoma perforated into the pericardial sac. A 16-year-old man was admitted to our hospital due to sudden severe anterior chest pain. Chest X-ray showed a mass shadow in the right middle lung field. Chest CT scan and MRI demonstrated a heterogeneous mass with fat component in the right anterior mediastium adjacent to the pericardium. Some squamous cells were obtained from the mass by CT guided percutaneous needle biopsy. Operation was performed with the diagnosis of mediastinal teratoma. The mass adhered to the pericardium and turbid pericardial effusion was noted. The mass was removed with the pericardium. The mass was 9 x 6.5 x 6 cm in size, which contained yellow sebaceous material and a tuft of white hair. The pathological diagnosis of the mass was mature cystic teratoma with perforation into the pericardial sac.     

A ruptured mature teratoma in which follow-up computed tomography observation at short intervals was useful for a definitive diagnosis

Rupture of mature mediastinal teratomas occasionally occurs, necessitating prompt surgical treatment. However, the clinical presentation of a ruptured teratoma can resemble that of pneumonia and/or pleuritis. We report a case of mediastinal teratoma rupture, in which follow-up computed tomography (CT) a short-interval after the first CT was useful for definitive diagnosis. The patient was a 29-year-old male who presented with chest pain. CT-revealed a fat-containing cystic tumor in the left anterior mediastinum and a small pleural effusion with consolidation of the lower lobe of the left lung. The diagnoses of pneumonia, pleuritis and teratoma rupture were considered, and antibiotic therapy was initiated to begin with. Eighteen hours later, a repeat CT-revealed an increase in the soft tissue area of the chest wall adjacent to the tumor, which led to the definitive diagnosis of ruptured teratoma, and immediate resection was performed. The histological diagnosis was a mature teratoma, and rupture was confirmed by the high lipase level in the pleural fluid. The patient's postoperative course was uneventful.     

Adenocarcinoma arising in anterior mediastinal mature cystic teratoma: Report of a case

Mediastinal mature teratoma with malignant components is a very rare condition. A 57-year-old man presented with a large (14 × 10 cm) encapsulated and lobulated cystic mass involving the anterior mediastinum. The most consistent diagnosis on the basis of radiological findings was mature cystic teratoma, and a surgical resection was thus indicated. The operation was performed through a median sternotomy, and the tumor was extirpated with a combined resection of the pericardium and left mediastinal pleura. Although the pathological diagnosis was mature cystic teratoma, this patient showed a recurrence of malignant effusion 7 months following the operation. The earlier resected specimen was pathologically re-reviewed according to the blocked entire mass, and small foci of adenocarcinoma were thus found within the tumor.     

Traumatic hemothorax resulting from rupture of mediastinal teratoma: a case report

Ruptured cystic mature teratoma of anterior mediastinum is rare. This 45-year-old woman complained of sudden onset of chest pain and dyspnea after a traffic accident. Physical examination revealed decrease of breath sounds over the left chest. Chest X-ray showed pleural fluid accumulation of the left pleural cavity. Computed tomography scan of the chest revealed a heterogenous cystic mass lesion approximately 11.5 x 10 x 7 cm in size in the left anterior mediastinum and left pleural effusion. Under the impression of mediastinal tumor and traumatic hemothorax, she received excision of the mediastinal mass and evacuation of left pleural fluid through a left lateral thoracotomy. She recovered uneventfully after operation and was discharged on postoperative day 11.     

A case report of mediastinal cystic lymphangioma

Mediastinal lymphangioma is very rare in the literature. A resected case of mediastinal cystic lymphangioma was reported. A 41-year-old man admitted to our hospital complaining of sore throat. A chest X-ray examination showed a large mediastinal mass on the right. At the right thoracotomy, a large cystic mass filled the anterior mediastinum and extended from the thoracic inlet to the posterior costophrenic angle. The cyst contained about 600 ml yellowish brown fluid and was adherent to the surrounding tissue, especially to the aorta and the left main bronchus. The resected tumor was 20 x 12 x 10 cm in size and 620 g in weight. Histological diagnosis was cystic lymphangioma. The patient is alive and well 26 months later, and there is no sign of recurrence of the tumor.     

A case of teratoma in both the mediastinum and the intrapulmonary system

A rare case of mature teratoma in both the mediastinum and the intrapulmonary system is presented. A 30-year-old male was admitted to our hospital due to tumor masses in the mediastinum and the left lung. We performed mediastinal tumor resection and left upper partial lobectomy. Neither tumor communicated with each other. Pathological findings revealed teratoma in the mediastinal lymph node and the intrapulmonary system including no malignant cells in either tumor. In this case, because metastasis and perforation were negative, we proposed that both tumors occurred at the same time in the early embryo.     

Mediastinal cavernous lymphangioma in an adult

Cavernous lymphangioma is a rare mediastinal benign tumor. A 43-year-old woman presented with cough and dyspnea for 1 month. Computed tomography of the chest showed a 3-cm well-circumscribed cystic mass in the posterior mediastinum. At thoracotomy, a cystic tumor in the mediastinum that was adherent to the descending aorta and esophagus was removed completely. The tumor, the cystic space of which was filled with lymph fluid, was diagnosed as cavernous lymphangioma based on pathological findings. Mediastinal lymphangiomas may insinuate into surrounding organs. As incomplete resection can result in recurrence, complete tumor removal should be performed based on accurate preoperative evaluation.     

Induction chemotherapy and radical resection for primary nonseminomatous mediastinal germ cell tumor (NSGCT); report of a case

A 15-year-old male was admitted to our hospital for treatment of an anterior mediastinal tumor. The tumor was visualized by chest radiography 3 months prior to admission. Computed tomography (CT) revealed a heterogeneous solid tumor located in the anterior mediastinum. Although CT-guided needle biopsy had been performed twice, histologic diagnosis could not be confirmed. We believed this tumor to be nonseminomatous mediastinal germ cell tumor (NSGCT) and started intensive chemotherapy with cisplatin (CDDP) without histologic diagnosis because his serum AFP level was rapidly increasing. After 2 courses of chemotherapy, his serum AFP level returned to the normal range and surgical resection of the tumor with part of right lung was performed. Histopathological examination revealed that the tumor consisted of mature teratoma and yolk sac tumor. He underwent 1 course of chemotherapy post-operatively because a small number of viable cells were histopathologically recognized in the yolk sac component. At the time of writing, the patient is alive without any evidence of recurrence.     

Resection of mediastinal teratoma in a patient with cardiac tamponade due to pericardial perforation

Benign teratoma of the mediastinum causes a variety of complications if left untreated, but reports of pericardial perforation have been rare. We report a case of mediastinal teratoma that perforated the pericardium and induced clinical cardiac tamponade. The patient was a 46-year-old male, who was admitted due to sudden chest pain. Since chest CT and echocardiography suggested perforation of the pericardium by a mediastinal teratoma, pericardial drainage was carried out. However, heart failure could not be resolved, and the tumor was resected on the 5th hospital day. From the intraoperative and pathologic findings, mature type mediastinal teratoma was found to have perforated the pericardium, causing massive influx of yellowish fluid from the cyst of the tumor. There have been only 10 cases reported to date in Japan and abroad in which mediastinal teratoma was complicated by cardiac tamponade.     

Life-threatening giant mediastinal cystic teratoma in a 4-month-old male baby

Cystic teratomas of the mediastinum are rare and present with severe respiratory distress during childhood. Aspiration of the cyst is indicated to reduce the cyst volume, alleviate the patient’s symptoms, and secure an operative field. This report describes a 4-month-old male baby with a large anterior mediastinal teratoma presenting with severe respiratory distress. The cystic teratoma was large enough to cause pectus carinatum. Respiratory distress secondary to airway obstruction was markedly reduced by percutaneous aspiration of the cyst. Surgical excision is indicated for a malignant or benign well-demarcated mass in any part of the mediastinum. In our patient, total surgical excision was performed. Preoperatively, percutaneous aspiration was performed twice, with the symptoms being reduced after each aspiration. Surgical excision is the best means of diagnosing and treating a benign teratoma. Percutaneous cyst aspiration not only improved ventilation but also facilitated easy excision of the cyst during surgical management.     

Hemangioma in the anterior mediastinum

Anterior mediastinal hemangiomas are very rare neoplasms in mediastinal tumors. A 58-year-old woman was revealed to have a mass measuring 4×3 cm in size in the anterior mediastinum with calcification on computed tomography. It was initially suspected to be a thymoma. We performed tumor extirpation in November 1998. The tumor was close to the thymus and slightly adhered to the superior vena cava, ascending aorta and right phrenic nerve, however, it did not invade any surrounding organs. Histopathologically, it was diagnosed to be a venous type hemangioma composed of vessels covered by smooth muscle and a cavernous type hemangioma composed of dilated vessels covered by one layer of endothelial cells.     

Benign teratomas of the mediastinum

Approximately 8% of all mediastinal tumors are benign teratomas. We reviewed 86 cases of benign teratoma seen at the Mayo Clinic from 1930 through 1981. The mean age of the patients was 28 years and the sex distribution was approximately equal. The most common symptoms were chest, back, or shoulder pain, dyspnea, and cough, but 36% were asymptomatic at the time of presentation. Chest roentgenograms showed a well-circumscribed anterior mediastinal mass which often protruded into one lung field. Detectable calcification was observed in 22 patients: a calcified tumor wall in seven, bone or teeth in the mediastinum of seven, and nonspecific calcifications in eight. Surgical excision remains the best means of diagnosing and treating this benign tumor. Though the tumors are histologically benign, they may present difficult surgical problems because of the vital structures involved. Since 1952 there has been a change in the clinical presentation of patients with this entity: More patients are asymptomatic and have smaller tumors and fewer complications than prior to 1952.     

Benign sacrococcygeal teratoma with spinal canal invasion and paraplegia

Sacrococcygeal teratomas can have a wide variety of clinical presentations depending on their size, vascularity, and degree of mass effect upon adjacent structures. Intradural invasion of a sacrococcygeal teratoma is a rare variant that has generally been associated with a favorable neurologic outcome. In this report, we present the case of a neonate with paraplegia secondary to a large Altman type III sacrococcygeal teratoma with extension into the spinal canal. The neoplasm was completely removed using a combined anterior and posterior approach after preoperative embolization of the lateral sacral arteries. Pathology showed a mature teratoma. The patient remains paraplegic without evidence of tumor recurrence at 1 year of age.     

Teratoma following cisplatin-based combination chemotherapy for nonseminomatous germ cell tumors: a clinicopathological correlation

From April 1975 through May 1981, 51 patients had teratoma resected from residual disease following cisplatin-based combination chemotherapy. All patients had normal serum markers before resection of abdominal (25), lung (12), mediastinal (5), thoracoabdominal (8) or other (1) disease. Teratoma was classified as mature in 29 cases, immature in 15 or immature with nongerm cell elements in 7. Of the 51 patients 31 (61 per cent) remain free of recurrent disease, while 20 either had recurrent carcinoma (10) or teratoma (10) requiring further therapy. Nine patients died, including 1 in whom angiosarcoma developed, which was thought to be secondary to previous radiation therapy. In 4 patients the initial relapse of carcinoma developed beyond 2 years after resection. Univariate factors predicting for relapse include tumor burden, immature teratoma with nongerm cell elements and site (mediastinum), while only immature teratoma with nongerm cell elements and site predicted for survival. Patients with immature teratoma had a comparable relapse-free and over-all survival as those with mature teratoma. Using a multivariate analysis, primary tumor site at the mediastinum was the most significant adverse factor predictive for relapse and survival. This study appears to support the various pre-clinical models that demonstrate multipotential capabilities of teratoma. Complete surgical excision of teratoma remains the most effective treatment with continued close followup recommended for high risk patients (immature teratoma with nongerm cell elements, large tumor burden and primary mediastinal tumors) with resected teratoma.     

Metachronous Mature Cystic Teratomas in the Left Ovary and Bilateral Diaphragm: Report of a Case

Mature cystic teratomas are found often in gonadal sites, but rarely in extragonadal sites, such as the retroperitoneum, mediastinum, central nerve system, lung, and liver. To our knowledge, only seven cases of pathologically benign mature cystic teratoma originating in the diaphragm have been reported. We report the case of a 45-year-old woman found to have a mature cystic teratoma below the left side of her diaphragm. She had undergone oophorectomy for a huge mature cystic teratoma in the left ovary 34 years earlier, followed 1 year later by excision of a tumor in the right side of the diaphragm. All sections of the pathological specimen showed evidence of a mature cystic teratoma and pathologically resembled the specimens obtained in the previous two operations. Although this tumor might have been a recurrence of the mature cystic teratoma in the left ovary, it is more likely that multicentric teratomatous foci metachronously developed in the gonadal and extragonadal sites.