Keywords

Mass, abdomen, mesenteric, teratoma

About the Authors

Sana Aboosalih, Leena Dennis Joseph, Prakash A, CN Sai Shalini, Rajendiran S Final Year MBBS Student Dept. of Pathology Dept. of Pediatric Surgery Sri Ramachandra Medical College and Research Institute, Porur, Chennai, Tamil Nadu Address for correspondence Dr Leena Dennis Joseph Dept. of Pathology Sri Ramachandra Medical College and Research Institute, Chennai Tamil Nadu - 600 116

Introduction

Extragonadal, intraperitoneal teratomas especially arising from the mesentery and mesocolon are very rare. Only a few cases have been reported, mostly ones in gastric, hepatic, mesocolic, mesosigmoid and mesenteric locations. Complete surgical excision is the treatment of choice for intra-abdominal teratoma. Complete tumor resection is sufficient for cure in benign teratomas. Mesenteric teratomas are rare in infants and children, but must be suspected if calcification is found by radiological investigation.

Case Report

An 1-year-old female child presented with bilious vomiting of 1-day duration. The vomiting was intermittent, 4-6 times and mainly following feeds. The child did not pass stools for 1 day and the parents complained of abdominal discomfort and tenderness in the baby. No history of fever or any chronic illness was noted. No history of rheumatic heart disease, jaundice or seizure disorders was present. Birth history and developmental milestones were normal. The child was immunized as per schedule. On physical examination, all the vital parameters were within normal limits. Per abdomen examination revealed a vague mass palpable in the right hypochondriac, epigastric and umbilical region. The mass was firm in consistency and was mobile. Ultrasonogram of the abdomen also showed a huge mass measuring 10  10 cm. A diagnostic laparoscopy was followed by laparotomy with resection, and anastomosis of jejunum. The mesenteric tumor was excised and sent for histopathology. Per operative, there was a huge mass of size 10  10 cm in size, which was adherent to the jejunum. There was no free fluid, rest of the bowel was normal. Grossly the mass was greyish yellow with adherent bowel loops. The cut surface of the soft tissue mass was soft with greyish white areas. On microscopic examination, the mass was a mature teratoma composed of bone, cartilage, glandular epithelium, muscle, skin and intestinal mucosa (Figs. 1 and 2). Extensive sampling did not reveal any immature or primitive components. The patient was discharged with antibiotics and advised follow-up. On follow-up, the baby is doing well and is regular with treatment.

Discussion

Teratomas are neoplasms that originate in pluripotent cells and are composed of a wide variety of tissue foreign to the origin or anatomic site in which they arise.1 They often occur in a paraxial or midline location, anywhere from the brain to the sacrum or they may arise in gonads. The most frequent tumor sites (in descending order) are: The sacrococcygeal region (33.8%), the ovaries (31.2%) and the testes (10.5%). Rare localizations include the mediastinum, the retroperitoneum, the head and neck region as well as the central nervous system.2

Extragonadal, intraperitoneal teratomas especially those arising from the mesentery and the mesocolon, are very rare in infants and children.3 There are very few mesenteric cysts reported in medical literature; due to their rarity there is lack of information and difficulty in classification.

Now a new classification for mesenteric cysts, based essentially on histopathological features include the six following groups: 1) Cysts of lymphatic origin (simple lymphatic cyst and lymphangioma); 2) cysts of mesothelial origin (simple mesothelial cyst, benign cystic mesothelioma and malignant cystic mesothelioma); 3) cysts of enteric origin (enteric cyst and enteric duplication cyst); 4) cysts of urogenital origin; 5) mature cystic teratoma (dermoid cysts) and 6) pseudocysts (infectious and traumatic cysts).5 The World Health Organization (WHO) classification of germ cell tumors distinguishes mature and immature teratomas as well as teratomas with malignant transformation.3

There are about 20 cases of mesenteric teratomas that have been reported so far. Teratomas have no pathognomonic signs or symptoms, and their clinical manifestation depends greatly on the size and location of the growth. The anatomy of the mesentery usually offers sufficient space for considerable growth before symptoms can appear, particularly when the lesion is located near the root. The symptoms may develop early if the lesion is localized at the periphery of the mesentery i.e., near the gut lumen. They present frequently, with a palpable mass or an increasing abdominal girth. Nausea, vomiting or constipation is the result of intestinal compression by the mass. An intractable chronic diarrhea as a manifestation has also been described.6-10

Complete surgical excision is the mainstay of management of intra-abdominal teratoma. Complete tumor resection is sufficient for cure in benign teratomas. Most of the abdominal teratomas are benign in nature and are composed of mature cells; however, 20-25% of these may also contain immature elements.6 Immature teratomas may contain variable quantities of immature neural tissue resembling embryonic components and these may coexist along with mature tissue. The presence of immature tissue in the histology of the excised tumor warrants the need for chemotherapy and regular follow-up. Serum -fetoprotein assay is a reliable method for detecting the recurrence in teratomas. Mesenteric teratomas are rare in infants and children, but must be suspected if calcification is found by radiological investigation.7

References

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