Teratoma is a common type of ovarian germ cell tumor, derived from germ cells. It is divided into mature teratoma (i.e., benign teratoma) and immature teratoma ( malignant teratoma ). Benign teratomas contain many components, including skin, hair, teeth, bones, grease, nerve tissue, etc. Malignant teratomas are poorly differentiated, have no or little formed tissue, and have unclear structures. Most early-stage teratomas have no obvious clinical symptoms and are mostly discovered accidentally during physical examination.
1. Intracranial teratoma
Symptoms: Because intracranial teratoma mainly occurs in the midline area such as the suprasellar area and pineal gland area, there are often no obvious signs of brain localization. Most patients present with increased intracranial pressure as the first symptom, including headache, nausea, and vomiting, and bilateral papilledema can be seen on eye examination. Teratomas located in the pineal gland area may cause the inability to look upward, ataxia, precocious puberty, cranial nerve palsy, etc. People in the sellar area may develop diabetes insipidus, drowsiness, visual field disorders, and water and fat metabolism disorders. Those in the posterior cranial fossa may suffer from cerebellar function damage and neck stiffness. People with cerebellopontine angle may suffer from headache, vomiting, diplopia, ataxia, deafness, nystagmus, cranial nerve damage, etc.
examination: The imaging features of intracranial teratoma have their own distinctive characteristics and can make a preliminary diagnosis.
(1) lumbar puncture Most patients have varying degrees of increased pressure during lumbar puncture manometry, and the cerebrospinal fluid protein content is generally not high.
(2) Most plain X-rays of the brain show signs of increased intracranial pressure, such as teeth, small bones, and calcifications, which are more helpful for qualitative diagnosis.
(3) CT scan: CT scan shows irregular, nodular and obviously lobulated space-occupying lesions with uneven density. They usually have solid components (high density) and cystic lines (low density). and calcification and ossification, etc., which are more common in polycystic patients. Fat components were seen in all patients, and intratumoral bleeding was rare. In a few cases, intraventricular greasy fluid can be seen swimming with body position changes (due to teratoma rupture into the ventricle). It is difficult to distinguish between teratoma and malignant teratoma on plain CT, but the latter becomes a cyst. There are relatively few points, calcifications and fat, and more solid parts. Benign teratomas often have grown for many years and are usually larger when discovered. Almost all of them in the pineal region have varying degrees of supratentorial ventricular enlargement. After injection, the solid part is significantly enhanced, the density is extremely uneven, and the cyst wall enhancement can appear as multiple ring-shaped shadows.
(4) The signals on the T1 and T2 images in MRI examination are extremely mixed, but the boundaries are clear, nodular or lobulated. The borders of benign teratomas have no edema (the T2 images show clear high signal). If there are peripheral Edema indicates that the tumor is malignant or malignant teratoma. The tumor wall and parenchyma are significantly enhanced after injection.
(5) The tumor marker CEA can be slightly or moderately elevated. AFP was significantly elevated in patients with immature teratomas and mixed GCTs containing this component.
Treatment methods : Benign teratomas are only surgically removed, but emphasis must be placed on three-dimensional and multi-point sampling of pathological specimens to avoid missing the diagnosis of malignant components. If it can be completely removed, it can be cured. Because tumors are often located in the midline, it is often difficult to completely remove them with surgery. Those who cannot be completely removed may undergo cerebrospinal fluid shunt surgery to relieve obstructive hydrocephalus. Radiotherapy and chemotherapy are ineffective against benign teratomas. Immature and malignant teratomas are treated with chemotherapy followed by radiotherapy. If the tumor does not disappear during reexamination, surgical resection is performed, and chemotherapy is continued for 2 courses after surgery.
2. Symptoms of gastric teratoma
: The main clinical manifestations are abdominal masses, mostly located in the left upper abdomen, abdominal distension, vomiting, hematemesis and/or melena, , dyspnea, and anemia. In newborns or infants, upper abdominal mass and upper gastrointestinal bleeding (most commonly intermittent melena) are the main clinical manifestations.
Examination: (1) X-ray examination ① Abdominal plain film shows an increased shadow with uneven density in the middle and upper abdomen or the entire abdomen. The border may be unclear, and the intestine may be squeezed to the right front and lower side. Strip-shaped bone-like or punctate sand-like calcifications can be seen in the shadow of the mass.② Barium meal fluoroscopy shows that the gastric body is compressed and deformed, and the small intestine is displaced downward; a filling defect can be seen in the stomach, which can also be expanded, with an air-liquid level and a large amount of fluid accumulation; or the contrast agent in the stomach is distributed along the mass and can also accumulate in the mass. among the leaflets of things. ③Barium enema shows that the transverse colon, descending colon and sigmoid colon are displaced downward due to pressure, and the upper abdomen shows a huge dense shadow. ④ Renal pyelvenography shows downward displacement of the left renal pelvis and possible pressure marks on the upper edge of the bladder.
(2) B-ultrasound examination shows various sonograms. When scanning across the left upper abdomen, it can be seen that the mass is located between the spleen and kidneys. The boundary may be clearly displayed or unclear. The mass may be multilocular and lobulated, and its internal sound appearance may be solid, multiple cystic, or mixed, and may also show calcifications.
(3) If the lesion is huge in CT examination, even occupying 4/5 of the abdominal cavity, multiple organs will be compressed and displaced. The internal structure of the lesion is disordered, the density is uneven, and it is a mixed dense shadow. It can also be composed of solid and cystic components.
(4) Gastroscopy is rarely used. It can only observe the size of lesions in the gastric cavity and their surface conditions, such as bleeding, erosion and superficial ulcers. Biopsy under direct vision is its advantage, but it is not suitable for gastric abnormalities. The diagnosis of tumors is of little help.
treatment methods : Gastric teratomas are mostly benign and require early surgical removal with a good prognosis. Long-term follow-up should be conducted after surgery, and AFP should be rechecked regularly. If AFP does not decrease or decreases and then increases, it indicates recurrence or metastasis, and further treatment is required.
3. Testicular teratoma
Symptoms: The age of highest incidence of testicular teratoma can be divided into two age groups: children and adults. The highest incidence of testicular teratoma in children is between 1 and 2 years old, and the highest incidence of testicular teratoma in adults is between 1 and 2 years old. 25~35 years old. The vast majority of patients present with painless testicular masses that are hard, nodular, or irregular.
examination: B ultrasound has important clinical value in determining the nature, size, location of testicular tumors, the proportion of testicular tissue occupied by the tumors, and even selecting treatment methods. The B-ultrasound manifestations of testicular teratoma are clear-demarcated, solid cysts, cartilage, immature bone tissue or calcification within the mass. The level of serum alpha-fetoprotein (AFP) in adult patients with testicular teratoma is related to benign and malignant conditions. The AFP levels of children with testicular teratoma are within the normal range for the corresponding age group, but the blood AFP levels of normal infants within 6 months vary greatly. Therefore, there is no clear clinical indication for the level of AFP levels in infants under 6 months of age. significance.
Treatment Methods : Surgery is the treatment of choice for testicular teratoma. For children with testicular teratoma, testicular preservation surgery can be considered if malignant tumors are ruled out based on normal AFP levels, B-ultrasound showing the presence of normal testicular parenchyma, and intraoperative frozen pathology examination results.
Patients with testicular dermoid cysts and testicular teratomas in children require no other treatment after surgery. Radical orchiectomy + retroperitoneal lymph node dissection was performed for patients with postpubertal testicular teratoma associated with retroperitoneal lymph node metastasis . The vast majority of teratoma metastases have the same pathological type as the primary tumor, but embryonal carcinoma components are also found in teratoma metastases.
4. Symptoms of ovarian teratoma
: The incidence of metastasis of this disease is high. The mode of metastasis spreads along the peritoneum. Common metastasis sites include the pelvic and abdominal peritoneum, omentum , liver surface, diaphragm, intestine and mesentery. Most metastases are superficial. Lymph node metastasis is not uncommon.
Check: (1) Serum alpha-fetoprotein (AFP) The serum AFP of patients with ovarian yolk sac tumors is lower than that of ovarian yolk sac tumors. This may be because the endodermal tissue of immature teratomas can also secrete a small amount of AFP. Another possibility is that it is germ cell malignancy. Many tumors are of mixed types. Immature teratomas may be mixed with a small amount of yolk sac tumor components, which can synthesize trace amounts of AFP.
(2) Nerve cell-specific enolase (NSE) Ovarian immature teratoma contains mature or immature nerve cells. Sometimes NSE can be detected in the serum, which is of reference significance for the diagnosis of this disease.
(3) Other B-ultrasound, CT, MRI, laparoscopy, and histopathological examination.
Treatment methods : (1) Treatment principles for immature ovarian teratomas: surgical principles, adopting fertility-preserving surgery; effective combination chemotherapy should be taken early after surgery. For recurrent tumors, treatment should be based on immature teratomas. According to the rules of reversal of tumor malignancy, different specific plans can be formulated based on different specific situations.
(2) Surgical treatment ① Most of the tumors in the surgical area are unilateral, and the patients are often very young. It is often recommended to perform unilateral appendectomy to preserve the fertility function. If the patient has no desire to have children and the tumor is stage II or III, bilateral adnexal and hysterectomy can be performed. The greater omentum is a common site of metastasis. Regardless of the stage of the tumor, omentectomy is performed sooner or later. There is no consensus on whether retroperitoneal lymph nodes should be routinely removed. For patients with extensive intraperitoneal implantation and metastasis, tumor cytoreduction should be performed as much as possible to achieve a basically clean removal of the tumor. ② Surgical treatment of recurrent tumors. Recurrent tumors of immature teratomas are still mainly treated with surgical resection, supplemented by effective combination chemotherapy. ③Second exploration surgery is currently not recommended.
(3) Chemotherapy is an indispensable treatment method for immature ovarian teratoma. After the initial surgery, early use of combined chemotherapy can prevent recurrence and improve the survival rate.
5. Sacrococcygeal teratoma
Symptoms: Sacrococcygeal teratoma varies in size, and most patients have difficulty urinating and defecating. Sometimes swelling of the buttocks and a mass in the sacrococcygeal area may be seen. Because tumors tend to grow on one side toward the buttocks, the buttocks often appear asymmetrical. Sometimes the tumor bulges from the perineum. People with rectal pressure or traction may have constipation or fecal incontinence. Those with huge tumors may affect their mother's delivery. The presacral mass may be palpable on digital rectal examination. Malignant teratomas grow rapidly and cause progressive constipation and dysuria.
examination: (1) Laboratory examination The positive rate of blood AFP (alpha fetoprotein) examination is high. When there is bacterial infection, the peripheral blood white blood cell count and neutrophil count are significantly increased.
(2) Other auxiliary examinations: Plain X-ray films show shadows of bones and teeth within the tumor. The lateral image shows a mass in the sacrococcygeal region. Barium enema shows that the rectum bends forward. Intravenous pyelography can help determine the extent and location of the tumor and whether it has metastasized. X-ray examination of the chest and bones is required.
treatment methods : Surgery is the preferred treatment. The tailbone must be removed as well. There are often tumor cells on the tailbone. If the teratoma is not completely removed, it will recur even if the teratoma is benign. Newborns should undergo surgery as soon as possible after birth to avoid malignant transformation. During the operation, special attention should be paid to the handling of the presacral artery to prevent dangerous bleeding. Pay attention to whether there is lymph node metastasis during surgery. In addition to surgical resection, malignant teratomas of the sacrococcygeal region must be given radiotherapy and chemotherapy.
How to deal with teratoma in pregnancy?
If ovarian teratoma is found during pregnancy, the patient will be temporarily observed during the first 3 months of pregnancy, and laparoscopic surgery will be performed after 12 weeks. Teratomas are most prone to torsion and acute abdomen, so in principle, teratomas in pregnancy should be treated with laparoscopic surgery. Teratomas found in the second and third trimester of pregnancy can be treated at the end of delivery. Teratomas discovered before pregnancy are best treated surgically to prevent the tumors from growing during pregnancy and requiring surgery. Contraception is not required after teratoma surgery.
