|Ahead of print publication
Gastric immature teratoma arising from the lesser curvature of the stomach: A rare case report
Madhu Kumar, Akanksha Singh, Damini Singh
Department of Pathology, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||26-Jun-2020|
|Date of Decision||14-Aug-2020|
|Date of Acceptance||14-Oct-2020|
|Date of Web Publication||15-Oct-2021|
Additional Professor, Department of Pathology, King George's Medical University, Shahmina Road, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Immature gastric teratoma is an uncommon germ cell tumor of the stomach. A 6-month-old male child was born through full-term vaginal delivery. After 1 month presented with a history of abdominal distension and palpable mass along with a history of Malena for the past 10 days. Computed tomography scan showed the presence of a large well-defined multilobulated solid cystic lesion with multiple calcifications in the abdominopelvic region. Radiological findings were suggestive of germ cell tumors. The exploratory laparotomy findings showed a large tumor mass with variegated consistency arising from the lesser curvature of the posterior wall of the stomach. The total excision of mass and primary closure of the gastric wall was done. Histopathology of excised specimens showed immature teratoma of the stomach. The child is still on follow-up regularly visited as outpatient, doing well day-to-day activity. We report a very rare case of immature gastric teratoma in an infant on the basis of clinicoradiological and pathological findings.
Keywords: Germ cell tumor, immature teratoma, stomach
| > Introduction|| |
Teratoma is defined as a germ cell tumor composed of tissues derived from ectoderm, endoderm, mesoderm, and described in various locations, including the gonad, intracranium, anterior mediastinum, retroperitoneum, and sacrococcygeal region. They are classified into mature and immature teratomas based on the presence and degree of differentiation of neuroglial tissue. Immature gastric teratoma is an uncommon germ cell tumor of the stomach. Gastric teratoma is a rare entity having incidence of <1% in all types of teratoma.
| > Case Report|| |
A 6-month-old male child was born through full-term vaginal delivery. Mother had no significant past medical or surgical history. The routine antenatal screening was unremarkable. The infant appeared healthy and after 1 month presented with a history of abdominal distension and palpable mass along with a history of the passage of black-colored stool for the past 10 days with no history of fever and vomiting. Abdominal examination revealed a firm, mass in the abdominopelvic region. Serum α-fetoprotein (AFP) was mildly raised, and other biochemical investigations were within normal limits.
The patient underwent a computed tomography scan (CT scan) showing the presence of a large well-defined intraperitoneal heterogeneously enhancing multilobulated solid cystic lesion with multiple calcifications in the abdominopelvic region. A large solid-cystic mass measuring 13.5 cm × 10.0 cm × 8.0 cm, arising from the lesser curvature of the posterior wall of the stomach. There was no infiltration to adjacent areas. CT scan findings were suggestive of germ cell tumors. The surgery was performed. Peroperative findings showed a large tumor with variegated consistency arising from the posterior wall of the stomach approaching to the lesser curvature. Specimen was sent to the department of pathology for histopathological examination.
The histopathology report revealed as on gross examination, a single globular soft-tissue piece measuring 13.0 cm × 10.0 cm × 7.5 cm. The outer surface was smooth, congested, and capsulated. Cut surface showed a variegated appearance with solid, cystic, greaish-white, and hemorrhagic areas which were soft to firm in consistency [Figure 1]. We also received excised omentum measuring 3.5 cm × 1.5 cm × 1.0 cm. Omental tissue measuring 3.5 cm × 1.5 cm × 1.0 cm in size. Tissue was processed, sections cut and stained with hematoxylin and eosin. Sections show a neoplasm consisting of the derivatives of all the three germ layers. Ectodermal derivatives consist of squamous epithelium, glial tissue, and immature neuroectodermal tissue in the form of the neuroectodermal epithelium, forming tubules, and pseudorossettes containing neuropils [Figure 2]. Various mesodermal and endodermal derivatives are also seen [Figure 3]. No evidence of any other germ cell tumor had been identified. The final histopathological diagnosis was an immature gastric teratoma-Grade 2 (Norris grading system) made. The infant recovered uneventfully from the neonatal unit. The child is still on follow-up regularly visited as an outpatient with serum alpha-fetoprotein level and abdominal ultrasonography. His postoperative serum alpha-fetoprotein level and abdominal ultrasonography are normal. He is feeding well and gaining weight.
|Figure 1: Gross examination of entire tumor shows well circumscribed, firm, and mass measuring 13.5 cm × 10.0 cm × 8.0 cm. The cut surfaces of the mass revealed a variegated appearance with solid-cystic and gelatinous appearance with focal cartilaginous like areas|
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|Figure 2: Immature gastric teratoma showsglial tissue (a), Neuroectodermal epithelium (b and c), cartilage and neuroectodermal epithelium (d), skin (e), lymph node, fat and blood vessels (f) (H and E, ×40)|
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|Figure 3: Paneth cells in the small intestine (a), goblet cells in large intestine (b), ductal epithelium (c), respiratory epithelium (d), bone (e) muscle (f). Muscle (H and E, ×40)|
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| > Discussuion|| |
Immature gastric teratoma is an uncommon germ cell tumor of the stomach. Teratoma originates from the precursor totipotential stem cells and is the most common germ cell tumor in children. It can be either gonadal or extragonadal tissue in origin. The sites of extragonadal teratoma are sacrococcygeal (60%–65%), mediastinal (5%–10%), sacral (5%), and rarely intracranial, retroperitoneal, cervical, and alimentary tract. Gastric teratomas are exophytic in the majority of cases (>60%), endophytic growths are present in about 30% of cases, mixed exophytic and endophytic growths may present. Mature gastric teratomas are considered benign, whereas the malignant potential is present in immature gastric teratoma. Gastric teratoma is uncommon, contributes < 1% among teratoma in pediatric patients. Almost all reported cases of gastric teratoma are of mature variety. Only few cases of immature gastric teratomas have been published in the literature. Moreover, immature gastric teratoma is relatively rare. There are thirty reported cases in the literature.,,,,,
Signs and symptoms depend on the site of tumor. Abdominal distention and palpable abdominal mass are common presenting complaints. Some infants can present with vomiting, hematemesis, or Malena because of ulceration of overlying mucosa in cases of endogastric component.
The most frequent clinical presenting symptoms are abdominal distension, palpable mass, and vomiting. Gastric teratoma most commonly arises from the greater curvature and posterior wall of the stomach and lesser curvature is an uncommon site.,
Mature glial tissue and other derivatives of at least one germ layer are present in mature gastric teratoma. Immature gastric teratoma contains immature glial tissue along with other derivatives of the germ cell layer and has malignant potential. Immature gastric teratoma is graded by the Norris grading system into 1, 2, and 3 by the proportion of tissue containing immature neuroectodermal epithelium and on the basis of mitotic activity in cells. Grade 1 contains immature tissue at one site in the whole slide, whereas Grade 2 contains immature tissue at <4 sites and Grade 3 contains at >4 sites in a slide.,
Radiographic evaluation of gastric teratomas can be differentiated from other common abdominal masses by the presence of associated calcification about 40%–60% of all gastric teratoma. The differential diagnoses of plain abdominal radiograph with the left upper quadrant soft-tissue mass containing internal calcification include mesoblastic nephroma, nephroblastoma, neuroblastoma, ganglioneuroblastoma, ganglioneuroma, and teratoma. Histopathological examination confirms the diagnosis. Treatment of choice is surgical excision with close follow-up. Immature gastric teratoma has an excellent prognosis after complete surgical resection. Adjuvant chemotherapy is not recommended. Recurrence of tumor is not described after complete resection. Adjuvant chemotherapy or radiotherapy therapy is not recommended Follow-up consists of regular observations and serum AFP measurement to monitor for recurrence. In case with rising AFP level after surgical resection of gastric teratoma, chemotherapy is recommended.
Prognosis is excellent as complete excision with primary closure of gastric wall defect gives recurrence-free survival without adjuvant chemotherapy and radiotherapy. Complete surgical resection remains the cornerstone of treatment.
| > Conclusion|| |
Immature gastric teratoma is an extremely rare tumor and it is common in males with presenting a history of abdominal distension and mass in the stomach. Lesser curvature is the least common site of origin. We conclude that when dealing with stomach mass in an infant, to keep the diagnosis of gastric immature teratoma in mind. Early diagnosis and surgical excision with follow-up is the important protocol for the treatment of the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]