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Journal Information

Online ISSN (English)
1305-3124

Print ISSN (Turkish)
1300-5251

Online ISSN (Turkish)
1305-3132

Established
1993

Editor-in-Chief
Cihat Şen

Editors
Murat Yayla, Oluş Api

Prenatal Diagnosis and Follow-up of Giant Sacrococcygeal Teratoma: Case report

Mucize Eriç Özdemir, Oya Demirci, Güher Bolat, Ayşenur Celayir, Suna Cesur

Article info

Prenatal Diagnosis and Follow-up of Giant Sacrococcygeal Teratoma: Case report. Perinatal Journal 2018;26(0):- DOI: 10.2399/prn.18.0261002

Author(s) Information

Mucize Eriç Özdemir1,
Oya Demirci1,
Güher Bolat1,
Ayşenur Celayir2,
Suna Cesur3

  1. University of Health Sciences, Zeynep Kamil Maternity and Children’s Research Hospital Department of Perinatology Istanbul TR
  2. Health Science University, Zeynep Kamil Maternity and Children Research Hospital Department of Pediatric Surgery Istanbul TR
  3. University of Health Sciences, Zeynep Kamil Maternity and Children’s Research Hospital Department of Pathology Istanbul TR
Correspondence

Mucize Eriç Özdemir, University of Health Sciences, Zeynep Kamil Maternity and Children’s Research Hospital Department of Perinatology Istanbul TR, ozdemir.mucize@gmail.com

Publication History

Manuscript Received: September 24, 2017

Manuscript Accepted: January 17, 2018

Earlyview Date: January 17, 2018

Conflicts of Interest

No conflicts declared.

Objective
To emphasize the favorable effect of elective and planned delivery of newborns with giant sacrococcygeal teratomas on neonatal outcomes.
Case(s)
A 26 years old, primigravid woman was admitted to hospital at 39 weeks of gestation because of severe polyhydramnios and  a giant solid-cystic mass in the sacrococcygeal area of the fetus. A healthy newborn with a giant sacrococcygeal teratoma (25x25x20 cm) was delivered by cesarean section in elective conditions. On the second postnatal day, total excision of the mass was performed by pediatric surgeons. Histopathologic examination revealed mature cystic sacrococcygeal teratoma. The newborn was discharged with a well-developed scar tissue on 15th postnatal day. 
 
Conclusion
Sacrococcygeal teratomas diagnosed in the prenatal period can reach very large sizes. Especially those without heart failure can reach up to the term. The planning of elective  delivery in these cases is of vital importance in terms of reducing perinatal mortality and morbidity. 
Keywords

Fetus, Sacrococcygeal Teratoma, Ultrasonography

Introduction
Although sacrococcygeal teratoma (SCT) is a rare tumor, it is an important cause of perinatal/postnatal mortality and morbidity. A multidisciplinary approach to determine the optimal time for surgical resection, to plan the mode of delivery, and to provide postnatal care and follow-up would minimize all these possible risks (1).
We aimed to present a case in which  successful  postnatal management of the fetus with a prenatally-diagnosed giant SCT was achieved by immediate postnatal excision of the mass .  
Case(s)
A 26-year-old primi gravid woman was referred to our hospital from another healthcare center due to severe polyhydramnios and a giant mass of the fetus which would possibly  need  pediatric surgery. The solid-cystic exogenous mass measured 25 x 25x 20 cm by ultrasound in the sacrococcygeal region (Figure 1). The columna-vertebralis was intact. Amniotic fluid index was measured as 35 cm and placentomegaly was noted. Arteriovenous shunting in the mass, fetal hydrops and fetal anemia  were not detected as  median cerebral artery  (MCA) Doppler flow indices were within normal ranges  (0.96 Mom). Fetal echocardiographic examination was normal and no other associated malformation was present. Fetal MRI was not planned  because of the  advanced gestational week. On the second day of admission, as the gestation was 39 weeks, cesarean section was performed because of the tumor size. 3,900 g girl baby was delivered with an Apgar score of 8 at 1 minute and 9 at 5 minutes. A skin-covered  giant mass with a diameter of 28 cm located at the sacrococcygeal region was observed at postpartum examination of the newborn (Figure 2). Alpha-Feto Protein (AFP), Beta-Human Choriogonadotropic Hormone and Carsinoembryogenic Antigen levels were measured as 37786 IU/ mL, 30mIU/mL and 3.2 ng/mL, respectively. Postnatal hemoglobin levels were 15.9 g/dl. Resection of the mass was planned as soon as possible before heart failure developed.  After neonatal umbilical vein and radial artery catheterization, total excision of the mass, along with coccyges, was achieved without rupture, although it was strictly adherent to the rectum and had presacral involvement. The mass weighted 1900 g. During the 4-hour-operation, 20 ml/kg/h IV fluid and 15 ml/kg/h erythrocyte suspension were given to the neonate who, after the operation, was transferred to the neonatal intensive care unit with mechanic ventilation. Also with postoperative albumin, fresh frozen plasma  and erythrocyte transfusions, the neonate went well hemodynamically at the early postoperative period. The neonate was extubated at 12th hour and discharged on the 15th day with a well-developed scar tissue overlying the operated sacral area.
Microscopically, the solid components were composed of a mixture of mature tissues including pancreatic tissue (Figure 3A), peripheral nervous tissue (Figure 3B), and stratified squamous epithelium (Figure 3C). Based on these histopathological features the diagnosis was mature cystic SCT. Levels of highly elevated tumor markers in the preoperative period were decreased to normal levels in the 3rd month postoperatively. The follow-up visits were problem-free for 9 months as this paper was written.
Discussion
In the era of routine prenatal screening and improved fetal imaging using ultrasonography (USG) and magnetic resonance imaging (MRI), most SCTs are now diagnosed in utero (2). Close surveillance with serial  ultrasonographic imaging and echocardiography is recommended so that fetal intervention or early delivery can be performed when necessary (2). There  are some prognostic factors in the SCTs. One of them is tumor size. The tumor size being greater than 10 cm is especially high in vascular tumors, and these tumors, along with  heart failure, increase the risk of fetal hydrops and intrauterine fetal demise (2). Although the diameter of the tumor  was 28 cm in our case, we did not detect any sign of heart failure. Gestational age is other prognostic factor. While the prognosis is poor among infants diagnosed before the 30th gestational week, the survival rate is very high among infants born just before term (3). The reason why such a large mass reaches to term without any complications is due to the absence of heart failure and additional organ anomalies, not ideal prenatal management. Anatomical location is important, too. Altman et al. described a four–stage- classification system of SCTs according to their anatomical location which appears to be associated with overall prognosis, with best survival being in Type 1 (4), as in our case. The incidence of various congenital malformations associated with SCTs range from 5 % to 26%. Of these, anorectal and genital malformations are of prime concern (5). Other associated anomalies include spinal dysraphism, sacral agenesis, dislocation of the hips caused by a large tumor, and meningocele (6). Sivrikoz TS et al. presented an atypical presentation of a tethered spinal cord,  associated with a SCT (7). Gothwal S et.al.reported a  SCT associated with Prune Belly Syndrome (8). Perrone et al. presented a SCT case with a large intraspinal component that was causing compression of the lower spinal cord (9). Due to the large tumor size, detailed examination and anatomical scanning with USG may not be possible in every case. Michal K et al. reported agenesis of the right forearm of a newborn, which had not been detected prenatally, despite many examinations (10).
In our case we performed  prenatal and postnatal USG and postnatal MRI  for detecting associated congenital malformations. No other malformations were detected.
The tumor size and location are essential for planning the mode of delivery in these cases. In the absence of obstetrical indications, vaginal delivery is acceptable for small tumors. Elective cesarean delivery is recommended for SCTs measuring more than 5 cm in diameter due to the risk for traumatic injury, rupture and subsequent hemorrhage from the tumor (11). Hemorrhage is the most common cause of neonatal mortality in patients with SCT. High-output cardiac failure, intratumoral hemorrhage and perioperative bleeding are the most common causes of early death and are all strongly associated with larger tumor sizes (12). Tumor rupture may be caused by uncontrolled labor or complications during delivery (13). Muataz A et al. reported a ruptured giant SCT during cesarean section and its successful postnatal management (14). Advanced gestational age may be related the resistance of the rupture in a SCT. According to literature, upper vertical incision is usually preferred during caesarian section (15), as in our case. However, lower segment incision was performed in some patients because of the increased risk of bleeding and uterine scar rupture at the following pregnancies (1). Maturation of a SCT is related to fetal/neonatal prognosis. Mature teratomas are the most common (16) and usually have excellent prognosis if completely excised. The surgical approach involves complete excision of the tumor including the coccyx in order to reduce recurrence (17), as in our case. Timing for tumoral resection in the postpartum period is important. Elective excision of the tumor is usually performed within the first few days of life (15). As recommended, resection was performed on the second postpartum day in our newborn. SCTs must be  followed up with  physical examination, USG, and MRI at the postpartum period.
Shortly, prenatal diagnosis has improved the perinatal management of these lesions that might benefit from fetal intervention. A comprehensive prenatal evaluation including conventional  USG, Doppler USG, echocardiography and fetal MRI, is essential for  adequate counseling and optimal perinatal management. Antenatal counseling helps the parents to better understand the natural history, fetal intervention, and perinatal management of these tumors. Fetal surgical debulking improves survival in cases of SCTs with cardiac decompensation. Additionally, the use of an EXIT procedure reduces the morbidity and mortality  in a complicated delivery in cases  with cervical and mediastinal-teratomas (18). Conditions amenable to intrauterine surgical treatment are rare; the mother may consider termination of pregnancy as an option. Fetal treatment can be lifesaving but  it carries risks to both the infant (preterm premature rupture of the membranes, preterm delivery) and the mother (19). One of the prenatal therapeutic options is to occlude the feeding vessels by radiofrequency ablation (20), but it has not been accepted as a  routine approach because of high mortality at term.
Conclusion
A multidisciplinary approach is crucial for SCT cases in both prenatal and postnatal period.
The aim of this paper is to present a giant mature SCT managed successfully without any pregnancy complications.  
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File/Dsecription
Mass on ultrasound
The solid-cystic exogenous mass was measured 25x25x20 cm
Giant mass at sacrococcygeal region
A gross mass with a diameter of 28 cm located at the sacrococcygeal region
Histopathological Features
Microscopic view of sacrococcygeal teratoma at 400 magnifications with hematoxylin eosin stain. Pancreatic tissue (A), peripheral nerve tissue (B), and stratum squamous epithelium (C) are indicated with arrows, respectively.