# Giant Intrapulmonary Teratoma: A Rare Case

Authors: Rayees Ahmad Dar; Majid Mushtaque; Sabiya Hamid Wani; Rayees Ahmed Malik
Journal: Case Reports in Pulmonology
 (2011)

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## Abstract

Teratomas  are  tumors  composed  of  tissues  derived  from  more  than  one germ  cell  line. Pulmonary  teratomas  are  rare  and  commonly  involve  the upper  lobe  of  the  left  lung. Criteria  for  pulmonary  origin  are the exclusion  of  a  gonadal  or  other  extragonadal  primary  site  and  origin  entirely  within  the  lung. We  report  a  case  of  a  giant  pulmonary  teratoma  in  a  2-year-old  male  child  and  review  the  relevant  literature.


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## Body

## 1. Introduction

Teratoma  is  a  common  tumor  of  the  mediastinum  but  is  rarely  found  in the  lung [1].  Furthermore, a  mature  teratoma  seldom  metastasizes  to  the  lung [2]. Mature  teratomas  are  the  most  common  histological  type  of  germ  cell tumors,  followed  by  seminomas [3].  These  lesions  originate  from  the  third pharyngeal  pouch  and  may  manifest  with  a  variety  of  clinical  and radiological  features.  Primary  lung  teratomas  have  rarely  been  reported since  Mohr's  description  of  this  entity  in  1839. Germ  cell  tumors  are predominantly  found  in  gonads,  while  the  anterior  mediastinum  is  the most  common  extragonadal  site.


## 2. Case Presentation

A  2-year-old male  child  was  referred  from  a  peripheral  hospital  to  our institute  as  a  case  of  progressively  aggravating  dyspnea  at  rest,  cough, intermittent  fever,  and  recurrent  chest  infections  from  the  last  5  months. The  chest  X-ray  showed  a  large  opacity  of  the  entire  left  hemithorax (Figure1). The  child  had  been  put  on  various  antibiotic  regimes,  but the child’s  condition  worsened  day  by  day. On  admission  in  our  institute,  the  child  was  in  acute  distress. On  chest  auscultation,  breath  sounds  on  the  left  side  were  absent. There was  no  adenopathy  or  testicular  mass. Computed Tomography  chest  was  advised  which  revealed  a  huge  mass occupying  the  entire  left  hemithorax  with  mediastinal  shift  to the  opposite side  (Figure 2).  It  was  adherent  to  the  left  anterolateral  subcostal  pleura and  the  mediastinal  pleura. The  lesion  showed  heterogeneous  density. No mediastinal  lymphadenopathy,  pleural effusion,  or  thickening  was  noted.  Routine  hematological  tests  and  abdominal  sonography  were  within  normal  limits.  Mantoux  test  was  negative. Tumor  markers  (α-fetoprotein and β-human chorionic gonadotropin)  were  both  normal.  Surgical management  was  first  in  the  priority  list  of  therapeutic  options.  A  left-sided  thoracotomy  revealed  a  cystic  tumor  arising  from  the  left  lung. Many  adhesions  existed  with  the  left  pulmonary  artery,  the  left  main bronchus,  the  pericardium,  the  aorta,  diaphragm,  and  parietal  pleura.  A combination  of  blunt  and  sharp  dissection  for  the  division  was  applied.  A purse  string  suture permitted  aspiration  of  sebaceous  content  via  a  small incision  in  the  wall  of  the  mass.  As  the  size  diminished,  manipulation was  facilitated.  A  pneumonectomy  had  to  be  carried  out  in  order  to remove  the  tumor  mass.  The  child  was  shifted  intubated  to  the Surgical Intensive  Care  unit  in  the  immediate  postoperative  period. The  child could not  maintain  oxygen  saturation,  and  his  condition  deteriorated,  and  he expired  on  the  second  postoperative  day. The  histopathological  examination revealed  a  benign  mature  teratoma  involving  the  left  lung,  containing  stratified  squamous  and  respiratory epithelium,  mature  adipose  tissue,  cartilage,  and  connective  tissue  (Figure 3).Figure 1
X-ray Chest PA view showing large opacity of entire left hemithorax with mediastinal shift.Figure 2
CT chest  revealing  a  huge  mass occupying  the  entire  left  hemithorax  with mediastinal  shift  to  opposite side  (fat is not delineated nicely).Photomicrographs of specimen of lung showing benign mature teratoma, containing stratified squamous and respiratory epithelium, mature adipose tissue, cartilage, and connective tissue.
(a)(b)


## 3. Discussion

The  first  case  of  pulmonary  teratoma  was  reported  by  Mohr  in  1839. Germ  cell  tumors  occur  typically  in  the  second  to  fourth  decades  of  life with  a  slight  female  preponderance.  Our  case  is  very  rare  keeping  in  view  the  age  of  the  child. Mature  teratomas  are  the  most common  histological  type  of  germ  cell  tumors.  Nearly  one  half  of  patients  have  no  signs  or  symptoms  when  the  mass  is  initially  diagnosed. Symptoms  commonly  present  are  chest,  back, or  shoulder  pain,  dyspnea, cough,  fever,  pleural effusion,  and  bulging  of  the  chest  wall.  Hemoptysis or  expectoration  of  hair (trichoptysis)  or  sebum  can  rarely  occur  when communication  between  the  tumor  and  the  tracheobronchial  tree  develops.  Trichoptysis is  the  most  specific  symptom [4].   Symptoms  can  also  derive from  the  pressure  exerted  on  the  surrounding  tissues  (for example, superior vena cava syndrome).  Intrapulmonary  teratomas  typically  range  from  2.8  to 3 cm  in  diameter  and  are  cystic  and  multiloculated  but  may  rarely  be predominantly  solid.  In  our  case,  it  was  exceptionally  large  tumor. Microscopically,  mesodermal  (bone, fat, and muscle),  ectodermal  (skin and hair),  and  endodermal  (respiratory epithelium and gastrointestinal tract) elements  are  seen  in  varying  proportions.  Mature  elements  often  take  the form  of  squamous-lined  cysts.  Thymic  or  pancreatic  elements  may  be seen  in  mature  teratomas.  Malignant  pulmonary  teratomas  present  as sarcoma  or  carcinoma  with  the  presence  of  immature  elements  like  neural tissue.  In  our  case,  tumor  was  composed  of  stratified  squamous  and  respiratory  epithelium,  mature  adipose  tissue,  cartilage,  and  connective  tissue.Diagnostic  assessment  is  performed  with  classical X-rays,  followed  by Computed  Tomography.  Computed  Tomography   accurately  estimates  the density  of  all  elements.  Magnetic  Resonance  Imaging   is  valuable  in detecting  the  anatomic  relation  to  mediastinal  and  hilar  structures,  such  as vessels  and  airways.  Surgical  resection  is  the  treatment  of  choice;  and radical  extirpation  leads  to  a  long  recurrence-free  survival [5].  Since,  in our  case,  tumor  was  involving  the  entire  left  lung,  pneumonectomy  was performed. Also  taking into  consideration  the  age  and  the very  sick  condition  of  the  child  preoperatively,  his  condition  deteriorated  in  the  immediate  postoperative  period  and  he  did not  survive.


## 4. Conclusion

Intrapulmonary  teratomas  are  rare  tumors.  They  originate  from  the  third pharyngeal  pouch  and  present  as  cystic  lesions  in  the  majority  of  cases.  A  giant  teratoma  involving  the  entire  left  lung,  as  seen  in  our  patient,  is noteworthy  and  has  not  been  reported.  Patients  present  with  chest  pain, cough,  hemoptysis,  and  trichoptysis.  Complete  resection  is  the adequate treatment  for  patients  with  a  good  long -term  prognosis.



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*Source: 298653-2011-09-25.xml*