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TERA’I’OMA

OF

THE

NECK

iN

A NEWBORN

iNFANT

Case

Report

By RoB!RT R. WHITi, M.D., F.A.C.S., ANI) RuFH S. GossILIN, MI).

Roche/er, “s. Y.

T

ERAI’OMAS have been described in practically every region of the body. They have been most commonly reported in the ovary, testis, sacro-coccygeal area and

mediasti-twin. Teratoma of the neck has been comparatively rare, having been reported only 60

times. Surgical removal has been attempted in 30 of these 60 patients with presumable cure

ill 26. Only 3 of the 60 cases reported were found to have malignant tumors. The young-est Patieit heretofore to have survived removal

of

a teratoma of the neck was 3 weeks of age.

FiG. 1. Pre-openative A-P view of L neck tumor. l:i(;. 2. Pre-operativi’ l.ttc’ral view (If 1. ne k tumor.

Cssr Rri-’oR’r

N.. a 3 d.ty old. 3.8 k.,’., white m.ik infant,1 Wa noted it birth to have a .trge swelling cc the lift neck. Hi’ had been delivered by low forceps tIter .01 uneventful pregn.Lncv. He cried

spo0t.iilcttisly .ind Wds noted to he entirely normal except for .i left iie k tumor m.iss. This ine.isured 8.8 cm. by () cm. by 5.0 cm. When feedings were begun the infant vomited sfll.iII iinounts of e.tclt

From the Departnients of Surgery and P.Ltll logy, R( hester Gener,i I H opt t.i I, Rt c llc’ster, N .1. (Reieived for publication Oct. 4, 1951.)

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FIG. 3. Gross specimen of tumor mass in cross section.

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TERATOMA OF THE NECK IN A NEWBORN INFANT 567

feeding. By the third day of life it was believed that the mass had increased considerably in size and was beginning to interfere with respirations.

Physical examination at this time revealed a well developed and well nourished infant whose left neck was completely filled by a large tumor mass (Figs 1 and 2). This extended from the

region of the left zygoma down to the left clavicle and from just posterior to the left ear forward

to just beyond the midline of the neck. The left ear was pushed upwards by the mass and the #{149} infant’s mouth was somewhat distorted. The head was pushed slightly to the right. There were

several large dilated veins visible in the skin overlying the tumor. The infant was in obvious respira-tory distress although no cyanosis was present. On palpation the mass felt cystic. The exact outlines of the tumor were vague and the mass appeared to transilluminate light well.

Laboratory Findings: The examination of the blood showed RBC 5.8 million/cmm., Hgb. 21.7

gm./100 cc., WBC 5.1 thousand/cmm. The differential count was 46% neutrophils, 10% eosinophils, 38% lymphocytes and 6% monocytes. Blood grouping was Type A and Rh factor positive. Fluoroscopy of the neck and chest showed that the soft tissue density was apparently confined to the neck and did not extend down into the thoracic cage. The heart, lungs and diaphragm were normal in appearance. Roentgenograms showed a large homogeneous soft tissue density in the left side of the neck which

extended anteriorly. In the upper portion the trachea appeared to be displaced slightly anteriorly and to the right.

The preoperative diagnosis was cystic hygroma. In view of the rapid growth and beginning

respiratory embarrassment, plans for immediate operation were made. A polyethylene catheter was placed in an ankle vein and the patient was transferred to the operating room.

Operation: Under intratracheal cyclo-propane-ether anesthesia, the patient was placed with his

head turned toward the right side. The entire left face, neck and upper chest were prepared and draped. A transverse elliptic incision was made across the center of the tumor mass. Bleeders were clamped and tied with 5 zero silk. The tumor appeared well encapsulated and was freed fairly

easily by sharp and blunt dissection. It extended deep in the neck and was loosely adherent to the major vessels and nerves, to the left submaxillary gland and to the larynx. The mass was firmly

adherent to the trachea and could be separated from this structure only by sharp dissection. The left lobe of the thyroid and thyroid isthmus were not visualized. When the tumor was completely freed, it was removed with immediate improvement in the infant’s respirations. The wound was then closed in one layer with interrupted 5 zero silks. A dry sterile dressing was applied and the patient was returned to the ward in good condition. Postoperatively 80 cc. of whole blood were given intrave-nously, followed by a slow 5% glucose in saline drip. The patient was also given 50,000 units of aqueous penicillin every 3 hr. and vitamin K 10 mg. intramuscularly.

PATHOLOGIC REPORT

Gross Description: The specimen removed at operation was a 7.5 x 6 x 2.5 cm. fibrous tumor which was slightly fluctuant. On cut section (Fig. 3) the mass was found to consist of multilocular spaces separated by soft, thick, yellowish fibrous walls. The tissue was slightly hemorrhagic, and the free surfaces had a smooth, shiny appearance. The soft tissue was very friable. The spaces contained

small amounts of clear straw-colored fluid.

Microscopic Description: The greatest part of the tissue was composed of various nervous ele-ments (Fig. 4). In predominance were cells having small round nuclei and clear cytoplasm with

numerous tiny fibrils forming a network between the cells, obscuring the cell boundaries. These were histologically like neuroglial elements of brain tissue. There was an island of small dark cells with abortive rosette formation reminiscent of the medulloblasts, forerunner of the neuron. There was

tissue resembling early meninges with darkly staining psammoma bodies like those seen in menin-giomas. A region of darkly pigmented cells, based on their arrangement and location amid brain tissue, resembled early choroid of the eye.

There was fairly well-differentiated thyroid tissue (Fig 5) both near the edge and well within the tumor. Other types of tissue identifiable were: stratified squamous epithelium both in solid sheets and lining cystic spaces (Fig. 6); glandlike structures lined with ciliated cells resembling respiratory epithelium (Fig. 7); fibrous tissue; and blood vessels. These tissues were an admixture

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FIG, 5, Well differentiated thyroid tissue.

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TERATOMA OF THE NECK IN A NEWBORN INFAN1’ 569

FIG. 7. Ciliated epitbelium, probably respiratory epithelium.

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Postoperative Course: The patient’s postoperative course was satisfactory except for some rhonchi and coarse rales in both lung fields during the 1st 2 days following operation. Sutures were

re-moved on the seventh postoperative day and the baby was discharged home on the eleventh post-operative day. He was last seen 7 mo. after operation at which time he was doing well and had a good cosmetic result (Fig. 8).

DiscussIoN

Tumors

of

the

neck

suggestive

of

teratoma

have

been

reported

as far

back

as

1691,

but the first proved case of teratoma of the neck was published by Hess1 in 1854. De-tailed knowledge of the early cases is lacking and in many instances the tumor was

ob-served in .stillborns. Bale,2 in a thorough review of the literature, recently collected 56 authenticated cases and added four additional cases not previously published. These 60

cases

are

grouped

according

to

their

anatomic

relationship

to

the

thyroid

gland

as

fol-lows :

(

1

)

those

tumors

supplied

by the

inferior

and/or

superior

thyroid

arteries,

the

true

teratomas of the thyroid gland (8 cases) ; (2)

those

tumors

not

supplied

by the

thyroid

vessels, which displace all or part of the thyroid, the teratomas in the region of the

thyroid gland (38 cases) ; and (3) those tumors not supplied by the thyroid vessels and not displacing any part of the thyroid gland but considered probably in the region of the thyroid gland because of their location and appearance

(

14 cases) . This case

would

seem

to fall

into

the

second

group,

a teratoma

in the

region

of the

thyroid

gland.

The most common tissues found in these tumors have been brain tissue and thyroid tissue.

It is the authors’ belief that the patient is the youngest yet reported to have survived

surgery

for

this

condition.

SUMMARY

The case history of a three day old infant with a huge teratoma of the neck, endanger-ing the infant’s life and demanding immediate surgical attack, is presented. This report illustrates still another condition amenable to operative relief at an early age.

REFERENCES

1. Hess, W., Beitrag zur Casuistik der Geschwulste mit Zeugungsahnlichen Inhalte, Inaugural Dis-sertation, M. Merck, Giessen, 1854. (cf. Wetzel).

2. Bale, G. F., Teratoma of neck in region of thyroid gland, Am. J. Path. 26:565, 1950.

SPANISH ABSTRACT

Teratoma del Cuello en el Recien Nacido; Presentaci#{243}n de un Caso

Los teratomas se han descrito pr#{225}cticamente en todas las regiones del cuerpo; mas frecuentemente

en los ovarios, testIculos, area sacro-coccigea y mediastino.

El teratoma del cuello es comparativamente raro; se han reportado #{252}nicamente 60 casos. La extir-paciOn quir#{252}rgica se ha intentado en 30, con curaciOn probable en 26. Unicamente 3 de los 60 casos fueron tumores malignos. El paciente nias joven que anteriormente habIa sobrevivido a la ex-tirpaciOn de un teratoma del cuello era de 3 semanas de edad.

PRESENTACiON DEL CA5O

N.N. de 3 dIas de edad, 8 libras y 7 onzas, de sexo masculino, present#{243} al nacimiento una tumoraciOn grande sobre el lado izquierdo del cuello. El parto fu#{233}por aplicaciOn de fOrceps bajo y

el embarazo fu#{233}normal. LIorO espont#{225}neamente y excepto por Ia masa tumoral del cuello no presentO ninguna otra anomalia. La tumoraciOn media 3#{189}pulgadas por 23/4 pulgadas por 2 pulgadas. Cuando se iniciO la alimentaciOn el niflo vomitO pequefias cantidades con todos los

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TERATOMA

OF

THE

NECK

IN

A

NEWBORN

INFANT

571

El examen fIsico en este momento mostrO a un niflo bien desarrollado y bien nutrido con el lado izquierdo del cuello ocupado por una masa tumoral que se extendia desde Ia regiOn del cigoma izquierdo hasta Ia clavicula izquierda y desde atr#{225}sde Ia oreja izquierda hasta un poco mas all#{225}de Ia lInea media del cuello. La oreja izquierda est.aba desviada hacia arriba por la tumoraciOn y Ia boca ligeramente distorcionada. La cabeza estaba inclinada hacia Ia derecha. HabIa vasos grandes, dila’ tados, visibles sobre Ia piel que recubrIa el tumor. El niflo se encontraba con dificultad respiratoria aunque sin cianosis. A Ia palpaciOn Ia tumoraciOn daba una sensaciOn quistica. Se transiluminaba con facilidad.

La fluoroscopIa del cuello y del tOrax mostrO que el tejido blando tumoral estaba aparentemente limitado al cuello y no se extendia a Ia cavidad tor#{225}cica. Las radiografias mostraron una densidad homogena producida por tejido blando en el lado izquierdo del cuello, apareciendo Ia traquea en Ia porciOn superior, ligeramente desplazada hacia adelante y hacia Ia derecha.

Bajo anestesia intratraqueal con ciclo-propano eter se trazO una incisiOn transversal elIptica por el centro de la tumoraciOn. Esta apareciO bien encapsulada liber#{225}ndose f#{225}cilimente y observ#{225}ndose que

se

extendIa profundamente en el cuello y que estaba ligeramente adherida a los grandes vasos y nervios, a gl#{225}ndula submaxilar y a la laringe. La tumoraciOn se encontraba firmemente unida a Ia traquea. Cuando el tumor se extirpO se presentO una mejoria inmediata en Ia respiraciOn del niiio.

El examen histopatolOgico demostrO que se trataba de un teratoma benigno. El curso post-operatorio fu#{233}satisfactorio.

Los 60 casos reportados en Ia literatura pueden ser agrupados de acuerdo con su relaciOn con Ia gl#{225}ndula tiroides en la forma siguiente:

(1) aquellos que reciben Ia circulaciOn de las arterias tiroides inferiores y/o superiores (8 casos); (2) los que no estfln irrigados por los vasos tiroides y movilizan todo o parte del tiroides (38 casos); y (3) aquellos que no estan irrigados por los vasos tiroides y que no desplazan Ia gl#{225}ndula tiroides (14 casos) -

Los

autores opinan que ci presente enfermo cae dentro de Ia categoria

del grupo segundo, o sea un teratoma en Ia regiOn de Ia gl#{225}ndula tiroides. En su opiniOn es este paciente el de menor edad que se ha reportado y que ha sobrevivido a la intervenciOn quirOrgica.

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1952;9;565

Pediatrics

ROBERT R. WHITE and RUTH S. GOSSELIN

TERATOMA OF THE NECK IN A NEWBORN INFANT: Case Report

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(9)

1952;9;565

Pediatrics

ROBERT R. WHITE and RUTH S. GOSSELIN

TERATOMA OF THE NECK IN A NEWBORN INFANT: Case Report

http://pediatrics.aappublications.org/content/9/5/565

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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