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Sonographic Diagnosis of Cervical Teratoma in Utero

Ramesh B. Patel,1 John Y. Gibson,i Cyril A. D’Cruz,2 and James L. Burkhalter1

With advances in sonographic equipment and diagnosis, pharynx was seen. Sagittal hemisection of the infant and postmor-
an increasing number of fetal abnormalities are diagnosed tern radiographs confirmed these findings (fig. 2). Fine linear cal-
cifications at the periphery of the mass were shown by radiographs
prenatally. Among the abnormalities that have been diag-
obtained by film mammography technique (fig. 2B). Histologic ex-
nosed are anencephaly, hydrocephaly, myelomeningocele,
arnination of the mass showed a large amount of predominantly
omphalocele, duodenal atnesia, hydrops, ovarian cysts,
primitive neuroectodermal tissue. Areas representing all three gen-
polycystic kidney disease, and hydronephrosis. Our search
minal layers were seen. No evidence of malignancy was noted.
of the English language literature revealed one cervical Microscopic foci of calcifications were confirmed. A diagnosis of
teratoma diagnosed prenatally by B-mode, gray-scale static benign cervical teratorna was made.
scanning [1 1. We describe a case of cervical teratoma
diagnosed in utero, in a 29-week-gestation prima gravida
with polyhydramnios, by real-time gray-scale sonography. Discussion

Sonographic examination affords increasing possibility of

prenatal diagnosis of fetal abnormalities. Newer techniques,
Case Report
especially the recent advances in resolution capability of
A 1 5-year-old prima gravida was referred for evaluation of rapidly real-time equipment, aid in evaluating structures such as
developed polyhydramnios and a possible fetal neck and chest fetal heart and vessels, urinary bladder, and the gastroin-
mass on real-time sonography. Contrast amniography had failed to
testinal tract. Complications of pregnancy, particularly
opacify the fetal gastrointestinal tract. A second sonographic ex-
polyhydramnios, should lead to a diligent sonographic ex-
amination, with a 3.5 MHz transducer in a water-bath system (SKI-
200 Multi-Focus Scanner), showed a single fetus in cephalic pre- amination of the fetus to elicit fetal abnormalities and etio-
sentation. The biparietal diameter corresponded to a mean gesta- logic factors. Of cases of polyhydramnios, 20%-40% have
tional age of 29 weeks. A large (8.0 cm) mass was noted to arise been found to have associated fetal anomalies [2, 3]. About
from the night anterolatenal aspect of the fetal neck and over the 7%-8% of patients with polyhydramnios carry a fetus that
anterior thorax. The mass was composed of two clearly defined has obstruction of the proximal gastrointestinal tract [2, 3].
components, one solid and the other cystic. The predominantly Not only the presence but also the magnitude of polyhy-
solid part of the mass also contained scattered, small cystic areas dramnios may be a guide to predicting etiologic factors. A
(fig. 1 ). The mass had a broad base of attachment to the neck, the marked amount of polyhydramnios in the third trimester, as
borders were well defined, and there were no apparent calcific
in our case, has been noted to be associated with fetal
areas. Further examination of the fetus revealed absence of a fluid-
abnormalities in nearly half the cases. Milder amounts are
filled stomach (fig. 1 A), normal appearing kidneys and bladder, no
usually seen with maternal etiologic factors [3].
detectable abnormalities of the spine or intracranial structures, and
normal heart activity. The fetus was thought to be hyperactive. Cervical teratoma is usually seen in stillborn or newborn
Marked polyhydramnios was seen. On the basis of sonography, a infants. Of cervical teratomas, 2O%-4O% are reportedly
diagnosis of probable cervical teratoma with obstruction to the associated with polyhydramnios [2, 3]. In a series of 34
gastrointestinal tract and resultant polyhydramnios was made. cases of cervical teratomas, Hajdu et al. [4] reported the
A primary elective cesarean section was performed because of association of polyhydramnios in nine of 1 2 cases when the
the unlikely possibility of an uncomplicated vaginal delivery. A 900 tumor was larger than 1 0 cm. However, polyhydramnios can
g female infant was delivered. Polyhydramnios was confirmed at occur with smaller cervical teratomas [5]. Occurrence of
surgery. Apgar score was 1 . An 8 cm mass was noted in the anterior
polyhydramnios with cervical teratomas is based on the
neck. Attempts at establishing an airway were difficult and only
inability of the fetus to swallow amniotic fluid because of
partially successful, and the infant died shortly after birth.
At autopsy, the mass was noted to be partly filled with fluid. compression of the upper gastrointestinal tract. This patho-
Extreme compression of the upper gastrointestinal tract and airway physiologic abnormality can be confirmed by contrast am-
was found. The tumor was confined to the floor of the mouth; niography [6]. Improved sonographic evaluations and tech-
destruction of the mandible was noted. No invasion of the larynx or niques can make the same deduction in a noninvasive

Received June 28, 1982; accepted after revision August 28, 1982.
, Department of Radiology, University of Mississippi Medical Center, Jackson, MS 3921 6. Address reprint requests to R. B. Patel.
2 Department of Pathology, University of Mississippi Medical Center, Jackson, MS 39216.

AJR 139:1220-1222, December 1982 0361 -803X/82/i 396-i 220 $00.00 © American Roentgen Ray Society
 AJR:i39, December 1982 CASE REPORTS 1221

Fig. 1 -A, Sagittal sonogram

through cervical mass and fetal body.
Cystic part of mass (arrowhead); solid
part of mass (black arrow); fetal heart
(open arrow): fetal abdomen (curved ar-
row) showing absence of fluid in stom-
ach. B, Transverse oblique sonogram
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through cervical mass and fetal head.

Cystic part
of mass (arrowheads); solid
part of mass (arrow); mandible (curved
arrow).

Fig. 2.-A, Sagittal hemisection of

specimen. Area of obstruction (arrow) at
proximal esophagus and upper airway.
Mandible (arrowheads) invaded by
mass. B, Postmortem radiograph with
film mammographic system. Minute cal-

in-
cific area at periphery (black arrow). Ob-
structed upper airway and esophagus
(white arrow). Mandible (arrowheads)
vaded by mass.

A B

manner by showing absence of fluid-filled stomach as illus- case we saw no definite evidence of calcific areas on
trated in our case. The previously reported case of cervical sonography, postmortem radiognaphs did show fine, linear
teratoma in association with polyhydramnios made no men- calcifications at the periphery. Failure to appreciate calcific
tion of the status of the fetal stomach on sonographic areas on sonography was thought to be due to resolution
examination [1 1. In another case of postnatal diagnosis of limitations of sonographic equipment.
cervical teratoma with associated maternal polyhydramnios, Differential diagnosis of cervical teratoma in utero would
no fetal abnormalities could be found on sonographic ex- include hygroma, a cystic lesion with poorly defined bor-
amination. Amniographic study, however, failed to opacity dens, and congenital goiter (a solid, symmetrical mass).
the fetal gastrointestinal tract [7]. Presumably, in such
cases, sonographic examination with newer techniques
would play an increasingly important role in demonstrating REFERENCES
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to contain calcific areas on radiography [7]. Although in our 1978;51 :742-744
 1222 CASE REPORTS AJR:i39, December 1982

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congenital anomalies. JAMA 1960;1 73:1552-1556 toma as a cause of polyhydramnios. Pediatrics 1 979;64 : 1 76-
3. Lloyd JR, Clatworthy HW. Hydramnios as an aid to the early 179
diagnosis of congenital obstruction of the alimentary tract: a 6. McLain CR. Amniography studies ofthe gastrointestinal motility
study of the maternal and fetal factors. Pediatrics 1958; of the human fetus. Am J Obstet Gyneco! 1 963;86 :1079-
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the neck in infants. Am J Dis Child 1966;1 1 1 :412-416 of the thyroid region. AJR 1965;95:25-3i