JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
A Case of Immature Teratoma in a Pregnant Female
Ugochukwu Odo, MD, William Robinson, MD
Neuroectodermal tumors are rare lesions that arise from cells of the primitive neuroectoderm located in the neural crest. Their occurrence in pregnancy is extremely rare and only a couple of case reports have been reported. This case report looks at a 20-year-old pregnant woman who presented at estimated gestational age of 22 weeks and four days with rapidly increasing abdominal girth and was found to have ascites and an ovarianmass. Pathology confirmed the diagnosis and patient underwent surgical resectionwith adjuvant chemotherapy.
INTRODUCTION
Immature teratomas of the ovary represents 3% of all teratomas, 1% of all ovarian cancers and 20% of malignant ovarian germ cell tumors. It mostly affects women in the first two decades of life. According to the World Health Organization (WHO), immature teratoma is defined as a teratoma containing a variable amount of immature embryonal type (generally) neuroectodermal tissue. 1 Immature teratomas that contain large amounts of immature neural tissue and those that have ruptured or disseminated through the abdominal cavity are treated as malignant. 4 Kleinmann et al., demonstrated that tumors composed exclusively of immature neuroectodermal tissue should be separated from other teratomas and treated as a distinct group of neoplasms. We report a case of neuroectodermal ovarian teratoma that occurred in a pregnant subject. To our knowledge, there have only been a few isolated case reports on this topic, including that of a primitive neuroectodermal ovarian tumor and a neuroectodermal renal tumor; both of which were diagnosed in subjects who were pregnant at the time.
On examination at our institution, vital signs were normal except formildly elevatedbloodpressureof 138/83. Shehadadistended abdomen that appeared tense and nearly rigid, consistent with massive ascites. Fundal height was difficult to palpate due to the tense nature of the abdominal wall. Fetal heart tracing was normal with heart rate in the 150’s. No contractions were noted on external tocometer. A complete blood count (CBC) and complete metabolic panel were all normal. Lactate dehydrogenase was 225mmol/L, alpha feto-protein 132.7ng/mL and beta human chorionic gonadotropin 117.0mIU/mL. A urine protein to creatinine ratio was 0.039. Abdominal ultrasound showed massive ascites with an intrauterine pregnancy of 21 weeks and five days gestation. She was initially thought be having nephrotic syndrome in the settingofdecreasedurineoutput, proteinuria, hypoalbuminemia and edema. A repeat ultrasound exam showed a left complex left sided pelvic mass, 9cm by 13cm by 7cm, consistent with an ovarian tumor. Magnetic resonance imaging (MRI) of the abdomen/pelvis further defined the mass as measuring 12cm by 10cm by 9cm. After extensive counseling, the subject agreed to performance of an exploratory laparotomy, with possible left salphingo- oophrectomy and surgical staging. Approximately 12 liters of ascitic fluid was aspirated intraoperatively. The left ovary appeared grossly abnormal, and was removed surgically, along with the left fallopian tube. Pathologic exam via rapid frozen section was performed which showed a malignant tumor, favoring ovarian teratoma. The final pathologic diagnosis confirmed the presence of a malignant teratoma (neuroectodermal monodermal teratoma) that measured 12.9 by 10.2 by 9.8cm. The tumor showed regional necrosis, neurophil formation and extensive immature neuroectodermal tubular structures resulting in primitive neural tubes. The stroma
CASE SUMMARY
20-year-old woman gravida 1 presented at 22 weeks and four days estimated gestational age (EGA) with complaints of a two- week history of abdominal pain and swelling. She reported that her abdominal size had greatly increased over the preceding weeks in a way which she felt was disproportionate to the progression of her pregnancy. She reported appropriate fetal movement throughout this period, and was seen for routine prenatal care at another facility where she was told there was no need for concern. The subject stated that an ultrasound exam of her abdomen and pelvis performed at that facility revealed no unusual findings.
40 J La State Med Soc VOL 170 MARCH/APRIL 2018
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