0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Pathological Case of the Month FREE

[+] Author Affiliations

Section Editor: Enid Gilbert-barness, MD

More Author Information
Arch Pediatr Adolesc Med. 2002;156(4):406. doi:.
Text Size: A A A
Published online

DENOUEMENT AND DISCUSSION: TYPE IV SACROCOCCYGEAL TERATOMA WITH YOLK SAC (ENDODERMAL SINUS) TUMOR PRESENTING WITH FAILURE TO THRIVE AND PERIANAL PAIN

Figure 1. Axial computed tomographic scan through the pelvis (with contrast enhancement) shows a large, multilobulated, heterogenously enhancing mass filling the lower pelvis and displacing bowel to the left (arrow) and indenting the posterior bladder (B) wall.

Figure 2. A, The characteristic Schiller-Duval bodies seen in yolk sac tumors, consisting of a central fibrovascular core surrounded by a rim of primitive epithelium (hematoxylin-eosin, original magnification ×200). B, Immunohistochemistry, using an anti–α-fetoprotein antibody reveals positive dark staining in many epithelial cells (immunoperoxidase with hematoxylin counterstain, original magnification ×200).

Sacrococcygeal teratomas account for 40% of all germ cell tumors and up to 78% of extragonadal germ cell tumors.1 The incidence of germ cell tumors in children in the United States is 2.4 cases per 1 million children, with a biphasic age distribution. The first peak occurs at 2 years of age and a second peak at 15 to 20 years of age.2 There are 3 distinct clinical presentations of germ cell tumors: (1) tumors of the adolescent testis and ovary; (2) extragonadal germ cell tumors of older children; and (3) tumors of infants and young children. The origin of extragonadal germ cell tumors is presumed to be either aberrantly migrated germ cells, or alternatively, totipotential embryonic cells. The most common locations for extragonadal germ cell tumors are sacrococcygeal, mediastinal (including the pericardium, heart, and lung), intracranial, and retroperitoneal, respectively.

The clinical presentation of sacrococcygeal tumors is classified into 4 types. Type 1 tumors (47%) are predominantly externalized, with limited extension into the pelvic region; type 2 (34%) have similar external components and intrapelvic extension; type 3 (9%) have a minimal external component, with significant pelvic and intra-abdominal extension; and type 4 (10%) tumors are internalized presacral tumors with no external evidence of disease.3 The single most important histologic distinction to be made with sacrococcygeal germ cell tumors is whether or not they also contain yolk sac tumor or embryonal carcinoma, which are the malignant components. The incidence of malignancy is highest in type 4 tumors.4 Benign sacrococcygeal lesions are commonly seen in newborns, whereas malignant tumors most commonly present in children older than 1 year of age.

The histologic features of yolk sac (endodermal sinus) tumors are characterized by several patterns with varying cytology, making histological identification sometimes difficult. The majority of yolk sac tumors show more than 1 histological type, though none are believed to have specific prognostic significance. Generally, however, yolk sac tumors are characterized by primitive tubular or "microscopic" structures lined by somewhat flattened primitive cuboidal epithelial cells. One of the most common histological variants is the "papillary type," in which the characteristic Schiller-Dural bodies are seen, as in the present case. Periodic acid–Schiff (PAS)–positive hyaline droplets can be frequently recognized in the cytoplasm of many of these cells. Immunohistochemically, these tumors characteristically stain for α-fetoprotein. Yolk sac tumor is the most common malignant germ cell tumor in prepubertal children and may be histologically differentiated from embryonal carcinoma on the basis of virtual nonexistence of the latter in young children. Yolk sac tumor is commonly, but not always, associated with elevated serum α-fetoprotein levels.

Preoperative diagnosis may be accomplished by one or more imaging modality techniques. Prenatal ultrasound can identify the tumor when it is sufficiently large. Postnatal computed tomography and/or magnetic resonance imaging can show the mass and its location. Identification of fluid, tissue fat, and calcium densities within the mass is characteristic of teratoma, but it is not determinate for malignant potential.

Treatment is complete surgical resection, including excision of the coccyx. In the absence of malignancy, the cure rate is 95%.1,2 Presence of malignancy necessitates addition of chemotherapy with platinum-containing regimens, and this is associated with an inferior prognosis. Levels of α-fetoprotein may be used to monitor for recurrence and metastases. It is necessary to differentiate high serum α-fetoprotein levels from the normal infancy-related elevation,5 spurious increase secondary to chemotherapy-induced tumor lysis,6 hepatic disorders, cholestasis secondary to anesthesia, and medications such as phenytoin or methotrexate.1

Impaired growth and malnutrition are not uniquely related to malignancy. Nonetheless, disturbances related to tumor cell turnover and by-products may contribute to altered nutrient metabolism and energy imbalance in vulnerable hosts.7,8 Other than malignancy, there was no other satisfactory clinical explanation for the poor growth pattern observed in the subject of this report. The perianal pain and altered bowel patterns were presumed to be secondary to pressure effects from the tumor.

Accepted for publication July 3, 2000.

Corresponding author: Timothy A. Sentongo, Division of Gastroenterology, Hepatology, and Nutrition, Children's Memorial Medical Center, 2300 Children's Plaza, No. 65, Chicago, IL 60614-3392 (e-mail: TSentongo@childrensmemorial.org).

Castleberry  RPCushing  BPerlman  EHawkins  EP Germ cell tumors. Pizzo  PAedPoplack  DGedPrinciples and Practice of Pediatric Oncology. 3rd ed. Philadelphia, Pa. Lippincott-Raven Publishers1977;
Perlman  E Germ cell tumors. Stocker  JTedAskin  FBedPathology of Solid Tumors in Children London, England Chapman & Hall1998;
Altman  RPRandolph  JGLilly  JF Sacrococcygeal teratoma: American Academy of Pediatrics Surgical section survey 1973. J Pediatr Surg. 1974;9389- 398
Link to Article
Schropp  KPLobe  TERao  B  et al.  Sacrococcygeal teratoma. J Pediatr Surg. 1992;271075- 1079
Link to Article
Wu  JTSudar  K Serum AFP levels in normal infants. Pediatr Res. 1981;1550
Link to Article
Vogelzang  NJLange  PHGoldman  A  et al.  Acute changes of alpha-fetoprotein and human chorionic gonadotrophin during induction chemotherapy of germ cell tumors. Cancer Res. 1982;424855- 4861
Picton  SV Aspects of altered metabolism in children with cancer. Int J Cancer Suppl. 1998;1162- 64
Link to Article
Van Eys  J Nutrition and cancer. Annu Rev Nutr. 1985;5435- 461
Link to Article

Tables

References

Castleberry  RPCushing  BPerlman  EHawkins  EP Germ cell tumors. Pizzo  PAedPoplack  DGedPrinciples and Practice of Pediatric Oncology. 3rd ed. Philadelphia, Pa. Lippincott-Raven Publishers1977;
Perlman  E Germ cell tumors. Stocker  JTedAskin  FBedPathology of Solid Tumors in Children London, England Chapman & Hall1998;
Altman  RPRandolph  JGLilly  JF Sacrococcygeal teratoma: American Academy of Pediatrics Surgical section survey 1973. J Pediatr Surg. 1974;9389- 398
Link to Article
Schropp  KPLobe  TERao  B  et al.  Sacrococcygeal teratoma. J Pediatr Surg. 1992;271075- 1079
Link to Article
Wu  JTSudar  K Serum AFP levels in normal infants. Pediatr Res. 1981;1550
Link to Article
Vogelzang  NJLange  PHGoldman  A  et al.  Acute changes of alpha-fetoprotein and human chorionic gonadotrophin during induction chemotherapy of germ cell tumors. Cancer Res. 1982;424855- 4861
Picton  SV Aspects of altered metabolism in children with cancer. Int J Cancer Suppl. 1998;1162- 64
Link to Article
Van Eys  J Nutrition and cancer. Annu Rev Nutr. 1985;5435- 461
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

* * SCHEDULED MAINTENANCE * *

Our websites may be periodically unavailable between midnight and 04:00 ET Thursday, July 10th, for regularly scheduled maintenance.

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles