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Abdominal Mass in a Neonate.

The patient was a 17-day-old male infant, who was born by cesarean section to a 27-year-old gravida 1, para 0 mother at 35 weeks' estimated gestational age; the infant weighed 5 lb, 3 oz at birth. He required delivery room resuscitation (oxygen administration), and his Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.

Following delivery, the infant appeared well initially, but had feeding difficulties. On day 3 of life, he developed temperature instability and relative neutropenia. A septic workup, including blood and cerebrospinal cultures, was negative. There was a firm palpable mass in the left upper abdomen. A nasogastric tube obtained bilious fluid that was hemoccult positive. Stools were also hemoccult positive. Hematologic laboratory studies were within normal limits.

Upper gastrointestinal contrast studies showed a filling defect in the stomach. Subsequently, a computed tomographic scan of the abdomen demonstrated a focally calcified, complex solid and cystic gastric mass with posterior extension outside the stomach (Figure 1). The mass compressed the aorta and left kidney. Following imaging studies, the mass was surgically removed via a subcostal incision and anterior gastrotomy. The infant's postoperative course was unremarkable.


Grossly, the tumor was dumbbell-shaped and measured 8 x 7 x 4 cm and weighed 105 g. The outside surfaces were smooth, whereas the cut surfaces had both solid and cystic areas (Figure 2). A small rim of normal gastric mucosa was present at the narrowed portion of the tumor.


Figure 3 demonstrates the tumor histology, which shows derivatives of all 3 germinal layers. Mesodermal components were immature tooth buds (Figure 3, A), cartilage, bone, and skeletal muscle (not shown). Endodermal components consisted of gastrointestinal structures resembling small bowel (Figure 3, B). Neuroectodermal components were immature neuroepithelial tubules (Figure 3, C). Ectodermal components consisted of fetal-type skin (not shown). No endodermal sinus tumor components were present. Immunohistochemistry for [Alpha]-fetoprotein was negative.


What is your diagnosis?

Pathologic Diagnosis: Congenital Gastric Teratoma

Gastric teratoma is a rare tumor usually seen in male infants. Approximately 60 case reports can be found in the world literature.[1,2] Fewer than 10 of these cases involved females. Only 3 cases have been reported in adults.[3] These tumors are benign and treatment consists of excision alone.

Teratomas are neoplasms consisting of a wide range of tissues, which are foreign to the location in which they arise. Endoderm, mesoderm, and ectoderm derivatives can be identified in the tumors. There are numerous theories that explain the etiology of teratoma. The oldest theories attribute the origin of teratoma to germ cells or to embryonic stem cells. Later theories of origin include extra-embryonic cells, stem cells other than embryonic stem cells, conjoined and maldeveloped twins, and undetermined cell types.[4] Gastric teratoma has also been hypothesized to originate from pluripotent cells in the gastric wall.[5]

Patients with gastric teratoma have had the following clinical findings: palpable mass, abdominal distension, vomiting, hematemesis or melena, respiratory distress, anemia, fever, weakness, abdominal pain, feeding problems, and constipation.[6]

In infants and children, teratomas are most common in the sacrococcygeal area, whereas the gonads and brain are the other, less common sites of origin.[7] Gastric teratomas are very rare, usually constituting less than 1% of most series. Also, gastric teratomas usually occur in males. Although there has been a report of histologic malignancy based on the presence of neuroepithelial tubules,[8] the general consensus is that gastric teratoma in an infant is always benign. Only one case of "malignant gastric teratoma" has been reported in the literature, based on the presence of focal endodermal sinus tumor.[9] There have been no reports of gastric teratoma behaving in a clinically malignant fashion.

Our case of gastric teratoma had components of all 3 germinal layers, including neuroepithelial tubules. We still consider this a benign tumor because no endodermal sinus components were evident. The finding of isolated neuroepithelial tubules in a newborn is not considered a sign of malignancy. The presence of neuroepithelial tubules would raise concern for malignant teratoma only if they were abundant, making up the bulk of the tumor The diagnosis of gastric teratoma as a benign lesion is very important, so that the affected infants will not be subjected unnecessarily to the treatments of malignant tumors.


[1.] Senocak M, Kale G, Buyukpamukcu N, Hicsonmez A, Caglar M. Gastric teratoma in children including the third reported female case. J Pediatr Surg. 1990;25:681-684.

[2.] Logani KB, Jain M, Ray K, Kumar A, Atal P, Jain R. Pedunculated gastric teratoma: a case report with review of the literature. J Indian Med Assoc. 1997; 95:526-527.

[3.] Gangopadhyay AN, Pandit SK, Sinha A, Gopal SC, Khanna S. Gastric teratoma: review of the literature. Indian J Pediatr. 1992;59:541-547.

[4.] Gonzalez-Crussi F. Extragonadal Teratomas. 2nd ed. Washington, DC: Armed Forces Institute of Pathology; 1982.

[5.] Mysorekar VV, Dandekar CP, Rao SG. Gastric teratoma in an infant: a case report. Indian J Med Sci. 1998;52:412-413.

[6.] Morrison L, Snodgrass P, Wiseman H. Gastric teratoma: report of a case and a review of the literature. Clin Pediatr. 1975;14:712-717.

[7.] Gobel U, Calaminus G, Engert J, et al. Teratomas in infancy and childhood. Med Pediatr Oncol. 1998;31:8-15.

[8.] Ravikumar VR, Ragupathy R, Das L, et al. Gastric teratoma in an infant. J Pediatr Surg. 1986;21:948.

[9.] Bourke CJ, Mackay AJ, Payton D. Malignant gastric teratoma: case report. Pediatr Surg Int. 1997;12:192-193.

Accepted for publication May 22, 2000.

From the Department of Pathology, Northwestern University Medical School, Chicago, III, and Children's Memorial Hospital, Chicago, III.

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Author:Oviedo, Angelica; Chou, Pauline; Gonzalez-Crussi, Frank
Publication:Archives of Pathology & Laboratory Medicine
Geographic Code:1USA
Date:Mar 1, 2001
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