Mediastinal teratomas are the most common extra-gonadal germ cell tumors. They account for approximately 15% of anterior mediastinal masses in adults and approximately 25% of anterior mediastinal masses in children. They are by far the most common mediastinal germ cell tumor, accounting for 50-70% of such tumors 9.
The age of presentation is wide, but typical presentation in adults is in the third or fourth decade (20s and 30s). In children below 1 year of age, immature teratomas are common (40%) and may be detected antenatally 9.
No definite gender predilection for mature teratomas has been identified (at most there is a slight female predilection). Immature teratomas however, occur almost exclusively in males 9.
The majority of patients are asymptomatic, with the mediastinal mass discovered incidentally when the thorax is imaged for another reason 7,9. Masses that become symptomatic can do so in a variety of ways:
- mass effect
- hormone production, e.g. beta-HCG, insulin
Mediastinal teratomas are germ cell tumors arising from ectopic pluripotent stem cells that failed to migrate from yolk endoderm to the gonad. By definition they should contain elements from all three embryological layers: endoderm, mesoderm and ectoderm. Frequently however elements from only two layers are evident 7 (see teratoma article).
A mediastinal dermoid cyst can be considered a variant of a mature teratoma, predominantly formed by squamous epithelium and skin appendages (ectoderm and mesoderm respectively) 9.
Teratomas may either be:
- mature: well differentiated
- immature: poorly differentiated
- with malignant transformation
- mature teratoma with non-germ cell malignancy arising from one of the components 2
Because they arise from primitive cells, they have variable neoplastic potential. Generally, cystic lesions tend to be benign whereas solid lesions tend to be malignant however the final diagnosis is made histologically.
Mature teratomas and most immature teratomas are benign tumors, but still carry a risk of malignancy despite being indolent initially and require close clinical, serological, and radiological follow-up, or surgical excision 4-5,9. There is also a low incidence of malignant transformation of somatic cells (i.e. non germ cell components) within these tumors, e.g. carcinoma, sarcoma, leukemia 6.
Usually occurs within or near the thymus gland.
Mature teratomas have been associated with
- Klinefelter syndrome (47, XXY) 9
Immature teratomas can be associated with
The vast majority of mediastinal teratomas are located in the anterior mediastinum (80%), with most of the remainder involving multiple compartments (13-15%). Isolated posterior or middle mediastinal location is uncommon (2-8%) 9.
Mature teratomas, by their very nature, may contain a very wide range of tissues and thus have variable imaging features. In general they have the following features:
- well-demarcated, displacing rather than invading adjacent structures
- large: 3-25cm 9
- usually cystic: 90% 9
- may be uni- or multiloculated
- septal/rim contrast enhancement
- variable attenuation, consistent with different tissues
- water density cystic spaces
- fat-fluid levels (specific)
- homogeneous soft-tissue density
- calcification: 26% 9
- identifiable teeth or bone is seen in up to 8% of cases 9
When rupture has occurred, the density of each component is less likely to be homogeneous, but rather each part of the teratoma is heterogeneous (i.e. the fat component is heterogeneous, as is the cystic component etc.) 7.
Immature teratomas are usually solid.
Appearances on chest radiography are usually indistinguishable from many of the other causes of an anterior mediastinal mass. Calcification may be visible.
CT is the mainstay of diagnosis. The appearance will depend on the type of teratoma, and whether or not a cystic teratoma has ruptured. They are all however usually located in the anterior mediastinum.
Treatment and prognosis
Treatment depends on whether the teratoma is mature or immature. In the former, surgical resection is curative. In the later management depends on alpha-FP levels. If these are elevated then postoperative chemotherapy is usually employed 8.
Prognosis of mature teratomas is excellent as they are benign tumors. Pure immature teratomas also usually have excellent prognosis especially in childhood. In up to 30% of cases however, immature teratomas have a malignant germ cell tumor component (most frequently yolk sac tumor), which result in frequent (25%) recurrence. Nonetheless with adjuvant chemotherapy a greater than 80% 3 year survival can be achieved in children. Prognosis in adults is less favourable 9.
Potential complications include
- respiratory distress/failure: infants>adults
- fistula(e) formation: aorta, SVC, esophagus, bronchus
On chest radiography, the differential is broad, and includes any cause of an anterior mediastinal mass:
On CT the differential in usually narrowed to tumors, and depends on the morphology.
- mass containing fat
- heterogeneous soft tissue
- predominantly cystic
- 1. Ueno T, Tanaka YO, Nagata M et-al. Spectrum of germ cell tumors: from head to toe. Radiographics. 24 (2): 387-404. doi:10.1148/rg.242035082 - Pubmed citation
- 2. Chen C, Zheng H, Jiang S. An unusual case of giant mediastinal teratoma with malignant transformation. Ann. Thorac. Surg. 2008;86 (1): 302-4. doi:10.1016/j.athoracsur.2007.07.087 - Pubmed citation
- 3. Jeung MY, Gasser B, Gangi A et-al. Imaging of cystic masses of the mediastinum. Radiographics. 2002;22 Spec No : S79-93. Radiographics (link) - Pubmed citation
- 4. Gonzalez-Crussi, F. (1982) Extragonadal Teratomas. Atlas of Tumor Pathology, Second Series, Fascicle 18. Armed Forces Institute of Pathology, Washington D.C.
- 5. Muscatello L, Giudice M, Feltri M. Malignant cervical teratoma: report of a case in a newborn. Eur Arch Otorhinolaryngol. 2005;262 (11): 899-904. doi:10.1007/s00405-005-0917-2 - Pubmed citation
- 6. Harms D, Zahn S, Göbel U et-al. Pathology and molecular biology of teratomas in childhood and adolescence. Klin Padiatr. 218 (6): 296-302. doi:10.1055/s-2006-942271 - Pubmed citation
- 7. Choi SJ, Lee JS, Song KS et-al. Mediastinal teratoma: CT differentiation of ruptured and unruptured tumors. AJR Am J Roentgenol. 1998;171 (3): 591-4. AJR Am J Roentgenol (abstract) - Pubmed citation
- 8. Romagnani E, Gallerani E, Cavalli F. Mediastinal mature teratoma with an immature component--what about the treatment? Ann. Oncol. 2006;17 (10): 1602-4. doi:10.1093/annonc/mdl091 - Pubmed citation
- 9. Travis WD. Pathology and genetics of tumours of the lung, pleura, thymus and heart. Iarc. (2004) ISBN:9283224183. Read it at Google Books - Find it at Amazon
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