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| LETTER TO EDITOR |
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| Year : 2010 | Volume
: 47
| Issue : 4 | Page : 486-487 |
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Growing teratoma syndrome: A rare complication of germ cell tumors
Rashmi1, G Radhakrishnan1, AG Radhika1, S Sharma2
1 Department of Obstetrics and Gynecology, University College of Medical Sciences, Guru Teg Bahadur Hospital, Shahdara, Delhi-110 095, India
2 Department of Pathology, University College of Medical Sciences, Guru Teg Bahadur Hospital, Shahdara, Delhi-110 095, India
| Date of Web Publication | 4-Dec-2010 |
Correspondence Address:
Rashmi
Department of Obstetrics and Gynecology, University College of Medical Sciences, Guru Teg Bahadur Hospital, Shahdara, Delhi-110 095
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-509X.73567
How to cite this article:
Rashmi, Radhakrishnan G, Radhika A G, Sharma S. Growing teratoma syndrome: A rare complication of germ cell tumors. Indian J Cancer 2010;47:486-7 |
Sir,
Growing teratoma syndrome (GTS) is an extremely rare metastatic complication of malignant germ cell tumors (GCT) with only 47 cases reported so far in ovarian GCT, a majority following stage III. Here we report a case of GTS following stage IA immature teratoma.
A 19-year-old unmarried girl presented in November 2004 with abdominal distension for 1 month without any associated complaints. On examination, there was a large solid-cystic mass arising from the pelvis. Ultrasonography and computed tomography (CT) scan of the abdomen suggested cystic ovarian tumor with solid components. The levels of serum markers a-fetoprotein (5378.4 ng/mL) and CA-125 (167.78 U/mL) were increased. She underwent staging laparotomy for ovarian GCT. Intraoperatively there was left ovarian neoplasm (cystic with solid areas) 20 Χ 25 cm with smooth surface. Other organs, peritoneal surface, omentum, and lymph nodes were normal, and there was no ascites. Left salpingo-oophorectomy with peritoneal cytology and omental biopsy was done. The ovarian tumor was removed intact without any spill. Histopathology revealed an immature teratoma grade III with predominantly immature neuroglial tissue mixed with mature elements. Omental biopsy and cytology were unremarkable. Final surgical-pathological staging was IA. Postoperatively she received 3 courses of chemotherapy. And then was lost to follow-up. No postoperative CT scan was done.
Three years later she presented with a dull pain in the abdomen with distension for 20 days without any associated complaints. On examination, the whole abdomen was filled with ill-defined solid-cystic mass. CT scan revealed a solid-cystic mass of 22 Χ 10 Χ 21 cm with multiple thick septation, interspersed areas of calcification, and fat attenuation with marked displacement of bowel loops. Uterus and right ovary were normal. Serum markers were normal. Laparotomy revealed a large solid-cystic mass of 20 Χ 20 cm [Figure 1] adherent to the peritoneum by fine adhesions, seemed to be arising from omentum. The peritoneum and bowel loops were studded with hundreds of small nodules, whereas the other organs were normal.
The mass was removed after adhesiolysis and infracolic omentectomy. Multiple biopsies were taken from peritoneal nodules, but complete removal of all nodules was not possible. Cut section of mass and nodules showed the presence of hair and sebum. Decision for conservative surgery was taken considering age and mature elements. Histopathology of all specimens revealed mature teratomas. She had been followed-up for 20 months and is asymptomatic.
The presence of enlarging or new masses after the treatment of a malignancy is considered to be malignant, but GTS is an exception where clinical or radiologic enlargement of benign masses are seen during or after chemotherapy associated with normalization of tumor markers. Surgical removal [1] rather than chemotherapy is the option as these are nonresponsive to chemotherapy. Despite the benign phenotype, 2 types of complications can be observed in GTS: mechanical compression and malignant transformation. GTS is generally seen following stage III disease. [1],[2] Only 3 cases have been reported earlier following stage I tumor. [2],[3],[4] In 2 of these cases, GTS developed in retroperitoneal lymph nodes where primary metastasis is likely to have been missed at the initial surgery. [2],[3] Only in 1 case GTS with peritoneal mass following stage IA immature teratoma has been reported. [4] Diffuse peritoneal involvement in GTS has been seen only in initial stage III disease and this is usually termed as peritoneal carcinomatosis. [2],[4],[5] This case, we believe, is the first of its kind where diffuse peritoneal seedling with mature teratomatous masses was detected after primary treatment of stage IA immature teratoma. As all these nodules were benign mature teratomas, we would like to introduce the term of "Peritoneal Teratomatosis" for such a type of presentation. Peritoneal involvement due to initial metastasis is unlikely in the present case. One may hypothesize that microscopic spill of tumor cells during the primary surgery and chemotherapy initiated growth of mature teratomas from these microscopic germ cells. The present case of GTS is being reported for its rarity and unusual presentation.
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[Figure 1]
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