Testicular Teratomas
Treatment
At operation, the surface of the affected ovary should be inspected to insure that the capsule is intact and smooth. In addition, the peritoneum and contralateral ovary should be evaluated to rule out metastasis and bilateral lesions, respectively. If the affected ovary has a smooth, intact surface, the contralateral ovary is normal and there is no ascites or evidence of metastasis, the tumor should be removed. Since 50% of ovarian tumors are teratomas and >90% of these are benign, an attempt should be made to preserve any remaining ovarian tissue.
Children's Oncology Group (COG) operative guideline for ovary tumors:
1. Collect ascites or peritoneal washings for cytology
2. Examine peritoneal surface and liver; excise suspicious lesions
3. Unilateral oophorectomy
4. Examine contralateral ovary and biopsy if suspicious lesion
5. Examine omentum and remove if adherent or involved
6. Inspection of retroperitoneal lymph nodes, biopsy of enlarged nodes.
The treatment algorithm for malignant ovarian tumors is surgery and observation for stage I and surgery and chemotherapy for higher-stage tumors.
Many adolescents present with primarily cystic lesions and most of these are benign. Laparoscopy has been widely utilized in the management of ovarian lesions in childhood, adolescents, and adults. The main controversy surrounds the ability to perform a cancer type procedure in cases where the exact tumor histology (benign vs. malignant) cannot be determined preoperatively. If the lesion is primarily solid or if the serum markers are elevated, an open procedure is indicated. If the serum markers are normal and the lesion is primarily cystic, particularly if there is a very large cystic component, a less invasive technique may be considered; however, avoidance of tumor spill must be assured.
One minimal access procedure involves laparoscopic excision of the tumor from its attachments, placement in a retrieval bag, and delivering the neck of the bag outside of the abdominal cavity through the umbilical opening. The cyst is then punctured, the fluid removed and the cystic lesion, contained within the bag removed without spill and sent for pathologic examination.
If there are bilateral teratomas, both should be enucleated, with preservation of ovarian tissue.
Testicular germ cell tumors in children are one of the rarer germ cell tumor types, with an incidence of 0.5 to 2.0 per 100,000. The bimodal age distribution of testes tumors, with a small peak in the first 3 years of life and a much larger peak in young adults, suggests a difference in the tumors of these age groups. The malignant germ cell tumors in the younger group are predominantly yolk sac tumors, whereas most adolescent and adult testes tumors are seminomas and mixed tumors.
Testicular tumors are rare in boys prior to puberty, and during this time non-germ cell Sertoli tumors and paratesticular rhabdomyosarcomas are more common, whereas germ cell tumors predominate in pubertal and adult males. Paratesticular neuroblastoma has also been reported arising from an embryonic adrenal rest along the spermatic cord.
They usually present as a painless testicular mass.
Ultrasound may show calcifications. Serum AFP and beta-hCG should be drawn preoperatively.
Current Children's Oncology Group staging system for childhood testes cancer:
I. Limited to testis (testes), completely resected by high inguinal orchiectomy; no clinical, radiographic or histologic evidence of disease beyond the testes.
II. Transscrotal biopsy; microscopic disease in scrotum or high in spermatic cord (<5 cm from proximal end). Tumor markers fail to normalize or decrease with an appropriate half-life.
III. Retroperitoneal lymph node involvement, but no visceral or extraabdominal involvement. Lymph nodes > 4 cm by CT; or > 2 cm and < 4 cm with biopsy proof.
IV. Distant metastases, including liver.
The standard approach consists of an inguinal incision, with initial control of the vessels at the level of the internal inguinalring with subsequent mobilization of the testes. A preoperative elevation of AFP indicates the presence of yolk sac tumor and thus precludes consideration of testes-sparing surgery, and a radical orchiectomy is performed with ligation of the cord at the internal ring. If the AFP is normal, there is a much greater chance that the mass represents a benign lesion. A retroperitoneal lymph node dissection is not indicated.
Patients with malignant teratomas should receive chemotherapy.