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2010-02-24-9 Answer to the case of the week #271 © Rodts-Palenik
Answer to the case of the week #271

July 1, 2010 - July 15, 2010

Sheryl Rodts-Palenik, MD, Scott Barrilleaux, MD

Acadiana Maternal-Fetal Medicine, Lafayette, Louisiana, USA.

Case report

This is a case of a 17-year-old primigravida who was referred to our center by her primary Obstetrician at 20 weeks of gestation for a solid neck mass noted on the ultrasound. She had no significant medical, surgical, or obstetrical history. Her family history was significant only for a grandmother with diabetes and a cousin with hypertension. She had no significant genetic history, and had a negative quad screen. 

Ultrasound evaluation demonstrated a right sided solid cervical mass emanating from just below the fetal ear and continuing down the side of the fetal neck measuring 2.5 cm. Color flow Doppler demonstrated blood supply from the mass orientating directly off the right carotid. There were no other structural anomalies and no evidence of fetal hydrops.
The patient was followed over the course of her pregnancy by MFM for any evidence of evolving hydrops and growth of the tumor. The tumor grew rapidly, about a centimeter a week initially, and evolved over the course of her pregnancy from a solid mass to a large, semi-cystic structure with vascularity only around the periphery.  A tentative diagnosis of fetal teratoma was made based on ultrasound imaging.  The fetus never showed any evidence of hydrops or compromise. The trachea was always well visualized and polyhydramnios never developed.
At 37 weeks the mass measured 16 centimeters in diameter and protruded down the fetus to lie on the fetal chest. An EXIT (ex utero intrapartum treatment)  procedure was performed, involving Maternal Fetal Medicine, Anesthesiologists for both mother and baby, Otorhinolaryngologist, Pediatric Surgeon and Neonatologist. The infant maintained oxygen saturations of over 80 percent during the 23 minutes required to intubate. Intubation was complicated by compression by the mass, and intraoperative drainage was required. Resection was performed the following day by Pediatric and Plastic surgery. 

A diagnosis of immature teratoma Grade III, with no elements of yolk sac present was determined on pathological examination. The infant did exceptionally well post-operatively, and was discharged home on postoperative day fifteen.

Images 1-4: 23 weeks, solid, encapsulated cervical mass (3-4 cm in diameter), with upper margine just below the ear and located along the side of the neck.


Images 5-8: 25 weeks, Doppler imaging of the tumor mass showing blood supply straight from the carotid artery.

Images 9-12: 34 weeks, note the size of the tumor and semi-cystic structure. 

Images 13,14: 37 weeks, delivery via cesarean section, note the large mass on the right side of the fetal neck.


Images 15,16: EXIT procedure, intubation of the neonate while still on the feto-maternal circulation.

Images 17,18: First day after delivery, resection of the tumor.

Image 19: Resected tumor.

This is an example of the excellent Answer for the case of the week send by Javier Cortejoso.

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