| Abstract|| |
A Mesenteric teratoma in an adult male is an extremely rare tumor. Cystic lesion in male abdominal cavity has limited differential diagnosis as compared to female. It causes diagnostic dilemma in clinical practice. We report an adult male patient who had a mesenteric teratoma. The purpose of this report is to familiarize radiologists with the characteristic imaging appearances of this tumour, which is commoner in females but still extremely rare.
The unique feature of this case is entire skull formation within the teratoma.
Keywords: Mesenteric teratoma, Germ cell tumour, Rokitansky protuberance
|How to cite this article:|
Hiral P P, Vasavada D P. A Mesenteric teratoma in an adult male - a rare case. Indian J Radiol Imaging 2004;14:257-9
| Introduction|| |
The cystic mature teratoma develops from pluripotential cells of embryonic remnants of the ectodermal lines and usually contains a combination of both cystic and solid elements, including hair, teeth, cartilage and dermal appendages such as hair follicles, sweat glands and sebaceous material. This tumour is commonly found in the ovary, but may occur in any theoretical pathway of ectodermal cell migration, mostly in the midline, from the cranium, mediastinum and retroperitoneum to sacrococcygeal regions. It occurs almost exclusively in the very young.
A mature mesenteric teratoma is very rare in an adult male. So it is not usually included in the differential diagnosis for an adult male presenting with abdominal lump. A plain abdominal radiograph demonstrates teeth and bone, thus it gives more than an idea that the tumour is a teratoma. On CT scan, it shows characteristic sign called Rokitansky protuberance (dermoid plug). And with this cross sectional imaging tumour can be exactly localized.
Here we described a case of mature cystic teratoma of mesentery in adult male.
| Case Report|| |
A 21-year-old male presented with lump in lower part of abdomen over a period of eighteen months, which gradually increased in size. He was complaining of dull pain on the lower part of abdomen. He did not have any specific gastrointestinal or genitourinary complains. On investigation, plain radiograph of abdomen showed a soft tissue opacity containing calcification and teeth. Ultrasonographic waves (sonodiagnostic 360 by Philips 3.5 MHz.) were interrupted by a calcified lesion. CT scan (tomoscan EG by Philips) of abdomen showed a large bilobed cystic lesion with fat-fluid level and solid calcified structure (mandible and teeth) protruding into the cyst cavity (Rokitansky protuberance, [Figure - 1]A. The lesion was displacing the contrast filled bowel loops on right side of abdomen. The bone window showed a large bony structure (mandible) in the solid part of lesion with tooth [Figure - 1]B.
Patient's abdomen was explored via lower midline incision. There was a well-circumscribed hard mass about 28 X 21 cms at the root of mesentery. The mass contained a deformed jaw with teeth. [Figure - 2]A. On cut surface there was thick sebaceous fluid with bunch of hair. X-ray of specimen showed deformed skull vault, mandible, alveolar process and multiple teeth [Figure - 2]B.
| Discussion|| |
If a mesenteric or omental mass is cystic in nature, the differential diagnosis may include mesenteric or omental cyst (lympangioma, enteric duplication cyst, enteric cyst and non-parasitic pseudocyst), cystic teratoma, cystic spindle cell tumours and cystic mesothelioma. The most common type of mesenteric or omental cyst is lymphangioma. Mesenteric cystic lymphangioma may mimic cystic teratoma radiologically, when calcification is seen. If a tumour contains teeth and bone as opposed to calcification then that is almost pathognomonic of a teratoma. Cystic lymphangioma may have a multiloculated appearance.
The clinical presentation is usually non-specific. Abdominal discomfort may be present because, tumour causes compression on bladder and gastrointestinal tract. Abdominal pain in the lower quadrant may be the first complain. On palpation hard lump can be felt. Per rectal examination can give idea of its consistency and probable relation to lower GIT.
On radiological investigation, a plain radiograph of abdomen is very useful investigation. Its shows teeth and bones, that gives more than an idea that the tumour is a nothing else but teratoma. And in fact it is diagnostic. On ultrasound the diagnosis of teratoma should be suspected if a cystic mass is detected with fat-fluid level and acoustic enhancement of calcification. Specific CT scan characteristic of mature mesenteric cystic teratoma is a predominantly fatty mass with denser dependent elements and globular foci of calcification in a solid protuberance that project into the cyst cavity (Rokitansky protuberance, dermoid plug) . Calcifications are commonly seen in the solid component or in the wall. In this case, whole mandible is well visualized with tooth [Figure - 1]B. On MRI, cystic teratomas reveal the signal characteristic of fat (hyperintense on T1-weighted images) and water (hypointense on T1 weighted images and hyperintense on T2-weighted images) . The major role of the radiologist is to document the cystic nature of these abdominal masses and their exact mesenteric or omental origin. The purpose of cross sectional imaging in this situation is to localize the tumour.
Pathologically, a mesenteric teratoma is a well-defined mass with both cystic and solid components containing multiple tissue types. In spite of newer cross sectional images, it is difficult to stamp the diagnosis of malignancy in teratomatous lesion. So histopathology is usually necessary to rule out changes of malignancy. Malignant degeneration may occur with frequency of 0.25-0.8%.
| References|| |
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P P Hiral
D-6/A Medical Campus, M.P. Shah Medical College, Jamnagar, Gujarat-361 008
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2]