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Table of Contents    
LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 1  |  Page : 216-217

Intradural sacral mature teratoma associated with a low-lying conus


1 Department of Neurosurgery, Firat University, School of Medicine, Elazig, Turkey
2 Department of Pathology, Firat University, School of Medicine, Elazig, Turkey

Date of Web Publication12-Jan-2017

Correspondence Address:
Sait Ozturk
Firat Universitesi Hastanesi, Beyin Cerrahisi Klinigi - 23119, Elazig
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.198208

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How to cite this article:
Akgun B, Ozturk S, Ucer O, Erol FS. Intradural sacral mature teratoma associated with a low-lying conus. Neurol India 2017;65:216-7

How to cite this URL:
Akgun B, Ozturk S, Ucer O, Erol FS. Intradural sacral mature teratoma associated with a low-lying conus. Neurol India [serial online] 2017 [cited 2017 Apr 27];65:216-7. Available from: http://www.neurologyindia.com/text.asp?2017/65/1/216/198208


Sir,

The incidence of spinal teratoma (ST) ranges from 0.2–0.5% of all spinal cord tumours.[1] STs may be associated with neural tube defects causing tethered cord syndrome (TCS) and are rarely localized at the level of filum terminale.[2]

A 13-year-old male patient presented with low-back pain and numbness in both legs. His neurological examination was normal. Lumbosacral magnetic resonance imaging revealed an intradural lesion measuring 47 × 20 mm, which was localized at the level of S1 and S2 vertebrae. The conus medullaris was seen at the level of S1, indicating tethering of the spinal cord by a thickened filum terminale [Figure 1]. Total microsurgical excision of the intradural lesion was achieved with the assistance of neuromonitoring after a S1 and S2 laminectomy had been performed. Surgery was completed by incising the filum terminale in order to relieve tethering due to the tight filum that had resulted in a low lying spinal cord. He had complete symptomatic improvement in the early postoperative period and was without any motor or sensory deficit, and bladder or anal sphincteric dysfunction. Histopathological examination revealed a mature teratoma [Figure 2]. Serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (β-HCG) levels were assessed and found to be in the normal range. At a follow-up after 6 months of treatment, the patient had no complaints. He had normal levels of AFP and β-HCG. In addition, there was no finding of recurrent or residual tumor in the 6-month follow up magnetic resonance imaging [Figure 3].
Figure 1: Preoperative lumbosacral magnetic resonance scan showing an intradural, well-circumscribed lesion with the size of 47 × 20 mm that is localized at the level of the S1 and S2 vertebrae. (a) The lesion is hypointense on T1-weighted sagittal image; (b) heterogeneously hyperintense on T2-weighted sagittal image; and, (c) there was no contrast enhancement after gadolinium injection on T1-weighted contrast enhanced image

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Figure 2: (a) The various glandular structures associated with a mature teratoma (H and E, ×100); (b) components of stratified squamous epithelium (H and E, ×200); (c) the presence of anuclear and nuclear squamous cells that represent keratinization and squamous epithelium (PAP, ×100)

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Figure 3: Postoperative lumbosacral magnetic resonance scans taken 6 months after the surgery. (a) T1-weighted sagittal image, (b) T2-weighted sagittal image, and (c) T1-weighted sagittal image after contrast enhancement. There was no finding of recurrence or residual tumor

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Teratomas are composed of mixed cell types derived from the three primitive germ layers. Based on the degree of differentiation, teratomas can be classified as mature, immature, or malignant.[3] Intramedullary teratomas may exist along the entire spinal cord with a predilection for the thoracolumbar region. Association of a thickened filum terminale with a teratoma has also been reported.[1],[4] The localization of the neoplasm in the filum terminale points to the occurrence of the developmental anomaly in the secondary neurulation period.[4] In the literature, an intradural teratoma that is localized in the sacral region, is causing a tethered cause syndrome and is not associated with an overt spinal dyraphism, as seen in our case, has rarely been reported. We suggest that misplacement of the pluripotent embryonic caudal mesenchymal cells occurring during the secondary neurulation period before closure of the neural tube could result in teratoma formation. This case supports the dysembryogenic theory for the pathogenesis of teratomas. Total surgical resection should be aimed for in the treatment of teratomas. If total excision cannot be achieved, a residual mature teratoma possesses the risk of malignant transformation.[1] Radiotherapy is not required in mature teratomas with normal levels of AFP and β-HCG.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Babu R, Reynolds R, Moreno JR, Cummings TJ, Bagley CA. Concurrent split cord malformation and teratoma: Dysembryology, presentation, and treatment. J Clin Neurosci 2014;21:212-6.  Back to cited text no. 1
    
2.
Kaplan M, Akgun B, Kazez A, Ucler N, Cobanoglu B. Posterior approach for sacrococcygeal posterior meningocele with anterior large mature cystic teratoma. Cent Eur Neurosurg 2010;71:221-3.  Back to cited text no. 2
    
3.
Maiti TK, Bhat DI, Devi BI, Sampath S, Mahadevan A, Shankar SK. Teratoma in split cord malformation: An unusual association: A report of two cases with a review of the literature. Pediatr Neurosurg 2010;46:238-41.  Back to cited text no. 3
    
4.
Ates O, Cayli SR, Koçak A, Alkan A, Onal C, Usta U. Mature spinal teratoma associated with thickened filum terminale. Neurol Med Chir 2005;45:375-8.  Back to cited text no. 4
    


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