Cystic Teratoma Treatment & Management

Updated: Nov 22, 2019
  • Author: Chad A Hamilton, MD; Chief Editor: Yukio Sonoda, MD  more...
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Surgical Care

Sacrococcygeal teratoma 

Sacrococcygeal teratomas diagnosed prenatally should be monitored closely. In high-risk (large, solid, vascular) sacrococcygeal teratoma, in utero surgery may be an option in carefully selected cases. In the presence of developing hydrops, other minimally invasive antenatal procedures such as fetoscopic laser ablation, radiofrequency ablation, interstitial laser ablation, or vascular coiling may be options to interrupt the vascular flow to the tumor. In selected high-risk fetuses, early delivery and ex utero surgery may be an option. [52, 53]

In fetuses with larger tumors, cesarean delivery should be considered to prevent dystocia or tumor rupture. Because of the poor prognosis associated with development of hydrops prior to 30 weeks' gestation, these fetuses may benefit from in utero surgery. In most cases, sacrococcygeal teratomas should be resected electively in the first week of life, since long delays may be associated with a higher rate of malignancy. [54]

Complete excision should be done through a chevron-shaped buttock incision, with careful attention to the preservation of the muscles of the rectal sphincter. The coccyx always should be resected with the tumor, as failure to do so results in a 35-40% recurrence rate. Hemorrhage from the middle sacral vessels and hypogastric arteries is the most common complication. [6]

Ovarian teratoma

Mature cystic teratomas of the ovaries may be removed by simple cystectomy rather than salpingo-oophorectomy. See the image below.

A 12-cm mature cystic teratoma of the ovary prior A 12-cm mature cystic teratoma of the ovary prior to excision.

Although malignant degeneration is quite rare, the cyst should be removed in its entirety, and if immature elements are found, the patient should undergo a standard staging procedure.

Guidelines issued by the Royal College of Obstetricians and Gynecologists (RCOG) in the United Kingdom recommend that when surgery is indicated, a laparoscopic approach be generally considered to be the gold standard for the management of all benign ovarian masses. In addition, laparoscopic bilateral salpingo-oophorectomy is recommended for removal of postmenopausal cystic teratomas at low risk of malignancy. [55]

The patient should be counseled appropriately about the risks and benefits of laparoscopy and laparotomy. Ample literature supports laparoscopy as an acceptable alternative approach in resection. Benefits include reductions in postoperative pain, blood loss, hospital stay, and total cost. Risks include prolonged operative time, increased operating room costs, and potential need for a prompt second staging procedure if an unexpected malignancy is revealed.

Some studies have found an increased intraoperative spillage rate with laparoscopy, while others have not. Spillage is associated with increased risk of chemical peritonitis (estimated incidence of 0.2%) and increased risk of adhesion formation. The risks of recurrence (4%), as well as malignant degeneration (0.2-2%), should be discussed. [56, 57, 58, 59, 60]

Testicular teratomas

Testicular teratomas traditionally have been treated by simple or radical orchiectomy. More recently, conservative excision by enucleation also has been recommended for prepubertal teratomas of the testis. [20, 61]  Several studies have failed to demonstrate negative sequelae for prepubertal testicular teratomas, so testis-sparing procedures are appropriate. [62, 63] Patients should be counseled regarding the following risks [38, 34] :

  • Inadequate sampling
  • Incorrect diagnosis by frozen section
  • Tumor spillage and seeding
  • Unidentified microinvasive disease

The risk of malignancy increases with maturation of the testes, and this is a significant concern in children at or near puberty. In this group, areas of normal surrounding testicular tissue should be excised and sent for frozen section. If frozen section reveals areas of maturity, proceeding to orchiectomy is recommended. Enucleation or partial orchiectomy for teratoma in pubertal or adult males is not recommended. [34]

Mediastinal teratomas

Mature teratomas of the mediastinum should be completely surgically resected. The tumor may be adherent to surrounding structures, necessitating resection of the pericardium, pleura, or lung. When complete resection is achieved, it results in excellent long-term cure rates with little chance of recurrence. When complete resection is impossible, partial resection often leads to symptom relief, frequently without relapse. [48, 41]