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    • dub inhibitor In most of the cases the

    2018-10-29

    In most of the cases, the preoperative diagnosis of gastric teratoma is difficult. Plain films usually reveal a soft tissue mass with associated irregular areas of calcifications. The presence of irregular areas of calcification on abdominal radiographs or on abdominal CT may give some clues to the diagnosis. Calcification is present in 35–60% of cases, according to various series, but in our study, it was seen in 87.5% of children. Most mature cystic teratomas can be diagnosed by ultrasonography. It demonstrates a large midline heterogeneous mass with mixed echogenicity. The other common appearance is a cystic lesion with a densely echogenic tubercle (Rokitansky nodule) projecting into the cyst lumen. Origin of tumor is usually not appreciated. Mild ascitis is usually present. Prenatal detection by ultrasonography has also been reported in the literature. The diagnosis of mature cystic teratomas is usually appreciable on CT, with findings of a well-defined upper abdominal mass with separate cystic and solid components in varying proportions, discrete areas with densities similar to that of fat, and coarse globular calcifications within solid components, areas of necrosis, and intratumoral vessels. A floating mass of hair can sometimes be identified at the fat–aqueous fluid interface. Tumor arises most commonly from the posterior wall of the stomach near the greater curvature, as seen in 87.5% of our cases. The other sites where it has been seen are the antrum, prepyloric region, anterior wall, fundus, lesser curvature, cardiac orifice, and very rarely the entire stomach. Some of these tumors are pedunculated. The mass is usually large and extends into the retrogastric tissues. The left kidney, spleen, visceral surface of the liver, and bowel loops are pushed by the tumor. It is exogastric in up to 70% of cases, while it is endogastric in 30% of cases. Contrast enhanced computed tomography (CECT) is the modality of choice, as it detects the organ of origin, its relation with other dub inhibitor and major blood vessels, tumor extent, and the presence of calcifications. Age-related serum alpha-fetoprotein levels are abnormally raised when there is presence of intestinal tissue in mature teratoma, in case of immature teratoma or its malignant counterpart. Baseline alpha-fetoprotein and beta-human chorionic gonadotropin levels help in postoperative follow-up to detect recurrence or presence of residual tumor and malignant transformation of the tumor. The differential diagnosis of a gastric teratoma in a neonate (with regard to the calcified mass in the left upper quadrant) would include mesoblastic nephroma, congenital neuroblastoma, infantile hemangioepithelioma, hepatoblastoma, Wilms\' tumor, and retroperitoneal teratoma. Gastric teratomas constitute 1.6% of all abdominal teratomas. Other differential diagnoses of pediatric abdominal masses include pancreatic cyst, omental cyst, mesenteric lymphangioma, duplication cyst, splenic cyst, rhabdomyosarcoma, and liposarcoma. Other benign gastric tumors in children include hyperplastic and adenomatous polyps, leiomyomas, and lipomas. Treatment of choice for gastric teratomas is total excision along with a small fringe of the involved gastric wall and primary closure (gastroplasty). If the tumor grows intramurally, then a greater area of the stomach may be involved. Partial, subtotal, and total gastrectomies have been performed as per the extent of stomach involvement. Pathological examination reveals mature adipose tissue, cartilage, smooth muscle, gastric mucosa, brain, choroid plexus, and skin. Bone, bone marrow, and teeth are pathognomonic of teratoma, but less frequently seen in gastrointestinal teratomas. Gastric teratomas, like other teratomas, are classified into three types according to the histological composition. (1) Mature variety, which forms bulk of the reported cases, consists of well-differentiated tissue, i.e., mature neuroglial tissue, along with other derivatives of all germinal layers. These types of teratomas are considered benign tumors and are given Grade 0. (2) Immature gastric teratomas, with ∼20 of cases reported in the literature, consist of immature/embryonic-appearing neuroglial and neuroepithelial tissues (varying degrees of immature fetal tissues). Immature teratomas are graded from 1 to 3, according to the amount of immature tissue contents (mainly neural elements) and the degree of mitotic activity according to the Norris grading system. In Grade 1, the immature neuroectodermal tissue is confined to one site in a slide, whereas in Grades 2 and 3, the immature tissue is found in less than four fields per slide and more than four fields per slide, respectively. Malignant potential is present in immature variety, and therefore histopathological examination is meticulously carried out to detect the presence of microfocus of yolk sac tumor, and in its absence, only close monitoring is carried out. (3) Malignant type contains at least one of the malignant germ cell elements. The term “malignant teratoma” is restricted to the yolk sac tumor and choriocarcinoma.