Journal of Perinatology (2008) 28, 649–651

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IMAGING CASE BOOK

Cervical teratoma
TE Herman and MJ Siegel
Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis Children’s Hospital,
St Louis, MO, USA

Journal of Perinatology (2008) 28, 649–651; doi:10.1038/jp.2008.84

Case presentation
A 31-year-old gravida 6, para 2 mother during her most recent
pregnancy was noted to have polyhydramnios. Therefore, a
maternal pelvic-fetal magnetic resonance imaging (Figure 1) was
performed because of a large neck mass on fetal sonography.
Progressive labor began at 33 weeks, which led to the decision to
perform an immediate cesarean section under general anesthesia
and an extrauterine intrapartum therapy to insure safe intubation
of the newborn. As the child was delivered, warmed artificial
amniotic fluid was instilled into the uterus. The newborn infant
girl was successfully intubated within 2 min of delivery of the arm
through the uterus. The child weighed 2030 g and was hypotonic,
probably related to anesthesia, but otherwise a normal female
except for the above findings. A postnatal cervical sonogram was
performed (Figure 2).

Denouement and discussion

A large anterior almost midline cervical mass of heterogeneous
intensity, which was compressing the cervical trachea, was noted
on the fetal magnetic resonance imaging. The mass extended into
the upper anterior mediastinum. This was believed to represent
either a cervical (cervicothymic) teratoma or a hemangio-
lymphangioma. Because of the tracheal compression, the
extrauterine intrapartum therapy was planned for the delivery.
The findings were confirmed on the postnatal sonogram, which
demonstrated a heterogeneous cervical mass extending to the level

Figure 1 (a) Midline sagittal fetal T2-weighted FLASH sonogram and

(b) midline T2-weighted HASTE fetal sonogram. Polyhydramnios (PH) with
bright signal fluid is present surrounding the fetus. There is a midline
bright cervical mass (black arrow) that is heterogeneous and compresses the
fluid-filled trachea posteriorly (white arrow).

Correspondence: Dr TE Herman, Department of Radiology, Mallinckrodt Institute of

Radiology, Washington University School of Medicine, St Louis Children’s Hospital,
510 South Kingshighway Blvd., St Louis, MO 63110, USA.
E-mail: hermant@mir.wustl.edu
Received 13 April 2008; accepted 28 April 2008
 Cervical teratoma
TE Herman and MJ Siegel
650

Figure 2 (a) Transverse neonatal neck sonogram and (b) longitudinal neonatal neck sonogram. The mass is heterogeneous with anechoic cystic areas, representing
fluid, and an area of shadowing, representing calcification or ossification (arrow). In addition, on the longitudinal image (b), the mass (M) is seen to extend
intrathoracically to abut the superior aspect of the thymus (TH) deep to the right first rib (R).

of the superior aspect of the thymus. At resection, the mass was
attached to the thymus, which was delivered into the neck in order,
and was easily separated from the mass. At histological
examination, the mass was an immature teratoma containing
pancreatic tissue, intestinal tissue and brain tissue.
A teratoma is a tumor composed of all three germ cell layers;
ectoderm, mesoderm and endoderm. Cervical teratoma is a rare
congenital tumor with a poor prognosis and a nearly 100%
mortality if not immediately managed and resected.1 The most
common location of congenital teratomas is the sacro-coccygeal
region; however, the head and neck is the second most common
site.1 Head and neck teratomas are primarily cervical teratomas
and oropharyngeal teratomas, referred to as epignathi.2 Among
patients with sacro-coccygeal teratomas and epignathi, there is a
distinct female predominance. Interestingly, this is not the case
among patients with cervical teratomas.2 Stillbirth and oral airway
obstruction are common problems with cervical teratomas.
A stillbirth frequency of 17% and an airway compression frequency
of 35% have been reported in infants with cervical teratoma.1
Polyhydramnios occurs in approximately 30%, probably secondary

Journal of Perinatology

to esophageal obstruction. Very large or giant cervical teratomas
may even result in fetal hydrops.
The primary differential considerations in cervical teratomas are
other congenital neck masses especially lymphangiomas and
hemangiomas, branchial cyst, cervical neuroblastoma, soft tissue
sarcoma, epignathus and cervical congenital thyroid goiter.3 Most
frequently, teratomas are more anterior and midline in the neck,
whereas lymphangiomas, hemangiomas and branchial cleft cysts
are more posterior and lateral in the neck. Epignathus or
oropharyngeal teratoma arises from the palate and extend through
the mouth and thus can be easily differentiated from cervical
teratomas by fetal sonography and magnetic resonance imaging.4
Congenital cervical neuroblastoma is primarily a nasopharyngeal
tumor and should be differentiated by location using fetal
sonography or magnetic resonance imaging from the cervical
teratomas.5 Congenital cervical goiter and congenital soft tissue
sarcomas of the neck are very rare conditions but might possibly
have features similar to congenital cervical teratoma.
The extrauterine intrapartum therapy is frequently performed in
patients with large head and neck masses to obtain a stable airway
in the infant while the placental circulation is preserved.6
Cervical teratoma
TE Herman and MJ Siegel
651
The extrauterine intrapartum therapy is done to avoid airway
obstruction, hypoxia and brain injury at the time of delivery of the
child with a neck mass. The procedure requires inhalational
anesthesia to obtain uterine relaxation and partially expose the
infant while maintaining intrauterine volume with fluid infusion.
The duration of placental support to the partially delivered fetus
may be up to 60 min.5
References
1 Goldstein I, Drugan A. Congenital cervical teratoma, associated with agenesis of corpus
callosum and a subarachoid cyst. Prenat Diagn 2005; 25: 439–441.
2 Woodward PJ, Sohaey R, Kennedy A, Koeller K. Comprehensive Review of fetal tumors
with pathologic correlation. Radiographics 2005; 25: 215–242.
3 Muscatello L, Giudice M, Feltri M. Malignant cervical teratoma; report of a case in a
newborn. Eur Arch Otorhinolaryngol 2005; 11: 899–904.
4 Pothari PR, Jiwan A, Kulkarni B. Congenital nasopharyngeal teratoma with cleft palate J.
Indian Assoc Pediatr Surg 2004; 9: 42–45.
5 Cardesa-Salzmann TM, Mora-Graupera J, Claret G, Agut T. Congenital cervical
neuroblastoma. Pediatr Blood Cancer 2004; 43: 785–787.
6 Omago M, Sugiyama T, Maeda Y, Kusaka H, Utsunomiya H, Tsubouchi M et al.
The ex-utero Intrapartum treatment (EXIT) procedure in giant fetal neck masses.
Fetal Diagn Ther 2005; 20: 214–218.
Journal of Perinatology