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J Thorac Cardiovasc Surg 2003;126:855-857
© 2003 The American Association for Thoracic Surgery

Brief communications

Benign intrapulmonary teratoma: report of a case

Mehmet Nesimi Erena, Akin Eraslan Balcia,*, Sevval Erena

a Department of Thoracic and Cardiovascular Surgery, Dicle University School of Medicine, Diyarbakir, Turkey

Received for publication November 15, 2002; accepted for publication November 25, 2002.

* Address for reprints: Akin Eraslan Balci, Firat University School of Medicine, Department of Thoracic Surgery, 23100, Elazig, Turkey
abalci{at}firat.edu.tr

Although intrathoracic teratomas are frequent, benign intrapulmonary teratomas seldomly occur. Only 37 cases have been reported so far. It is known that these tumors originate from the third pharyngeal sac. Teratomas occur with the same incidence in men and women.

These tumors generally become manifest with their complications such as lung abscess, bronchiectasis, empyema, and hemoptysis. Preoperative diagnoses are usually inaccurate. We review the literature and report a case.

Case report

An 18-year-old patient presented with a 2-month history of left side pain, cough, expectoration, and fever. The patient had been given nonspecific treatment a week before. Later she was hospitalized with a prediagnosis of lung abscess in another clinic. Conservative treatment for lung abscess, lung biopsy, and antibiotic treatment according to the biopsy yielded no result. The patient was referred to us with a diagnosis of chronic lung abscess.

There was a cavitary area measuring 61 x 72 mm near the middle-lower zone on the chest radiograph (Figure 1, A and B). A round hypodense cystic mass was observed on thorax computed tomography (Figure 2). Adjacent lung collapse and bronchiectasis were present.



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  		Figure 1. A, Tomographic image of the patient with pulmonary teratoma. B, Lateral chest radiograph of the patient.

 


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  		Figure 2. Computed tomographic image of the patient.

 
The diagnosis was cystic lung abscess. The patient refused bronchoscopy. Medical therapy was continued but no improvement was observed; thus we decided to operate. Left anterolateral thoracotomy was performed. After freeing the lung, it was observed that the left upper lobe was nonfunctioning and destroyed. Additionally, a mass measuring 5 x 5 x 4 cm covered with hair was seen in the lung. Upper lobectomy was performed (Figure 3).



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  		Figure 3. Postoperative chest radiograph of the patient.

 
On macroscopic examination, the specimen measured 6 x 4 x 4 cm and had a grayish-white outer surface. At cut section, it was filled a dense fluid. Wall thickness of the mass was 0.5 to 1 cm.

Microscopically, the lumen was lined with stratified epithelium. On the fibrocollagen stroma, under the epithelium, there were hair follicles and sebaceous and eccrine glands that made another wall. Figure 4 shows stratified epithelium, hair follicles, and glands.



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  		Figure 4. Microscopic view of the intrapulmonary teratoma.

 
The patient had an uneventful postoperative period. She has no complaint 16 years after the operation.

Discussion

Teratomas include different germinal layer derivations. Intrapulmonary teratomas are rare. They originate from a teratomatous focus in the mediastinum. Schlumberger1 stated that the association of endodermal components with intrathoracic teratomas stems from their origin in the third pharyngeal pouch and enlargement of the thymus.

According to 37 reports that we found, chest pain, cough, expectoration, and hemoptysis are the most commonly observed findings. A different finding, trichoptysis (hair expectoration), has been reported.2,3 There was no hemoptysis or hair expectoration in this case, which made preoperative diagnosis more difficult. This also indicates that there was no pathological communication with the bronchi. However, hair follicles were observed in the specimen of this case.

This kind of tumor is usually located in the left upper lobe, as in our case. Because of the presence of thymic tissue in some mediastinal and intrapulmonary teratomas, it has been speculated that these tumors might originate in the thymic tissue. However, the suggestion that early embryogenesis can cause separation or displacement of the thymus can be correct only for tumors found in the anterior mediastinum. The other explanation is that during the initial embryo period, a teratomatous focus in the mediastinum enters that tissue during respiratory growth and settles there. We have not encountered thymic tissue in histologic examinations.2-4

Intrapulmonary teratoma is treated by surgical resection. It has been reported that 5 of 18 patients in whom resection was performed died within 1 year. In addition, 4 patients died during the immediate postoperative period. Thus, this kind of tumor causes mortality and morbidity.2,5-7 Lobectomy was successful in our case.

References

  1. Schlumberger HG. Teratoma of the anterior mediastinum in a group of military age. Arch Pathol. 1946;41:398
  2. Morgan DE, Sanders C, McElvein RB, et al. Intrapulmonary teratoma: a case report and review of the literature. J Thorac Imaging. 1992;3:70–77
  3. Ustun MO, Demircan A, Paksoy N, et al. A case of intrapulmonary teratoma presenting with hair expectoration. Thorac Cardiovasc Surg. 1996;44:271–273[Medline]
  4. Day DW, Taylor SA. An intrapulmonary teratoma associated with thymic tissue. Thorax. 1975;30:582–587[Abstract/Free Full Text]
  5. Collier FC, Dowling EA, Plott DBS, Schneider H. Teratoma of the lung. AMA Arch Pathol. 1959;68:138–142[Medline]
  6. Ali MY, Wong PK. Intrapulmonary teratoma. Thorax. 1964;19:228–235
  7. Trivedi SA, Mehta KN, Nanavaty JM. Teratoma of the lung: report of a case. Br J Dis Chest. 1966;60:156–159[Medline]



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