Growing Teratoma Syndrome in the Setting of Sarcoidosis: A Case Report and Literature Review

Abstract

Growing teratoma syndrome (GTS) is rare and can mimic disease recurrence in patients with a history of immature teratoma. Benign hypermetabolic lymphadenopathy found on staging and surveillance computed tomography (CT) and positron emission tomography (PET) may lead to the presumption of metastatic malignancy. We report a case of a 38 year old with mixed mature and immature teratomas who developed new peritoneal masses after adjuvant chemotherapy despite a normalization of tumor markers. In addition to low FDG uptake observed in these peritoneal masses, a PET scan showed hypermetabolic lymphadenopathy and pulmonary and spleen lesions suggesting widespread metastases. Subsequent surgical resection confirmed a mixed pathology with GTS and sarcoidosis. We reviewed the current literature evidence of GTS and sarcoidosis as a benign cause of lymphadenopathy in cancer patients. We emphasize the importance of a tissue diagnosis before instituting therapy for presumed cancer recurrence to avoid potentially fatal diagnostic traps and management errors. A multiple disciplinary team approach is imperative in managing patients with suspected recurrent immature teratomas.

Keywords: growing teratoma syndrome; immature teratoma; sarcoidosis.

Figure 1

Histopathological features. (A) H&E slide ×20 magnification shows area of immature teratoma comprising primitive neuroectodermal elements (green arrow). There is surrounding cartilage, which represents part of mature teratoma (red arrow); (B) H&E slide ×20 magnification shows benign glands’ architecture (black arrow) with fibroblasts, fat and a small portion of cartilage in the background. No immature teratoma is identified; (C) H&E slide ×40 magnification shows large granulomas with epithelioid and Langerhans’s giant cells, focally with central hyalinization and necrosis in sections of spleen. Mycobacterial and fungal stains are negative; (D) H&E slide ×40 magnification shows well-formed, noncaseating granuloma with few surrounding lymphocytes in porta hepatis lymph nodes.

Figure 2

Radiological features. (A) Progress CT at completion of adjuvant chemotherapy found new peritoneal lesions; (B) Peritoneal lesions demonstrate only low FDG uptake (SUVmax of 3.9); (C) On the contrary, portal hepatis/peripancreatic lymphadenopathy is highly FDG avid (SUVmax of 13.3); (D) High FDG uptake (SUVmax of 9.3) is also observed in the splenic lesions.