Primary rectal teratoma Deborshi Sharma, MS,a Sanjeev Kumar, MBBS,a Ashutosh Tandon, MBBS,a Amrita Ghosh Kar, MD,b Mohan Kumar,b and V. K. Shukla, MCha, India From the Departments of Surgerya and Pathology,b Institute of Medical Sciences, Banaras Hindu University, Varanasi – 221 005, India
A 14-year-old female presented with one episode of bleeding per rectum. Her general and physical examination was unremarkable except that a hard pedunculated polyp was palpated in the rectum about 7 cm from the anal verge. The mass was non-tender, had a slightly irregular surface and could be pulled near to the anal opening. There was no bleeding on touch. Under general anesthesia, rectal examination was done which revealed a 7 ⫻ 5 cm polyp covered with hairs, deliverable through the anal opening (Fig 1). The mass had a variegated consistency and was attached to the anterior rectal wall by a small stalk. Polypectomy was done with suture trans-fixation of the stump at the base. The cut surface of the mass revealed components from all layers of development (Fig 2). On histopathological examination the tumor was lined by mature stratified squamous epithelium with numerous pilosebasecous units scattered underneath. The substance of the polyp was predominantly composed of fibroadipose tissue. Attenuated colonic mucosa with thinned out muscularis propria could be identified at the edge. These findings were consistent with a mature teratoma (Fig 3). DISCUSSION Primary rectal teratomas are exceedingly rare. Generally teratomas are found in the midline body structures such as in ovaries and testes.1 Rubin et al.2 have put forward a theory of parthenogenesis suggesting that they arise from aberrant germ cells in the embryonic digestive tract that do not require
Fig 1. Mature teratoma with the overlying hair expressed out through the anal canal.
Fig 2. Opened mass showing cartilegenous and muscle tissue with stalk.
Accepted for publication May 1, 2007. Reprint requests: Dr. Deborshi Sharma, Department General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi – 221 005, India. E-mail:
[email protected]. Surgery 2008;143:570-571. 0039-6060/$ - see front matter © 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.05.007
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fertilization. Primordial germ cells are observed at three to four weeks of gestation in the endoderm of the umbilical vesicle and move from the dorsal mesentery of the hindgut through the mesenchyme towards the gonadal ridge. As the adrenal gland, urinary tract, gonads, and rectum are the adjoining structures, the germ cells have a chance
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females.1 The diagnosis is made by the presence of hair over the mass, seen in most cases. If hair is not seen, the differential diagnosis would include submucosal tumors such as leiomyoma, lymphoma, or myogenic tumor.1 The treatment of choice is excision by ligation of the stalk as most teratomas are pedunculated. The majority of primary rectal teratomas are mature and thus benign.1 Occasionally teratomas from an ovary or the pre-sacral region can erode through the rectum, a circumstance to be excluded before operating.3,4 Primary rectal teratomas have a squamous epithelium on the surface, whereas the ovarian teratomas are cystic with squamous epithelium inside the mass.1 Fig 3. Squamous epithelial lining with pilosebaceous unit lining the outer surface of the polyp (hematoxylineosin, original magnification ⫻40).
to enter the rectum aberrantly and create a rectal teratoma.1 Because germ cells from the nearby ovaries can potentially enter the rectum in females, all but one of the reported cases has occurred in
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