Diagnosis And Treatment Of Adrenal Teratoma

Background:Teratomas are formed by the abnormally developed cells from the three primitive germ layers(including ectoderm,mesoderm,and endoderm),most of which derived from the ectoderm,and the least is derived from the endoderm.Teratomas can be divided into embryonic tumors of gonadal origin and embryonic tumors of non-gonadal origin.Patients with teratoma usually have no obvious clinical symptom.Most teratomas are found during physical examinations.The adrenal gland is composed of cortex and medulla.The adrenal cortex is derived from the mesoderm,and the adrenal medulla is derived from the ectoderm.Their structures and secretory functions are relatively independent.The adrenal cortex is composed of globular zone,fascicular zone and reticular zone,which mainly secrete mineralocorticoids,glucocorticoids and sex hormones.The adrenal medulla is composed of chromaffin cells and ganglion cells,and mainly secretes catecholamines.Adrenal surgical diseases are divided as adrenal gland tumors and other non-adrenal gland tumors.Adrenal teratoma is a germ cell tumor derived from totipotent cells,which can be divided into functional and non-functional according to the state of endocrine function.It lacks typical clinical manifestations,and is often found accidentally during physical examination or diagnosis and imaging examinations during treatment of diseases unrelated to the adrenal glands.The final diagnosis depends on the postoperative pathological results.Adrenal teratoma is relatively rare clinically,and there is no uniform international standard for its diagnosis and treatment.Adrenal teratomas mostly appear in the form of "incidental tumors",and clinicians lack enough experience in their diagnosis,treatment and perioperative management.Objective:Through collecting the clinical data of patients with adrenal teratoma in the First Affiliated Hospital of Zhengzhou University,we retrospectively analyzed the diagnosis,differential diagnosis,treatment and prognosis of the disease in combination with the literature at home and abroad,so as to provide ideas for the clinical diagnosis and treatment of adrenal teratoma,a rare disease.In addition,we explored the application value of surgery in the clinical diagnosis and treatment of adrenal teratoma as well as the advantages of laparoscopic surgery of adrenal teratoma,so as to provide experience for further study of the diagnosis and treatment of adrenal teratoma.Method:The clinical data of 21 patients with adrenal teratoma admitted to the First Affiliated Hospital of Zhengzhou University from February 2008 to February 2021 were collected.The medical history,preoperative examination,operation,postoperative pathology,perioperative and prognostic follow-up and the other relevant data were retrospectively analyzed.The t test of two independent samples or Wilcoxon rank sum test were used to analyze the advantages of laparoscopic surgery in adrenal teratoma.Searched in China National Knowledge Infrastructure(CKNI)with " adrenal teratoma" as the search term and limit it in the abstract b,as well as searched in Pubmed with "adrenal teratoma" as the search term,and then screened documents according to inclusion and exclusion criteria,combined ’with the medical records of our hospital,summarize and discuss the diagnosis and treatment of adrenal teratoma.Result:1.A total of 40 qualified Chinese documents were collected from March 1976 to February 2021,and 12 qualified English documents were collected from January 1965 to February 2021.A total of 73 cases with complete clinical data and met the inclusion and exclusion criteria were selected from the documents.2.Among the 21 patients with adrenal teratoma in our hospital,5 were males and 16 were females,all of which were unilateral onset,and only 5 have clinical symptoms.In the documents,there were 18 males and 55 females with adrenal teratomas,both unilateral onset,25 cases on the left side and 48 cases on the right side.Nearly half of the patients with adrenal teratoma were accidentally discovered by imaging examinations during physical examination or diagnosis and treatment of diseases unrelated to the adrenal glands.The peak age of onset of 94 patients was 21-30 years old.3.There were 2 patients with adrenal gland-related endocrine examination abnormalities in our hospital,and there is 1 case of adrenal gland-related endocrine examination abnormalities in the documents.Ultrasonography of adrenal teratoma revealed a mass in the adrenal area,a hyperechoic fatty-rich component or a mixed echo of a hypoechoic cystic area.CT scan showed mixed density,fat,bone or other soft tissue density or calcification can be seen,and a slight enhancement can be seen in the soft tissue components or cyst wall.Magnetic resonance imaging showed equal signals on T1-weighted imaging(T1WI),while T2-weighted imaging(T2WI)shows a slightly higher signal,with nodular focus or clear boundaries.4.94 cases of adrenal teratoma were treated with surgery.One case of mature adrenal teratoma was reported in the documents was malignantly transformed,after surgery,BEP chemotherapy(bleomycin,etoposide,cisplatin)was used.Follow-up 13 Months,this patient was alive healthily,no progression or metastasis was seen,and the remaining cases did not undergo special treatment after surgery.Analyzing the postoperative data of 21 patients in our hospital,it was found that the laparoscopic surgery group had shorter operation time(P<0.01),less blood loss(P<0.01),shorter postoperative drainage tube removal time(P<0.01)and postoperative hospitalization days(P<0.001),and there was no significant difference in the gastrointestinal recovery time between the two groups(P>0.05).In addition,after analyzing the postoperative data of patients with tumor volume>6 cm in our hospital,similar results were obtained.5.21 patients in our hospital were pathologically diagnosed as adrenal mature teratoma after operation.Among them,19 cases were diagnosed as mature adrenal teratoma by ordinary pathology,and the other 2 cases were diagnosed as mature adrenal teratoma by immunohistochemistry.It was reported in the documents that a patient with a mature teratoma of the adrenal gland undergoes malignant transformation.The 21 cases in our hospital were followed up for 1-10 years after surgery.There was no local recurrence or malignant transformation of the tumor,and the prognosis was good.Conclusion:1.Adrenal teratoma is a rare tumor derived from germ cells.Its clinical features lack specificity.The incidence of females is higher than that of males.The peak age of onset is 21-30 years old.The preoperative tumor markers,adrenal-related endocrine examinations and imaging examinations are helpful for the initial diagnosis,and the final diagnosis depends on the postoperative pathological results.2.Early detection and early diagnosis,complete removal of the tumor is the key to treatment.Laparoscopic surgery has obvious advantages in the treatment of adrenal teratoma and can be used as the first choice.For the tumor volume>6cm Japaroscopic surgical resection of adrenal teratoma is also feasible.3.Most mature adrenal teratomas are benign tumors,with good prognosis after surgery and generally do not require special treatment,but there is the possibility of malignant transformation,so regular review is necessary.Immature teratoma is a malignant tumor and requires adjuvant radiotherapy and chemotherapy after surgery and lifelong follow-up.