Can you imagine sitting there with your newborn baby, feeling so much joy and excitement, you're feeding them milk, and all of a sudden, it all comes back up, you decide to try again, and the same thing happens. A few months go by and you begin to see something growing in the neck of your child, it starts off pea-sized and you blink and it is the size of a tennis ball, these are just a few of the things cervical teratomas can lead to but not to worry here we’ll discover the nature of this condition and the ways that have been developed to help those living with it and even a resolution for it.

What are Cervical Teratomas?

Cervical teratomas (CT) are rare germ cell tumours known as neoplasms that occur in the neck.¹ The tumours are quite large and are made up of partly solid and partly fluid.² This condition commonly occurs in children and is classed as non-cancerous, but it can also occur in adults and is usually cancerous when it is present in adults.¹ You may be questioning why this condition then causes feeding and breathing difficulties? Let's briefly tap into that. The tumours that the condition causes can compress (imagine trying to push down a ball of dough with the palm of your hand) and deform key structures and when they are not found before birth they can appear as neck mass that can become hard and firm and pushes on the structures that you need to breathe and press on the airways or cause pulmonary hypoplasia 3, which is where there is little to no room for a baby's lungs to grow.⁴

It is therefore essential for cervical teratomas to be identified early on, preferably prenatally (before birth) and that management strategies begin soon as the longer it takes it can result in the development of associated problems such as fetal heart failure due to the heart having to work much harder and also fetal anaemia due to the amount of red blood cells decreasing as a result of them being trapped by the tumours.⁵

Cervical teratomas have been found to be prevalent in 1 in 50,000 births and can be diagnosed by ultrasounds, which can help healthcare professionals recognise the giant neck masses or large amounts of amniotic fluid, which is also an indicator of the condition. Fetal MRIs (magnetic resonance imaging), a detailed imaging technique, can also help to identify this condition as it gives a more zoomed perspective of key structures that the ultrasound may not have focused on, like the baby's organs, in order to show us the airways or the oesophagus, where we learned the masses can appear on.⁶

Breathing difficulties

The tumours that cervical teratomas cause can really cause disruption to the breathing of individuals with the condition, and we’ll look at how they are caused and how they appear in children:

Causes

• Before birth, an embryo's cells are undifferentiated, meaning they can become any type of cell
• As development continues, these cells spread throughout the body and mature
• In CT, the teratomas are made up of germ cells, and these cells spread to the neck
• The cells divide rapidly and divide in the baby's neck, forming a mass
• The tumours can grow directly on the neck area or on the mediastinum, which is the area separating the lungs
• They can also grow largely into the airway, taking up space for air and therefore blocking breathing

Clinical manifestations

• Wheezing
• Noisy breathing
• Shortness of breath
• Chest pain
• Cough
• Tiredness

Diagnostic evaluation

• If CT has been confirmed by a prenatal ultrasound, an fMRI is used to look at the airways and see the characteristics of the mass
• If CT is not discovered before delivery, a post-natal computed tomography or MRI is used to evaluate the masses that are causing problems to the respiratory area and to plan if any surgical procedures need to happen so the child’s breathing can improve⁹

Feeding difficulties

The tumours involved in CT can also make feeding difficult for the individual who has it, this can be both pre-natally and post-natally

Causes

• Prenatally, the tumour compresses the oesophagus, meaning the baby can't swallow amniotic fluid, which is why there is such a large build-up of the fluid during pregnancy. This is known as polyhydramnios
• Postnatally, the tumours can affect the baby's ability to swallow, and this means they can't intake food as easily. This is because the structure called the hypopharynx is obstructed, and since it is connected to our food pipe, the oesophagus, the blockage means nothing is able to go down

Clinical manifestations

• Coughing or choking when trying to swallow food
• Vomiting after eating
• Gagging whilst eating

Assessment

• These feeding difficulties can be assessed by an ultrasound, in which, if the result is an empty stomach, it shows there is a blockage in the oesophagus, which shows this blockage is causing the feeding difficulties²
• Specific tests, such as a Barium swallow test, can be done, which shows healthcare providers that there may be a cancer-causing issue with the swallowing of food

Management Strategies

There are 3 main strategies that can be carried out to help make the lives of children with CT easier, these are:

Airway management

• This involves a procedure called EXIT (Ex-utero intrapartum treatment)
• It is used when it is suspected that a baby will have breathing problems as a result of cervical teratomas
• The baby is provided with continuous oxygen from the mother until its airway is secured

Feeding support

• A feeding tube may be given to aid the swallowing of food and drink
• A dietician may also be provided with this strategy to help inform on what to eat or drink and how to manage the tube

Surgical treatments

• This involves an excision, which means to remove something, and in this case, the tumour from the neck is removed.
• A lot of counseling takes place with the child's family before this takes place
• Antibiotics and anaesthesia are also given before the procedure
• If the tumour isn't that large, an incision (cut) is made over the mass and along the lines of a future natural skin crease. If it is large, the incision is made over the mass, and any excess skin can be removed after

FAQs

Can having one pregnancy with CT increase the chance of it happening again?

The risk of a CT occurring again in a future pregnancy is very low, but a genetic counsellor can inform you of the risk.

Are there any complications after the surgery treatment of CT?

Yes, some babies have still had trouble swallowing after the tumour is removed¹⁴ and wound complications can happen as a result of infection, speech issues can happen if there is damage to any nerves, and there can be quite a bit of swelling.³

Can the tumours still return even after the surgical procedure?

Yes, it can.¹⁵

Can CT be spotted before birth?

Yes, it can, especially when healthcare providers are carrying out key pregnancy scans.

Are the methods used to diagnose CT-free?

Yes, these procedures are free under the NHS.

Do the feeding and breathing difficulties show at birth?

Yes, they can show at birth, but for some babies, they may show later on.

Summary

Cervical teratomas are quite a rare cancer, but with developments in diagnostic techniques, it has made it a bit easier for healthcare professionals to identify when a fetus is displaying it. Therefore, attending ultrasound appointments is extremely important when it comes to CT as the earlier the indications of CT are spotted, the earlier treatment plans can begin to be drawn out by monitoring the mother, carrying out more detailed scans and planning surgery if needed. Airway management is always prioritised first once a child is born with CT, but if the case is more severe, that is when surgery is resorted to, and surgery being carried out earlier helps to increase a child's survival, enabling them to live a happier, healthier, longer life!