Epicardial Teratoma in a Preterm Neonate: Just Another Mediastinal Mass?

Abstract

1. Introduction / Background

Prenatally diagnosed mediastinal teratomas are exceedingly rare, with only isolated case reports in the literature.1-4 These tumors may cause significant cardiopulmonary compromise through mass effect, pericardial effusion, and compression of vascular or airway structures.5 In utero, they are associated with hydrops fetalis and anasarca, often necessitating early delivery or fetal intervention.6 Postnatally, concerns shift toward tamponade physiology, respiratory failure, and the anesthetic risks of airway or vascular collapse. We report the case of a preterm infant with a large epicardial teratoma complicated by tamponade, requiring staged multidisciplinary intervention from birth through surgical resection.

2. Learning Objectives

·      Discuss neonatal teratomas/mediastinal masses and potential interventions both pre/postnatally

o   Identify epidemiology

·      Discuss clinical challenges of mediastinal masses and perioperative management.

·      Identify signs/symptoms of tamponade and management.

3. Case Report

We present the case of a 32w5d female infant delivered prematurely given known anterior mediastinal mass with effusion and concern for evolving hydrops. She had apnea and bradycardia in the delivery room requiring intubation but was quickly able to extubate within the first week of life. Her exam showed decreased right breath sounds and positional bradycardia. Workup showed a large heterogeneous epicardial mass with a large pericardial effusion. She had progressive respiratory distress and developed tamponade physiology on day of life 11 which required emergent pericardiocentesis with drain placement. Anesthetic management was uneventful for that procedure. She continued to worsen requiring epinephrine, inhaled Nitric Oxide, neuromuscular blockade, and high frequency oscillatory ventilation. On day of life 22, she presented for her mass resection which was able to be performed without cardio-pulmonary bypass. Anesthetic was complicated by cautious positioning, need to exchange for a cuffed ETT, and risk of SVC compression. Post-operatively, she progressed as expected, extubated well, and did not reaccumulate any pericardial effusion. Pathology showed a complex teratoma.

4. Discussion

This case presents numerous anesthetic challenges including tamponade physiology, an anterior mediastinal mass, and neonatal physiology/management. Management of tamponade physiology involves optimizing preload and maintaining the compensatory tachycardia and increased contractility.7,8 Anterior mediastinal masses come with risks of compression to the vena cava, trachea, and occasionally the heart. That makes hemodynamic and respiratory management tenuous. Positioning and airway management are paramount in these cases.9 This case also shows the importance of step-wise management of complex neonatal mediastinal masses. Earlier, elective pericardial drain placement may have been warranted in this case.

4. Conclusion

This case highlights the diagnostic and anesthetic challenges of epicardial tumors in neonates. The management of these cases is complex, often requiring multiple anesthetics/procedures and can have significant perioperative risks not limited to tamponade, airway compression, and impaired venous return. Neonatal mediastinal masses require a staged, multidisciplinary strategy with detailed anesthetic planning to reduce procedural risk and optimize outcomes.

5. References

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3. Macchiarini P, Ostertag H. Uncommon primary mediastinal tumours. Lancet Oncol. Feb 2004;5(2):107-18. doi:10.1016/S1470-2045(04)01385-3

4. Moore SW, Satge D, Sasco AJ, Zimmermann A, Plaschkes J. The epidemiology of neonatal tumours. Report of an international working group. Pediatr Surg Int. Sep 2003;19(7):509-19. doi:10.1007/s00383-003-1048-8

5. Heerema-McKenney A, Harrison MR, Bratton B, Farrell J, Zaloudek C. Congenital teratoma: a clinicopathologic study of 22 fetal and neonatal tumors. Am J Surg Pathol. Jan 2005;29(1):29-38. doi:10.1097/01.pas.0000146006.46468.ef

6. Khawand C, Orbach D, Berrebi D, et al. Prenatal diagnosis and postnatal management of perinatal thoracoabdominopelvic tumors: multicenter experience. Ultrasound Obstet Gynecol. Oct 2025;66(4):499-508. doi:10.1002/uog.70000

7. Tan A, Nolan JA. Anesthesia for children with anterior mediastinal masses. Paediatr Anaesth. Jan 2022;32(1):4-9. doi:10.1111/pan.14319

8. Tobias JD. Anaesthesia for neonatal thoracic surgery. Best Pract Res Clin Anaesthesiol. Jun 2004;18(2):303-20. doi:10.1016/j.bpa.2003.11.005

9. Hack HA, Wright NB, Wynn RF. The anaesthetic management of children with anterior mediastinal masses. Anaesthesia. Aug 2008;63(8):837-46. doi:10.1111/j.1365-2044.2008.05515.x