Therapeutic hypothermia (head or whole-body cooling) improves survival and neurodevelopmental outcome in term newborns with moderate-to-severe encephalopathy. Hypothermia treatment is well tolerated; the most common side effect is thrombocytopenia. In about 1% of infants, focal subcutaneous fat necrosis has been reported. We describe a case of clinically unsuspected massive visceral fat necrosis in a term infant with Apgar score 0 at 1 min ("resuscitated apparently stillborn" infant) who was treated with therapeutic hypothermia for 72 h and expired on the 25th day of life following a neonatal course complicated by severe encephalopathy, pulmonary artery hypertension, persistent thrombocytopenia, hypoglycemia, and severe basal ganglia-thalamic abnormalities on magnetic resonance imaging. Postmortem examination revealed extensive visceral (brown) fat necrosis, involving thoracic, abdominal, and retroperitoneal adipose tissue, with distinctive sparing of the subcutaneous (white) fat. The fulminant-yet clinically occult-visceral fat necrosis seen in this case suggests that (lesser degrees of) fat necrosis may go unrecognized in hypoxic-ischemic newborns, especially in those treated with hypothermia, and underscores the importance of close monitoring of encephalopathic newborns both in the short and long terms for complications of fat necrosis (hypercalcemia and nephrocalcinosis).
Teratoma of the anterior mediastinum is the most common extragonadal germ cell tumor in adults. Infrequently a malignant nongerm cell component is present. We report a case of teratoma with angiosarcoma and malignant glioma components. The patient is a 34-year-old man who presented with right-sided chest pain and shortness of breath. A chest X-ray showed a right anterior mediastinal mass which measured 11x15cm on computerized tomography. The alpha-fetoprotein was elevated at 128 ng/mL. A biopsy was performed and showed papillary vascular proliferation with cytological atypia. The patient received 1 cycle of vinblastine, ifosfamide, and cisplatin (VIP) chemotherapy. The mediastinal mass was refractory to chemotherapy and increased in size and subsequently excised. At gross dissection, the mass measured 19.4 × 14.1 × 9.6 cm and weighed 1.4 kg. Cut sections showed an encapsulated lesion with hemorrhage, focal calcifications, and multiple cysts with necrosis and hemorrhage. Microscopy showed extensive necrosis and mature teratoma admixed with well-differentiated angiosarcoma and a malignant glioma component. The angiosarcoma showed irregular anastomosing vascular channels lined by atypical endothelial cells with occasional mitoses and focal spindle cell proliferation. The vascular channels were positive for CD34 and CD31. The malignant glioma showed marked nuclear pleomorphism, increased mitosis and high proliferation index. Mature teratoma with nongerminal malignant tumor is a rare entity. The lesions occur in the anterior mediastinum and are more common in men. The malignant component may be a carcinoma or a sarcoma including embryonal rhabdomyosarcoma, angiosarcoma, and leiomyosarcoma. The sarcoma can exist in a pure form or in combination and arises in the primary tumor, recurrence or metastasis. There is poor response to conventional germ cell tumor chemotherapy. Mediastinal teratoma with a sarcomatous component is an aggressive disease and further investigation is needed to elucidate the lesions origins and behavior.
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