Sacrococcygeal Teratoma (Altman) Fetal MRI

Step-by-step decision

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1. [Decision] Altman type + vascularity + cardiac failure signs
   Altman type + solid/vascularity + cardiac failure signs? (The most common congenital tumor, 75% female, with malignant potential. Altman classification (anatomic): I mainly external + small presacral; II external + significant intrapelvic; III external + predominantly abdominopelvic; IV entirely intrapelvic/presacral, no external component. MRI assesses abdominopelvic extension (typing), cystic/solid nature, compression, excludes meningocele (especially cystic), T1 for hemorrhage.)
   • Predominantly cystic, sparse vascularity, no cardiac failure/hydrops (usually Altman I–II) → Predominantly cystic · relatively good prognosis
   • Altman III–IV (abdominopelvic extension, compressing kidney/rectum) → Altman III–IV · assess abdominopelvic extent
   • Solid hypervascular / TFR >0.12 (<24 weeks) / raised cardiothoracic ratio / hydrops/enlarged placenta → Solid hypervascular/high-output → fetal intervention
2. [End] Predominantly cystic · relatively good prognosis
   Predominantly cystic, sparse vascularity, no high-output cardiac failure (usually Altman I–II): relatively good prognosis; serial ultrasound + echocardiography + Doppler monitoring of tumor growth and cardiac function; MRI typing + exclude meningocele; plan delivery by size (cesarean for a large tumor to prevent rupture), postnatal resection (including the coccyx) + AFP follow-up.
3. [End] Altman III–IV · assess abdominopelvic extent
   Altman III–IV (abdominopelvic extension): MRI focuses on intrapelvic/abdominal extent and compression (hydronephrosis, bowel, bladder) — type IV is prone to delayed diagnosis of malignancy; multidisciplinary surgical planning, complete postnatal resection + long-term tumor follow-up.
4. [End] Solid hypervascular/high-output → fetal intervention
   High-risk (solid hypervascular → high-output cardiac failure; TFR >0.12 (<24 weeks), raised cardiothoracic ratio, hydrops, enlarged placenta, rapid growth): critical; <27–28 weeks with high-output failure/hydrops → refer to a fetal therapy center to assess open fetal surgery/intervention; near term → early delivery; cesarean for a large tumor to prevent rupture and hemorrhage.

Source guidelines & references

• Fetal sacrococcygeal teratoma Altman classification and MRI/TFR prognosis (AJR 2002; JPS)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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