Reshaping a Life: Teratomas

What Are Teratomas?

Loraine Kelly, parent of Emily: I had Emily June 1, 1998. And in my fifth month of pregnancy, they found that she had a giant neck mass.

Victoria Dougherty, parent of Josephine: We had a lot of questions when we first got the teratoma diagnosis.

Loraine Kelly: It was just scary because we never heard of this before.

Victoria Dougherty: The things that I was looking for were Down syndrome and the types of birth defects that you hear about.

Loraine Kelly: There were eight friends and family members that were pregnant at the same time as me, and I was the only one that was going to have a baby that was going to have a problem.

Victoria Dougherty: That was the hardest part, I think, is having to come to terms with all the things that could go wrong.

Loraine Kelly: But the care that we had down at Children's and all the doctors and nurses just made it really comforting for us, and they were really helpful in walking us through everything.

Alan W. Flake, MD: I think any type of teratoma is one of the most difficult things to deal with as a prospective mother and family.

Lori J. Howell, RN: One day they might seem perfectly in control. Another day they might be all in tears.

N. Scott Adzick, MD: They come to us looking for help, and they come to us looking for hope.

Alan W. Flake, MD: It's a situation that is extremely stressful and difficult and one that you never anticipate will happen to you.

N. Scott Adzick, MD: So the good news for families is that there are places like this where there is multidisciplinary expertise that can enhance the baby's chances to survive and to survive with a good life.

Alan W. Flake, MD: A teratoma is a tumor that's derived from stem cells, actually. And they're the type of stem cells that can turn into any tissue of the body.

N. Scott Adzick, MD: Imagine a tumor that can have virtually any sort of body tissue within it, yet it be in a place in the body where those tissues don't normally occur.

Lori J. Howell, RN: Oftentimes they can be almost as big as the baby, prenatally. And so it's very difficult for parents to even imagine what their baby might look like with that ugly mass either on their neck or their butt or in their chest.

N. Scott Adzick, MD: Teratomas appear in the midline in unusual locations — the tailbone, for a sacrococcygeal teratoma, the mediastinum, which is in the chest, and cervical teratomas, which are in the neck.

Mark P. Johnson, MD: I think, of all the anomalies that we deal with on a relatively routine basis, the teratomas are probably the most difficult, challenging and frustrating.

N. Scott Adzick, MD: Teratomas are quite rare. Sacrococcygeal teratomas are the most common tumors of newborns.

Alan W. Flake, MD: The cause of teratomas is mysterious. We really don't know why they occur.

Lori J. Howell, RN: In the fetal period, early neonatal period, these are nonmalignant tumors.

N. Scott Adzick, MD: Most of the teratomas diagnosed before birth or those diagnosed in newborns are not cancerous yet. But invariably, if they are not dealt with, cancer will occur in almost all circumstances.

Alan W. Flake, MD: So we like to resect the tumors early and, in most circumstances, it's curative.

Diagnosing a Teratoma

Stefanie Kasperski: Yes, good morning; this is Stefanie Kasperski. I'm one of the coordinators here at the Center for Fetal Diagnosis and Treatment. I understand that you have some questions.

Lori J. Howell, RN: Before a family even arrives, we have reviewed their prenatal records and have set up a comprehensive evaluation that will occur in one day so that by the end of the day, they'll have the answers they need to make the best decision they can for their pregnancy.

Victoria Dougherty, parent of Josephine: You want answers, and you want answers right away so that you can start feeling like you have, you know, a handle on the situation.

N. Scott Adzick, MD: The diagnosis can be tricky, particularly in the early to mid-gestation.

Alan W. Flake, MD: Misdiagnosis can occur with any fetal diagnosis and, because of that, whenever we're referred a patient, we always reevaluate that patient with our own imaging.

N. Scott Adzick, MD: Which includes maternal fetal ultrasound, very detailed, looking at the characteristics of the teratoma and also to make certain that there is nothing else wrong, an ultra-fast fetal MRI, which is another way of getting anatomic information, and the third crucial test is a fetal echocardiogram, a look at the fetal heart just to look at fetal heart performance in particular.

Victoria Dougherty: It was actually strangely comforting and meditative going through the tests because you felt like this process was starting to happen and that at the end of the day you were going to know something.

N. Scott Adzick, MD: We think it's extremely important for the mother to have at least the ultrasound, the MRI and the echocardiogram done in one day, one after the next, meet with our genetic counselors, our advanced practice nurses, have some financial counseling, if need be, and then to meet with the team at the end of the day so we can review the findings and go through our recommendations.

Victoria Dougherty: No one was going to tell me, "Everything's going to be all right," because they couldn't tell me that. And no one was going to say, "This is how we think the teratoma's going to grow," because they couldn't tell me that. They could say, "This is how we hope it's going to be, and we're going to keep monitoring it. And if it continues in this vein, this is what will probably happen." But, you know, at that point in time there were a lot of "ifs" and a lot of question marks.

Lori J. Howell, RN: A major focus of our program is to provide education of families.

Victoria Dougherty: My questions were answered, and I felt like we could move forward and start making decisions. And I also felt like I needed to hear a very sobering diagnosis, and I needed to hear what could happen.

Lori J. Howell, RN: It's very important to us that families leave here knowing what their diagnosis is and how best to take care of them the rest of the pregnancy.

Types of Teratomas

N. Scott Adzick, MD: We can have teratomas in various sites in the body, usually based on the midline. Some are cystic, contain large fluid filled spaces. Some are solid and highly vascular, the blood supply to them is very rich. And there is some that are a mixture of cystic and solid components.

Alan W. Flake, MD: Cystic teratomas are almost like balloons. They have a very thin outer rim and they contain a large amount of fluid inside the cyst. And the cyst can be single, or they can be multiple cysts that are separated by membranes. A solid teratoma, on the other hand, is like any tissue; it's firm, comprised of either spongy or solid components, and all of that contains blood vessels that run throughout the tumor.

Lori J. Howell, RN: There are those that occur in the neck. There are those that occur in the chest. And then there are those that occur in the sacral area right off the butt.

N. Scott Adzick, MD: A sacrococcygeal teratoma, we call them an SCT, is a teratoma that arises from the tailbone, from the sacrococcygeal area, from the coccyx.

Alan W. Flake, MD: It's an area called "Hensen's node," named after pathologist, and it contains a cluster of pluripotent stem cells, so stem cells that can turn into any tissue of the body.

N. Scott Adzick, MD: And there are four types. Type I is predominantly on the outside of the baby.

Alan W. Flake, MD: So it grows out of the fetus, rather than into the fetus.

N. Scott Adzick, MD: Type II is mostly external, but a small internal component that comes up through the pelvic ring.

Alan W. Flake, MD: Type twos can manifest more problems with compression of pelvic structures like urinary output, the urethra, the bowel, etc.

N. Scott Adzick, MD: Type III is principally internal through the pelvic ring and can get quite large in the abdomen but still a small external component, so you can see it.

Alan W. Flake, MD: And in that circumstance, the tumors can cause complications related to compression of intra-abdominal structures.

N. Scott Adzick, MD: And type IV is the mysterious one because that's all on the inside and, in a newborn baby who has this, you might not even notice it, of course.

Alan W. Flake, MD: Because they aren't detected early, type fives often evolve into malignancies before they're noticed in children. It's one of the advantages of prenatal diagnosis is that if you can recognize a type IV before birth, you can remove it early on and perhaps prevent the malignancy.

N. Scott Adzick, MD: It is better as a whole to have a largely external sacrococcygeal teratoma. Once there's an internal component, bad things can occur. The urinary tract can get blocked, the tumor can grow up into the spinal canal, and most importantly, one cannot treat by fetal surgery those fetuses who have a large teratoma with a large internal component because one can't resect the internal component safely before birth.

Alan W. Flake, MD: A cervical teratoma is a teratoma that forms in the neck. And teratomas in the neck are like other teratomas in that they contain all types of tissue.

N. Scott Adzick, MD: Cervical teratomas can be cystic, solid, or a combination or both. Many are a combination of both, actually.

Alan W. Flake, MD: The most common problem that cervical teratomas cause is distortion of the airway or compression of the trachea and airway in the neck.

Mark P. Johnson, MD: So that after delivery there's no way for the baby to breathe.

Alan W. Flake, MD: And that's the reason that we need to follow them closely and ultimately deliver them by an EXIT procedure to establish an airway in the fetus.

N. Scott Adzick, MD: A mediastinal teratoma is a fancy expression for a teratoma in the midline in the chest.

Alan W. Flake, MD: The mediastinum is the compartment between the lungs that surrounds the heart. And the typical mediastinal teratoma forms in the upper mediastinum, above the heart, in front of the trachea and airways.

N. Scott Adzick, MD: The main problem with mediastinal teratomas is just space occupying, taking up space in the tiny fetal chest.

Alan W. Flake, MD: So the heart can be squished downward against the diaphragms, the lungs can be pushed to the side, and the airway can be flattened behind the tumor.

Prenatal Monitoring

N. Scott Adzick, MD: Teratomas are mischief makers for two basic reasons — one is the location and the size; the size can compress adjacent developing organs, the airway in the neck or intra-abdominal structures for sacrococcygeal teratomas that grow into the abdomen. They can also have consequences in terms of their blood supply. If they're solid and richly supplied with blood, that tumor, that teratoma tumor, can steal blood away from the developing fetus and placenta and cause cardiovascular failure.

Jack Rychik, MD: The solid portion of the tumor is relatively well vascularized.

Alan W. Flake, MD: So what it is comprised of is a circuit, an abnormal circuit of blood flow, that flows through the tumor instead of through the placenta or through the fetus's tissues, and we call that a "vascular steal."

N. Scott Adzick, MD: The richly vascular tumors has blood vessels that have minimal resistance.

Alan W. Flake, MD: Because the teratoma has lower resistance for blood flow than the fetal tissues do, or the placenta, they will tend to steal more and more blood flow other time.

N. Scott Adzick, MD: These findings are important to follow extremely closely by serial sonography and by fetal echocardiography.

Lori J. Howell, RN: The fetal echocardiograms that are performed in an ongoing way tell us the degree of heart failure or how hard the heart is working.

N. Scott Adzick, MD: Heart failure in the fetus equals hydrops. The findings of hydrops are straightforward to see by maternal-fetal ultrasound because there is an accumulation of fluid in the body cavities of the fetus.

Alan W. Flake, MD: Fluid around the lungs, fluid around the heart, fluid in the skin, and other organs.

N. Scott Adzick, MD: That fluid can accumulate in the placenta as well which has maternal health consequences, such as the maternal mirror syndrome.

Alan W. Flake, MD: And that's the syndrome where the maternal physiology begins to look like the fetal physiology.

N. Scott Adzick, MD: These mothers can become incredibly sick, require transfer to the intensive care unit, require even intubation, because the fetal problem has caused issues with maternal health.

Mark P. Johnson, MD: So really the only treatment is delivery of the baby. And you're forced into that situation no matter what the gestational age is.

N. Scott Adzick, MD: The main way to prevent fetal hydrops from occurring or, at least not to be surprised by the findings, is to monitor the maternal-fetal unit extremely closely.

Alan W. Flake, MD: We've followed patients as often as three times a week with complete imaging and measuring of cardiac output and other parameters just to try to detect the onset of high output physiology, or hydrops, as early as possible.

Mark P. Johnson, MD: If it looks like the baby is going into high output heart failure, we can either deliver the baby at an earlier gestational age to allow treatment with the baby out of the uterus or, in some rare cases, we are forced to try to deal with the tumor before birth with fetal surgery.

Alan W. Flake, MD: Because hydrops is uniformly lethal to the fetus, it's one indication that we feel comfortable offering fetal surgery for.

Mark P. Johnson, MD: We actually partially deliver the baby, take a portion of the tumor off that we can, safely. And then put the baby back in the uterus and try to get as many weeks as we can before the mom goes into preterm delivery or ruptures membranes or some other thing occurs that requires us to deliver the baby.

Alan W. Flake, MD: Teratomas can also cause trouble just from their sheer bulk and size.

Mark P. Johnson, MD: It's a volume, space-occupying mass within the uterus. And it can get so big that it fools the uterus into thinking it's time to go into labor and deliver.

Alan W. Flake, MD: And so if you have a patient with a very large cystic teratoma that's threatening preterm labor because of tumor bulk, you might actually consider draining the fluid out of the tumor.

N. Scott Adzick, MD: Sort of like a fancy amniocentesis where you remove fluid for the cyst to decrease the tumor size.

Alan W. Flake, MD: Another manifestation of teratomas can be polyhydramnios.

Mark P. Johnson, MD: Polyhydramnios is just too much amniotic fluid.

Alan W. Flake, MD: Fetuses produce amniotic fluid by peeing and they reduce amniotic fluid by swallowing. So if you interfere with either of those mechanisms, it impacts amniotic fluid quantity.

Mark P. Johnson, MD: And too much amniotic fluid causes the uterine cavity to expand to get much bigger than it should be, and the uterus can be fooled into thinking it's time to go into labor.

N. Scott Adzick, MD: Sometimes this can be managed in the symptomatic mother with polyhydramnios with amnioreduction.

Alan W. Flake, MD: Taking off amniotic fluid with a needle and trying to reduce the size of the uterus and the likelihood of preterm labor.

Mark P. Johnson, MD: Starting the patient on medication that reduces blood flow to the baby's kidneys, that limits the amount of urine that the baby produces and makes management of the polyhydramnios easier so that we don't have to repeatedly go in with needles and draw the fluid off.

Alan W. Flake, MD: Another one of the detrimental manifestations of an SCT or any teratoma is its potential for rupture.

N. Scott Adzick, MD: Which is almost invariably fatal. The fetus bleeds to death.

Alan W. Flake, MD: And that can occurs spontaneously before birth.

Mark P. Johnson, MD: And there's no way to predict that event.

Alan W. Flake, MD: Or it can occur at the time of birth and that's one of the real risks associated with SCT that requires special attention and care to prevent.

Mark P. Johnson, MD: So even when things are going good, the baby is developing great, everything seems to be on track, we could still get blindsided by these tumors and that's why, perhaps, we are so focused on following them.

Delivery

Mark P. Johnson, MD: Sometimes potential risks to the baby are so great that it necessitates, kind of, a team approach to delivery.

N. Scott Adzick, MD: Two adjacent operating rooms — one operating room for the mother and the obstetrical team with a number of obstetricians, advanced practice nurses, anesthesiologists and so forth. And then the adjacent operating room where the pediatric surgeon, the neonatologist, appropriate neonatal surgical nurses, advanced practice nurses, are ready to resuscitate the baby and, if need be, if there's an issue with the tumor such as a rupture, to deal with it on an emergent basis. So when we make the diagnosis of sacrococcygeal teratoma, planned cesarean delivery is recommended with the team there to resuscitate the newborn, if that's required.

Alan W. Flake, MD: It's underappreciated how large these tumors are, and how difficult they are to deal with through standard sorts of hysterotomies, or incisions in the uterus.

Mark P. Johnson, MD: Sometimes the masses are so big that we ... the only option we have for delivery is to do a cesarean section where we make a classical-type incision, which is the vertical up and down incision, that provides us with more room to deliver the baby and the very, very large mass.

Alan W. Flake, MD: We'll sometimes open a uterus over its entire length to deliver one of these teratomas and that prevents rupture at the time of delivery, which can also be a lethal event.

N. Scott Adzick, MD: The goal is to do a smooth delivery with an intact tumor, a stable baby, and then transfer the baby to the intensive care nursery.

Mark P. Johnson, MD: Where the baby can stabilize going from fetal life to newborn life and become a much better surgical patient.

Alan W. Flake, MD: Deliveries for cervical teratoma are a special circumstance. If you can imagine a tumor that's really this size and bending the fetal head backward, it compresses the airway.

N. Scott Adzick, MD: In some circumstances it is impossible despite laryngoscopy, bronchoscopy to get an endotracheal tube through the mouth beyond the teratoma because the airway is frequently crushed by the teratoma.

Mark P. Johnson, MD: And that's a scenario where we might talk about an EXIT delivery.

Alan W. Flake, MD: The EXIT procedure is a procedure that's developed to allow us time to place an airway on a fetus.

Mark P. Johnson, MD: It's really a huge team effort with anesthesiologists and surgeons and obstetricians and fetal echocardiography support to make sure that the baby is very, very stable and everybody plays a little bit different role.

N. Scott Adzick, MD: The fetal head, the teratoma in the neck, the arms are delivered out of the uterus. The bottom half of the fetus stays in the uterus and the fetus is still hooked up to the placenta via the umbilical cord to maintain that maternal-placental-fetal circulation, basically heart-lung bypass for the fetus, if you will.

Alan W. Flake, MD: The placenta normally provides oxygenation for the fetus and, as long as the placenta is receiving blood flow, then the fetus is fine.

N. Scott Adzick, MD: So the EXIT approach is a way to convert what could be an emergency or catastrophe into a controlled situation in which airway control can be obtained.

Alan W. Flake, MD: And then once that airway's established, we can divide the umbilical cord and take the baby to an adjacent operating room and actually remove the tumor under controlled circumstances.

N. Scott Adzick, MD: We have experience with more than 70 EXIT procedures, the largest experience in the world, and many of those cases were for cervical teratomas.

Alan W. Flake, MD: The same can be said for mediastinal teratomas. If you can imagine a tumor inside the chest that's taking up space, compressing adjacent structures away from it, it can compress the intrathoracic or the airway within the chest cavity. And that's really the same sort of a situation.

Mark P. Johnson, MD: In those cases when we look at delivery, we have to plan delivery to get the mass out. And that's another scenario where an EXIT delivery would be appropriate in many cases.

Alan W. Flake, MD: We actually open the fetal chest and relieve the compression of the tumor and then we're able to establish an airway. Most of the time we actually go ahead and remove the mediastinal teratoma during the EXIT procedure so it's all done on maternal bypass, if you will.

Surgery: Sacrococcygeal Teratoma (SCT)

Alan W. Flake, MD: Postnatal surgery for SCT requires fairly meticulous dissection to remove the tumor.

N. Scott Adzick, MD: For those tumors that have both an internal and an external component, it may be necessary to work both in the abdomen to control the blood supply to the large vascular tumor as well as working on the bottom.

Alan W. Flake, MD: The tumor can often be massive. It usually displaces the anus and rectum, and that's something that you have to be very careful to preserve, obviously. It also displaces the nerves and blood vessels as they come out of the pelvis. And so you have to be very careful because these structures are displaced and they may not be in their normal position, to meticulously stay on the capsule of the tumor and follow the tumor into the pelvis and up to its origin from the coccyx.

N. Scott Adzick, MD: The goal of the operation is to remove all of the tumor, to remove the tailbone because there's a recurrence risk if the coccyx is not removed because that's the location where the tumor arises from.

Alan W. Flake, MD: It's as high as 30 percent recurrence rate if you don't resect the coccyx. And so we resect the coccyx, we remove the entire tumor including the pelvic component, if necessary, and most of the time that will cure the baby from the SCT.

Lori J. Howell, RN: They'll also do a reconstruction of their buttocks area and have a nice scar formation so that you can actually tell that there is definition to their bottom later on.

Victoria Dougherty, parent of Josephine: You're thinking, "Are there going to be any developmental problems?" Even down to, you know, is she going to feel bad in a bathing suit when she gets to be 14?

Alan W. Flake, MD: The cosmetic appearance of SCTs is something that may not be of great concern at the time, but in the long term for the children and the families, I think it's a very important consideration.

N. Scott Adzick, MD: The first obligation we have as pediatric surgeons is to resect the tumor completely, do as complete of a reconstruction as possible, and then to make things look as normal as possible, although that can't also be done in one setting.

Alan W. Flake, MD: What you normally try to do is preserve everything that's been distorted by the tumor, put it back together in an anatomic way, and most of the time you can have a fairly good cosmetic appearance with that.

N. Scott Adzick, MD: And it is necessary in some cases to do a scar revision for very large tumors, for instance.

Alan W. Flake, MD: There's still a scar there. There's no way to do this without a scar, but at least the contour of the area looks pretty normal.

Surgery: Cervical Teratoma

Alan W. Flake, MD: The surgical treatment of a cervical teratoma is very different from an SCT because it's in the neck, obviously, and it compresses structures that are in the neck that are very important.

N. Scott Adzick, MD: The usual morbidity relates to the airway — how much compression and damage to the airway that was caused before birth. And we do have several children who've required tracheostomies for as long as a year or two until the airway problem either gets better on its own or it can be fixed.

Lori J. Howell, RN: In fetal life, that big, ugly mass has been compressing that airway the entire time so our cartilage in our airway is very floppy and it takes a good couple years for it to become very stiff.

Alan W. Flake, MD: Most of the time the airway can re-form and end up being adequate without reconstructive surgery.

N. Scott Adzick, MD: In many cases with a large cervical teratoma, the lesion appears to arise from near to the thyroid so it would not be unusual to need to resect the thyroid, in which case the child would need lifelong thyroid replacement therapy, a medication a day sort of thing.

Alan W. Flake, MD: Which actually is very effective and compatible with a fairly normal life.

Lori J. Howell, RN: Once the tumor comes off in a plane, it's not like there are a bunch of incisions that we're dealing with. It's really one incision.

Loraine Kelly, parent of Emily: She just has some scarring but you can hardly tell it starts here and it goes down to here. But it's just that, you don't even really notice that.

Alan W. Flake, MD: And we can usually remove the entire teratoma surgically and have very good outcomes with essentially minimal chance of recurrence or other problems.

Surgery: Mediastinium Teratoma

Alan W. Flake, MD: Mediastinal teratomas have different treatments depending on how they manifest, either before or at the time of delivery.

N. Scott Adzick, MD: Small- to medium-sized teratomas diagnosed before birth can simply be followed and addressed after birth. For those very large teratomas that cause compression of the developing heart and compression of the developing lungs, they can lead in turn to hydrops, usually based on the location and compression of the chest mass, which may require fetal intervention.

Alan W. Flake, MD: We've had to resect mediastinal teratomas in fetuses that have developed hydrops that we felt would not survive without fetal intervention.

N. Scott Adzick, MD: We have had cases of mediastinal teratomas that became mischief-makers late in gestation, and those have been managed via the ex utero intrapartum therapy approach.

Alan W. Flake, MD: In that circumstance, you actually have to decompress the chest in order to put a tube in the airway, and we do that by opening the fetal chest, removing the tumor, and then establishing the airway and then dividing the umbilical cord and delivering the fetus.

Life after Teratoma

Alan W. Flake, MD: Babies that survive the fetal period with teratoma and can undergo a resection of tumor after birth have very good outcomes.

N. Scott Adzick, MD: So in the big view, many of these kids do quite well, but you still need to do the homework of the precise follow-up, not only in the short term but also in the long term.

Alan W. Flake, MD: You have to monitor a baby for about three years before you can be absolutely sure that there's no recurrence of the tumor.

N. Scott Adzick, MD: So follow up by examination, potentially by imaging studies such as MRI and by tumor markers such as alpha-fetoprotein and beta-hCG are important.

Lori J. Howell, RN: Most importantly is the follow-up we need to do for their first several years of life, in terms of filing their alpha-fetoprotein level at one month, and three month, and then six month, and then annual.

N. Scott Adzick, MD: To rule out a tumor recurrence because if the tumor is not completely resected, it can come back. The residual tumor can become malignant. Metastases can occur, and the teratoma then becomes a germ cell tumor.

Alan W. Flake, MD: Most of those recurrences, if they're detected early, can be treated as well.

Lori J. Howell, RN: And that's why making sure that they're followed later on throughout their life is very important.

Alan W. Flake, MD: But aside from the occasional malignancy that you see with SCT, most of the kids can have very normal lives with good outcomes.

Importance of a Specialized Center

Lori J. Howell, RN: Everything we do at the Center for Fetal Diagnosis and Treatment is complicated; it's complex.

Mark P. Johnson, MD: It's really being able to see volumes of these tumors that give us the unique experience, the expertise that, I think, makes us better at managing them.

Lori J. Howell, RN: So for us it seems commonplace. Even dealing with a rare problem such as a teratoma.

N. Scott Adzick, MD: When one has such an environment, it naturally attracts a world-class and worldwide talent pool that all sort of congeal to make the next cohort of advances.

Lori J. Howell, RN: The team that we bring to bear for fetuses with a teratoma is the same team that we bring to bear for every birth defect that we see.

N. Scott Adzick, MD: One needs pediatric surgeons.

Alan W. Flake, MD: The maternal-fetal medicine doctors

N. Scott Adzick, MD: The fetal cardiologists

Alan W. Flake, MD: All of the caretakers that are needed after birth — the NICU staff, neonatologists.

N. Scott Adzick, MD: Genetic counselors, advanced practice nurses

Mark P. Johnson, MD: Lots of family service supports

Lori J. Howell, RN: A coordinator that our families will interact with.

N. Scott Adzick, MD: Multiple areas of expertise

Mark P. Johnson, MD: To take care of not only the patient, not only the baby, but the family in general.

Victoria Dougherty: The practice is so integrated that after a really short period of time, after I kind of got over the initial shock of the diagnosis, I couldn't really imagine wanting to do it anywhere else.

Loraine Kelly: From the very beginning I was given the best information, and the way they walked us through it and they just put me at ease. And it turned out fine, and the result is I have a beautiful, healthy little girl.

Alan W. Flake, MD: We're all here because we gain intrinsic satisfaction from helping people and helping patients.

Lori J. Howell, RN: Providing families with the education they need in order to make the best decisions about their baby.

Mark P. Johnson, MD: Seeing these kids at the family reunions five years out is what really motivates us, really keeps us focused, really keeps us pushing the envelope.

N. Scott Adzick, MD: And so that's one of the reasons we do what we do. Because that's inspiring. It's really inspiring.