Primary germ cell tumors in the mediastinum: a 50-year experience at a single Japanese institution

Neuroendocrine Lesions Arising From Mediastinal Teratoma-A Case Report and Literature Review

Background. Neuroendocrine lesions arising from mediastinal teratomas are rare tumors with only small number of patients reported in literature. The behavior of these lesions appears to be different from traditional neuroendocrine neoplasms. A comprehensive review will be valuable for histologic assessment and treatment planning for similar cases. Case presentation. We present an example of a 57-year-old man who presented with cough. Subsequent work-up revealed an anterior mediastinal mass of 2.1 cm on computed tomography. The patient underwent robot-assisted thoracoscopic thymectomy. Histological examination revealed a mature cystic teratoma with a neuroendocrine component consisting of clusters of tumor cells with round to oval nuclei and a "salt-and-pepper" chromatin pattern. The tumor cells were immunoreactive to cytokeratin, synaptophysin, chromogranin, and INSM1, with a Ki-67 proliferative index of 4%. A histological diagnosis was mature teratoma with well-differentiated low-grade neuroendocrine tumor (carcinoid) was made. The patient was well and without disease after complete surgical excision at 10 months. Literature review. Literature reviewed yielded 13 examples of neuroendocrine lesions arising from mediastinal teratomas. No disease-related mortality was reported, even in lesions with high-grade neuroendocrine, carcinomatous, or immature teratomatous components. Conclusions. Surgical removal is the mainstay of treatment of these lesions, and the presence of a neuroendocrine component does not appear to negatively affect prognosis.

[Surgery for mediastinal teratoma containing pancreatic tissue]

Surgery for mediastinal tumors is still one of the most difficult in modern medicine. This is due to vital organs and various nature of tumors in this area. Teratomas are relatively rare among mediastinal tumors. However, they have certain features that is important for treatment strategy and management of possible complications. This can complicate diagnostic algorithm, exclude transthoracic biopsy and contribute to active surgical approach even for benign process. Oncogenesis of teratoma has its own characteristics. Tissues of different organs are always present in this tumor. Among these, pancreatic tissue inclusions are rare. A few data in the world literature on the treatment of such patients do not allow to develop a universally accepted algorithm of diagnosis and treatment. The authors present two patients with mediastinal teratoma. The second patient had teratoma with pancreatic tissue. The authors discuss the diagnostic algorithm for similar cases. A special attention is paid to description of possible complications throughout long-term follow-up period. Surgical aspects including the choice of access and local spread of process (adhesions in the area of surgical interest) are considered. The report on the treatment of two patients with rare mediastinal tumors containing pancreatic tissue will be useful for primary care physicians, thoracic surgeons, oncologists and morphologists.

A massive immature mediastinal teratoma treated with chemotherapy and surgical resection: a case report

BACKGROUND

Teratoma is a type of germ cell tumor consisting of one or multiple tissues derived from germinal layers. The location and size of the tumor can cause various presentations. Here we report one of the largest ever cases of immature cystic teratoma.

CASE PRESENTATION

In this report, we presented a 24-year-old patient with dyspnea, chest pain, nausea, and anorexia. A computed tomography scan revealed a giant, right-sided mass measuring about 190 × 150 × 140 mm. Chemotherapy was initiated for the patient, followed by thoracotomy. Histopathological evaluation revealed the nature of the mass to be an immature mediastinal teratoma.

CONCLUSION

the incidence of immature mediastinal teratoma is uncommon, and due to its rarity, the diagnosis needs more profound evaluation studies such as radiological and pathological assessments. Immature teratomas are optimally treated by a combination of chemotherapy and complete resection.

Refractory primary mediastinal malignant germ cell tumor with multiple systemic metastases: A rare case report

The incidence of extra-gonadal germ cell tumor is low. There are few reports about liver metastasis and multiple systemic metastasis of mediastinal germ cell tumor. Here, we report a case of a 42-year-old young man with mediastinal mass discovered by computed tomography, which was finally confirmed as mediastinal germ cell tumor after many pathological biopsies. After radiotherapy and chemotherapy, the mediastinal mass was stable, but a new mass appeared in the liver. Mediastinal mass remained stable after modification of treatment regimen, but multiple metastases were found throughout the body. He finally died after 8 months of treatment because of his poor health.

The Polyvalent Role of CD30 for Cancer Diagnosis and Treatment

CD30, also known as TNFRSF8 (tumor necrosis factor receptor superfamily member 8), is a protein receptor that is heavily glycosylated inside the Golgi apparatus, as well as a tumor marker that is found on the surface of specific cells in the body, including certain immune cells and cancer ones. This review aims to shed light on the critical importance of CD30, from its emergence in the cell to its position in diagnosing various diseases, including Hodgkin lymphoma, where it is expressed on Hodgkin and Reed-Sternberg cells, as well as embryonal carcinoma, anaplastic large cell lymphoma (ALCL), and cutaneous T-cell lymphoma (CTCL). In addition to its role in positive diagnosis, targeting CD30 has been a promising approach treating CD30-positive lymphomas, and there is ongoing research into the potential use of CD30-targeted therapies for autoimmune disorders. We aim to elaborate on CD30's roles as a tumor marker, supporting thus the hypothesis that this receptor might be the aim of cytostatic treatment.

Primary mediastinal germ cell tumors (PMGCT): A real-world analysis from a tertiary cancer care centre in India

BACKGROUND

Primary mediastinal GCT (PMGCT) is a rare entity and comprises 10-15% of all mediastinal tumors . We present our institutional experience of MGCT treated with multimodality management.

MATERIALS AND METHODS

We conducted a retrospective analysis between 2010 to 2020 of all mediastinal germ cell tumors registered at our center. Data on patient demographics, treatments received, treatment toxicities and response were recorded. Overall survival and relapse free survival were estimated using Kaplan-Meier methods.

RESULTS

A total of 30 patients were identified. The median age was 25.5 (range, 18-45) years. Common presenting features included cough (70%) and shortness of breath (70%) . Histology wise, 60% patients were non seminomatous histology whereas 33.3% patients were Seminoma.Twenty seven (90%) patients received chemotherapy as the first-line treatment, of whom five patients (16.6%) underwent surgery and radiation therapy subsequently. Median follow-up was 26.9 months. Thirteen patients (43.3%) had complete response (43.3%) and 8 patients had partial response (26.7%), while three patients (5.5%) had progressive disease. Three year relapse free survival rate was 69.6% (95% confidence interval [CI], 42.8-85.6%). Overall survival (OS) at 3 years was 73.4% (95% CI, 49.4- 87.3%). Patients with seminoma had a 3 year OS of 90.0% (95% CI, 47.3-98.5%) compared to those with non-seminoma (63.53% [95% CI, 32.3-83.3%]).

CONCLUSIONS

Multiagent chemotherapy is the backbone of treatement in PMGCT. Seminomatous PMGCT have excellent prognosis, while further improvement is needed in those with non-seminomatous tumor.

Surgical management of primary mediastinal mature teratoma: A single-center 20 years’ experience

Background

This study aims to investigate the clinical efficacy of video-assisted thoracic surgery (VATS) in treating mediastinal mature teratoma (MMT) and explore the clinical factors that increase the difficulties associated with VATS.

Method

We retrospectively reviewed 101 consecutive patients with MMT who underwent surgical excision between November 2001 and June 2021. Follow-up was done by telephone or at an outpatient clinic. The deadline for follow-up was February 2022.

Results

The operative time, the chest tube indwelling time, and the hospital stay duration were significantly shorter in the VATS group compared with the thoracotomy group. The intraoperative and postoperative complication rates in the VATS group were lower than that of the thoracotomy group (P < .05). In thoracoscopic surgery, the clinical symptoms during the course of the disease were significantly associated with bleeding loss increasing [odds ratio (OR) = 3.562; 95% confidence interval (CI) 1.180–10.753, P = .024] and operation time extension (OR = 5.697; 95% CI 1.529–21.221, P = .010). The relationship between lesions and superior vena cava or innominate vein from preoperative CT imaging was significantly associated with bleeding loss increasing (OR = 4.629; 95% CI 1.463–14.639, P = .009). A maximal lesion diameter greater than 7 cm was significantly associated with increased risks of operation time extension (OR = 5.019; 95% CI 1.641–15.348, P = .005).

Conclusion

Compared with traditional thoracotomy surgery, VATS can be performed safely in selected patients with MMT. A surgical method for complete resection needs to be determined according to preoperative imaging and intraoperative conditions to reduce the unnecessary damage.

Peri-treatment adverse events of primary mediastinal non-seminomatous germ cell tumors

Primary mediastinal non-seminomatous germ cell tumors (PMNSGCT) are rare but life-threatening thoracic cancers. We report our experience from eight patients with peri-treatment adverse events. By analyzing changes in tumor extent, serum tumor markers, and pathologies between diagnosis and transfer, those events could be attributed to postbiopsy respiratory insufficiency, growing teratoma syndrome, secondary histiocytic malignancy, and PMNSGCT progression. Subjecting patients to respiratory therapy, conventional or high-dose chemotherapy, and surgery controlled the disease, with five of the eight patients surviving disease free. These outcomes indicate that integrated appropriate and timely approaches are important in tackling peri-treatment adverse events.

Survival Outcomes of Patients With Primary Mediastinal Germ Cell Tumors: A Retrospective Single-institutional Experience

BACKGROUND/AIM

Primary mediastinal non-seminomatous germ cell tumors (PMNSGCTs) are occasionally complicated by a hematologic malignancy, as with somatic-type malignant tumors called germ cell tumors with somatic-type malignancy (GCTSTM) and are known to have a poor prognosis.

PATIENTS AND METHODS

Data obtained between September 1997 and February 2020 for patients with mediastinal germ cell tumor at our institution were retrospectively analyzed. Key outcome measures included survival rates and the clinical features of non-seminoma cases.

RESULTS

Of 16 patients, 9 had pure seminoma, and 7 had non-seminoma. At the median follow-up of 56.2 months, the 5-year survival rate was significantly higher in patients with seminoma (100%) than in those with non-seminoma (37%) (log-rank test, p=0.0153). Regarding PMNSGCT, two patients evolved into GCTSTM and three had concomitant hematological malignancies.

CONCLUSION

Patients with PMNSGCTs, GCTSTM complications, and hematologic malignancies showed poor survival, suggesting the need for the development of treatment strategies.

Increased 68Ga-FAPI Uptake by Mediastinal Benign Teratoma on 68Ga-FAPI PET/CT

ABSTRACT

Mediastinal teratoma is a relatively rare disease that usually contains tissue from the endoderm, mesoderm, and ectoderm. We report a finding that mediastinal benign teratoma showed intense FAPI activity on 68Ga-FAPI PET/CT, which may lead to misdiagnosis of this benign lesion. It is necessary to realize that benign teratoma is also one of the reasons for the intense FAPI uptake in mediastinal masses, so as not to be misdiagnosed as a malignant tumor.

Chemoradiotherapy is an alternative choice for patients with primary mediastinal seminoma

Background

The low incidence of primary mediastinal seminomas has precluded the development of clinical trials on mediastinal seminomas. We investigated the clinicopathologic characteristics, prognosis of patients with primary mediastinal seminomas as well as the efficiency of nonsurgical treatments compared with treatments containing surgery.

Methods

We retrospectively collected data on the clinicopathologic characteristics, treatments, toxicities, and survival of 27 patients from a single center between 2000 and 2018. Patients were divided into two groups according to whether they received operation. Survivals were assessed using the Kaplan–Meier method. Univariate analysis was performed using the log-rank test.

Results

The median age was 28 (13–63) years. The most common symptoms were chest pain (29.6%), cough (25.9%), and dyspnea (22.2%). There were 13 and 14 patients in surgery and non-surgery group. Patients in the non-surgical group were more likely to be with poor performance scores (100% vs. 76.9%) and disease invaded to adjacent structures (100% vs. 76.9%) especially great vessels (100% vs. 46.2%).The median follow-up period was 32.23 (2.7–198.2) months. There was no significant difference of overall survival (5-year 100% vs. 100%), cancer-specific survival (5-year 100% vs. 100%), local regional survival (5-year 91.7% vs. 90.0%, p = 0.948), distant metastasis survival (5-year 90.9% vs. 100.0%, p = 0.340) and progression-free survival (82.5% vs. 90.0%, p = 0.245) between patients with and without surgery.

Conclusions

Primary mediastinal seminoma was with favorable prognosis, even though frequently invasion into adjacent structures brings difficulties to surgery administration. Chemoradiotherapy is an alternative treatment with both efficacy and safety.

Mediastinal germ cell tumors: a narrative review of their traits and aggressiveness features

OBJECTIVE

Mediastinal extragonadal germ-cell tumors (MEGCTs) are rare neoplasms with a multifaceted clinical behavior. This paper is devoted to review their main characteristics, including histological patterns and different factors of aggressiveness in MEGCTs. Proper understanding of the latter can help to better stratify patients' prognoses and improve clinical management.

BACKGROUND

Different theories exist on the origin of MEGCTs, including primordial germ cells deposition during embryogenesis. MEGCTs predominantly affects young males and aggressiveness follows the ability of local and systemic spread of each germ-cell neoplasia subtype, as well as their distinct responsiveness to therapy. Indeed, non-seminomatous MEGCTs have a worse prognosis. Unfortunately, they are also more frequent than seminomas in the mediastinum. Regardless of histological type, local aggressiveness can follow tumoral expansion with compression on or infiltration of mediastinal structures. Chemotherapy can be effective in reducing neoplastic volume, but different levels of sensitivity can be found in different MGCTs. In particular, a chemo-resistant teratoma component of a mixed MEGCTs can undergo a paradoxical enlargement after chemotherapy, while other components of the tumor regress. This is reflected by a concomitant normalization of serum tumoral markers and cardiopulmonary deterioration due to compression. Such clinical phenomenon, called growing-teratoma syndrome (GTS), requires a prompt surgical approach.

METHODS

A literature research of pertinent epidemiological, pathological and clinical articles was conducted.

CONCLUSION

The mediastinum can harbor different kinds of neoplasia, including GCTs. The full spectrum of MEGCTs includes a variety of tumors with different clinical behaviors. Aggressiveness follows the inherent ability of local and systemic spread of each neoplastic type, as well as their distinct responsiveness to therapy.

Unusual giant multilocular thymic cyst with mature teratoma including a carcinoid component in the mediastinum

Background

Teratoma is the second most common mediastinal neoplasm, but malignant transformation in mature teratomas is uncommon, and cases of carcinoid tumor with teratoma are described in only a few studies. In addition, multilocular thymic cyst associated with mature mediastinal teratoma is also a rare entity. There have been no reports of case with the coexistence of these three pathological lesions.

Case presentation

The patient was a 24-year-old man who was referred to our hospital due to a 2-day history of left shoulder pain, a feeling of severe chest tightness and high fever. Pre-operative computed tomography (CT) showed a large, fluid-filled and well-demarcated multilocular cyst in the anterior to superior mediastinum measuring up to 12 cm in size. Contrast-enhanced CT also revealed that the tumor contained a solid component with slight contrast enhancement and spotty wall-thickening septation. Therefore, cystic thymoma, thymic cyst, cystic teratoma, or germ cell tumor with an inflammatory reaction were considered as differential diagnoses. The patient underwent tumor extirpation under median sternotomy. The pathological diagnosis was multilocular thymic cyst with mature teratoma including carcinoid tumor (Grade 2) in the mediastinum.

Conclusions

The relationship between thymic cyst, teratoma and carcinoid tumor is unclear at present; therefore, further research is needed to clarify the relationship between these entities. In this report, we present a case of multilocular thymic cyst with mature teratoma including a carcinoid component in the mediastinum that was detected by complete surgical resection.

Life-Threatening Mediastinal Teratoma of Infant Requiring Emergency Surgical Removal

Background  Teratoma is a tumor derived from fetal germ cells with aberrant differentiation.

Case Description  A 3-month-old infant with a mediastinal tumor was referred to our heart center. She presented with progressive dyspnea, cyanosis, and the need to be manually ventilated. The computed tomography scan displayed a huge tumor restricting the distal trachea including the bifurcation. An emergent operation was performed and the tumor was completely removed. Histological examination confirmed a mature teratoma.

Conclusion  In such life-threatening situation, the early detection and the immediate operation are very important for the management of rapidly-progressing mediastinal teratomas compressing the respiratory tract.

Survival Outcomes of Patients With Mediastinal Germ Cell Tumors: Experience of a Cancer Center in South America

PURPOSE

Mediastinal germ cell tumors (GCT) are rare neoplasms associated with poor survival prognosis. Due to their low incidence, limited information is available about this disease in South America. The objective of this study is to report the clinical characteristics and outcomes of patients with mediastinal GCT in a cancer center in Colombia.

MATERIALS AND METHODS

We conducted a retrospective analysis of patients with mediastinal GCT treated at the National Cancer Institute at Bogota (Colombia) between 2008 and 2020. Survival curves were presented using the Kaplan-Meier method. Chi-square and Cox proportional hazard model tests were used for data analysis.

RESULTS

Sixty-one patients were included in the study. Of them, 60 were male and 51 (83.6%) of whom had non-seminomatous germ cell tumors (NSGCT). Twenty-nine patients (47.5%) presented with superior vena cava syndrome, and 18 (29.5%) patients had extrapulmonary metastatic involvement. The three-year overall survival (OS) of NSGCT patients was 26%. The 3-year OS of NSGCT patients who underwent surgical resection of residual mediastinal mass after chemotherapy was 59%. Non-surgical management after first-line chemotherapy was associated with a worse survival prognosis in NSGCT patients (p = 0.002). Ten patients with mediastinal seminomatous germ cell tumors (SCGT) achieved a 3-year OS of 100%.

CONCLUSION

Mediastinal NSGCT had poor outcomes. Surgery of the residual mass after first-line chemotherapy seems to improve the outcome of NSGCT patients. Advanced disease at presentation may reflect inadequate access to reference cancer centers in Colombia and potentially explain poor survival outcomes in this cohort. On the other hand, mediastinal SCGT is a biologically different disease; most patients will achieve disease remission and long-term survival with first-line chemotherapy.

Successful treatment of radiotherapy and apatinib in patient with mediastinal mixed non-seminomatous germ cell tumor: A case report

RATIONALE

Mediastinal non-seminomatous germ cell tumors (MNSGCTs) are rare malignancies. Chemotherapy followed by surgical resection has been regarded as the standard management, but treatment options for chemotherapy-refractory patients or those with unresectable tumors are limited, resulting in a very poor prognosis.

PATIENT CONCERNS

An 18-year-old female presented with symptoms of cough, chest tightness, and shortness of breath for 2 months, and the symptoms gradually worsened.

DIAGNOSIS

Computed tomography (CT) revealed a large mediastinal mass invading the pericardium and great blood vessels. Serum human chorionic gonadotropin (HCG) and α-fetoprotein (AFP) levels were normal. Histopathological examination of biopsy specimens revealed mixed MNSGCT with embryonal carcinoma and immature teratoma components.

INTERVENTIONS

The patient achieved complete remission (CR) and long-term survival after multimodal therapy comprising chemotherapy, positron emission tomography/CT (PET/CT)-guided volumetric-modulated arc therapy (VMAT), and anti-angiogenic targeted therapy.

OUTCOMES

The patient was followed up for more than 4 years without recurrence, metastasis, or treatment-related adverse effects.

LESSONS

The case presented here highlights the importance of multidisciplinary diagnosis and treatment, providing evidence that radiotherapy and anti-angiogenic therapy may play an important role in unresectable or residual tumors after failure of conventional treatments of MNSGCT. Percutaneous biopsy is necessary for diagnosis if the tumor is unresectable, and serum AFP and HCG levels are normal. Additionally, PET/CT is an effective method for evaluation of efficacy and radiotherapy guidance for patients with MNSGCTs.

The clinical features and prognostic outcomes of primary mediastinal yolk sac tumors: A retrospective analysis of 15 rare cases from multiple centers

Primary mediastinal yolk sac tumors (PMYSTs) are a rare occurrence. As such, the clinicopathological features, treatment, and prognosis, of this disease still remain unclear. In this study, we aimed to provide further information relating to this rare malignancy in order to facilitate the creation of more specific clinical guidelines for the diagnosis and treatment of patients with PMYSTs.In this retrospective study, we recruited 15 patients who had been diagnosed with PMYST from four medical institutions to create a population-based cohort. We then used Kaplan-Meier analysis and the log-rank test to investigate and compare overall survival (OS) and progression-free survival (PFS).A total of 15 cases were identified. The mean age was 27.3 years (range: 19-34 years). The estimated 1- and 2-year PFS rates were 66.7% and 60.0%, respectively. The 1- and 2-year OS rates were both 73.3%. Computer tomography scans revealed tumors were located in the anterior middle mediastinum (5 cases), the anterior superior mediastinum (1 case), the left anterior mediastinum (3 cases), and the right anterior mediastinum (6 cases). Of the 15 patients receiving extended resections, the majority (40.0%) underwent tumor resection, partial pericardiotomy, pulmonary wedge resection, and mediastinal lymphadenectomy. R0 resections were achieved in eleven patients. Four patients underwent R2 resection and experienced postoperative complications, including pneumonia (2 cases), atelectasis (1 case), and bronchopleural fistula (1 case). Four patients developed postoperative lung metastasis. Three patients died due to progressive diseases. Disease recurred in all patients at a median of 8.0 months (range: 6.0-11.0 months).PMYST is a rare but highly malignant tumor with a poor prognosis. Tumor resection, with optimal extended surgical management, may provide patients with the best chance of a cure although postoperative complications relating to the pulmonary systems should be treated with caution.

Mediastinal Masses in Children: Radiologic-Pathologic Correlation

Most pediatric masses in the chest are located in the mediastinum. These masses are often initially detected incidentally on chest radiographs in asymptomatic children, although some patients may present with respiratory symptoms. At chest radiography, the mediastinum has been anatomically divided into anterior, middle, and posterior compartments. However, with the International Thymic Malignancy Interest Group classification scheme, which is based on cross-sectional imaging findings, the mediastinum is divided into prevascular, visceral, and paravertebral compartments. In the prevascular compartment, tumors of thymic origin, lymphomas, germ cell tumors, and vascular tumors are encountered. In the visceral compartment, lymphadenopathy and masses related to the foregut are seen. In the paravertebral compartment, neurogenic tumors are most common. Using the anatomic location in combination with knowledge of the imaging and pathologic features of pediatric mediastinal masses aids in accurate diagnosis of these masses to guide treatment and management decisions. An invited commentary by Lee and Winant is available online. ^©RSNA, 2021.

Primary mediastinal germ cell tumours with high prevalence of somatic malignancy: An experience from a single tertiary care oncology centre

BACKGROUND

Primary mediastinal germ tumours (PMGCT) constitute, a mere 3-4% of all germ cell tumours (GCT). Although they account for approximately 16% of mediastinal tumours in adults and 19-25% in children as per western literature, there is hardly any large series on PMGCT reported from the Indian subcontinent.

DESIGN

We have retrospectively analysed clinicopathological features of 98 cases of PMGCT diagnosed over 10 years (2010-2019) from a tertiary-care oncology centre.

RESULTS

The study group (n = 98) comprised predominantly of males (n = 92) (M:F ratio-15:1), with an age range between 3 months to 57 years (median: 25 years). The tumours were predominantly located in the anterior mediastinum (n = 96). Broadly, Non-seminomatous germ cell tumours (NSGCT) were more common (n = 73, 74%) compared to pure seminoma (n = 25, 26%). Mixed NSGCT was the most common histological subtype (n = 30) followed by pure mature teratoma (n = 18), pure Yolk sac tumour (n = 13), mixed seminoma and NSGCT (n = 5), pure immature teratoma (n = 3) and GCT; NOS (n = 4). Interestingly, all female patients had exclusive teratomas. Nine cases revealed secondary somatic malignancy (5 carcinomas and 4 sarcomas). The majority of patients received neoadjuvant chemotherapy (n = 71). Surgical excision was performed in 60 patients. Follow up was available in 68 patients. NSGCT showed a poor prognosis as compared to seminoma (p value = 0.03) and tumours with somatic malignancies had a more aggressive clinical course.

CONCLUSION

PMGCT was seen predominantly in young adult males and somatic malignancies were noted in as high as 9% of cases. Patient with somatic malignancy have aggressive clinical course, hence, extensive sampling and careful histopathological evaluation are recommended for the identification and definitive characterization.

Nomograms for Predicting Prognosis of Primary Mediastinal Seminoma: A Population-Based Study

Objectives

Primary mediastinal seminoma (PMS) was an uncommon carcinoma, and the appropriate treatment remained controversial due to the low incidence. We aimed to investigate the demographics and tumor biological characteristics to determine the potential effective treatment and predict the prognosis.

Methods

Patients diagnosed with PMS were selected between 1975 and 2016 from Surveillance, Epidemiology, and End Results (SEER) database. Kaplan–Meier analysis and Cox proportional hazard model were conducted to determine the prognostic factors, and nomograms were employed to visually predict the prognosis. Concordance index (C-index), calibration curve, and receiver operating characteristic (ROC) curve were conducted to validate the prediction model.

Results

A total of 476 patients were included with a median age of 31 years (range, 2–76 years), and a median size of the tumor was 11.6 cm (range, 0.2–24.0 cm). The 5- and 10-year overall survival (OS) rates were 70.4% and 68.4%, respectively. Age, the extent of the primary site, metastatic status, and surgery performance were independent prognostic factors. Not received surgery was considered a poor prognostic factor for OS (HR, 1.86; 95% CI, 1.13–3.03; P=0.013). The C-index was 0.733 (95% CI, 0.685–0.781) and 0.819 (95% CI, 0.737–0.901) for internal and external validation for predicting OS, respectively. The area under the ROC curve (AUC) was 0.743 (95% CI, 0.681–0.804) for predicting OS (sensitivity, 0.532; specificity, 0.887) in the training cohort.

Conclusions

The nomogram could efficiently predict the survival of patients with PMS. Surgery was the potential effective treatment, and chemotherapy was strongly recommended for patients over 40 years.

Mediastinal mature teratoma with chest pain onset and subsequent perforation: A case report

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Ruptured mediastinal teratomas (RMTs) may lead to mediastinitis.

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RMTs may also cause the rupture of adjacent tissues.

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Immediate resection of RMTs should be performed once perforation is confirmed.

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Radiography and MRI may provide useful information for RMT diagnosis.

Introduction

Mediastinal mature teratomas are often benign, asymptomatic, and incidentally detected during routine chest roentgenography. Enzymes secreted by intestinal or pancreatic tissue in teratomas may lead to mediastinitis or the rupture of adjacent tissues. Herein, we present a case of a patient who experienced sudden onset of chest pain followed by the perforation of a mediastinal teratoma.

Presentation of case

A 10-year-old boy presented with chest pain 2 days before admittance to the hospital. Chest radiography showed an anomalous mass shadow, and computed tomography showed an anterior mediastinal mass. Radiography revealed an increase in the mass shadow size and dullness of the left costal phrenic angle. Magnetic resonance imaging revealed pleural effusion and intratumoral haemorrhage, indicating perforation of the tumour. Emergency excision and thymectomy via sternotomy were performed. Pathology confirmed that the mediastinal tumour presented no immature or malignant elements.

Discussion

In the present case, the onset of chest pain occurred 2 days before admission, and the initial computed tomography did not reveal tumour perforation. Subsequent chest radiography and magnetic resonance imaging indicated that the tumour had perforated. Surgical tumour excision was planned at the time of admission; however, once perforation was confirmed, emergency surgery was performed. The pleural effusion had high cancer antigen 19-9 levels, and this was expected as the pleural effusion contained pancreatic digestive enzymes.

Conclusion

The perforation of a mediastinal mature teratoma cannot be predicted based on the symptoms, tumour size, or onset of pain alone. Once perforation is confirmed, surgical excision should be performed immediately.

Successful resection of giant mediastinal tumor with growing teratoma syndrome by bilateral transmanubrial approach, clamshell and median sternotomy

A 25-year-old man was initially diagnosed with a giant mediastinal nonseminomatous germ cell tumor. Chemotherapy was administered and the tumor markers were normalized; however, the tumor grew in size (20 cm), invading the left brachiocephalic vein (BCV) and the superior vena cava (SVC). Bilateral transmanubrial approach with median sternotomy and bilateral clamshell thoracotomy was required for the complete resection of the giant tumor with the SVC reconstruction. Bilateral TMA provided the surgical field of view around the bilateral phrenic nerves and bilateral BCVs. Given the final pathological diagnosis of the mature teratoma, this was considered growing teratoma syndrome where surgery is the only treatment option.

Primary mediastinal germ cell tumors - A retrospective analysis of >30 years of experience in a single institution

Background

This study was performed to clarify the treatment outcome of patients with primary mediastinal germ cell tumors (PMGCTs), focusing on the clinical manifestations and management during definitive therapy and long‐term follow‐up.

Methods

In this study, we retrospectively reviewed the medical records of patients with PMGCTs treated at Shinshu University School of Medicine, and examined the clinical profiles and treatment outcomes of 22 patients (mean age of 29 years) with primary mediastinal GCTs treated at our hospital between 1983 and 2019.

Results

Five patients were diagnosed with pure seminoma and 17 had nonseminomatous GCT. A total of 21 patients were treated with cisplatin‐based chemotherapy and 15 patients (68.2%) underwent thoracic surgery after chemotherapy. Although all cases of nonseminomatous GCT were negative for tumor markers after cisplatin‐based chemotherapy, two cases showed variable GCT cells and two had somatic components (angiosarcoma and rhabdomyosarcoma) in resected specimens. Three relapsed soon after surgery. Growing teratoma syndrome developed during chemotherapy in four cases. Urgent thoracic surgery was performed in three patients, but one case was inoperable. The calculated 10‐year overall survival rates were 100% in mediastinal seminoma and 64.7% in NSGCT. During follow‐up, second non‐GCT malignancies developed in three patients (colon cancer, 190 months; thyroid cancer, 260 months; non‐small cell lung cancer, 250 months after the initial chemotherapy) and one patient with primary mediastinal seminoma was associated with multiple type I endocrine tumors.

Conclusions

Our experiences demonstrated that long‐term survival and/or cure can be achieved with adequate chemotherapy followed by local surgical treatment even in patients with mediastinal GCTs. However, the clinical manifestations and biological behaviors during and/or after chemotherapy were complex and varied. In addition, the development of secondary malignancies should be taken into consideration for long‐term follow‐up. Clinicians should be aware of the various clinical features and secondary malignancies in primary mediastinal GCTs.

Primary malignant mediastinal germ cell tumors: A single institutional experience

Background:

Primary mediastinal malignant germ cell tumour (PMMGCT) is rare with unsatisfactory prognosis and pose difficulty in management due to lack of guidelines.

Methods:

All cases of PMMGCT diagnosed and treated between years 2014 to 2018 were retrospectively evaluated for clinico-pathological features, multimodality treatment and follow up.

Results:

Among a total of five PMMGCT cases, three were seminomatous and two were non seminomatous tumour [Yolk- sac tumour (n-1) and Mixed tumour (n-1)]. Four of these cases were non - metastatic with locally advancement and another one presented with metastasis to supraclavicular lymph node. All patients received platinum based induction chemotherapy. Post-induction chemotherapy, two cases of non seminomatous tumours underwent surgery. Among the three seminoma cases, one patient showed complete metabolic response; one with metastasis succumbed to the disease and the in-operable case of seminoma received local radiotherapy.

Conclusion:

PMMGCT needs a multi-disciplinary approach for appropriate diagnosis and management. Clinicopathological features like tumour site, extension, histopathological type, tumour stage and serum tumour marker are necessary for prognostication and decision making of further treatment plan.

Mediastinal Germ Cell Tumors: Updates in Diagnosis and Management

Primary mediastinal nonseminomatous germ cell tumors represent a rare but important malignancy that occurs in otherwise young and healthy patients. Treatment is challenging and involves cisplatin-based chemotherapy followed by surgery to remove residual disease. Avoiding bleomycin-containing chemotherapy in the treatment of primary mediastinal nonseminomatous germ cell tumors is important. Prechemotherapy and postchemotherapy pathology as well as postoperative serum tumor markers are independent predictors of long-term survival.

Clinical Characteristics and Outcomes of Patients With Primary Mediastinal Germ Cell Tumors: A Single-Center Experience

Purpose: Primary mediastinal germ cell tumors (PMGCTs) are rare. The natural history and optimal treatment strategies still need to be defined. The aim of the study was to summarize the clinical characteristics, treatment outcomes, and prognostic factors of PMGCTs.

Methods: Twenty-four patients with PMGCTs who were treated from December 2008 to January 2019 were evaluated retrospectively. The Kaplan–Meier method and Cox regression analysis were used to evaluate factors associated with prognosis.

Results: The study population consisted of 23 male patients and 1 female patient. Five patients were diagnosed with seminoma and 19 patients were diagnosed with nonseminoma. The median follow-up time for all patients was 15.8 (3.9–114.5) months. The 5-year overall survival (OS) and progression free survival (PFS) rates for all patients were 65.2 and 44.3%. For nonseminoma and seminoma, the 5-year OS rates were 54.1 and 100% (P = 0.093), respectively, and the 5-year PFS rates were 28.7 and 100%, respectively (P = 0.044). In patients with nonseminoma, first-line radiotherapy indicated superior OS and PFS (P = 0.037 and 0.027, respectively). The median survival time after recurrence was 4.3 months and the 1-year survival rate after recurrence was 23.4%.

Conclusion: These results indicated that in PMGCTs, the prognosis of seminoma is superior to that of nonseminoma. Radiotherapy may be an essential treatment in patients with nonseminoma. Patients with relapse have unfavorable prognosis.

Imaging findings of three cases of large mediastinal mature cystic teratoma

Mature cystic teratoma (MCT) is a benign, slow-growing tumor and accounts for approximately 75% of mediastinal germ cell tumors. Patients with MCT are often asymptomatic when the tumors are small. Most of the symptoms are frequently related to compression of the mediastinal structures. We herein describe 3 adult cases of MCT. The patients were a 37-year-old man, a 35-year-old woman, and a 54-year-old woman. They were hospitalized with compression-related symptoms, such as chest pain, dyspnea, and cough. Findings from conventional chest radiograph, computed tomography (CT), magnetic resonance imaging were characterized. Conventional chest radiography still plays a major role in the initial evaluation of MCT, while CT remains the preferred modality for initial cross-sectional imaging evaluation of mediastinal lesions. However, thoracic magnetic resonance imaging provides more detailed and often definitive evaluation of mediastinal masses than CT because of its superior tissue characterization.

Surgical treatment of benign mediastinal teratoma: summary of experience of 108 cases

Background

Mediastinal teratoma is a rare disease, many cases were reported before, but few articles focus on large case analyses. The objective of this article is to summarize the clinical characteristics of benign mediastinal teratoma and the experience of surgical treatment, especially thoracoscopic surgery for benign mediastinal teratoma.

Methods

The clinical data of 108 patients with benign mediastinal teratoma confirmed by operation and pathology from January 1992 to January 2018 were analyzed retrospectively. The clinical symptoms, imaging examination, surgical methods and prognosis of all patients were analyzed. We compared the difference of thoracoscopic surgery and thoracotomy surgery using 102 patients underwent only chest surgery. Normally distributed continuous variables were compared by independent sample t test. Categorical variables were analyzed by chi-square test.

Results

Imaging examination showed that all 108 cases of mediastinal teratoma were located in the anterior region of mediastinum. All cases underwent surgical resection, postoperative pathology confirmed that all cases were benign. 1 case was taken simple neck collar incision, 5 case was taken median thoracotomy combined with neck incision, other 102 cases were taken thoracoscopic surgery (22) or thoracotomy surgery (80). 4 cases were treated with partial pericardial resection due to adhesions, 12 cases underwent partial pericardial resection, 5 cases underwent lobectomy, 9 cases underwent wedge resection of lobe, and 2 patients underwent anonymous vein angioplasty. 1 case underwent second operation because of postoperative bleeding, 1 case of chylothorax, 1 case of recurrent laryngeal nerve injury, 2 cases of wound infection, 1 case of secondary pulmonary infection. 106 cases were followed up, period from 12 months to 10 years, no recurrence of tumor was found. Comparing to take thoracotomy surgery, patients underwent thoracoscopic surgery has strong advantage on intraoperative blood loss and hospital stay days after surgery (P < 0.05). tumor maximum diameter is larger for thoracotomy surgery group, as well as more patients suffer estimated adhesions from preoperative imaging. so we compared above parameters in patients with tumor diameter less than 10 cm with or without estimated adhesions from preoperative imaging, a strong advantage still can be found in thoracoscopic surgery group, inpatients with estimated adhesions from preoperative imaging, intraoperative blood loss (38.75 ± 15.53 vs 169.17 ± 208.82., P = 0.04) and hospital stay days after surgery (5.50 ± 0.93 vs 9.43 ± 6.54., P = 0.04) were better. In patients without estimated adhesions from preoperative imaging, intraoperative blood loss (46.67 ± 10.00 vs 110.53 ± 123.13., P = 0.06) and hospital stay days after surgery (4.70 ± 1.16 vs 7.53 ± 2.32., P = 0.01) were better. Especially, in thoracoscopic surgery group, hospital stay days after surgery was significantly shorter.

Conclusion

The clinical manifestations and imaging performance of benign mediastinal teratoma were complicated, and the surgical treatment was effective. Compared with traditional thoracotomy surgery, thoracoscopic surgery can improve patients’ quality of life, less intraoperative blood loss, and less hospital stay days after surgery, so if condition is permitted, thoracoscopic surgery should be a better choice.

Thoracoscopic surgery approach to mediastinal mature teratomas: a single-center experience

Background

Mediastinal mature teratomas are rare tumors with diverse surgical approaches. The aim of this study is to review our experience of thoracoscopic surgery management in patients with teratomas.

Methods

We retrospectively reviewed 28 consecutive patients with mediastinal mature teratomas who underwent thoracoscopic surgery at Viet Duc University Hospital from January 2008 to August2018. Patients were divided into 2 groups with 2 types of thoracoscopic surgery, closed thoracoscopic surgery (CTS) group and video-assisted thoracoscopic surgery (VATS) group. The selection of sugical approach was based on sizes, locations and characteristics of tumors. Post-operative outcomes were assessed and compared between these 2 groups.

Results

There were 14 female and 14 male patients with a median age of 41.2 ± 13.8 years. A total of 22 teratomas were located on the right side of the chest cavity and 6 on the left side. We performed CTS in 21 patients (75%) and VATS in 7 patients (25%) for tumor resection. There were 3 cases (10.7%) required conversion to minithoracotomy (5 cm in incision length). Skin appendages accounted for the highest rate (96.4%) in pathology. There was no record of mortality or tumor recurrence detected by computerized tomography.

Conclusion

A thoracoscopic surgery for a mediastinal mature teratoma was a feasible choice. Challenging factors such as large tumors, intraoperative bleeding and strong tumor cell adhesion were considered handling by conversion to mini-thoracotomy that could ensure safety procedures and complete removal of tumors. Extraction of tumor contents might be performed for patients with large mature cystic teratomas to facilitate thoracoscopic surgery.

Growing teratoma syndrome of mediastinal nonseminomatous germ cell tumor

Mediastinal nonseminomatous germ cell tumor (NSGCT) is rare. NSGCT shows excellent response to cisplatin-based chemotherapy. However, some tumors continue to enlarge despite normal tumor markers after chemotherapy, a rare condition called growing teratoma syndrome (GTS). Recognition of this condition is imperative for prompt surgical resection to prevent further cardiopulmonary compression and to improve survival. Multidisciplinary team meeting is important for perioperative preparation and care to improve the outcome of this high-risk surgery. Here, we report two cases of mediastinal GTS and underwent surgical resection, of which one died of pericardial decompression syndrome and the other is well.

Neutrophil-to-lymphocyte ratio in primary mediastinal germ cell tumors: A retrospective analysis of >20 years single institution experience

OBJECTIVES

To obtain information on outcome stratified by histology, extent and primary treatment patients' data with primary malignant mediastinal germ cell tumors treated between 1998 and 2018 were retrospectively analyzed.

METHODS

The primary treatment for localized malignant mediastinal germ cell tumors was neoadjuvant bleomycin + etoposid + cisplatin (BEP) ± surgery (n = 22); or surgery ± adjuvant BEP (n = 16). For disseminated disease (n = 21) first line BEP ± second line chemotherapy were administered. For nonseminomas (NS) the NLR at start of BEP was analyzed in relation to disease-free survival (DFS), progression-free survival (PFS), and overall survival (OS).

RESULTS

After neoadjuvant treatment the 5-year DFS was 100% for seminomas (S), and 63.4% for NS. The 5-year OS was 100% for S, and 76.9% for NS. The 5-year DFS and OS after surgery ± BEP for S was 72.9% and 100%, for NS was 75% and 87.5%, respectively. The 5-year PFS and OS of metastatic patients for S was 60% and 80%, while the median PFS and OS of NS were 5.7 and 11.1 months, respectively. Objective response (P = 0.006) and low NLR (P = 0.043) were independent prognostic markers of longer OS.

CONCLUSIONS

We confirmed the good outcome of BEP-treated S, while NS had poorer prognosis. Previously published prognostic models for NS were validated. Based on NLR and response a new prognostic model was developed.

Asymptomatic azygos vein overflow in a young patient with primary mediastinal seminoma

The azygos system is the most important pathway for decompression of the superior vena cava (SVC) when a blood flow obstruction to the right atrium is present. Thoracic and mediastinal malignancies, mainly lung cancers, are responsible for 60%–85% of superior vena cava syndrome (SVCS) cases. An uncommon origin of SVCS is primary malignant mediastinal germ cell tumor (PMMGCT) which represent 1%–4% of all mediastinal tumors and can be divided into two broad groups: seminomas and nonseminomatous germ cell tumors (NSGCTs). Primary mediastinal seminomas clinical presentation is often nonspecific, even if the majority of patients present with superior vena cava involvement. Here, we present the radiologic features of asymptomatic azygos system overflow in a patient with primary mediastinal seminoma.

Management and Long-term Outcomes of Giant Mediastinal Germ Cell Tumors in Children

Purpose: The purpose of the study is to evaluate the outcome of children with giant mediastinal germ cell tumors (GCTs). Materials and Methods: A retrospective study of children diagnosed with GCTs treated at our hospital from 1998 to 2014 was performed. They were evaluated for their tumor size, malignancy, treatment, complications, and outcome. Results: Twelve giant mediastinal GCT patients were included in the study. Age ranged from 7 to 144 months (median 12 months) and all except one were males. The average tumor size was 10.4 cm (range 6 cm × 5 cm–16 cm × 13 cm) and in four patients, they were large enough to occupy nearly the entire hemithorax. Nine children had benign tumors, and these were resected upfront. The remaining three cases with malignant disease received neoadjuvant chemotherapy. No significant reduction in size was noticed in these patients, but alpha-fetoprotein levels decreased in all the three, and they were later resected. Eight (67%) were resected through posterolateral thoracotomy and 4 (33%) through median sternotomy approach. One patient had a dumbbell-shaped thoracoabdominal tumor extending through a Bochdalek hernia. He required additional laparotomy as well as diaphragmatic repair. There were no postoperative complications. The malignant GCTs received total four courses of PEB. All patients were alive and asymptomatic at a mean follow-up of 55.4 months (range 10–146 months). Conclusions: Mediastinal GCTs have bimodal age distribution and show male preponderance. Malignant mediastinal GCTs responded well to neoadjuvant chemotherapy through a reduction in size was not noticed. Complete excision often in coordination with cardiothoracic-vascular surgeons can lead to long-term symptom-free survival even in giant tumors.

Extragonadal germ cell tumors: Not just a matter of location. A review about clinical, molecular and pathological features

Extragonadal germ cell tumors (EGGCTs) are uncommon neoplasms, which arise in anatomical locations other than gonads. The pathogenesis of these neoplasms is still poorly understood and it is a matter of debate if they really represent extragondal primary neoplasms or rather extragondal metastasis from occult gonadal neoplasms. The actual observations suggest that EGGCTs represent a unique entity, so their biology and behavior are substantially different from gonadal counterparts. The diagnosis of EGGCTs is often challenging, and differential diagnosis is particularly wide. Nevertheless, a correct diagnosis is essential for the correct management of the patient. We summarize the state of art about EGGCTs, with particular emphasis on diagnosis and prognosis.

Primary mediastinal neoplasms: a report of 1,005 cases from a single institution

BACKGROUND

This study was an epidemiological analysis of all primary mediastinal neoplasms (PMNs) diagnosed between 2000 and 2016 at the National Tuberculosis and Lung Diseases Research Institute, Poland.

METHODS

All patients with any mediastinal abnormality were included in the analysis. The patients' age and gender were obtained from the institutional database.

RESULTS

From a cohort of 5,108 patients, 3,691 primary mediastinal lesions were found, including 1,005 (19%) PMNs: lymphomas (533, 53% of PMNs), thymomas (215, 21%), neurogenic tumors (NTs) (100, 10%), germ cell tumors (GCTs) (62, 6%), soft tissue tumors (STTs) (47, 5%) and thymic carcinomas/thymic neuroendocrine tumors (TCs/TNETs) (37 in total, 4%). The most frequent lymphomas were classical Hodgkin lymphomas [256] and primary mediastinal large B-cell lymphomas [163]. Type AB [73] predominated in thymomas and squamous cell carcinomas [9] and carcinoids [10] in TCs/TNETs. NTs encompassed mainly schwannomas [49], ganglioneuromas [21] and neurofibromas [10]. The most frequent STTs were hemangiomas [13] and lymphangiomas [11]. Lymphomas, thymomas and NT were more often in women, TCs/TNETs in men (P<0.001). Lymphomas predominated between the 2nd and 4th decade of life, NTs under the 3rd decade and thymic epithelial tumors between the 6th and 8th decade (P<0.001). There was no correlation between the subtypes of thymomas and the patients' gender (P=0.389) but it was found between histology and patients' age: in patients <30 years of age type B2 and B3 thymomas and >70 years of age AB type and micronodular thymomas with lymphoid stroma (P<0.001) predominated. In the group of GCTs half of them were malignant and these were noted exclusively in men. No correlation between subtypes of NTs or TCs/TNETs and patients' age and gender was found (P>0.05).

CONCLUSIONS

PMNs are rare conditions thus awareness of basic epidemiology may be very helpful for final diagnosis.

Primary Seminoma Localized in Mediastinum: Case Report

BACKGROUND

Primary mediastinal seminomas most commonly occur in young men, and they are localised in the anterior mediastinum.

CASE PRESENTATION

The presented study is a case report of a 34-year-old man suffering from a mediastinal tumour in size of 19 cm, with pleural and pericardial effusion. The patient complains of cough, difficulty breathing, weight loss, and pronounced tiredness. CT of lungs and biopsy of the mediastinal change was performed. The histopathological analysis was in favour of a primary mediastinal seminoma. The patient initially had pronouncedly increased levels of LDH and β-hCG tumour marker. Pericardiocentesis was realised due to threatening tamponade of the heart, followed by 4 cycles of chemotherapy by BEP protocol. Following 2 cycles of chemotherapy, normalisation of LDH and β-HCG levels and significantly improved the clinical condition in the patient was found. Upon completion of 4 chemotherapy cycles by BEP protocol, the patient performed an FDG-PET scan with partial response and reduced dimension of a primary tumour in the mediastinum. Radiotherapy of residual tumour mass up to a total dose of 40Gy in 20 fractions was realised. Control FDG-PET scan had a finding of complete response to a tumour and absence of FDG uptake. The last follow-up examination was performed in October 2018, and the patient was disease-free for 54 months.

CONCLUSION

Multimodality treatment approach of chemotherapy followed by radiation consolidation ensured long-term survival in primary advanced mediastinal seminoma.

Development of angiosarcoma in a mediastinal non-seminomatous germ cell tumor that exhibited growing teratoma syndrome during chemotherapy

Herein, we report a case of an angiosarcoma in a mediastinal non-seminomatous germ cell tumor that exhibited growing teratoma syndrome during chemotherapy. A 26-year-old man presented with a giant anterior mediastinal mass, which was diagnosed as a non-seminomatous germ cell tumor. The patient was administered three cycles of chemotherapy (bleomycin, etoposide, and cisplatin), but the mass grew despite normalization of tumor markers. Massive bleeding during thoracic surgery resulted in incomplete resection, and the mass was clinically and pathologically diagnosed as growing teratoma syndrome (only mature teratoma). The residual mass continued to grow, and complete resection was subsequently achieved after a detailed analysis of its vascular anatomy using angiography. The final pathological findings revealed angiosarcoma, which indicated a rare somatic type of mediastinal non-seminomatous germ cell tumor.

Mediastinal mature teratoma perforating the right lung that was successfully resected with complete thoracoscopic surgery: A case report

•

Open surgery is usually performed for a perforating mediastinal mature teratoma.

•

Asymptomatic perforation involving a teratoma is very rare.

•

Complete thoracoscopic surgery was successfully used in this case.

•

Complete thoracoscopic surgery might be meaningful in cases of few or no symptoms.

Introduction

A perforating mediastinal mature teratoma can cause severe inflammation and adhesion; therefore, open surgery is usually performed. Asymptomatic perforation involving a teratoma is very rare. Complete thoracoscopic surgery is often difficult because of inflammation associated with perforation and the frequently large size of a mediastinal mature teratoma. We report a rare case of an asymptomatic perforating mediastinal mature teratoma successfully treated with complete thoracoscopic surgery.

Presentation of case

The patient was a 15-year-old girl with an abnormal shadow at the mediastinum seen on chest radiography at a health examination performed at her junior high school; an asymptomatic mediastinal tumour was suspected. Enhanced computed tomography revealed a 6.5 × 3.5-cm tumour associated with the right upper lobe. Thoracoscopic surgery was performed using 4 access ports. Although there were inflammatory changes, hemi-thymectomy and right upper lobectomy were achieved with complete thoracoscopic surgery. The tumour included the skin, sebaceous glands, hair, and pancreatic tissue and was diagnosed as a mature teratoma perforating the right upper lobe.

Discussion

There might be limited inflammatory changes if the patient has few or no symptoms, as in our case. In such cases, the tumour may be excised even if it is large.

Conclusion

We report a rare case of an asymptomatic perforating mediastinal mature teratoma that was successfully treated with complete thoracoscopic surgery. Although infection, inflammatory adhesion, large tumour size, and the need for radical cure are concerns, complete thoracoscopic surgery might be helpful. In cases of few or no symptoms, thoracoscopic surgery is worth challenging.

Primary mediastinal seminoma

Background

The objective of this study was to evaluate the long term treatment results of patients with primary mediastinal seminoma.

Methods

Sixteen patients aged 21-46 diagnosed with primary mediastinal seminoma between 1983 and 2014. Mean size of the tumor was 65 cm². In all patients gonadal involvement was excluded. In 6 patients, metastases to regional lymph nodes were found and none of them presented with distant metastases. HCG was elevated in 6 patients (38%). Eight patients underwent surgery as first-line of the treatment: 7 partial and 1 complete resection of the tumor. Chemotherapy (CTH) and radiotherapy (RTH) were methods of treatment in 14 cases. Tumor was irradiated to total dose of 36.0-50.4 (median 42.5) Gy. In statistical analysis overall survival (OS) was calculated using Kaplan-Meier method.

Results

During median time of 11 years of the follow-up, complete or partial regression (PR) of the tumor was seen in all patients after primary treatment. Recurrence of the tumor was seen in 3 patients. The 5-, 10- and 15-year local control rates were 75%. One was treated with CTH, other two with RTH. All of them responded with complete regression (CR) of the tumor. Three patients died during the follow-up. All others are alive without disease. The 5-, 10- and 15-year OS was 100%, 91% and 91% respectively.

Conclusions

Chemoradiotherapy of primary mediastinal seminoma gives satisfactory treatment results with good local control rate. The treatment outcome is comparable to primary testicular seminoma.

Superior Mediastinal Syndrome in an Infant Caused by Mediastinal Teratoma: Case Report

A 3-month-old male infant presented with superior mediastinal syndrome due to a large mediastinal teratoma. The child suffered from severe cardiorespiratory compromise that required emergency treatment. Mediastinal teratomas are potentially lifethreatening in infancy. Close cooperation among pediatric oncologists, surgeons, anesthesiologists, intensivists, and radiologists is crucial in the management of these rare tumors

Extragonadal germ cell tumor of the posterior mediastinum in a child complicated with spinal cord compression: a case report

BACKGROUND

Germ cell tumors (GCTs) in children are rare neoplasms with diverse pathological findings according to the site and age of presentation. The most common symptoms in children with mediastinal GCTs, which are nonspecific, are dyspnea, chest pain, cough, hemoptysis, vena cava occlusion syndrome, and fatigue/weakness. Because of these nonspecific symptoms, it is difficult to suspect a mediastinal mass. A posterior mediastinal tumor causing spinal cord compression is an important example of an oncologic emergency arising from a neurogenic tumor.

CASE PRESENTATION

Children with posterior mediastinum GCTs can be easily mistaken as having a neurogenic tumor because of site of tumor origin. We treated our 7-year-old patient with emergency decompression surgery and high-dose steroid pulse therapy to prevent secondary injury to the spinal cord. Primary injury was a result of spinal cord compression due to the initial manifestation of GCT in the posterior mediastinum. Cisplatin-based chemotherapy was also administered. The patient was followed up regularly for 3 years and is undergoing rehabilitation without any signs of recurrence.

CONCLUSIONS

We present an extremely rare case of a child with paraparesis caused by extradural spinal cord compression as the initial manifestation of GCT in the posterior mediastinum. The child was treated with emergency decompression surgery and high-dose pulse steroid therapy to prevent secondary injury to the spinal cord.

Primary mediastinal and retroperitoneal malignant germ cell tumors in children and adolescents: Results of the TGM95 trial, a study of the French Society of Pediatric Oncology (Société Française des Cancers de l'Enfant)

PURPOSE

To examine the clinical presentation, treatment and results in children and adolescents with primary mediastinal (PM) and retroperitoneal (RP) germ cell tumors (GCTs).

METHODS

The TGM95 trial for malignant GCTs was conducted in France between 1995 and 2005 to evaluate a strategy adapted to prognostic factors with cisplatin-based chemotherapy and surgical management. We reviewed patients with TGCTs at PM and RP sites.

RESULTS

Among 239 patients, there were 16 patients with PM and 5 with RP tumors, which represent 9% of all patients, highlighting the rarity of these extragonadal locations. A bimodal demographic distribution was observed (11/21 patients <5 years old and 7/21 patients >12 years old). A majority of patients presented with bulky tumors that required urgent care with neoadjuvant chemotherapy. In all patients, elevation of alpha-fetoprotein indicated a yolk sac tumor component. Human chorionic gonadotrophin was elevated in five patients (four adolescents), suggesting a choriocarcinoma or seminoma component. The diagnosis was based on elevation of these tumor markers in addition to imaging. Chemosensitivity was observed for a majority of patients. An aggressive surgical approach allowed a microscopic complete resection in 12/15 patients with PM tumors and 4/5 with RP tumors. Overall, 14/16 and 4/5 patients survived, respectively. Three adolescents died of tumor progression.

CONCLUSION

In children with mediastinal or RP GCTs, the prognosis is favorable when a strategy of delayed aggressive surgery is performed after cisplatin-based chemotherapy. Younger patients have a better prognosis. Relapses were observed only in adolescents and could not be cured.

Non-Seminomatous Germ Cell Tumor Presenting with Superior Vena Cava Syndrome

Patient: Male, 24

Final Diagnosis: Non-seminomatous primary mediastinal germ cell tumor

Symptoms: Chest pain • dyspnea

Medication: —

Clinical Procedure: Chemotherapy

Specialty: Oncology

Role of post-chemotherapy radiation in the management of children and adolescents with primary advanced malignant mediastinal germ cell tumors

OBJECTIVE

Primary malignant mediastinal germ cell tumors (MMGCTs) are rare in children and adolescents and have a poorer prognosis than their gonadal counterparts. We report a single institutional experience of a 10-year period of primary advanced MMGCTs treated with chemotherapy, followed by radiotherapy in those who had residual mass.

METHODS

Children and adolescents with primary advanced MMGCTs between 2005 and 2014 were identified from the Cancer Center, Sun Yat-Sen University. Medical records were reviewed for clinicopathological characteristics, treatments, and outcomes.

RESULTS

Twenty-four children and adolescents with either stage III or IV primary advanced MMGCTs met the inclusion criteria. There were 23 males and one female with a median age of 16 (range 10-18). Seven cases were seminomas (29.2%); four (16.7%) yolk sac tumors (YST); three (12.5%) choriocarcinomas; and ten (41.6%) nonteratomatous combined germ cell tumors (CGCTs). All patients were treated with first-line cisplatin-based chemotherapy regimens (PEB: 19, VIP: 5). Thirteen (54.2%) and Twelve (50%) patients received surgery and radiotherapy, respectively. With a median follow-up of 46.2 months (range 9.6-124.8 months), a total of five (20%) patients died of disease progression; the five-year overall survival (OS) and disease-free survival (DFS) rates were 82.3% and 64.9%, respectively.-Seven patients with seminoma GCTs received post-chemotherapy irradiation were alive with sustained CR (5-year OS and DFS, 100%, respectively). Five patients with NSGCTs were administered irradiation and one relapsed 35 months later and died of metastasis (5-year OS, 100%; 5-year DFS 66.7%). Univariate analysis identified histology and stage were prognostic factors.

CONCLUSION

Multimodality treatment approach of chemotherapy followed by radiation consolidation ensured long-term survival in primary advanced MMGCTs. Further research is warranted to improve the prognosis of children with primary advanced MMGCTs.

Metachronous Germ Cell Tumors of the Mediastinum

We report a rare case of mediastinal nonseminomatous germ cell tumor arising after 2 complete resections of mediastinal mature teratomas 18 and 10 years prior. After three cycles of chemotherapy for the mediastinal nonseminomatous germ cell tumor, the serum α-fetoprotein and β-human chorionic gonadotropin levels were normalized. However, chest radiography revealed that the mediastinal tumor had remarkably increased in size, and thus growing teratoma syndrome was diagnosed. The patient underwent urgent resection of the tumor, and a pathologic examination showed an encapsulated mature teratoma without any malignant viable cells. The patient was well without disease 54 months after the third operation.