Elsevier

Current Surgery

Volume 61, Issue 6, November–December 2004, Pages 576-579
Current Surgery

Original reports
Anterior mediastinal nonseminomatous germ cell tumor with malignant transformation: A case report

Presented and awarded the Surgeon General’s Award for the Thoracic Surgery Scientific Session at the 50th Annual Symposium of the Society of Air Force Clinical Surgeons.
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Objective

We report a case of a 21-year-old man who presented with the unusual symptoms of heart failure and was found to have an anterior mediastinal yolk sac tumor.

Methods

A review of the literature using the Ovid search engine was performed.

Results

The patient was treated with the current standard of neoadjuvant chemotherapy: bleomycin, etoposide, and cisplatin (BEP) with marked reduction in tumor size, followed by en bloc surgical resection. The final pathology revealed teratoma with malignant change: chondrosarcoma, adenocarcinoma, and poorly differentiated sarcoma.

Conclusions

This is a rare initial presentation of an anterior mediastinal germ-cell tumor with treatment consisting of neoadjuvant therapy and surgical resection. In addition, we present the adverse and extremely rare malignant degeneration of this tumor.

Introduction

Primary neoplasms of the anterior mediastinum are a rare occurrence; nonseminomatous germ cell tumors (NSGCT) account for a small percentage of these. In a review of 702 cases of primary anterior mediastinal tumors in adults, 47% were thymic tumors (primarily thymomas), 22% were lymphomas, 16% were endocrine tumors, and 15% were germ-cell tumors.1 Each of these clinical entities varies in their presentation, diagnosis, treatment, and prognosis. Thymoma may present with symptoms of a paraneoplastic syndrome, such as myasthenia gravis, hypogammaglobulinemia, or pure red cell aplasia; is usually diagnosed with fine needle aspiration (FNA) biopsy; and is generally cured with complete surgical excision.2 Lymphoma should be diagnosed with excisional biopsy but is treated with chemotherapy.3 Germ cell tumors represent a spectrum of the disease process ranging from benign encapsulated masses to extremely aggressive invasive neoplasms. This case report illustrates an unusual presentation of a rare benign primary mediastinal germ cell tumor, which after appropriate neoadjuvant treatment, progressed to malignant degeneration with metastases.

Section snippets

Case report

A previously healthy 20-year-old Hispanic man presented to the Emergency Department with complaints of 1 week of intermittent nausea, fatigue, orthopnea, and minimal dysphagia. The remainder of his medical history was unremarkable. His physical examination revealed a generally healthy appearing young man with no signs of superior vena cava syndrome, no lymphadenopathy, and no abnormalities on genital examination. Significant positive findings included distant heart sounds as well as bilateral

Discussion

The anterior mediastinum is the most common extragonadal site for germ cell tumors.7 These tumors account for only 5% of the 7000 germ cell tumors identified each year in the United States,8with approximately 85% benign. Germ cell neoplasms are classified as either seminomatous or nonseminomatous. Nonseminomatous are further subclassified into embryonal, yolk sac (endodermal sinus), teratocarcinoma, choriocarcinoma, or mixed. Overall, 15% of germ cell tumors have malignant potential, the

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The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Government, the Department of Defense, or the United States Air Force.

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