Mediastinal germ cell tumors: Surgical experience with twenty nine patients

None; None; None; None

Abstracts

Background: To review and inform about the experience acquired with management of germ cell tumors of the mediastinum at the Calderón Guardia Hospital. Methods: Twenty-nine patients with mediastinal germ cell tumors were operated between 1986 and 2012 in the Thoracic Surgery Department. General information was obtained from the department´s database and these patients’ clinical files were reviewed with authorization from the Hospital’s Ethics Committee. Results: Subjects were predominantly young males with a gender ratio of 13.5:1 and a mean age of 26. Masses were located in the anterior mediastinum in 28 cases and in the middle mediastinum in 1 case. Twenty-seven cases were suspected due tomediastinal widening on chest x-ray examination, 1 to pleural effusion and 1 to pleural effusion and mediastinal widening. The most frequently found symptoms were dyspnea, retrosternal chest pain, fever, cough, weight loss, superior vena cava syndrome, hemoptysis and gynecomastia in one male with coriocarcinoma. Tissue for diagnosis was obtained in 14 cases by mediastinotomy, in 8 by thoracotomy, in 4 by video assisted thoracoscopy, in 1 by sternotomy, in 1 by mediastinoscopy and in 1 by bronchoscopy. Conclusion: Germ cell tumors of the mediastinum are infrequent, with higher prevalence in young males. Complete surgical excision remains the treatment of choice for resectable tumors, which are usually of more benign histology. Cure is not guaranteed by apparent total resection of malignant germ cell tumors, therefore primary or adjuvant chemotherapy should always be considered given that it was curative for some partially resected tumors and others with apparent total resection recidivated.

Germ cell tumors; extragonadal germ cell tumors; tumors of the mediastinum

Objetivo: revisar e informar la experiencia adquirida con el manejo de tumores de células germinales del mediastino, en el Hospital Calderón Guardia. Metodología: previa autorización del Comité de Ética del Hospital, se realizó un análisis descriptivo de la información acumulada en la base de datos del Servicio de Cirugía de Tórax y los expedientes clínicos de 29 pacientes con tumores de células germinales del mediastino, operados entre 1986 y 2012. Resultados: se encontró mayor frecuencia en hombres jóvenes con una relación por género de 13.5:1, y edad promedio de 26 años. La localización correspondió en 28 casos al mediastino antero superior y 1 al medio. La presentación en 27 casos fue una radiografía de tórax con ensanchamiento del mediastino, uno con derrame pleural y uno con derrame pleural y mediastino ensanchado. Los síntomas más frecuentes fueron: disnea, dolor retroesternal, fiebre, tos, pérdida de peso, síndrome de vena cava superior, hemoptisis y ginecomastia en un varón con coriocarcinoma. La muestra para diagnóstico se obtuvo por mediastinotomía en 14 casos, toracotomía en 8, videotoracoscopia en 4, esternotomía en 1, mediastinoscopia en 1 y broncoscopia en 1. Conclusión: los tumores germinales del mediastino son infrecuentes; la extirpación quirúrgica es el tratamiento de elección para los técnicamente resecables y se acompaña de curación de los benignos. En los malignos, la aparente resección completa no es garantía de curación, por lo que debe considerarse la quimioterapia adyuvante, que demostró ser de gran utilidad, por cuanto varios tumores parcialmente resecados se curaron con quimioterapia, y algunos con aparente resección completa recidivaron. los tumores germinales del mediastino son infrecuentes; la extirpación quirúrgica es el tratamiento de elección para los técnicamente resecables y se acompaña de curación de los benignos. En los malignos, la aparente resección completa no es garantía de curación, por lo que debe considerarse la quimioterapia adyuvante, que demostró ser de gran utilidad, por cuanto varios tumores parcialmente resecados se curaron con quimioterapia, y algunos con aparente resección completa recidivaron.

tumores de células germinales; tumores de células germinativas extragonadales; tumores del mediastino

Background: To review and inform about the experience acquired with management of germ cell tumors of the mediastinum at the Calderón Guardia Hospital. Methods: Twenty-nine patients with mediastinal germ cell tumors were operated between 1986 and 2012 in the Thoracic Surgery Department. General information was obtained from the department´s database and these patients’ clinical files were reviewed with authorization from the Hospital’s Ethics Committee. Results: Subjects were predominantly young males with a gender ratio of 13.5:1 and a mean age of 26. Masses were located in the anterior mediastinum in 28 cases and in the middle mediastinum in 1 case. Twenty-seven cases were suspected due tomediastinal widening on chest x-ray examination, 1 to pleural effusion and 1 to pleural effusion and mediastinal widening. The most frequently found symptoms were dyspnea, retrosternal chest pain, fever, cough, weight loss, superior vena cava syndrome, hemoptysis and gynecomastia in one male with coriocarcinoma. Tissue for diagnosis was obtained in 14 cases by mediastinotomy, in 8 by thoracotomy, in 4 by video assisted thoracoscopy, in 1 by sternotomy, in 1 by mediastinoscopy and in 1 by bronchoscopy. Conclusion: Germ cell tumors of the mediastinum are infrequent, with higher prevalence in young males. Complete surgical excision remains the treatment of choice for resectable tumors, which are usually of more benign histology. Cure is not guaranteed by apparent total resection of malignant germ cell tumors, therefore primary or adjuvant chemotherapy should always be considered given that it was curative for some partially resected tumors and others with apparent total resection recidivated. Germ cell tumors of the mediastinum are infrequent, with higher prevalence in young males. Complete surgical excision remains the treatment of choice for resectable tumors, which are usually of more benign histology. Cure is not guaranteed by apparent total resection of malignant germ cell tumors, therefore primary or adjuvant chemotherapy should always be considered given that it was curative for some partially resected tumors and others with apparent total resection recidivated.

Germ cell tumors; extragonadal germ cell tumors; tumors of the mediastinum

Mediastinal germ cell tumors.

José A. Mainieri-Hidalgo¹,Valeria Rees-Alpízar², Isabel Gamboa-González² y Marcelo Mainieri-Breedy²

Work done at the Thoracic Surgery Department, “Dr. R. A. Calderón Guardia” Hospital. Caja Costarricense de Seguro Social Authors´ affiliation: ¹Thoracic Surgery Department “Dr. R. A. Calderón Guardia” Hospital. ²Medical students. MedicalSciencesUniversity. * mainierijose@hotmail.com

CalderónGuardiaHospital.

2012 in the Thoracic Surgery Department. General information was obtained from the department´s database and these patients’ clinical files were reviewed with authorization from the Hospital’s Ethics Committee.

¹so the theory is that some of these cells may be left in the mediastinum and they give rise to germ cell tumors. Another theory says that they are metastatic tumor cells that originated in the gonads, however, it is rare to find the association of mediastinal germ cell tumors with gonadal tumors.²

³

⁴

⁵

⁶

⁷In some cases, surgical resection of the residual tumor is necessary, being of a good prognosis the finding of necrotizing tissue.^8,9

The presentation, in 27 cases, was with widened of the mediastinum at the chest X-rat, one with a pleural effusion and one with pleural effusion and widened of the mediastinum. Only in 24 cases adequate clinical information was found about symptoms in the clinical record; 4 patients were asymptomatic, 20 were symptomatic and the most common symptoms were: 16 cases with dyspnea, 12 cases with retrosternal pain or discomfort, 11 cases had fever, 9 cases had cough, 8 cases had weight loss, 8 cases had superior vena cava syndrome, 1 case had hemoptysis and 1 case had male gynecomastia in a patient with choriocarcinoma.

Table 1, where the highest frequency was mixed tumors, then followed by teratomas and seminomas, and it is less frequent to find coriocacinomas and yolk sac tumors.

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Table 1

¹⁰The Thoracic Surgery Department of HCG, is a reference center, and in a period of 26 years only 29 patients were operated with a rate of 1.1 case per year. Some tumors were diagnosed and treated using exclusively serological markers, so the frequency is higher than the one reported.¹¹In a study by Navarro et al, in metropolitan hospitals in Costa Rica in 1996, germ cell tumor was the most frequent mediastinal tumor.¹²

¹³Diagnosis is performed when looking at an abnormal widening of the mediastinum and CT scan provides valuable information regarding the particular characteristics of the tumor, especially to plan the route to take a biopsy or to perform a surgical approach.¹⁴

^{15, 16}

⁶

⁹

¹⁷

References

References

1. Ronson RS, Duarte I, Miller JI. Embryology and surgical anatomy of the mediastinum with clinical implications. Surg ClinNA 2000; 80:157-169.
2. Díaz VM, Muñoz P, Shahi, Hernández B, Encinas S, Arranz JA, Pérez G. Tumores germinales mediastínicos. Ann Med Interna2008; 25:241-243.
3. Craig N. Testicular Cancer. Curr ProbCancer 1998; 22:187-274.
4. Dowe BV, Sterman DH, Musani AJ. Tumors of the Mediastinum.Chest 2005; 128:2893-2909.
5. Moran CA, Suster S. Primary Germ Cell Tumors of the Mediastinum. Analysis of 322 cases with special emphasis on teratomatous lesions and a proposal for histopathologic classification and clinical staging. Cancer 1997; 80:681-690.
6. Hiroshi D. Diagnostic Strategies for Mediastinal Tumors and Cysts. Thorac Surg Clin2009; 19:29-35.
7. Bokemeyer C, Droz JP, Horwich A, Gerl A, Fossa SD, Beyer J, Kanz L, et al. Extragonadal seminomaan international multicenter analysis of prognostic factors and long term treatment outcome. Cancer 2001; 91:1394-1401.
8. Kesler K, Einhorn L. Multimodality Treatment of Germ Cells Tumors of the Mediastinum. Thorac Surg Clin2009; 19:63-69.
9. Ganjoo K, Rieger K, Kesler K, Sharma M, Heilman D, Einhorn L. Results of modern therapy for patients with mediastinal nonseminomatousgerm cell tumors. Cancer 2000; 88:1051-6.
10. Johnson DE, Laneri JP, Mountain CF, Luna M. Extragonadal germ cell tumors. Surgery 1973; 73:85-90.
11. Hori K, Uematsu K, Yasoshima H, Yamada A, Sakurai K, Ohya M. Testicular seminoma with human chorionic gonadotopin production. Pathol Int1907; 47:592-599.
12. Navarro M, Luis G, Salazar C. Análisis y seguimiento de pacientes con tumores mediastinales egresados de los hospitales metropolitanos de Costa Rica durante 1996. Acta Méd Costarricense2003; 45:68-74.
13. Silverman NA, Sabiston DC. Mediastinal masses. Surg ClinNorth Am 1980; 60:757-777.
14. Muller NL. Computed tomographyand magnetic resonanceimaging: past, present and future: Eur Resp J Suppl2002; 35:2-12.
15. Olak J. Paraesternal mediastinotomy: Chest ClinN Am 1996; 6:31-40.
16. Yim AP, Lee TW, IzzatMB, Wan S. Place of video thoracoscopy in thoracic surgical patients. Worl J Surg2001; 25:157-161.
17. Schomoll HJ, Souchon R, Krege S, Albers P, Beyer J, Kollmannsberg C, Fossa SD, et al. European consensus on diagnosis and treatment of germ cell cancer; a report of the European Germ Cell Cancer Consensus Group. Ann Oncol 2004; 15:1377-1399.

en_bart05v55n3

Received: November 8, 2012 Accepted: May 2, 2013

References

1. Ronson RS, Duarte I, Miller JI. Embryology and surgical anatomy of the mediastinum with clinical implications. Surg ClinNA 2000; 80:157-169.
2. Díaz VM, Muñoz P, Shahi, Hernández B, Encinas S, Arranz JA, Pérez G. Tumores germinales mediastínicos. Ann Med Interna2008; 25:241-243.
3. Craig N. Testicular Cancer. Curr ProbCancer 1998; 22:187-274.
4. Dowe BV, Sterman DH, Musani AJ. Tumors of the Mediastinum.Chest 2005; 128:2893-2909.
5. Moran CA, Suster S. Primary Germ Cell Tumors of the Mediastinum. Analysis of 322 cases with special emphasis on teratomatous lesions and a proposal for histopathologic classification and clinical staging. Cancer 1997; 80:681-690.
6. Hiroshi D. Diagnostic Strategies for Mediastinal Tumors and Cysts. Thorac Surg Clin2009; 19:29-35.
7. Bokemeyer C, Droz JP, Horwich A, Gerl A, Fossa SD, Beyer J, Kanz L, et al. Extragonadal seminomaan international multicenter analysis of prognostic factors and long term treatment outcome. Cancer 2001; 91:1394-1401.
8. Kesler K, Einhorn L. Multimodality Treatment of Germ Cells Tumors of the Mediastinum. Thorac Surg Clin2009; 19:63-69.
9. Ganjoo K, Rieger K, Kesler K, Sharma M, Heilman D, Einhorn L. Results of modern therapy for patients with mediastinal nonseminomatousgerm cell tumors. Cancer 2000; 88:1051-6.
10. Johnson DE, Laneri JP, Mountain CF, Luna M. Extragonadal germ cell tumors. Surgery 1973; 73:85-90.
11. Hori K, Uematsu K, Yasoshima H, Yamada A, Sakurai K, Ohya M. Testicular seminoma with human chorionic gonadotopin production. Pathol Int1907; 47:592-599.
12. Navarro M, Luis G, Salazar C. Análisis y seguimiento de pacientes con tumores mediastinales egresados de los hospitales metropolitanos de Costa Rica durante 1996. Acta Méd Costarricense2003; 45:68-74.
13. Silverman NA, Sabiston DC. Mediastinal masses. Surg ClinNorth Am 1980; 60:757-777.
14. Muller NL. Computed tomographyand magnetic resonanceimaging: past, present and future: Eur Resp J Suppl2002; 35:2-12.
15. Olak J. Paraesternal mediastinotomy: Chest ClinN Am 1996; 6:31-40.
16. Yim AP, Lee TW, IzzatMB, Wan S. Place of video thoracoscopy in thoracic surgical patients. Worl J Surg2001; 25:157-161.
17. Schomoll HJ, Souchon R, Krege S, Albers P, Beyer J, Kollmannsberg C, Fossa SD, et al. European consensus on diagnosis and treatment of germ cell cancer; a report of the European Germ Cell Cancer Consensus Group. Ann Oncol 2004; 15:1377-1399.

en_bart05v55n3

Received: November 8, 2012 Accepted: May 2, 2013

Publication Dates

Publication in this collection
11 Sept 2014
Date of issue
Sept 2013

History

Received
08 Nov 2012
Accepted
02 May 2013

[1] 1. Ronson RS, Duarte I, Miller JI. Embryology and surgical anatomy of the mediastinum with clinical implications. Surg ClinNA 2000; 80:157-169.

[2] 2. Díaz VM, Muñoz P, Shahi, Hernández B, Encinas S, Arranz JA, Pérez G. Tumores germinales mediastínicos. Ann Med Interna2008; 25:241-243.

[3] 3. Craig N. Testicular Cancer. Curr ProbCancer 1998; 22:187-274.

[4] 4. Dowe BV, Sterman DH, Musani AJ. Tumors of the Mediastinum.Chest 2005; 128:2893-2909.

[5] 5. Moran CA, Suster S. Primary Germ Cell Tumors of the Mediastinum. Analysis of 322 cases with special emphasis on teratomatous lesions and a proposal for histopathologic classification and clinical staging. Cancer 1997; 80:681-690.

[6] 6. Hiroshi D. Diagnostic Strategies for Mediastinal Tumors and Cysts. Thorac Surg Clin2009; 19:29-35.

[7] 7. Bokemeyer C, Droz JP, Horwich A, Gerl A, Fossa SD, Beyer J, Kanz L, et al. Extragonadal seminomaan international multicenter analysis of prognostic factors and long term treatment outcome. Cancer 2001; 91:1394-1401.

[8] 8. Kesler K, Einhorn L. Multimodality Treatment of Germ Cells Tumors of the Mediastinum. Thorac Surg Clin2009; 19:63-69.

[9] 9. Ganjoo K, Rieger K, Kesler K, Sharma M, Heilman D, Einhorn L. Results of modern therapy for patients with mediastinal nonseminomatousgerm cell tumors. Cancer 2000; 88:1051-6.

[10] 10. Johnson DE, Laneri JP, Mountain CF, Luna M. Extragonadal germ cell tumors. Surgery 1973; 73:85-90.

[11] 11. Hori K, Uematsu K, Yasoshima H, Yamada A, Sakurai K, Ohya M. Testicular seminoma with human chorionic gonadotopin production. Pathol Int1907; 47:592-599.

[12] 12. Navarro M, Luis G, Salazar C. Análisis y seguimiento de pacientes con tumores mediastinales egresados de los hospitales metropolitanos de Costa Rica durante 1996. Acta Méd Costarricense2003; 45:68-74.

[13] 13. Silverman NA, Sabiston DC. Mediastinal masses. Surg ClinNorth Am 1980; 60:757-777.

[14] 14. Muller NL. Computed tomographyand magnetic resonanceimaging: past, present and future: Eur Resp J Suppl2002; 35:2-12.

[15] 15. Olak J. Paraesternal mediastinotomy: Chest ClinN Am 1996; 6:31-40.

[16] 16. Yim AP, Lee TW, IzzatMB, Wan S. Place of video thoracoscopy in thoracic surgical patients. Worl J Surg2001; 25:157-161.

[17] 17. Schomoll HJ, Souchon R, Krege S, Albers P, Beyer J, Kollmannsberg C, Fossa SD, et al. European consensus on diagnosis and treatment of germ cell cancer; a report of the European Germ Cell Cancer Consensus Group. Ann Oncol 2004; 15:1377-1399.

<b>Mediastinal germ cell tumors</b>: <b>Surgical experience with twenty nine patients</b>

Abstracts

References

References

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History