eMedicine Specialties > Radiology > Chest

Mediastinum, Germ Cell Tumors: Follow-up

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist, North Manchester General Hospital, The Pennine Acute NHS Trust, Manchester UK
Coauthor(s): Klaus L Irion, MD, PhD, Consulting Staff, The Cardiothoracic Centre Liverpool NHS Trust, The Royal Liverpool University Hospital, UK; Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute; Nigel Thomas, MBBS, Vice-Chair, Manchester (North) Research Ethics Committee; Honorary Lecturer, Visiting Professor, University of Salford, UK
Contributor Information and Disclosures

Updated: Jul 25, 2008

Intervention

Fine-needle aspiration (FNA) or core-needle biopsy guided by sonography, conventional radiography, or CT is considered safe and is increasingly used instead of surgical biopsy. Experts in cytopathology are needed to interpret the results. Differentiation between various types of mediastinal tumors such as thymomas, lymphomas, and germ cell tumors is possible when core-needle biopsy material is subjected to special histologic staining, including immunohistochemical techniques.

Cervical mediastinoscopy and substernal extended mediastinoscopy are techniques commonly used in staging bronchogenic cancers and in evaluating the retrovascular pretracheal area of the mediastinum. These techniques may be modified and applied as substernal extended mediastinoscopy to evaluate the prevascular area of the mediastinum. Thymic masses and any tumors found in the anterior mediastinum, such as germ cell tumors and lymph nodes of the aortopulmonary window, are accessible by biopsy.

Anterior mediastinotomy through a parasternal approach has been used in situations in which standard cervical mediastinoscopy is inadequate. In many centers, the technique is being replaced by extended cervical mediastinoscopy or video-assisted thoracic surgical techniques. Video-assisted thoracoscopy is increasingly being used for mediastinal mass biopsy and resection of small masses.

Despite the fact that numerous minimally invasive options are available for tissue sampling in the diagnosis of mediastinal tumors and cysts, open surgical access by means of sternotomy and thoracotomy may be needed.

Treatment selection for a given mediastinal tumor or cyst depends on the diagnosis. Surgical resection is indicated for benign teratomas. Although a seminoma often requires biopsy, primary resection of seminoma is indicated only in select cases. These include cases involving asymptomatic patients, cases in which the mass does not extend beyond the margins of the anterior mediastinal compartment, and cases in which no signs of metastatic spread are present.

Surgical resection is not the primary treatment for malignant nonseminomatous germ cell tumors. Surgical resection may be indicated for a residual mediastinal mass in patients in whom levels of serum tumor markers are negative following the completion of a course of chemotherapy. Resection is performed both for diagnosing the remaining mass and for preventing possible future malignant degeneration of any residual abnormal tissue.

The preferred treatment of mediastinal seminoma is radiation therapy. Chemotherapy is often reserved for patients older than 35 years or for those with features of advanced disease. Surgery has no role in the treatment of mediastinal seminomas. Mediastinal tumors for which nonsurgical treatment is advocated include seminomas, malignant nonseminomatous germ cell tumors, lymphomas, and advanced-stage neuroblastomas in children. Surgical resection is advised in nonseminomatous malignant germ cell tumors of the mediastinum when imaging studies show residual mediastinal disease after appropriate chemotherapy.

Residual masses are observed in 10-20% of cases after chemotherapy. Resection of residual masses in these cases is performed to determine whether viable residual tumor is present or absent. If viable tumor is found, additional chemotherapy may or may not be considered. Resection of residual masses after medical therapy is somewhat debated.

Some clinicians maintain that no surgical intervention is needed and that imaging follow-up is a more appropriate course. Others maintain that residual masses greater than a specified size should be resected. Surgery is the treatment of choice for benign teratomas.27,28,29,30,31

Medicolegal Pitfalls

  • Accurate tissue diagnosis is required because the treatment and prognosis depend on the type of germ cell tumor present.

Special Concerns

  • In superior vena cava syndrome secondary to the presence of germ cell tumors, careful planning of intravenous line placement is required, and image-guided placement should be considered.
  • Intravenous lines should not be placed in the neck, because jugular venous pressure may be markedly elevated, and accidental extravasation of blood from these sites may compromise the airway.
 


More on Mediastinum, Germ Cell Tumors

Overview: Mediastinum, Germ Cell Tumors
Imaging: Mediastinum, Germ Cell Tumors
Follow-up: Mediastinum, Germ Cell Tumors
Multimedia: Mediastinum, Germ Cell Tumors
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Giron J, Fajadet P, Sans N, et al. Diagnostic approach to mediastinal masses. Eur J Radiol. Mar 1998;27(1):21-42. [Medline].

  2. Luketich JD, Ginsberg RJ. The current management of patients with mediastinal tumors. Adv Surg. 1996;30:311-32. [Medline].

  3. Rosado-de-Christenson ML, Templeton PA, Moran CA. From the archives of the AFIP. Mediastinal germ cell tumors: radiologic and pathologic correlation. Radiographics. Sep 1992;12(5):1013-30. [Medline].

  4. Shields TW. Overview of primary mediastinal tumors and cysts. In: Shields TW, et al, eds. General Thoracic Surgery. Vol 2. Philadelphia, PA: Lippencott, Williams & Wilkins;. 2000: 2105-9.

  5. Strollo DC, Rosado-de-Christenson ML. Tumors of the thymus. J Thorac Imaging. Jul 1999;14(3):152-71. [Medline].

  6. Strollo DC, Rosado de Christenson ML, Jett JR. Primary mediastinal tumors. Part 1: tumors of the anterior mediastinum. Chest. Aug 1997;112(2):511-22. [Medline]. [Full Text].

  7. Takeda S, Miyoshi S, Ohta M, et al. Primary germ cell tumors in the mediastinum: a 50-year experience at asingle Japanese institution. Cancer. Jan 15 2003;97(2):367-76. [Medline].

  8. Virgo KS, Johnson FE, Naunheim KS. Follow-up of patients with thoracic malignancies. Surg Oncol Clin N Am. Apr 1999;8(2):355-69. [Medline].

  9. Weidner N. Germ-cell tumors of the mediastinum. Semin Diagn Pathol. Feb 1999;16(1):42-50. [Medline].

  10. Whooley BP, Urschel JD, Antkowiak JG, Takita H. Primary tumors of the mediastinum. J Surg Oncol. Feb 1999;70(2):95-9. [Medline].

  11. Chhieng DC, Lin O, Moran CA, et al. Fine-needle aspiration biopsy of nonteratomatous germ cell tumors of themediastinum. Am J Clin Pathol. Sep 2002;118(3):418-24. [Medline].

  12. Das DK, Pant CS, Rath B, et al. Fine-needle aspiration diagnosis of intra-thoracic and intra-abdominallesions: review of experience in the pediatric age group. Diagn Cytopathol. Aug 1993;9(4):383-93. [Medline].

  13. Shabb NS, Fahl M, Shabb B, et al. Fine-needle aspiration of the mediastinum: a clinical, radiologic, cytologic, and histologic study of 42 cases. Diagn Cytopathol. Dec 1998;19(6):428-36. [Medline].

  14. Singh HK, Silverman JF, Powers CN, et al. Diagnostic pitfalls in fine-needle aspiration biopsy of the mediastinum. Diagn Cytopathol. Aug 1997;17(2):121-6. [Medline].

  15. Yang GC, Hwang SJ, Yee HT. Fine-needle aspiration cytology of unusual germ cell tumors of the mediastinum: atypical seminoma and parietal yolk sac tumor. Diagn Cytopathol. Aug 2002;27(2):69-74. [Medline].

  16. Geibel A, Kasper W, Keck A, et al. Diagnosis, localization and evaluation of malignancy of heart and mediastinal tumors by conventional and transesophageal echocardiography. Acta Cardiol. 1996;51(5):395-408. [Medline].

  17. Jeung MY, Gasser B, Gangi A, et al. Imaging of cystic masses of the mediastinum. Radiographics. Oct 2002;22 Spec No:S79-93. [Medline].

  18. Mathews VP, Broome DR, Smith RR, et al. Neuroimaging of disseminated germ cell neoplasms. AJR Am J Roentgenol. Jun 1990;154(6):1299-304. [Medline].

  19. Moeller KH, Rosado-de-Christenson ML, Templeton PA. Mediastinal mature teratoma: imaging features. AJR Am J Roentgenol. Oct 1997;169(4):985-90. [Medline].

  20. Takao H, Shimizu S, Doi I, Watanabe T. Primary malignant melanoma of the anterior mediastinum: CT and MR findings. Clin Imaging. Jan-Feb 2008;32(1):58-60. [Medline].

  21. Boiselle PM. MR imaging of thoracic lymph nodes. A comparison of computed tomography and positron emission tomography. Magn Reson Imaging Clin N Am. Feb 2000;8(1):33-41. [Medline].

  22. Choi SJ, Lee JS, Song KS, Lim TH. Mediastinal teratoma: CT differentiation of ruptured and unrupturedtumors. AJR Am J Roentgenol. Sep 1998;171(3):591-4. [Medline].

  23. Erasmus JJ, McAdams HP, Donnelly LF, Spritzer CE. MR imaging of mediastinal masses. Magn Reson Imaging Clin N Am. Feb 2000;8(1):59-89. [Medline].

  24. Serna DL, Aryan HE, Chang KJ, et al. An early comparison between endoscopic ultrasound-guided fine-needleaspiration and mediastinoscopy for diagnosis of mediastinal malignancy. Am Surg. Oct 1998;64(10):1014-8. [Medline].

  25. Bachmann J, Ernestus K, Werner T, Garnier Y, Mallmann P, Pietsch C. Detection of primary choriocarcinoma in the mediastinum by F-18 FDG positron emission tomography. Clin Nucl Med. Aug 2007;32(8):663-5. [Medline].

  26. Rubello D, Rampin L, Nanni C, Banti E, Ferdeghini M, Fanti S, et al. The role of 18F-FDG PET/CT in detecting metastatic deposits of recurrent medullary thyroid carcinoma: a prospective study. Eur J Surg Oncol. May 2008;34(5):581-6. [Medline].

  27. Rieger R, Schrenk P, Woisetschlager R, Wayand W. Videothoracoscopy for the management of mediastinal mass lesions. Surg Endosc. Jul 1996;10(7):715-7. [Medline].

  28. Bacha EA, Chapelier AR, Macchiarini P, et al. Surgery for invasive primary mediastinal tumors. Ann Thorac Surg. Jul 1998;66(1):234-9. [Medline].

  29. Kaga K, Nishiumi N, Iwasaki M, Inoue H. Thoracoscopic diagnosis and treatment of mediastinal masses. Usefulness of the Two Windows Method. J Cardiovasc Surg (Torino). Feb 1999;40(1):157-60. [Medline].

  30. Lanciego C, Chacon JL, Julian A, et al. Stenting as first option for endovascular treatment of malignant superior vena cava syndrome. AJR Am J Roentgenol. Sep 2001;177(3):585-93. [Medline].

  31. Stremmel C, Passlick B. [Surgery of mediastinal tumors.]. Chirurg. Jan 2008;79(1):9-17. [Medline].

  32. Coskun U, Gunel N, Yildirim Y, et al. Primary mediastinal yolk sac tumor in a 66-year-old woman. Med Princ Pract. Oct-Dec 2002;11(4):218-20. [Medline].

  33. De Backer A, Madern GC, Pieters R, Haentjens P, Hakvoort-Cammel FG, Oosterhuis JW, et al. Influence of tumor site and histology on long-term survival in 193 children with extracranial germ cell tumors. Eur J Pediatr Surg. Feb 2008;18(1):1-6. [Medline].

  34. Hsu YJ, Pai L, Chen YC, et al. Extragonadal germ cell tumors in Taiwan: an analysis of treatment resultsof 59 patients. Cancer. Aug 15 2002;95(4):766-74. [Medline].

  35. Kesler KA, Brooks JA, Rieger KM, et al. Mediastinal metastases from testicular nonseminomatous germ cell tumors: patterns of dissemination and predictors of long-term survival with surgery. J Thorac Cardiovasc Surg. Apr 2003;125(4):913-23. [Medline].

  36. Leshnower BG, Morris RJ, Pechet TT. Management of an anterior mediastinal pheochromocytoma causing tracheomalacia. Ann Thorac Surg. Dec 2007;84(6):2088-90. [Medline].

  37. Malagón HD, Valdez AM, Moran CA, Suster S. Germ cell tumors with sarcomatous components: a clinicopathologic and immunohistochemical study of 46 cases. Am J Surg Pathol. Sep 2007;31(9):1356-62. [Medline].

  38. Mukai S, Yao H, Yamamura M, et al. [Thymic carcinoma (mixed small cell undifferentiated squamous cell carcinoma); report of a case]. Kyobu Geka. Jun 2003;56(6):509-12. [Medline].

  39. Murakawa Y, Satake N, Kato S, et al. Alpha-FP normalization as a prognostic factor for mediastinal originembryonal carcinoma: report of five cases. Intern Med. Oct 2002;41(10):883-8. [Medline].

  40. Ozergin U, Gormus N, Aribas OK, et al. Benign mature cystic teratoma of the anterior mediastinum leading to heart failure: report of a case. Surg Today. 2003;33(7):518-20. [Medline].

  41. Protopapas Z, Westcott JL. Transthoracic hilar and mediastinal biopsy. J Thorac Imaging. Oct 1997;12(4):250-8. [Medline].

  42. Robertson SA, Nazir S, Bowker C, Lakhoo K. Superior mediastinal teratoma containing well-differentiated bowel. Fetal Pediatr Pathol. Mar-Apr 2007;26(2):69-73. [Medline].

  43. Shiota S, Nakaya Y, Sakamoto K, et al. Spontaneous hemothorax secondary to immature teratoma of the mediastinum. Intern Med. Sep 1999;38(9):726-8. [Medline].

  44. Sinclair DS, Bolen MA, King MA. Mature teratoma within the posterior mediastinum. J Thorac Imaging. Jan 2003;18(1):53-5. [Medline].

  45. Yokoi K, Tanaka N, Furukawa K, Ishikawa N, Seya T, Horiba K, et al. Male choriocarcinoma with metastasis to the jejunum: a case report and review of the literature. J Nippon Med Sch. Apr 2008;75(2):116-21. [Medline].

[ CLOSE WINDOW ]

Further Reading

Related eMedicine topics

 Germ Cell Tumors

Mediastinal Cysts

Mediastinal Seminoma

[ CLOSE WINDOW ]

Keywords

germ cell tumors, germ cell neoplasm, mediastinal germ cell tumor, GCTs, Klinefelter syndrome, teratoma, seminoma, epidermoid cyst, dermoids, dermoid cyst, mediastinal dermoid

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist, North Manchester General Hospital, The Pennine Acute NHS Trust, Manchester UK
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Institute of Ultrasound in Medicine, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Klaus L Irion, MD, PhD, Consulting Staff, The Cardiothoracic Centre Liverpool NHS Trust, The Royal Liverpool University Hospital, UK
Klaus L Irion, MD, PhD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Sumaira MacDonald, MBChB, PhD, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

Nigel Thomas, MBBS, Vice-Chair, Manchester (North) Research Ethics Committee; Honorary Lecturer, Visiting Professor, University of Salford, UK
Disclosure: Nothing to disclose.

Medical Editor

Kitt Shaffer, MD, PhD, Director of Undergraduate Medical Education, Associate Professor, Department of Radiology, Cambridge Health Alliance
Kitt Shaffer, MD, PhD is a member of the following medical societies: American Roentgen Ray Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

W Richard Webb, MD, Professor, Department of Radiology, University of California at San Francisco
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Kavita Garg, MD, Professor, Department of Radiology, University of Colorado Health Sciences Center
Kavita Garg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.