eMedicine Specialties > Thoracic Surgery > Tumors

Mediastinal Seminoma: Workup

Author: Shabir Bhimji, MD, PhD, Locum Cardiothoracic and Vascular Surgeon, Saudi Arabia and Middle East Hospitals
Contributor Information and Disclosures

Updated: Oct 31, 2008

Workup

Laboratory Studies

  • Laboratory features
    • Alpha-fetoprotein (AFP) and human chorionic gonadotrophin (HCG) levels are usually not elevated in patients with pure seminomas, although approximately 10% may have a slight increase in levels of these tumor markers. If levels of HCG, AFP, or both are elevated, diagnoses other than seminoma should be considered.
    • Serum low-density lipoprotein levels are frequently elevated in patients with seminomas.
    • Patients with pure seminomas have only a mild elevation in HCG levels; however, a mixed tumor may be present and cause elevations in AFP levels.

Imaging Studies

  • A benign tumor may not be visible on a plain chest radiograph as a mediastinal mass. Usually, the tumor must be sufficiently large in order to show any evidence of mediastinal widening.
  • In 30% of cases, seminomas manifest as coincidental findings. These tumors tend to become quite large before they cause symptoms, yet they do not demonstrate pathognomonic radiographic findings.
  • CT scans and MRIs are useful for determining the precise anatomic relationship and morphologic features.
  • CT scans are usually adequate, but consider MRIs if surgery is a possibility. MRIs have better resolution of nearby tissue and vascular invasion.
  • CT scan features of seminomas include the following:
    • Benign tumors tend to be round masses that grow slowly. They are most commonly located in the superior mediastinum. Calcification may be present but is usually of no help in the diagnosis because calcification is also observed in other anterior mediastinal tumors, including thymomas and thyroid goiters.
    • In general, malignant tumors tend to be larger than benign ones, to be lobulated, and to grow faster.
    • CT scanning may also reveal evidence of mediastinal invasion, adenopathy, and metastatic disease in the lungs.

Diagnostic Procedures

  • Needle biopsy
    • In general, tissue diagnosis is necessary even if typical radiologic features are noted or if serum levels of markers are elevated. Percutaneously performed aspiration needle biopsy is the first step.
    • If the tumor is encroaching the trachea or a bronchus, transbronchial biopsy can be performed.
    • A CT-guided needle biopsy is performed if the diagnosis cannot be confirmed with the aspiration needle or transbronchial biopsy.
    • Cytologic diagnosis is not always sensitive; tissue biopsy is preferred because mediastinal tumors have been diagnosed as lymphomas, which also manifest as bulky lesions in the anterior mediastinum and in persons of the same age range.
  • Open biopsy
    • Occasionally, a percutaneous technique cannot yield adequate tissue or the mass is in a difficult area; in such cases, an open biopsy is required.
    • Open biopsy is best performed as a small anterior thoracotomy. The procedure is generally accomplished with the patient under general anesthesia, and a small parasternal incision is adequate for most patients.
    • Strict airway maintenance is required because large anterior mediastinal tumors can compress the trachea and make intubation difficult. A rigid bronchoscopy cart should always be available during this procedure.
    • All anesthesia must be reversed before extubating the patient. Some patients may require longer intubation times and may be extubated slowly, after the administration of steroids and bronchodilators.
    • The biopsy can also be performed using thoracoscopy. The thoracoscopic procedure facilitates better evaluation of the tumor and allows for biopsy specimens to be taken from multiple, otherwise inaccessible sites.
  • Extragonadal workup
    • Because mediastinal germ cell tumors are not distinguishable from their gonadal counterparts, all extragonadal tissue must be carefully examined.
    • The histology of a mediastinal seminoma is similar to the histology of its gonadal counterpart. All patients with biopsy-proven mediastinal seminomas must undergo careful staging with scrotal examination and sonogram, measurement of serum tumor markers, and CT scanning of the abdomen and retroperitoneum.
    • Blind biopsy of the testes and orchiectomy are not indicated in the workup of seminomas.
    • Evidence of disease below the diaphragm suggests metastasis. The presence of metastatic disease mandates the use of induction chemotherapy in the management of mediastinal seminomas.

More on Mediastinal Seminoma

Overview: Mediastinal Seminoma
Workup: Mediastinal Seminoma
Treatment: Mediastinal Seminoma
Follow-up: Mediastinal Seminoma
References
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References

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Further Reading

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Keywords

mediastinal seminoma, germ cell, germ cell tumor, germ-cell tumor, germ cell mass, germ-cell mass, malignant germ cells of the mediastinum, seminoma, radiation, mediastinum, gonads, mediastinal mass, cisplatin-based chemotherapy, respiratory compromise, intrathoracic mass, anterior mediastinal mass, extragonadal malignancy, totipotential cells, spermatogenesis, median sternotomy, median sternotomy exploration, teratoma, radiation, chemotherapy, cisplatin, vinca alkaloids, etoposide, ifosfamide, bleomycin, combination chemotherapy, induction chemotherapy, mediastinum cancer, mediastinal cancer, malignant seminoma, benign seminoma

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Contributor Information and Disclosures

Author

Shabir Bhimji, MD, PhD, Locum Cardiothoracic and Vascular Surgeon, Saudi Arabia and Middle East Hospitals
Shabir Bhimji, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Chest Physicians, American Lung Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine
Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, Southwest Oncology Group, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shreekanth V Karwande, MBBS, Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center
Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

 
 
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