Teratomas and Other Germ Cell Tumors of the Mediastinum Clinical Presentation

Updated: Oct 31, 2017
  • Author: Dale K Mueller, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Presentation

History and Physical Examination

A large percentage of mediastinal tumors and cysts produce no symptoms and are found on an incidental chest radiograph or other imaging study of the thorax performed for an unrelated reason.

Symptoms are present in about one third of adult patients with a mediastinal tumor or cyst but are observed more commonly in the pediatric population where nearly two thirds present with some symptoms, usually related to the respiratory tract. In adults, asymptomatic masses are more likely to be benign. Most patients with seminomas are symptomatic, whereas almost all patients with nonseminomatous germ cell tumors of the mediastinum are symptomatic.

Symptoms associated with the respiratory tract predominate in pediatric patients because airway compression is more likely. This occurs because of the significant amount of malleability of the airway structures and the small size of the chest cavity in infants and children. Symptoms most commonly observed include persistent cough, dyspnea, and stridor. If the location and size of the mass produce partial or complete obstruction, obstructive pneumonia also can occur.

Constitutional symptoms (eg, weight loss, fever, malaise, and vague chest pain) commonly occur with malignant tumors in pediatric patients but can be observed in some adults as well.

Symptoms associated with compression of some portion of the respiratory tract can be produced in adults by benign lesions as well, but this occurs much less frequently than in children. However, malignant lesions are more likely to produce signs and symptoms of obstruction and/or compression because they invade or transfix normal mediastinal structures.

Clinical findings commonly associated with malignancy include cough, dyspnea, stridor, and dysphagia, as well as more dramatic findings such as superior vena cava syndrome (SVCS).

Invasion of the chest wall or pleura by a malignant neoplasm can produce persistent pleural effusions and a significant amount of local pain. Invasion of nearby nerves within the thorax also can produce local and referred pain, as well as various other findings such as hoarseness from recurrent nerve involvement, diaphragmatic paralysis from phrenic nerve involvement, Horner syndrome from autonomic nerve invasion, and even motor paralysis from direct spinal cord involvement. Pain in the shoulder or upper extremity can occur from invasion of the ipsilateral brachial plexus.

Invasion or extrinsic compression of the superior vena cava can produce SVCS.

With reference to malignant germ cell tumors, about 30% of patients found to have mediastinal seminoma are asymptomatic at the time of discovery. When present, symptoms result from local compression or invasion of nearby structures.

In cases of nonseminomatous germ cell tumors, symptoms of compression or invasion of nearby structures virtually always are present at the time of presentation. Patients with this type of tumor usually appear ill and have local or systemic symptoms from metastatic disease.

Various hematologic malignancies and other syndromes can be observed on occasion with nonseminomatous germ cell tumors of the mediastinum. Interestingly, this association is not found to exist with germ cell tumors of gonadal origin.

Mediastinal tumors that produce bioactive substances will be associated with symptoms produced by those substances, as discussed in the previous section.