Mediastinal seminoma difficult to differentiate from thymoma through preoperative biopsy; report of a case

A case of a 36-year-old male patient with mediastinal seminoma is presented. He consulted a physician with a complaint of back pain and an abnormal shadow was detected on chest X-ray. Chest computed tomography (CT) scan revealed a pulmonary nodule and an anteriormediastinal mass. Preoperative percutaneous needle biopsy suggested that the tumor was similar to thymoma. Complete surgical excision of the mediastinal mass was performed. Immunohistochemical studies showed positive staining of the tumor cells with placental alkaline phosphatase. The final diagnosis was seminoma. Additional postoperative chemotherapy (cisplatin + etoposide) was done. He is alive and well 34 months after the operation.     

Spontaneous regression of anterior mediastinal seminoma with normalization of β-human chorionic gonadotropin levels

IntroductionAlthough spontaneous regression (SR) of anterior mediastinal seminoma is very rare with normalization of β-human chorionic gonadotropin (β-hCG) level, video-assisted thoracic surgery (VATS) is the most effective solution for definite diagnosis of indeterminate anterior mediastinal masses.Diagnosis, therapeutic interventions, and outcomesA rare case of an asymptomatic 37-year-old man with an anterior mediastinal mass that was detected on a routine chest X-ray is presented. Computed tomography (CT) showed a large anterior mediastinal tumor with superior vena cava invasion and SR before VATS for definitive diagnosis. On pathology, the definitive diagnosis was seminoma. Microscopic examination showed abundant apoptotic cells within the tumor. Chemotherapy (bleomycin 30 mg/day, etoposide 200 mg/day, cisplatin 40 mg/day) was given to this patient, and the tumor showed high sensitivity.ConclusionAnterior mediastinal seminoma showing SR induced by spontaneous apoptosis of tumor cells may have good sensitivity to chemotherapy, and a good clinical outcome may be achieved in these patients. This case also highlights that VATS is the most effective solution for definite diagnosis of indeterminate anterior mediastinal masses.     

Iterative surgery in germ cell tumor

Between 1979 and 1988, iterative surgery was performed on 13 patients for a germ-cell tumor. Apart from orchidectomy, surgery was not the first modality of treatment. On the other hand, 21 surgical procedures were performed for residual tumoral masses after chemotherapy or recurrences. In one third of the cases, only necrosis of fibrosis was resected. Out of 13 patients, 7 died of tumor; 6 are alive (3 with complete remission). Surgery is always indicated in stage IIA to IV nonseminomatous tumors in case of residual tumoral deposits after chemotherapy. For seminoma, surgery is carried out only for retroperitoneal residues larger than 3 cm in diameter. Surgery is also indicated for persistent pulmonary or mediastinal metastases following chemotherapy. Complete surgical excision of residual masses may be technically difficult but is of prime importance as combined chemotherapy and surgery doubles the complete remission rate in comparison to chemotherapy alone.     

Primitive seminoma of the mediastinum: a case report

In this study, the case has been reported of a 36-year old male who was treated at the Ibn Rochd Oncology Center in Casablanca for a primary mediastinal seminoma revealed by a symptomatology including cough, dyspnea, laterocervical swelling, rachidial pain and gait disorder. The preliminary investigation showed significant mediastinal enlargement with a right pleuritis and vertebral metastases; tumor markers were normal. The diagnosis of seminoma was confirmed by pathological and immunohistochemical analysis of the cervical adenopathy. Disease management consisted of BEP/cisplatin type chemotherapy and lumbar, mediastinal, and supraclavicular radiotherapy. The response after four courses of combined chemo-/radiotherapy was estimated at 25%, but the patient died from respiratory failure five months after the initiation of treatment.     

Chemotherapy of advanced seminoma: clinical significance of radiological findings before and after treatment

The predictive significance of the mass detected following chemotherapy was assessed in 46 patients with advanced seminoma. Patients with residual viable seminoma in the post-chemotherapy operation specimen or who developed recurrent disease were regarded as chemotherapy failures. This group included 1 of 20 patients in whom the retroperitoneal masses were less than or equal to 10 cm2 3 to 4 weeks after chemotherapy and 4 of 15 patients whose residual masses were greater than 10 cm2. Four of 11 patients with mediastinal tumours achieved a complete remission (mediastinal masses less than or equal to 1 cm2). However, 2 of these 4 patients relapsed, as did 2 of the 4 who achieved a partial remission. In no case was the original size of the tumour significantly related to treatment failure. Three patients had residual lung masses; 1 of these contained histological evidence of viable tumour. In one-third of the irradiated relapse-free patients, slightly enlarged masses were visible on follow-up computed tomography scans taken several years after treatment, even in patients without tumour activity. There is a 25% risk of relapse in patients with advanced seminoma who have retroperitoneal masses greater than 10 cm2 following cisplatin-based chemotherapy. They should be followed up regularly for many years.     

Primary mediastinal seminoma: a comprehensive assessment integrated with histology, immunohistochemistry, and fluorescence in situ hybridization for chromosome 12p abnormalities in 23 cases

Accurate diagnosis of mediastinal seminoma is critical because of its favorable response to radiation therapy and/or cisplatin-based chemotherapy. Immunohistochemical staining for OCT4 has recently been validated as a powerful tool for detecting gonadal seminoma. However, discrepancies between the genetic alterations and immunoprofiles of mediastinal and testicular seminomas have been reported, raising the question of whether techniques that are useful in the diagnosis of gonadal seminoma are applicable to its mediastinal counterpart. The present study was conducted to evaluate the morphologic and immunohistochemical characteristics and chromosomal abnormalities of 12p in 23 primary mediastinal seminomas and to compare their applicability as diagnostic tools. Dual-color fluorescence in situ hybridization (FISH) analyses for chromosome 12p and immunostains for OCT4, c-kit, placental-like alkaline phosphatase, CD30, and a panel of cytokeratins, including cytokeratin AE1/AE3 (AE1/3), high molecular weight cytokeratin (34betaE12, HMWCK), CAM5.2, cytokeratin 7 (CK7), cytokeratin 20 (CK20), and epithelial membrane antigen were performed. Lymphocytic infiltration was found in all 23 cases (100%). The incidence of other histologic characteristics were as follows: fibrous septa/stroma (21 cases, 91%), prominent tumor cell nucleoli (21 cases, 91%), clear tumor cell cytoplasm (20 cases, 87%), distinct tumor cell borders (20 cases, 87%), granulomatous inflammation (17 cases, 74%), cellular pleomorphism (10 cases, 43%), necrosis (8 cases, 35%), prominent cystic change (2 cases, 8%), intercellular edema (1 case, 4%), and syncytiotrophoblasts (1 case, 4%). The mean mitotic count was 4.4 (range 0 to 16) per 10 high-power fields. Moderate to strong nuclear OCT4 staining was identified in all 23 cases (100%). Seventeen tumors (74%) showed membranous expression of c-kit, with variable staining intensity and percentages. Weakly to moderately intense immunostaining for placental-like alkaline phosphatase was identified in 10 cases (43%) with occasional background staining artifact. The incidences of positive staining were 43% for AE1/3, 39% for HMWCK, 48% for CAM5.2, 39% for CK7, and 9% for epithelial membrane antigen, respectively. In most cases, these epithelial markers highlighted only a small proportion of tumor cells with variable intensities. Immunostaining for CD30 and CK20 was completely negative in all seminomas. Twenty-two seminomas (96%) revealed chromosome 12p abnormalities, including 12p amplification in 20 cases (87%) or i(12p) in 15 cases (65%). Lymphocytic infiltration is the most common histologic feature observed in primary mediastinal seminoma and both OCT4 immunostain and FISH for 12p abnormalities can be very helpful in diagnosing mediastinal seminoma. The intense staining pattern of OCT4 and the high sensitivity of FISH make them superior to other auxiliary diagnostic utilities for detecting seminoma. In addition, the incidences of cytokeratin expression of primary mediastinal seminoma are similar to those of its gonadal counterpart and pathologists must exercise caution in the interpretation of epithelial markers in mediastinal neoplasms.     

Radiologic staging of chest in testicular seminoma

We investigated the usefulness of chest x-ray (CXR), conventional planar tomography (TOM), and computerized axial tomography (CAT) in evaluating patients with Stages I and II testicular seminoma. All patients had a CXR, and 22 patients had either TOM or CAT as part of initial staging. No occult pulmonary or mediastinal nodal disease was found during initial staging, and none of the patients manifested recurrence of tumor in these sites as a first event. Review of the literature corroborates our finding of a very small thoracic failure rate in early stage seminoma. Routine use of CAT or TOM is not indicated in staging these patients.     

Video-assisted thoracoscopic surgery for a cystic seminoma of the mediastinum

Mediastinal seminomas are uncommon primary mediastinal neoplasms, and most are solid in appearance. Cystic mediastinal seminoma is an unusual type of extragonadal germ cell tumor that has rarely been reported in the literature. Here we describe a 36-year-old man with a 7.5-cm cystic mediastinal seminoma. The tumor was excised successfully by video-assisted thoracoscopic surgery. No recurrence was noted during 28 months of follow-up.     

Induction chemotherapy and radical resection for primary nonseminomatous mediastinal germ cell tumor (NSGCT); report of a case

A 15-year-old male was admitted to our hospital for treatment of an anterior mediastinal tumor. The tumor was visualized by chest radiography 3 months prior to admission. Computed tomography (CT) revealed a heterogeneous solid tumor located in the anterior mediastinum. Although CT-guided needle biopsy had been performed twice, histologic diagnosis could not be confirmed. We believed this tumor to be nonseminomatous mediastinal germ cell tumor (NSGCT) and started intensive chemotherapy with cisplatin (CDDP) without histologic diagnosis because his serum AFP level was rapidly increasing. After 2 courses of chemotherapy, his serum AFP level returned to the normal range and surgical resection of the tumor with part of right lung was performed. Histopathological examination revealed that the tumor consisted of mature teratoma and yolk sac tumor. He underwent 1 course of chemotherapy post-operatively because a small number of viable cells were histopathologically recognized in the yolk sac component. At the time of writing, the patient is alive without any evidence of recurrence.     

A case of cranial and intracranial metastasis from testicular seminoma]

The case presented is of a 44-year-old man with skull and intracranial metastasis of seminoma. He was operated on for a testicular tumor at 41 years of age. Pathologically, it was pure seminoma. Coronal CT scan showed tumor invasion of the subcutaneous vault, and of the epidural and intraparenchymal region of the right parietal region. We treated him with a combination of surgical excision, radiation and PVB chemotherapy. He was neurologically disease-free for ten months after being discharged. However, he then succumbed to liver metastasis of seminoma. Seminoma mainly metastasizes via the lymph stream. CNS metastasis of seminoma is only 0.7% in Japan. We would like to stress that prophylactic chemotherapy would be essential even after patients get remission from CNS metastasis of seminoma.     

Primary mediastinal seminoma

Three new cases of primary mediastinal seminoma are presented, and 124 other cases in the literature are reviewed. These tumors primarily affect white males in the third decade. Chest pain is the most common symptom, but 20 per cent of the patients can be asymptomatic. Testicular atrophy occurred in only 7 patients. In one of these a testicular seminoma developed seven years after treatment of a primary mediastinal tumor. Supraclavicular adenopathies were found in 10 patients. Chest x-ray films typically show an anterior mediastinal noncalcified mass with smooth lobulated borders. Twenty-eight of 74 surgical resections attempted were successful; 13 of these received adjuvant irradiation. Of 64 cases in which radiation therapy was the primary mode of treatment, local failures occurred only in 7 cases. These tumors spread primarily by distant metastases. Theories of tumoral origin and patterns of spread are discussed. A dose of 3,000 rad in three weeks and 4,500 rad in four and one-half weeks to the mediastinum and supraclavicular areas is recommended for minimal and bulky disease. Primary mediastinal seminoma is as radiosensitive as its testicular counterpart.     

A case of mediastinal seminoma which penetrated pericardium and invaded left upper lobe]

A 35-year-old man admitted at our hospital, with a complaint of anterior chest pain. Chest x-ray film and CT showed an anterior mediastinal tumor. An invasive thymoma was suspected by the biopsy specimen, invading left upper lobe of the lung. Resections of the tumor, thymus, invasion to the part of the left upper lobe and the pericardium were performed. The pathology showed pure seminoma penetrating the pericardium. As testis and the retroperitoneum were normal, the tumor was diagnosed as mediastinal origin. Adjuvant chemotherapy (CDDP, BLM and etoposide) and irradiation were performed. The patient is alive and well for 7 months postoperatively.     

Survival outcomes for men with mediastinal germ-cell tumors: The University of Texas M. D. Anderson Cancer Center experience

ObjectivePrimary mediastinal germ-cell tumors are rare, and the effect of newer drugs and treatment strategies in this disease on overall survival is not known. We retrospectively assessed treatment outcomes at a single institution.Materials and methodsWe identified men seen at our institution from 1998 through 2005 for mediastinal germ-cell tumors. Medical records were reviewed for patient characteristics, histology, tumor markers, treatment, and survival outcome.ResultsThirty-four patients met study criteria, of whom 27 had nonseminomatous germ-cell tumor (NSGCT) and 7 had pure seminoma. Eleven patients (41%) with NSGCT were alive at last contact with a median overall survival time of 33.5 months. Among 13 patients with NSGCT referred to us at initial diagnosis, 7 (54%) were alive and recurrence-free at a median follow-up of 56.5 months. Progression-free survival was associated with absence of risk factors (any histology other than endodermal sinus tumor, β-hCG > 1000 mIU/mL, or disease outside the mediastinum). For the patients whose disease progressed (n = 5) or who had been referred to us for salvage treatment (n = 14), the 3-year overall survival from the date of first progression was 23%. Conversely, patients with seminoma did uniformly well with platinum-based chemotherapy; most did not undergo radiation or surgery.ConclusionChemotherapy given to maximum effect followed by surgical consolidation resulted in long-term progression-free survival for 54% of patients with mediastinal NSGCT. The number of risk factors present at diagnosis may be associated with survival outcome and should be studied in a larger test group.     

Healing of superior vena cava defect in mediastinal seminoma with invasion

We present an unusual case of mediastinal seminoma with direct intraluminal invasion into the superior vena cava (SVC) and extension to the right atrium. Magnetic resonance imaging demonstration of the SVC defect due to tumor invasion was important for determining treatment strategy because rapid posttherapeutic tumor regression may increase the risk of SVC rupture. Gradual healing of the SVC defect at the tumor entrance site was attained using a tailored treatment plan with radiotherapy and chemotherapy.     

Unusual seminoma revealed by bone metastasis

We report a first case of primitive mediastinal seminoma revealed by bone metastasis without testicular tumor. In a 24-year-old patient with a 6-month history of isolated right hip pain, having normal X-ray and blood tests, we discovered a clinically silent chest mass being diagnosed as seminoma on needle biopsy. Etoposide-ifosfamide-cisplatin chemotherapy was chosen because of the presence of multiple lesions and its lesser toxicity. Germ cell tumors are a rare cause of bone metastases and need to be known to rheumatologists because of their excellent prognosis when recognized and treated early. We discuss new diagnostic (CT, MRI and PET-Scan) and treatment (chemotherapy and radiotherapy) strategies applied to our patient.     

Huge mediastinal mature teratoma with combined resection of adjacent structures; report of a case

We report a case of a 64-year-old woman with an anterior mediastinal tumor on a chest computed tomography (CT) before operation of uterine cancer. After the radical surgery and a chemotherapy for uterine cancer, surgical resection of mediastinal tumor was performed in July 2005 because of gradually progression in tumor size. Under the median sternotomy, the tumor revealed intensive adhesion to the right lung and the left brachiocephalic vein. We performed a complete resection of the tumor with combined resection of adherent parts of them. The tumor was 9 x 8 cm in size, containing with yellow cream-like fluid and hair. Histologically, the tumor was diagnosed as a mature teratoma with the tissue of bone, digestive tract epithelium, bronchial epithelium and so on. In benign teratoma, it is not rare to perforate to the adjacent structures. So, we concluded if the mediastinal teratoma was suspected, long-term observation had the risk for adhesion and perforation to adjacent tissue, and in case of operation, we should keep in mind the possibility of combined resection of involved organs.     

Primary mediastinal lymphoma; a clinicopathologic case series

Treatment for primary mediastinal lymphoma generally involves chemotherapy and radiotherapy, and treatment regimens depend on histologic subtypes of lymphoma. The histologic subtype of lymphoma is mostly determined by computed tomography (CT)-guided core-needle biopsy or surgical procedures, including thoracotomy, thoracoscopy and mediastinoscopy. We describe the clinicopathologic features and diagnostic procedures of 8 cases of primary mediastinal lymphoma. The male-to-female ratio was 1:1, and median age at diagnosis was 27 years. The median size of the primary mediastinal tumor on CT was 8.5 cm. Five patients were diagnosed by CT-guided core-needle biopsy, 1 by open biopsy and 2 by surgery. Three patients were diagnosed with nodular sclerosis Hodgkin lymphoma, 3 with mediastinal diffuse large B-cell lymphoma, 1 with precursor T-lymphoblastic leukemia/lymphoma and 1 with thymic extranodal marginal zone B-cell lymphoma. According to their histological subtypes, 5 patients were treated with chemoradiotherapy, 2 patients with chemotherapy and 1 patient of thymic extranodal marginal zone B-cell lymphoma with surgery alone. All patients survived in the median follow-up of 34.5 months. Appropriate biopsy procedure should be performed in patients with suspected mediastinal lymphoma.     

A case of testicular tumor in an elderly man

Testicular tumor is seen exclusively in men from 30 to 50 years old. In elderly men, the incidence of testicular tumors is rarer than that of other malignant tumors. Herein we report a case of an elderly patient with a testicular tumor comprised solely of seminoma. A 60-year-old man was seen at the urologic clinic of Osaka Kita Municipal Citizen's Hospital because of painless swelling of the left scrotal contents. At the time of clinical visit, physical examinations and scrotal sonography showed a fist-sized mass with solid echo pattern in the left scrotum. He was hospitalized for the exploration of the suspected testicular tumor. The testicular mass was removed surgically through the left inguinal incision. Histopathological examinations of the resected tumor revealed pure seminoma. Chest film, computerized axial tomography, retroperitoneal ultrasound study and specific tumor markers were all negative which indicated stage 1 testicular tumor confined to the scrotal region according to Dixon and Moore's staging. He received adjuvant irradiation at the level of mediastinal lymph node after the operation. Postoperatively, he recovered well without any evidence of recurrence. In this report, the prognosis of non-bulky pure seminoma in elderly men are briefly reviewed in association with a conventional therapy to this disease in elderly patients described in the literature.     

A case report: testicular pure seminoma metastasized to costal bone after 2 years post-operatively

A 32-year-old man underwent orchiectomy for his right testicular tumor (pure seminoma, pT1, stage A(I)). Pelvic and para-aortic lymph nodes were irradiated with 18 Gy as adjuvant therapy. Two years later, he developed low back pain. Computed tomography, magnetic resonance imaging and bone scans showed an enhanced mass at the 10th left costa. Aspiration cytology showed seminoma. After administration of chemotherapy with bleomycin, etoposide and cisplatinum, following high dose chemotherapy with peripheral blood stem cell transplantation, the costal lesion was diminished and symptoms relieved. Then radical costectomy was performed. A histopathological study showed non-viable cells of seminoma. Post-operative progress was uneventful. Testicular pure seminoma with bone metastasis is rare, and to our knowledge, only 9 cases have been reported.     

Das primäre Seminom

This is a report on three patients with primary mediastinal seminoma. Two patients had no symptoms, and one had had thoracic pain for the last few years. The preoperative diagnosis was thymoma in all cases, and in one patient the radiologist had suspected a seminoma. We removed the tumor after performing median sternotomy (n=2) and anterolateral left thoracotomy (n=1). The presence of a primary gonadal seminoma was excluded with a urological and ultrasound examination. All patients are still alive following adjuvant chemotherapy (n=2; 120 and 8 months) and radiotherapy (n=1; 84 months). Chemotherapy consisted of four cycles of cisplatin, etoposide and ifosfamide or combination therapy with cisplatin, bleomycin and velbe.