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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 140-143

Germ cell tumor of anterior mediastinum: A rare case in young adult


Department of Community Medicine, People's College of Medical Science and Research Centre, Bhopal, Madhya Pradesh, India

Date of Submission20-Aug-2020
Date of Acceptance03-Apr-2021
Date of Web Publication24-Dec-2021

Correspondence Address:
Dr. Raghvendra Gumashta
Department of Community Medicine, People's College of Medical Science and Research Centre, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_99_20

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  Abstract 

A 30-year-old diabetic male, urban resident, nonsmoker with Karnofsky performance score 80 was diagnosed with germ cell tumor of 13 cm × 9 cm with Stage I at right anterosuperior mediastinum after short duration of cough and hemoptysis. He did not have any difficulty in breathing or weight loss. The effort tolerance of the patient was up to four floors. The case received VIP-based chemotherapy with etoposide, ifosfamide, and cisplatin at a center of excellence. Thereafter, the surgical excision of the solid mass may be the optional line of treatment.

Keywords: Anterior mediastinal mass, giant cell tumor, yolk sac tumor


How to cite this article:
Kumar S, Gumashta R. Germ cell tumor of anterior mediastinum: A rare case in young adult. Indian J Community Fam Med 2021;7:140-3

How to cite this URL:
Kumar S, Gumashta R. Germ cell tumor of anterior mediastinum: A rare case in young adult. Indian J Community Fam Med [serial online] 2021 [cited 2022 Jan 23];7:140-3. Available from: https://www.ijcfm.org/text.asp?2021/7/2/140/333669




  Introduction Top


Mediastinal neoplasms are uncommon tumors. They usually pose diagnostic and therapeutic challenge for treating oncologist.[1] Germ cell tumors (GCTs) are rare neoplasms affecting gonads although observed in alternative body sites also in structures of median line, such as endocrine gland, retroperitoneum, anterior mediastinum, and sacrococcygeal region.[2] Ten percent to twenty percent of all mediastinal cancers are GCT. Yolk sac tumor, a subtype of germ cellular tumor, is malignant.[3]


  Case Report Top


A 30-year-old unmarried male, northern India, did not have any physical ailments during earlier years. His X-Ray chest was normal 2 years back [Figure 1]. His body mass index was 26.03 kg/m2. His blood pressure was 130/86 mmHg and 97% SpO2. He has no history of any tumor, chest pain, breathlessness, heaviness, fever, sickness, or behavioral risk factors except for last few weeks complaint of cough with increasing severity. The cough was, however, off and on. The case immediately sought medical expert opinion after observing cough in the morning which was associated with blood-tinged sputum, who after seeing X-ray chest advised for computed tomography (CT) scan thorax. As a routine, the chest X-ray of the patient was done by local medical expert, and an oval X-ray opaque region was seen in the right middle mediastinum as space-occupying lesion [Figure 2]. Considering it suspected case of pneumonia, the treatment with ciprofloxacin was initiated to which the patient was nonresponsive. He has no history of smoking but occasionally takes alcohol. The patient, however, did not report to any emergency department at that time and was taken by his relatives to get appropriate treatment for the inconvenient cough. The patient was recently diagnosed Type-II diabetes mellitus and was started on oral hypoglycemic agents. He was operated for inguinal hernia at the age of 6 years. The effort tolerance of the patient was up to four floors. It is also noticed that the chest X-ray of the case taken during health assessment for new job was in the preceding 2 years [Figure 1]. He is happily employed for his technical expertise at electrical department located at site office of a large infrastructure, construction, and development company.
Figure 1: Chest skiagram 2017

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Figure 2: Chest skiagram 2019, showing mediastinal mass

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As per his reports of treatment, care, and support at a highly sophisticated specialized center of excellence, “Contrast-enhanced CT (CECT)” performed for thorax, abdomen, and pelvis on a multidetector CT scanner revealed that there is a large heterogeneously enhancing anterior mediastinal mass measuring 10 cm × 13 cm × 9 cm (anteroposterior mediolateral caudocranial) [Figure 3]. No fat density or calcific areas were seen within it. The mass was seen abutting pericardium along right atrium and right ventricle showing more than 180° angle of contact with ascending aorta and main pulmonary trunk. However, the right main coronary artery was reported as encased by the mass at the origin, which was seen displacing right lung parenchyma with resultant volume loss of right hemithorax. Right middle lobe collapse was also noticed with subsegmental atelectasis seen in posterior segment of right upper lobe. Traces of pleural effusion were also noted on the right side. No evidence of any suspicious pulmonary nodule was seen. Few enlarged paratracheal prevascular nodes were seen, largest measuring 20 mm × 12 mm. No abnormality was seen in the liver, biliary tree, gall bladder, pancreas, spleen, kidney, adrenals, gastrointestinal tract, urinary bladder, prostate, and seminal vesicles. No significant retroperitoneal lymphadenopathy was seen. There were no ascites. The visualized bones were unremarkable. Electrocardiogram was normal. The echocardiographic report impression showed anterior mediastinal mass with mild pulmonary hypertension. The left ventricular ejection fraction was 55%. Bilateral ultrasonography testis depicted microlithiasis.
Figure 3: Computed tomography thorax, showing anterior mediastinal mass

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Fasting blood glucose (163 mg/dL), postprandial blood glucose (192 mg/dL), serum globulin (3.96 g/dL), and serum lactic acid dehydrogenase (LDH) (307 U/L) were raised, whereas serum creatinine (0.60 mg/dL) and serum albumin (3.41 g/dL) were low. The biochemical investigation of serum urea (15.9 mg/dL), serum uric acid (5.77 mg/dL), serum sodium (135 mmol/L), serum potassium (4.82 mmol/L), serum chloride (101.8 mmol/L), serum bicarbonates (25.1 mmol/L), serum protein (7.37 g/dL), serum alkaline phosphates (84 U/L), total bilirubin (0.51 mg/dL), serum aspartate aminotransferase (22 U/L), and serum alanine aminotransferase (38 U/L) were normal. The biochemical LDH (283 U/L) and alpha-fetoprotein (AFP) (1468 ng/ml) were high.

Beta-human chorionic gonadotropin (19.7 mIU/mL) was mildly raised, whereas serum carcinoembryonic antigen (1.71 ng/mL) was normal. Serum ferritin (428.43 ng/Ml) was high. CT biopsy showed malignant GCT. Semen analysis did not show any spermatozoa in centrifuged deposit. Prothrombin time (16.400 s) was high. Red blood cell distribution width in complete blood count report was 15.00% CV (high). Hepatitis B surface antigen, hepatitis C antibodies (anti-HCV), and HIV antibodies were nonreactive. The histopathology report showed malignant GCT, the yolk sac tumor. Renal cortical functions of all the kidneys are shown as normal, done by gates method. Dynamic images of both kidneys were acquired with camera placed posteriorly after injection of 5.5 mCi of 99 mTc-DTPA.

The case underwent chemotherapy twice as per the treatment protocol at a centre of excellence. PET-CT scan showed irregular poorly circumscribed lesion in anterior mediastinum infiltrating the right atrium and ascending aorta. Resection of anterior mediastinal mass was done for lesion measuring about 5.3cc cm × 7.7TR cm × 4.9AP cm standardized uptake value max 3.0. The AFP level fell to normal level (5.9 ng/mL). However, thereafter, it raised to 353 ng/mL after a week and 1102.06 ng/mL in subsequent week. The biopsy of pericardial margin did not show any residual viable tumor. No obvious abnormality was seen in CECT scan of the neck and abdomen.

The patient has been advised by the treating oncologist to consider undergoing four cycle of chemotherapy, and thereafter, the option of radiotherapy may be exercised if AFP remains still on the raising trend. The case is rare because the AFP is still increasing despite no viable tumor detection postoperatively.


  Discussion Top


A 30-year-old male, urban resident, Karnofsky performance score 80, nonsmoker having predominant symptoms of cough and hemoptysis with GCT Stage I of 13 cm × 9 cm at right anterosuperior mediastinum was advised by the treating oncologist that the surgery may be done after 4 sessions of chemotherapy, so that tumor markers return back to normalcy.[1] As has been observed in 25% of the cases, our case did not show any lymphadenopathy or lymphadenitis. He also did not have any difficulty in breathing or weight loss. The patient is receiving standard treatment of systemic chemotherapy with VIP [etoposide (VePesid), ifosfamide, and cisplatin (Platinol)]-based chemotherapy comprising of etoposide, ifosfamide, and cisplatin. The patient is responding to the treatment, and further, therapy shall be provided to him as per the protocol of the treating hospital.[2] Germs cell tumors have been reported to occur generally in the age group of 21–30 years. However, the studies have revealed that majority of the cases are benign tumors with preponderance of thymic epithelial regions followed by lymphoma, GCT, and sarcoma in the anterior mediastinum.[4]

The alpha-fetoproteins of the patients are usually found elevated, which were also observed to be high in our reported case.[5] The tumor-induced compression and therefore total lung collapse as observed in similar cases of sudden reporting of chest pain and cough have been observed, however, no such findings have been seen in the chest X-ray of herein reported case.[6] Since our case has been asymptomatic with minimal symptoms at the time of the first diagnosis, it is unlike the other cases of mediastinal masses presenting with evident symptoms due to compromised lung function.[7] As has been reported elsewhere, the diagnosis of GCTs made by histopathology reports in our case is in resonance with radiological findings.[8]

There are cases where the patient got bilateral pulmonary hemorrhage within couple of days postneedle biopsy suggestive of progressive lesions, however, the present case showed it infiltrating right atrium and enhancing to ascending aorta.[9] As surgical excision of mediastinal teratoma is recommended, the same was done the present case but the AFP, the indicator of tumor, is still on the rising trend despite biopsy being normal.[10]

Declaration of patient consent

The case has given his written consent for the images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published.

Financial support and sponsorship

Nil.

Conflicts of interest

There is no conflict of interest.



 
  References Top

1.
Rattan R, Yadav BS, Kapoor R, Thakur P. Characteristics of malignant mediastinal tumours presenting in tertiary care center in India and the problems the oncologists have faced over time. Ann Cancer Epidemiol 2019;3:7.  Back to cited text no. 1
    
2.
Silva LL, Vergilio FS, Yamaguti DC, Cruz IA, Queen JA. Yolk sac primary tumor of mediastino: A rare case in a young adult. Einstein (Sao Paulo) 2017;15:496-9.  Back to cited text no. 2
    
3.
Nakhla SG, Sundararajan S. A rare case of primary anterior mediastinal yolk sac tumor in an elderly adult male. Case Rep Oncol Med 2016;2016:1-4.  Back to cited text no. 3
    
4.
Aggarwal R, Rao S, Chopra P, Bhalla S, Vijay CL, Asaf BB, et al. Morphological spectrum of mediastinal lesions with special emphasis on evaluation of needle biopsy: An experience from a tertiary care hospital. Indian J Med Res 2016;144:544-51.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Tinica G, Butcovan D, Cimpeanu C, Târcoveanu E. A mediastinal germ cell tumor of yolk sac type – Case report. Chirurgia (Bucur) 2010;105:831-4.  Back to cited text no. 5
    
6.
Dalal U, Jora MS, Dalal AK, Attri AK, Singal R, Gupta S. Primary germ cell tumor of the mediastinum – Presenting as a huge mass. Int J Prev Med 2014;5:230-2.  Back to cited text no. 6
    
7.
Ganeshan P, Kapoor A, Bajpai J, Agarwal S, Thulkar S, Kumar L. Mediastinal masses – the bad, the ugly and the unusual. Ind J Med Paed Oncol 2007;28:11 6.  Back to cited text no. 7
    
8.
Szolkowska M, Szczepulska-Wojcik E, Maksymiuk B, Burakowska B, Winiarski S, Gatarek J, et al. Primary mediastinal neoplasms: A report of 1,005 cases from a single institution. J Thorac Dis 2019;11:2498-511.  Back to cited text no. 8
    
9.
Sakane T, Okuda K, Murase T, Watanabe T, Oda R, Tatematsu T, et al. Mixed-type primary germ cell tumor of the mediastinum in a young adult male with a sudden life threatening condition: A case report. Thorac Cancer 2020;11:166-9.  Back to cited text no. 9
    
10.
Meshram RM, Abhisheik S, Hardas V, Siddharth K. Massive hemoptysis: A rare presentation of anterior mediastinal teratoma in an adolescent. Indian J Med Paediatr Oncol 2017;38:215-7.  Back to cited text no. 10
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