Mediastinal germ cell tumors

Surgical treatment of complex malignant anterior mediastinal tumors invading the superior vena cava

Determining the appropriate surgery-based treatment for complicated anterior mediastinal malignancies (CAMM), especially those invading the superior vena cava (SVC) and its branches, remains a challenge for general thoracic surgeons. In this report, we summarize our experience and lessons regarding this issue in order to discuss a reasonable strategy for diagnosis and treatment of CAMM. Between January 2001 and April 2003, 15 patients with CAMM invading the SVC and/or its branches with or without invasion of other neighboring organs were surgically treated in our institution by a single surgeon team. We collected clinical data from the medical charts and from surgeons' specific notes for complicated cases, and performed a comprehensive analysis. There were 9 patients with malignant thymoma. Thymic carcinoma, teratoma, embryonal carcinoma, Hodgkin's lymphoma, non-Hodgkin's lymphoma, and mixed teratoma with thymoma were diagnosed in 1 patient each. All procedures were performed via median sternotomy. Some angioplasty techniques were successfully used to resect and reconstruct the SVC. Ten of the 15 patients also underwent pulmonary resection due to involvement of pulmonary parenchyma. Four of the patients underwent perioperative chemotherapy. There were no perioperative deaths. Two patients suffered prolonged ventilation after surgery, and there were no other severe complications related to surgery. One patient died 10 months after surgery. The remaining 14 patients were still living and their progress is still monitored. As of August 2004, the median follow-up duration for all patients was 35 months, and the disease-free survival duration was 10-43 months. CAMM can be safely and completely resected via a median sternotomy, even if it has invaded other mediastinal structures. CAMM should be pathologically identified before initial treatment. A good outcome for patients with CAMM is possible if a suitable strategy combining accurate diagnosis and appropriate treatment, especially surgical resection, is established.

An autopsy case of primary mixed choriocarcinoma and mature teratoma located in the thymic region associated with elevated human chorionic gonadotropin levels and characteristic testicular changes

An autopsy case of a 19-year-old male Japanese student with a primary mixed choriocarcinoma and mature teratoma in the thymic region is reported. The patient died 7 days after he first noticed fever and dyspnea. On autopsy, an anterior mediastinal mass was found to be in contact with the thymic gland. The mass weighed 270 g and measured 12.5 cm x 10 cm x 5 cm. The left thoracic cavity contained 2200 ml bloody pleural effusion and 200 g coagula due to hemorrhage from the tumor. Metastasized choriocarcinoma was seen in both lungs and the liver. High serum levels of human chorionic gonadotropin (HCG, 1 634 000 mIU/ml) and a decreased weight of the testes (2.0 g each) with Leydig cell hyperplasia/hypertrophy and the seminiferous tubules with hyaline ghost tubules or Sertoli cell only tubules were seen; other male reproductive organs were histologically normal. Although the serum testosterone level was within the normal range (5.75 ng/ml), luteinizing hormone (LH, 0.1 mIU/ml) and follicle-stimulating hormone (FSH, 0.3 mIU/ml) levels were decreased. High serum levels of HCG and characteristic testicular changes are drscribed.

Chest pain and ST segment depression caused by expansion of gastric tube used for esophageal reconstruction

We describe a 76-year-old man in whom a gastric tube was used for esophageal reconstruction via the anterior mediastinum after esophagectomy for esophageal cancer. Stenosis of the tube resulted in fluid accumulation, which directly compressed the heart and caused angina-like chest pain associated with ST-segment depression in lead V(2-3) on the electrocardiogram (ECG). Coronary angiography revealed no stenosis. Drainage of the fluid in the gastric tube resulted in immediate relief of symptoms and normalization of ECG. Angina-like chest pain associated with ST segment changes were caused by expansion of the gastric tube and compression of the heart.

Life-threatening airway obstruction caused by mediastinal germinoma in a 9-year-old girl

The authors report a case of a 9-year-old girl with a mediastinal germinoma that required emergent surgical extirpation because of tracheal compression and asphyxia. The tumor was successfully debulked under general anesthesia with the capability of extracorporeal circulation immediately available. Postoperatively, the tumor responded to adjuvant chemotherapy and irradiation and the patient survived without evidence of recurrence.

Imaging of the mediastinum: applications for thoracic surgery

The diagnostic approach to patients who have mediastinal masses should include thorough preoperative imaging. Once limited to plain radiographic techniques, the radiologist now has a wide variety of imaging modalities to aid in the evaluation of the mediastinum. CT is the imaging modality of choice for evaluating a suspected mediastinal mass or a widened mediastinum, and it provides the most useful information for the diagnosis, treatment, and evaluation of postoperative complications.

High-dose chemotherapy in adult patients with germ cell tumors

BACKGROUND

Approximately 80% of patients with advanced germ cell tumors (GCTs) can be cured with cisplatin-based chemotherapy. Patients with poor-prognosis disease have a cure rate of only 50%, whereas patients with first relapse have only a 25% chance of prolonged survival and potential cure following standard therapy. High-dose chemotherapy (HDC) is being investigated in patients with GCTs to improve the results of salvage treatment and in first-line setting for poor prognosis disease.

METHODS

The authors review the results of the clinical trials that have evaluated the role of HDC in GCT patients. Data were obtained using a computer-assisted MEDLINE search, and meeting abstracts with clinical relevance in this field were hand-searched. Open randomized phase III studies are described and examined.

RESULTS

Several phase II studies have shown a possible benefit for patients with recurrent disease, but the preliminary results of a phase III randomized trial did not demonstrate a survival advantage for HDC after three courses of standard-dose chemotherapy in the salvage therapy of patients in whom first-line treatment has failed. Three prospective, randomized trials are evaluating the role of HDC in a first-line setting.

CONCLUSIONS

New HDC strategies are emerging, involving new drugs (eg, paclitaxel), intensive induction regimens, and upfront and/or multiple courses of HDC. The evaluation of mature data of randomized trials will better define the role of HDC in this disease.