A Study of Patients with Primary Mediastinal Germ Cell Tumors Treated Using Multimodal Therapy

Current Trends in the Surgical Management of Yolk Sac Tumors

Mediastinal yolk sac tumors (YST) constitute a highly malignant subtype of primary non-seminomatous germ cell tumors, which are often locally advanced and unresectable at diagnosis. Due to their rarity and aggressiveness, there is not yet a standard optimal treatment approach. A widely employed multimodal strategy involves neoadjuvant cisplatin-based combination chemotherapy followed by consolidation surgery. Tumor infiltration into the lungs and adjacent cardiovascular structures is common, such that surgical intervention typically requires extensive resections, performed either by sternotomy or thoracotomy. For this review, we extensively searched the PubMed and Embase medical databases, identifying articles describing surgical treatment of mediastinal yolk sac tumors. The current literature provides limited details regarding the utilized surgical procedures, leaving clinicians without comprehensive guidance about the demanding nature of these resections. Here, we present a narrative description of the range of current surgical procedures. By highlighting these techniques, we provide a comprehensive overview of the current surgical landscape, thereby helping clinicians understand the potential complexities and considerations involved in managing these rare and aggressive tumors.

Primary mediastinal yolk sac tumor: A case report and literature review

Key Clinical Message

There are limited published cases of primary mediastinal yolk sac tumor (PMYST), with no consensus on the best treatment alternative. By far, the surgery oriented comprehensive therapies are the main treatment methods. The surgical strategy should be individualized and aimed at radical resection, considering all the possibilities, including the use of cardiopulmonary bypass and prosthetic materials.

Abstract

A 15-year-old boy was diagnosed as PMYST. The tumor, with a size about 13 × 12 × 8 cm, was located in the right upper mediastinum, closely adhering to ascending aorta, superior vena cava, right atrium, and the right hilum. After 6 cycles chemotherapy of bleomycin, etoposide, and cisplatin (BEP), no significant change was found in the size of tumor. Subsequently, an extended tumor excision including partial resection of the right lung, the pericardium, the diaphragm and the right phrenic nerve, was performed successfully with cardiopulmonary bypass on standby. During 6 months of follow-up, there was no tumor recurrence. Meanwhile, in PubMed, we searched the English case reports and case series of PMYST during the past decade. A total of 73 articles were retrieved, in which 22 articles on the therapy and prognosis of PMYST were extracted and reviewed, included 16 case reports and 6 case series with a total of 52 patients. Due to the rarity of PMYST, it is difficult to provide a specific treatment regimen. The surgery-oriented comprehensive therapies are still the main treatment methods. The surgical strategy should be individualized and aim at radical resection, considering all the possibilities, including the use of cardiopulmonary bypass and prosthetic materials.

Primary mediastinal germ cell tumors (PMGCT): A real-world analysis from a tertiary cancer care centre in India

BACKGROUND

Primary mediastinal GCT (PMGCT) is a rare entity and comprises 10-15% of all mediastinal tumors . We present our institutional experience of MGCT treated with multimodality management.

MATERIALS AND METHODS

We conducted a retrospective analysis between 2010 to 2020 of all mediastinal germ cell tumors registered at our center. Data on patient demographics, treatments received, treatment toxicities and response were recorded. Overall survival and relapse free survival were estimated using Kaplan-Meier methods.

RESULTS

A total of 30 patients were identified. The median age was 25.5 (range, 18-45) years. Common presenting features included cough (70%) and shortness of breath (70%) . Histology wise, 60% patients were non seminomatous histology whereas 33.3% patients were Seminoma.Twenty seven (90%) patients received chemotherapy as the first-line treatment, of whom five patients (16.6%) underwent surgery and radiation therapy subsequently. Median follow-up was 26.9 months. Thirteen patients (43.3%) had complete response (43.3%) and 8 patients had partial response (26.7%), while three patients (5.5%) had progressive disease. Three year relapse free survival rate was 69.6% (95% confidence interval [CI], 42.8-85.6%). Overall survival (OS) at 3 years was 73.4% (95% CI, 49.4- 87.3%). Patients with seminoma had a 3 year OS of 90.0% (95% CI, 47.3-98.5%) compared to those with non-seminoma (63.53% [95% CI, 32.3-83.3%]).

CONCLUSIONS

Multiagent chemotherapy is the backbone of treatement in PMGCT. Seminomatous PMGCT have excellent prognosis, while further improvement is needed in those with non-seminomatous tumor.

The clinical features and prognostic outcomes of primary mediastinal yolk sac tumors: A retrospective analysis of 15 rare cases from multiple centers

Primary mediastinal yolk sac tumors (PMYSTs) are a rare occurrence. As such, the clinicopathological features, treatment, and prognosis, of this disease still remain unclear. In this study, we aimed to provide further information relating to this rare malignancy in order to facilitate the creation of more specific clinical guidelines for the diagnosis and treatment of patients with PMYSTs.In this retrospective study, we recruited 15 patients who had been diagnosed with PMYST from four medical institutions to create a population-based cohort. We then used Kaplan-Meier analysis and the log-rank test to investigate and compare overall survival (OS) and progression-free survival (PFS).A total of 15 cases were identified. The mean age was 27.3 years (range: 19-34 years). The estimated 1- and 2-year PFS rates were 66.7% and 60.0%, respectively. The 1- and 2-year OS rates were both 73.3%. Computer tomography scans revealed tumors were located in the anterior middle mediastinum (5 cases), the anterior superior mediastinum (1 case), the left anterior mediastinum (3 cases), and the right anterior mediastinum (6 cases). Of the 15 patients receiving extended resections, the majority (40.0%) underwent tumor resection, partial pericardiotomy, pulmonary wedge resection, and mediastinal lymphadenectomy. R0 resections were achieved in eleven patients. Four patients underwent R2 resection and experienced postoperative complications, including pneumonia (2 cases), atelectasis (1 case), and bronchopleural fistula (1 case). Four patients developed postoperative lung metastasis. Three patients died due to progressive diseases. Disease recurred in all patients at a median of 8.0 months (range: 6.0-11.0 months).PMYST is a rare but highly malignant tumor with a poor prognosis. Tumor resection, with optimal extended surgical management, may provide patients with the best chance of a cure although postoperative complications relating to the pulmonary systems should be treated with caution.

Multimodality treatment outcome in patients with primary malignant mediastinal germ cell tumor in adults

BACKGROUND

Malignant mediastinal germ cell tumor (MGCT) is rare and has poor outcomes even after multimodality treatment. Data from resource-poor countries are scarce in the literature.

AIMS

To evaluate the clinicopathologic features and treatment outcome of primary malignant MGCT at our center.

METHODS AND RESULTS

Single institutional data review of patients aged ≥18 years, treated with a diagnosis of malignant MGCT between Nov'2013 and Nov'2019. Risk stratification was done as per International Germ Cell Cancer Collaborative Group (IGCCCG) classification. Patients were treated with platinum based chemotherapy and surgical resection for the residual disease was performed in non-seminomatous histology.28 patients had MGCT with a median age of 25 years (range:18-36) and all were male. Seven patients had superior vena cava obstruction (SVCO) at diagnosis and pre-treatment histological diagnosis was available in 23 (82%) patients. Seven (25%) patients had seminoma histology, all were of good risk as per IGCCCG risk criteria, whereas others had non-seminoma histology with poor-risk group. Seven patients with seminoma histology achieved a complete response after initial treatment. Six patients with non-seminoma histology underwent complete resection of residual disease post-chemotherapy and five revealed residual viable tumors. After a median follow-up of 10.8 months (range:2.9-75), 3-year progression-free survival (PFS) and overall survival (OS) estimate was 61.2% and 94.7% in the whole cohort, respectively and 3-year PFS and OS estimate was 100% in patients with seminoma histology.

CONCLUSIONS

This is the largest data set of MGCT patients' outcomes reported from India with multi-modality treatment. All patients were male and one-fourth had SVCO at presentation. Seminoma histology patients had a 100% outcome after initial platinum based chemotherapy. But, those with non-seminoma histology had a poor outcome even with chemotherapy and surgery.

Incidentally discovered primary mediastinal germ cell tumor

Most germ cell tumors arise from the testicles and often are self-diagnosed. Extragonadal germ cell tumors are rare and vary greatly in their clinical presentations. This case report describes a 24-year-old man with an unusual presentation for an extragonadal germ cell tumor.

Primary mediastinal yolk sac tumor: a case report and literature review

Primary mediastinal yolk sac tumors (YSTs) are rare and have a high degree of malignancy. This article reports a 42-year-old man with a primary mediastinal YST. The patient presented with chest tightness and shortness of breath. Using a contrast-enhanced computer tomography (CT) scan, the mediastinal space was found to be occupied by a mass shadow, about 10 cm × 8 cm with a clear boundary and low density. Serum alpha-fetoprotein (AFP) was elevated to 7169.66 ng/ml. The 5th day after hospitalization, a percutaneous biopsy of the mediastinal mass was performed. Malignant tumor cells were found by cytologic examination. According to the pathological morphology and immunohistochemical results, the tumor was diagnosed as primary mediastinal YST. Subsequently, the patient underwent five cycles of adjuvant chemotherapy including bleomycin, etoposide, and cisplatin (BEP) and surgical tumor removal. One month after operation, AFP was elevated to 252.96 ng/ml. CT examination showed that the tumor recurred. As of September 12, 2020, the patient has undergone four cycles of VIP (etoposide, ifosfamide, cisplatin) chemotherapy after relapse, and the patient's condition is currently in partial remission.

Choriocarcinoma Presenting as a Pleural Effusion

Choriocarcinoma is a germ cell tumor characterized by widespread metastases and poorly differentiated cells. Non-gestational choriocarcinoma, or primary choriocarcinoma is a trophoblastic disease which is associated with a poor patient prognosis and is markedly angioinvasive. Primary non-gestational mediastinal choriocarcinoma is a very rare disease and represents an aggressive malignancy, primarily seen in young males. Those with primary mediastinal choriocarcinoma have symptoms that are non-specific such as cough, dyspnea, hemoptysis, and chest pain.

Here we present the case of a 47-year-old Caucasian female who presented with worsening dyspnea and cough. Laboratory testing revealed elevated alkaline phosphatase, human chorionic gonadotropin, and cancer antigen 125. Chest X-ray was significant for a large right pleural effusion and a computed tomography angiogram of the chest showed a soft tissue mass in the anterior medial right lung base/right middle lobe. Thoracentesis yielded results consistent with malignant cells favoring a germ cell tumor. Biopsy of the mediastinal mass revealed positivity for inhibin and both human chorionic gonadotropin and CD-10 which led to the diagnosis of primary choriocarcinoma.

Primary mediastinal choriocarcinoma is uncommon and often has a non-specific clinical presentation. A high degree of suspicion is needed as this malignancy can be aggressive, necessitating urgent definitive tissue biopsy diagnosis to guide appropriate therapy.

Consideraciones en torno a los tumores del mediastino

Introducción. El desarrollo de las imágenes diagnósticas hizo posible el diagnóstico topográfico de los tumores de mediastino; sin embargo, aún con los avances actuales de la cirugía, la anestesiología y la reanimación, el acceso quirúrgico a ese espacio medio de la caja torácica continúa siendo el gran reto que enfrentan los cirujanos torácicos. Objetivo. Profundizar en los diferentes aspectos cognoscitivos actualizados sobre los tumores mediastinales. Métodos. Búsqueda documental digital en bases de datos: Scielo, Lilacs, Web of Science, PubMed, realizada en enero de 2019, de publicaciones sobre el tema en la presente centuria. Resultados. Las neoplasias mediastinales son poco frecuentes, pueden aparecer a cualquier edad, aunque son más frecuentes entre la tercera y quinta décadas, y la mayoría se descubren incidentalmente en una radiografía de tórax de rutina en pacientes asintomáticos. Los tumores malignos del mediastino son poco frecuentes, pero los benignos constituyen un desafío diagnóstico para radiólogos y patólogos. En las neoplasias malignas se identifica una amplia gama de variedades histológicas, atribuibles a las características del órgano afectado. Conclusiones. El diagnóstico definitivo generalmente se establece mediante el estudio histopatológico posquirúrgico, si bien la tomografía computarizada, asociada o no a la biopsia percutánea, es el estándar de oro para el diagnóstico preoperatorio. La selección de la vía de entrada al tórax, así como el procedimiento quirúrgico, están condicionados por la localización y el tamaño del tumor en el mediastino.

Primary mediastinal choriocarcinoma in a female patient: Case report and review of the literature

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Primary mediastinal choriocarcinoma is rare, especially in female patients.

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Genomic losses predominated our case, which has not been previously reported.

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This tumor lacked human chorionic gonadotropin and required histologic diagnosis.