Primary mediastinal giant teratocarcinoma

Abstract

A 25-year-old male presented with right hemi-thoracic chest pain, brassy cough, and progressively worsening dyspnoea for last two months. He developed facial puffiness and edema of both the upper limbs for last one month.Examination revealed mild pallor, distended and nonpulsatile jugular veins, and bilateral gynaecomastia. Other general examination was normal.Chest examination revealed bulging right thoracic wall with ipsilateral reduction of respiratory movements. The same areas were dull on percussion with marked reduction of vocal fremitus, vocal resonance and breath sounds. De-spine sign was positive up to T8 vertebra. Cardiac examination was normal except for shift of cardiac apex 3 cm lateral to mid clavicular line in 5 th intercostal space on left side. Abdomen including genitalia, and nervous system examination were normal.Skiagram chest PA view revealed homogeneous opacification of right hemi thorax with obliteration of right costophrenic and cardiophrenic angles, and right border of heart. There was mediastinum shift towards left side [ Figure 1].Contrast enhanced CT scan chest revealed a huge (20.8 × 13.0 × 16.0 cm) heterogeneously enhancing soft tissue density mass lesion in the anterior mediastinum extending from the thoracic inlet almost till the diaphragm occupying nearly the entire right hemi-thorax with extension across the midline to left. This mass was causing severe compression of the mediastinal vessels and bronchial orifices [Right>left]. The cardiac silhouette was also markedly pushed to the left side [ Figure 2]. Moderate amount of pleural fluid was also seen on right side.Hemorrhagic pleural fluid was aspirated with plenty of malignant cells. USG guided trucut biopsy of the mass was diagnostic of teratocarcinoma.Extragonadal germ cell tumors are uncommon nonetheless the anterior mediastinum is the most common extragonadal site. Mostly mediastinal teratomas (>75%) are benign, and have equal incidence in men and women, but 90% of malignant tumors are seen in men. [1] Mature teratomas demonstrate a mixture of tissues from one or more of the germinal layers, i.e. ectoderm, endoderm, and mesoderm. If the tumor contains any immature or embryonal structures, it is considered an immature teratoma. A mature teratoma may rarely undergo malignant transformation of one of the mature elements. The term teratocarcinoma is used for the combination of teratoma plus embryonal carcinoma.Review of literature regarding the size of teratocarcinoma mentions size ranging from 4 to 13 cm in diameter. [2,3] In our patient, the size of the tumor (20.8 × 13.0 ×

A Giant Primary Mediastinal Teratocarcinoma in a Male Adult

“…Patients with a large mediastinal mass are likely to present with symptoms of local compression including dyspnoea, dysphagia, and chest pain or tightness [3, 4, 6]. 85-90% of patients with NSGCTs are symptomatic as these tumors are usually invasive at the time of diagnosis [3, 5].…”

“…Benign GCTs have no gender predilection, and they account for 70-80% of mediastinal GCTs [1, 3]. Malignant GCTs, on the other hand, occur more frequently in males [1, 4, 5].…”

“…Tumors in the mediastinum can be life threatening because they grow in a confined space between the lungs. People with mediastinal tumors can be asymptomatic but are most likely to present with symptoms of mediastinal obstruction, such as dyspnoea, dysphagia, and chest pain [1, 3, 4, 6].…”

Primary malignant teratoma of the mediastinum with poor outcome: A case report

“…A rapid growth and invasive behavior are the rule 15 . The usual signs and symptoms of malignant extragonadal germ cell tumors due to a local extension of the tumor are: chest pain, breathing problems, cough, fever, headache, change in bowel habits, fatigue, walking problems, vision problems, symptoms due to elevated -HCG levels (gynecomastia, hyperthyreoidism) 5,8,9 . Our patient developed the superior vena cava obstruction signs.…”

“…Teratoma is a common tumor of the anterior mediastinum and malignant teratoma seldom metastasizes to the lung. The most frequently involved extrathoracic metastatic site is the skeletal system 8,9 . About 5%-10% of mediastinal tumors in adults are teratomas and about 85% of them are benign 1,[9][10][11][12] .…”