Genetic testing for the i(12p) chromosomal abnormality, a finding consistent in GCT but rarely in other tumors, may be helpful in cases with diagnostic uncertainty. Core needle biopsy or, when appropriate, surgical biopsy, typically via anterior mediastinotomy (Chamberlain procedure), will assist in establishing the diagnosis of GCT which can mimic poorly differentiated carcinoma ( 6). The pathologic discrepancy between histology and fine-needle aspiration (FNA) is 6%. We recommend histologic diagnosis once positive tumor markers are obtained. Teratoma with elevated tumor markers should be treated similarly to NSGCTs with neoadjuvant VIP and potential for post-chemotherapy surgical resection. ![]() Mature teratoma with normal tumor markers should be surgically resected with no role for chemotherapy or radiation even in incomplete resection. ![]() With a histologic diagnosis of pure seminoma and the absence of tumor marker elevation, chemotherapy with (BEP) provides an excellent prognosis without surgical resection. Patients with normal tumor markers should have biopsy of their mass. Of note, bleomycin is toxic to the lungs. Chemotherapy with etoposide (VP-16), ifosfamide, and cisplatin (VIP) is preferred over bleomycin, etoposide, and cisplatin (BEP) to spare pulmonary complications in these patients who often require extensive surgical resection. Some institutions treat any anterior mediastinal mass with β-HCG >1,000 and/or any elevation in AFP as a confirmed primary NSGCT ( 5). In mature teratomas, the markers are normal ( 2). Elevated serum AFP is not seen with pure seminomas and is an indication that yolk sac tumor and embryonal cell carcinoma is present in the primary or in a metastatic site. The elevation of any nonseminomatous tumor marker, even in a tumor with predominantly seminomatous histology, is classified and treated as a NSGCT. Patients may have elevation of both AFP and β-HCG or either marker in isolation ( 3, 4). In younger male patients, high β-HCG can lead to gynecomastia. Tumor marker elevation is seen in a majority of patients with AFP increased in 80% of NSGCTs and β-HCG in 30% to 35%. Mediastinal NSGCTs can be accompanied by hematological disease including megakaryocytic leukemia, myelodysplastic syndrome, refractory thrombocytopenia, or refractory anemia. We describe the work up and crucial preoperative considerations, various incisions and their applications to tumor size and location, and resectable structures and factors to consider in their removal.įigure 3 Histologic types of germ cell tumors. Appropriate pre-surgical planning, positioning, approach, exposure, and intraoperative decision making are all integral to successful resection. Surgery can be challenging due to tumor size, location, and adherence to important structures. These typically anterior tumors can be found adjacent to and invading any of the major mediastinal vessels, nerves, lung, and hila. The remaining nonseminomatous germ cell tumors are treated with neoadjuvant chemotherapy and post-chemotherapy resection regardless of tumor marker persistence. Pure mediastinal seminomas are usually curable with chemotherapy alone, while mature teratomas are treated with surgery alone. ![]() Chemotherapy and/or surgery is the mainstay of treatment of these primary mediastinal germ cell tumors.
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