대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesArchive of Old Cases

Case No : 459 Date 2006-08-14

  • Courtesy of Kun Young Lim, MD, Su Hyun Lee, MD, Hyae Young Kim, MD. / National Cancer Center, Korea.
  • Age/Sex 27 / M
  • Chief ComplaintCough
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Mediastinal Seminoma
Radiologic Findings
Chest simple radiograph shows large mass shadow along left heart border. Left heart border is obliterated. CT scans show an anterior mediastinal mass with relatively homogeneous attenuation with focal cystic portion. Fat or calcifications were not seen in the mass. The fat plane between mass and heart is obliterated.

Serum levels of hCG and LDH were elevated. Serum level of AFP was not elevated. PCNA was performed. The pathological diagnosis was seminoma.
Brief Review
Germ cell tumors accounts for 10-15% of anterior mediastinal masses and are thought to arise from mediastinal remnants left behind after embryonal cell migration. Histologic types of malignant germ cell tumors that occur in the mediastinum include seminoma, embryonal carcinoma, endodermal sinus tumor, choriocarcinoma, and mixed germ cell tumors. Seminoma is the most common pure histologic type in men and accounts for 40% of such tumors. Malignant mediastinal germ cell tumors are usually encountered in young adults and are much more common in men than women.

Malignant mediastinal germ cell tumors are more frequently symptomatic than benign teratomas. Common presenting complaints include cough, dyspnea, and chest pain. SVC obstruction is reported in up to 10% of affected patients. Weight loss may also be a notable feature. However, between 10 and 30% of affected patients are asymptomatic at presentation, with the mass discovered on routine chest radiographs.

On chest radiographs, seminoma manifest as focal, typically unilateral, mediastinal masses. On CT or MRI, they are usually large lobulated masses of homogeneous attenuation or signal intensity, often indistinguishable from lymphoma. Cysts or areas of necrosis may also be seen in association with mediastinal seminoma. Invasion of adjacent structures is uncommon and calcification is rare. Metastases to regional nodes can occur. Usually hCG and AFP levels are normal, but hCG levels are elevated in 7-18% of patients with seminoma. Elevated serum levels of LDH correlate with tumor burden and rate of tumor growth.
References
1. Hansell DM, Amstrong P, Lynch DA, McAdams HP. Mediastinal and aortic diseases. In Huston M. editor. Imaging of diseases of the chest. 4th ed. St. Louis; Mosby; 2005, p.921-925

2. Moran CA, Suster S, Przygodzki RM, Koss MN. Primary germ cell tumors of the mediastinum: Mediastinal seminomas-a clinicopathologic and immunochemical study of 120 cases. Cancer 1997;80:691-698.

3. Bokemeyer C, Droz J-P, Horwich A, Gerl A, Fossa SD, Beyer J, et al. Extragonadal seminoma; An international multicenter analysis of prognostic factors and long term treatment outcome. Cancer 2001;91:1394-1401.
Keywords
Mediastinum, Malignant tumor,

No. of Applicants : 42

▶ Correct Answer : 20/42,  47.6%
  • - Inje University Ilsan Paik Hospital, Korea Bae Geun Oh
  • - National Taiwan University Hospital, Taiwan Yu-Feng Wei
  • - Asan Medical Center, Korea Eun Jin Chae
  • - Hangang Sacred Heart Hospital, Korea Eil Seong Lee
  • - Radiologie Guiton, La Rochelle, France Denis Chabassiere
  • - Dong-Eui Medical Center, Busan, Korea Hoon Sik Jung
  • - Hospital Sotiria, Athens, Greece Tzilas Vasilios
  • - Incheon Sarang Hospital, Korea Jung Hee Kim
  • - Airforce Hospital, Korea Hyun Seok Choi
  • - Unknown Trupti Dabholkar
  • - Doctors Hospital, Nassau, Bahamas N.B.S.Mani
  • - CHU Nancy, France Abraham Bohadana
  • - CHU Grenoble, France Bing Fabrice
  • - Maimonides Medical Center; Brooklyn, NewYork, USA Naomi Twersky
  • - Sam Anyang Hospital, Korea Jae Seung Seo
  • - Diskapi Yildirim Beyazit Hospital, Ankara, Turkey Meric Tuzun
  • - Pgimer, Chandigarh, India Ram Prakash Galwa
  • - Zulekha Hospital, Dubai Julie Arora
  • - China Medical University Hospital,Taiwan Jun-Jun Yeh
  • - Monaldi Hospital,Naples, Italy Gaetano Rea
▶ Correct Answer as Differential Diagnosis : 8/42,  19.0%
  • - Annecy Hospital, France Antoine Marie
  • - Ev. Krkhs. Hubertus, Berlin, Germany Michael Weber
  • - Homs National Hospital, Homs, Syria Rami Abou Zalaf
  • - Radiologie Guiton, La Rochelle, France Jean Luc Bigot
  • - Pgimer, Chandigarh, India Ashish Gupta
  • - Max Hospital, New Delhi, India Vickrant Malhotra
  • - MGM, Indore, India Sonali Jain
  • - Annemasse, Polyclinique de Savoie, France Gay-Dpassier Philippe
▶ Semi-Correct Answer : 1/42,  2.4%
  • - Annecy Hospital, France Gilles Genin
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