대한흉부영상의학회 Weekly Chest Cases

Case No : 366 Date 2004-10-30

Courtesy of Jung-Nam Heo, M.D., Joon Beom Seo, M.D., Jae-Woo Song, M.D., Jin Seong Lee, M.D. / Asan Medical Center, Seoul, Korea
Age/Sex 14 / M
Chief ComplaintIncidental findings of abnormality on the chest radiograph

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Diagnosis With Brief Discussion

Diagnosis: Mediastinal teratoma with malignant transformation
Radiologic Findings: Chest radiograph shows a mass in the left side of the anterior mediastinum.

Chest CT scans show a heterogeneously enhancing low-attenuated mass in left portion of the anterior medistinum. It contains fat component, calcified foci and enhancing tubular structure suggesting vascular structure.

Gross specimen of thymectomy presented as the anterior mediastinal mass. The cut surface shows a well-demarcated and ovoid firm mass containing focally solid, cystic, and chondroid components. Multiple foci of hemorrhage are noted. (Mature and immature teratoma with angiosarcomatous component.)
Brief Review: The most common histologic type of mediastinal germ cell tumor is mature teratoma, which occurs in young patients and usually occurs within or near the thymus gland and account for up to 75% of primary germ cell tumors of the mediastinum.

Benign teratomas are frequently discovered on routine chest radiography while the patient is asymptomatic.

Radiographically the typical appearance is that of a sharply demarcated, rounded or lobulated anterior mediastninal mass which projects beyond the mediastinal boundaries into adjacent lung fields. Radiographic evidence of calcification has been reported in approximated 20-43% of cases. It may represent calcification of the wall of the tumor, calcification in the tumor substance, ossification in mature bone, or calcification in a tooth or teeth within the tumor. Another specific sign for the diagnosis of teratoma is the presence of a fat-fluid level, which is seldom seen radiographically.

In this case, angiosarcomatous elements were intermingled with teratomatous elements and the patient's primary germ cell tumor contained malignant and atypical teratomatous elements as well as prominent vascular proliferation. Association of angiosarcoma with a germ cell tumor was reported several cases in English literature. Most of reported cases were testicular teratoma. Only one case was reported the development of angiosarcoma as a complication of mediastinal teratoma previously. Several explanations have been offered for the appearance of second malignancies. Among treatment-related causes, radiation-induced carcinogenesis has been well recognized for nearly a century. Sarcomas, in particular, are typical of being causally related to ionizing radiation. Although angiosarcoma is not commonly encountered among such sarcomas, its occurrence after radiotherapy is well documented, especially in the treatment of breast and cervical carcinomas. However, in some cases of GCT, it is unclear whether the mechanism of malignant transformation is de novo or therapeutically induced.
References: 1. Kathleen H. Muller, Mellssa L. Rasadi-de-Chrisenson, Philip A. Templeton. Mediastinal mature teratoma : imaging features. AJR 1997 ; 169 : 985-990

2. Saito A, Watanabe K, Kusakabe T, Abe M, Suzuki T. Mediastinal mature teratoma with coexistence of angiosarcoma, granulocytic sarcoma and a hematopoietic region in the tumor: a rare case of association between hematological malignancy and mediastinal germ cell tumor. Pathol Int. 1998;48(9):749-53

3. Sahoo S, Ryan CW, Recant WM, Yang XJ. Angiosarcoma masquerading as embryonal carcinoma in the metastasis from a mature testicular teratoma. Arch Pathol Lab Med. 2003;127(3):360-3
Keywords: Mediastinum, Malignant tumor,

No. of Applicants : 41

▶ Correct Answer : 27/41, 65.9%

- Annecy Hospital, France Gilles Genin
- Asan Medical Center, Korea Eun Jin Chae
- Centre d'imagerie Jacques Callot, Nancy, France Lionel Cannard
- CH lyon sud, France Xavier Riviere
- CHU Grenoble, France Mathieu Rodiere
- CIM Saint Dizier, France JC Leclerc
- Eulji hospital, Korea Jeong Joo Woo
- European Hospital, Paris, France Rached Triki
- Gwangmyoung Sung-Ae Hospital, Korea Jiyong Rhee
- Hangang sacred heart hospital, Korea Young-Jae Kim
- Hangang SacredHeart Hospital, Korea Eil Seong Lee
- Hanyang University Guri Hospital, Korea Hyunji Kim
- Hanyang University Hospital, Seoul, Korea Yo Won Choi
- Homs National Hospital, Homs, Syria Rami Abou Zalaf
- Hospital Donostia, Spain Fran Basterrechea
- Hopital Notre Dame, CHUM, Montreal, Qc, Canada JS Billiard
- Incheon Sarang Hospital, Korea Jung Hee Kim
- Jikei University of Medicine, Japan Shigeki Misumi
- Kocaeli medical school, Turkey Salih Topcu
- Maggiore Hospital, Bologna, Italy Marcellino Burzi
- Maimonides Medical Center, Brooklyn, NY, USA Naomi Twersky
- Marien Hospital, Hamm, Germany Davis Chiramel
- Seoul National University Hospital, Korea Heesun Park
- Sharma Clinic, Jaipur, India Dinesh Sharma
- Shinsegae Rad Clinic, Korea Gi Beom Kim
- Social Security Hospital, Ankara, Turkey Meric Tuzun
- Swaidaa National Hospital, Syria Marwan Alchami

▶ Semi-Correct Answer : 11/41, 26.8%

- Aditya Imaging Centre, Baroda, India Vivek Patel
- CHU Nancy-Brabois, France Denis Regent
- Dong-A University Hospital, Korea Ki-Nam Lee
- Ev. Krkhs. Hubertus, Berlin, Germany Michael Weber
- Govt. Medical College, Gujarat , India Vijay Vaidyaz
- Kyungpook Nnational University Hospital, Korea Shin Kyung Min
- Mallinckrodt Institute of Radiology, USA Jin Mo Goo
- Nancy, France Julien Mathias
- Ondokuz Mayis University, Samsun, Turkey Cetin Celenk
- Samsung Medical Center, Korea Ha Young Kim
- Seoul National University Hospital, Korea Lee Ho Yun

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 366 Date 2004-10-30

Discussion

No. of Applicants : 41