Clinician-to-Clinician Update Clinician-to-Clinician Update

Aggressive Surgery for Complete Resection of Rare Thoracic Cancer

May 2015

Contributed by Eitan Podgaetz, MD

Germ cell tumors are among the most common cancers in young adult men. Although they generally originate in the gonads, extragonadal germ cell tumors are present in 1% to 5% of cases. Extragonadal germ cell tumors display one of the histologies associated with gonadal origin and commonly affect the pineal gland, retroperitoneum, brain, and mediastinum in males.1 The gold standard of treatment is cisplatinbased chemotherapy followed by surgical resection of residual disease; however, complete resection of the tumor is not always possible.2 Here we describe the case of a young, active male patient with a large and fastgrowing mediastinal germ cell tumor who was successfully treated with chemotherapy and a complete surgical tumor resection.

Patient

A 25-year-old male patient presented to his primary care physician with pain in the left shoulder. The patient was employed as a physical trainer, so the physician prescribed analgesics for musculoskeletal pain. After no improvement was seen, the patient was referred to an orthopedist who diagnosed bursitis. Physical therapy and analgesics provided no relief. The patient was sent for thoracic CT imaging, which revealed a very large mediastinal tumor (Figure 1). Biopsy confirmed it was of mixed germ cell origin. Chemotherapy was initiated rapidly at the local hospital, and the patient was referred to a University of Minnesota Cancer Care location.

Preop-coronal-CT-image tumor Podgaetz-case-study-443x316
— Figure 1. Preoperative coronal CT image showing massive mediastinal tumor
Intraop-image Podgaetz-case-study-443x299
— Figure 2. Intraoperative image showing the heart, aortic arch, and head vessels dissected free of tumor

Treatment

After completing four rounds of chemotherapy, the patient underwent open surgical resection of the tumor via clamshell thoracotomy. Surgeons took an aggressive surgical approach, as the tumor was very large and fast growing. Although a vocal cord nerve was sacrificed in the procedure, a complete tumor resection was achieved (Figure 2). The patient recovered from the surgery without complications other than the expected unilateral vocal cord paralysis. He subsequently underwent two further cycles of chemotherapy with isofosfamide, etoposide, and cisplatin. The vocal cord paralysis and resulting hoarseness were followed by providers at the Lions Voice Clinic at the University of Minnesota. Nerve transposition was performed with a good outcome. The patient has resumed work as a physical trainer and continues to be free of tumor recurrence at 18-months postprocedure.

Discussion

Patients with mediastinal germ cell tumors have a 5-year relative survival rate of 58%.1 Patients with complete surgical resection have an improved rate of 5-year survival.3, 4 Surgery is technically demanding because the residual mass often infiltrates into surrounding mediastinal structures after chemotherapy. Reports indicate that the skill and experience of the oncology center and especially the expertise of the thoracic surgical oncologist are of pivotal importance in achieving a successful outcome.5

References

1. Stang A, et al. Gonadal and extragonadal germ cell tumors in the United States, 1973–2007. Int J Androl. 2012;35(4):616-625.

2. Liu Y, et al. Management of the primary malignant mediastinal germ cell tumors: experience with 54 patients. Diagn Pathol. 2014;9:33.

3. Kang CH, Kim YT, Jheon SH, et al. Surgical treatment of malignant mediastinal nonseminomatous germ cell tumor. Ann Thorac Surg. 2008;85(2):379-384.

4. Kuwano H, Tsuchiya T, Murayama T, et al. Outcomes of combined modality therapy for patients with stage III or IV mediastinal malignant germ cell tumors. Surg Today. 2014;44(3):499-504.

5. Radaideh SM, Cook VC, Kesler KA, et al. Outcome following resection for patients with primary mediastinal nonseminomatous germ-cell tumors and rising serum tumor markers postchemotherapy. Ann Oncol. 2010;21(4):804-807

Related Articles

May 2015

Minimally Invasive Thoracic Cancer Surgery Reduces Complications

Research comparing outcomes of thoracic cancer patients indicates that minimally invasive techniques are associated with improvements in morbidity rates, lengths of hospital stay, and postsurgical pain.

Continue reading

May 2015

Cancer Care Specialty Updates

The University of Minnesota Cancer Care lung-screening program is named a center of excellence. Find this and other UMN Cancer Care news.

Continue reading