INTRODUCTION: Extragonadal germ cell tumor is a rare tumor and usually characterized by their location on the midline from pineal gland to coccyx. Yolk sac carcinoma is a very virulent carcinoma with early hematogenous dissemination potential and high affinity for liver metastasis. Treatment moralities include radiation, chemotherapy, and surgery for residual masses. Obstructive cardiomyopathy is a well described left ventricular entity causing significant reduction in cardiac output.
CASE PRESENTATION: Patient is 19 years old white male with out any significant past medical history presented with complaint of 2-3 weeks history of left chest pain with worsening short of breath and fever. On physical examination, pt was in moderate respiratory distress with increase work of breathing. Clinical findings demonstrated reduced air entry to the left hemi-thorax. Patient's clinical status deteriorated required intubation for air way protection. Hypotension also occur requiring large volume of fluid to maintain blood pressure. Computerized Tomography of chest showed a large mediastinal mass @ 15x11 cm extending across Left hemi-thorax as well as a hepatic mass measuring @ 18x 11 cm. Tran esophageal echocardiography show enlarge right ventricle with extracardiac mass compressing on right ventricular outflow tract creating outflow tract obstruction. Fine needle aspiration of liver mass revealed a yolk sac tumor. Clinical course was complicated via acute respiratory failure secondary to the mass effect on the left lung. Repeated hypotensive collapse secondary to right ventricular outflow tract obstruction. Patient received 4 cycle of chemotherapy and radiation therapy with substantial clinical response. PET scan shows persistence activity of hepatic mass w/o any activity of mass of left hemi-thorax.
DISCUSSIONS: This patients mediastinal lesion compressing the right ventricular outflow tract causing right ventricular failure in a manner which clinically seem analogous to left ventricular outflow tract obstruction. This patient required intensive and prolonged respiratory and hemodynamic support with emergent radiation and chemotherapy for relief of right ventricular and left lung compression. Yolk sac carcinoma s/p chemotherapy with hepatic metastasis placed patient at high risk for thromboembolic complication. Given his low pulmonary reserved and high propensity for pulmonary embolic events, patients also received superior vena cava and inferior vena cava filter placed with long term anticoagulation. Surgical removal of residual tumor with salvage chemotherapy is required in nonseminomas germ cell tumor secondary to high propensity for recurrence and malignant transformation.
CONCLUSION: Mass effect secondary to mediastinal yolk sac carcinoma with right ventricular outflow tract obstruction requiring prolonged and aggressive fluid and vasopressor support, whilst awaiting outcome of cytotoxic therapies.
(1) American College of Chest Physicians, Pulmonary Board Review 2003Cancer6 Medicine via Holland. FreiUptoDate online 12.3
DISCLOSURE: Yu Ya Huang, None.
Yu Ya Huang MD * Brody School of Medicine, Greenville, NC
COPYRIGHT 2005 American College of Chest Physicians
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