S Takeda(*); S Miyoshi; M Minami; M Ohta; M Okumura; H Hirabayashi and H Matsuda. Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
PURPOSE: Primary germ cell tumors (GCT) of the mediastinum are rare and account for approximately 10 to 15% of all tumors of this area. The purpose of this study is to reviews our Asian institutional experience of GCT, emphasizing the clinical spectrum, time trends of treatment and recent advance of therapeutic modalities for malignant GCT.
METHODS: Between 1949 and 2000, 129 patients (70 males and 59 females) underwent surgical treatment for GCT, which account for 16.0% of 806 mediastinal tumors during the same period. There were 93 mature teratomas, 13 seminomas, and 23 non-seminomatous germ cell tumors (NSGCT: 11 embryonal cell carcinomas, 3 choriocarcinomas, 2 yolk sac tumors and 7 others); with median age of 25.7 years, 26.5 years and 26.3 years respectively.
RESULTS: Symptoms of chest pain, cough and fever were seen in 24/72 (33.3%) in adult patients ([is greater than] 16 years) with mature teratomas. In contrast, 11/21 (52.4%) presented with symptoms of dyspnea, cyanosis and chest pain in pediatric groups (under 15-year-old). Two infants (age of Day 17 and 50) received emergent operation because of progressive cyanosis due to the mass of the posterior mediastinum. All patients with mature teratomas were cured by radical resection alone, without disease-related death. Eight of 13 patients with seminoma were symptomatic due to the large mass in the anterior mediastinum. One patient died under anesthesia, and one patient developed near-cardiac arrest necessitating emergent cardiopulmonary bypass followed by resection. Ten of 13 patients (83.3%) survived after resection and radiation with/without chemotherapy. Twenty of 23 patients (87.0%) with NSGCT showed symptoms of dyspnea, chest pain, hoarseness and superior vena cava syndrome. Five patients had multiple intrapulmonary metastases at presentation. Before 1970, 5 of 7 patients received radical resection alone. From 1971 to 1985, 3 patients underwent radical resection followed by chemoradiation therapy, and 4 patients received chemoradiation. All 14 patients died of disease progression, with a median survival of 4.9 months and 10.4 months, respectively. After 1986, 7 of 9 patients received cisplatin-based induction chemotherapy, and 3 patients were given additional high-dose chemotherapy with a support of peripheral blood stew cell transplantation (PBSCT) until tumor marker normalized. One patent died of infection, one developed complete remission of tumor by chemotherapy alone and 5 underwent salvage resection. Six patients (66.7%) are disease free at present with a median survival of 58.3 months.
CONCLUSION: The results of our institutional experience indicate the benignity in mediastinal mature teratomas and excellent prognosis o seminoma. Anesthesia with severe symptomatic patients with GCT should be carefully planned with reference to the therapeutic strategy. Improved survival advantage was ensured by cisplatin based high-dose preoperative chemotherapy with/without PBSCT support in patients with NSGCT. The significance of salvage tumor resection for patients with initial lung metastasis remains to be determined.
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