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© 2001 American Society for Clinical Oncology
Unusual Presentations of Germ Cell TumorsCase 1. Recurrent Laryngeal Nerve Palsyin Mediastinal SeminomaSydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, Australia A 27-year-old white man was admitted to hospital with a 3-day history of anterior left-sided pleuritic chest pain. He had been involved in a motor vehicle accident 8 days earlier. His past history was noncontributory and his physical examination was unremarkable. A chest x-ray revealed a widened mediastinum. A subsequent computed tomographic (CT) scan demonstrated a paratracheal mass high in the anterior mediastinum. The differential diagnosis included a hematoma, false aneurysm, thymoma, or other neoplastic condition; however, given the history of trauma, an aortogram was performed, the results of which were normal. After review by a cardiothoracic surgeon, a mediastinotomy, mediastinal biopsy, and bronchoscopy were performed. Histopathologic examination revealed fibroadipose tissue with focal chronic inflammation. He was discharged with ongoing chest pain for follow-up in the outpatient clinic. The patient did not return for follow-up. Six weeks later he represented with a 4-week history of hoarse voice. His chest pain had resolved but he had developed night sweats. A repeat CT scan showed an increase in the size of the mediastinal mass ( Fig 1). Indirect laryngoscopy confirmed a right vocal cord paralysis consistent with a right recurrent laryngeal nerve palsy. A left anterior mediastinotomy and biopsy were performed. Histopathologic examination of the frozen section was reported as a large-cell neoplasm that could be lymphoma. Bone marrow aspiration and trephine showed no evidence of lymphoma. A gallium scan showed the mediastinal mass and a possible area of uptake in the left infraclavicular region.
Subsequent review of the biopsy specimen revealed a small area of crushed large cells with some probable seminomatous elements. Serum beta-human chorionic gonadotropin and alpha-fetoprotein levels were within normal limits. Results of a scrotal ultrasound were normal. A median sternotomy with open biopsy was performed 3 weeks after the previous cardiothoracic procedure. The pathology confirmed a seminoma with an adjacent granulomatous reaction ( Fig 2A; magnification x 400). Immunoperoxidase stains were positive for placental alkaline phosphatase and negative for EMA, S100, CD30 and AE1AE3 (Fig 2B; placental alkaline phosphatase staining, magnification x 400). The final diagnosis was mediastinal seminoma with recurrent laryngeal nerve paralysis.
The plan was to treat the patient with four cycles of bleomycin, etoposide, and cisplatin (BEP). Unfortunately, bleomycin had to be discontinued after two cycles due to a fall in the DLCO from 83% of predicted to 68%. The cisplatin was tolerated very poorly; consequently, carboplatin was substituted at cycle 4. A repeat CT scan 4 weeks after the conclusion of the fourth cycle showed almost complete resolution of the mediastinal mass ( Fig 3), and a gallium scan showed normal uptake. In addition, the patient’s voice had returned to normal, and repeat laryngoscopy showed normal vocal cord movement bilaterally.
There is scant evidence in the literature of nerve palsies associated with seminoma in any location in the body. This is surprising in view of the aggressive nature of the tumor and its propensity to cause symptoms by compression or invasion of local structures, such as the superior vena cava, pericardium, chest wall, lung, and pleura. Mediastinal seminomas represent a very small subset of extragonadal germ cell tumors (EGCT).1 Jain et al2 reported 21 patients with extragonadal seminomas of whom one presented with a hoarse voice and two had phrenic nerve palsies. Goss et al3 reviewed the presenting symptoms of 19 patients with EGCT seminomas, none of whom had vocal symptoms. Other series of EGCT seminoma,4-8 although not specifically documenting the presenting symptoms, have not reported evidence of nerve palsies. A search of MEDLINE and CANCERLIT revealed only one other report of compression neuropathy associated with seminoma. Hans et al9 described a brachial plexus neuropathy from metastatic testicular seminoma that resolved after surgery and radiotherapy. The primary treatment of the neuropathy is treatment of the underlying malignancy. REFERENCES 1. Hainsworth JD, Greco FA: Extragonadal germ cell tumours and unrecognised germ cell tumours. Semin Oncol 19: 119-127, 1992[Medline] 2. Jain KK, Bosl GJ, Bains MS, et al: The treatment of extragonadal seminomas. J Clin Oncol 2: 820-827, 1984[Abstract] 3. Goss PE, Schwertfeger L, Blackstein ME, et al: Extragonadal germ cell tumours. Cancer 73: 1971-1979, 1994[Medline] 4. Hainsworth JD, Einhorn LH, Williams SD, et al: Advanced extragonadal germ cell tumours. Ann Intern Med 97: 7-11, 1982 5. Logothetis CJ, Samuels ML, Selig DE, et al: Chemotherapy of extragonadal germ cell tumours. J Clin Oncol 3: 316-25, 1985[Abstract]
6.
Israel A, Bosl GJ, Golbey RB, et al: The results of chemotherapy for extragonadal germ-cell tumours in the cisplatin era: The Memorial Sloan-Kettering Cancer Center experience (1975 to 1982). J Clin Oncol 3: 1073-1078, 1985 7. Pizzocaro G, Salvoni R, Piva L, et al: Cisplatin combination chemotherapy in advanced seminoma. Cancer 58: 1625-1629, 1986[Medline] 8. Gerl A, Clemm C, Lamerz et al: Cisplatin-based chemotherapy of primary extragonadal germ cell tumours. Cancer 77: 526-532, 1996[Medline] 9. Hans S, Lindner DW, Webster JD: Brachial plexus neuropathy from metastatic testicular seminoma: Prolonged survival after surgery and radiotherapy. Urology 25: 398-400, 1985[Medline]
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Copyright © 2001 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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