A 35 year old gentleman whom hitherto have been well presented to a district hospital with complaints of chest pain that radiated to his left shoulder. He was admitted and treated for unstable angina where he received anticoagulant therapy and initiated on Dual Antiplatelet Therapy.
A week thereafter he had presented to a tertiary centre for persistent chest pain associated with non-productive cough for about a week. He also complains of loss of weight for about 1 year duration, however is unable to quantify objectively. Otherwise, he has no history of fever, loss of appetite, prolonged cough, haemoptysis or family history of malignancy.
In the emergency department, point of care ultrasound was done which revealed a large pleural effusion with fibrin over the left hemithorax. Pleural tapping was performed and 1 litre of haemoserous fluid was drained, which were exudative in nature. The patient also had several episodes of tachycardic rate uncontrolled atrial fibrillation. Whilst initially responding to Amiodarone, eventually he required cardioversion twice at 50J and 100J’s respectively.
Once stabilised a left pigtail catheter was inserted under radiological guidance and drained 1.5 litres of haemorrhagic effusion.
At this point the patient was subjected to a computed tomography (CT) of his thorax which revealed the presence of a large heterogenous mildly enhancing hypodense mass at the anterior mediastinum measuring about 20cm x 9.4cm x 11cm. There was contrast extravasation visible which may be indicative of active intratumoral haemorrhage. The mass appears to abut the pericardium forming an indentation with pericardial effusion raising the suspicion of tumour infiltration. Features of the imaging was suggestive of an anterior mediastinal mass with high suspicion of active intratumoural haemorrhage. Possibility of GCT, Lymphoma and invasive thymoma were all considered however Tumour markers for AFP (Alpha fetoprotein) were elevated at 818.1 IU/mL narrowing it down to GCT.
At this point the patient was referred to our cardiothoracic centre for further management. At our centre the patient was counselled and planned for sternotomy and resection of the tumour. Intraoperatively, it was noted that the tumour was closely abutting the sternal bone which caused some bleeding upon the sternotomy. The large tumour measuring 10x20cm was densely adhered to the medial portion of left lung parenchyma and loosely adhered to the pericardium. The sheer mass had pushed the heart infero-laterally to the right, which was restored to its original position post tumour excision. En-bloc resection of the tumour together with the portion of tumour attached to lung parenchyma was resected and sent for histopathological examination.
The histopathological examination for the anterior mediastinal mass came back as mixed germ cell tumour. It was predominantly a immature teratoma, and a minor component of yolk-sac tumour. The resected let lung parenchyma showed positivity of malignancy as it was infiltrated by the yolk-sac component. Tumour markers showed an elevated AFP 818.1 IU/ml and BHCG 23.9 IU/L reading. The patient was planned for completion of staging via CT scan and started on chemotherapy with Bleomycin, Etoposide, and Platinum (BEP Regime) for 4 cycles.