NON-SEMINOMATOUS GERM CELL TUMOR PRESENTING AS EARLY PERICARDIAL TAMPONADE

Abstract

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: The most frequent mediastinal lesions in adults are thymoma, lymphoma, thyroid masses and germ cell tumors. Potential complications of these masses due to localized invasion include hemoptysis, post-obstructive pneumonia, and superior vena cava syndrome. However, our patient was found to have large pericardial effusion and signs of early cardiac tamponade, which as complications of extragonadal germ cell tumors, have rarely been previously reported. CASE PRESENTATION: A 28-year-old male presented with a 1-week history of pleuritic chest pain, worsening shortness of breath and non-productive cough. On physical examination, he was in distress and preferred sitting position. JVD was elevated and heart sounds were muffled. EKG showed sinus tachycardia with low voltage complexes. CXR showed contour deformity along the R border of the heart ( Image 1). CTA chest revealed a large pericardial effusion ( Image 2) with a heterogeneous anterior mediastinal mass which abut the pericardium ( Image 3) along with two nodules in the right lung parenchyma. Patient was admitted to the ICU where emergent echocardiogram showed findings suggestive of early tamponade. It was decided to drain the effusion percutaneously followed by right thoracoscopy along with wedge resection of the lung nodules and pericardial window. On labs, AFP came out be very high at 8132 (nl<11ng/ml), LDH 453 ( nl 199-220U/L) and b HCG 46( nl<4U/L). . Pericardial fluid cytology was negative for malignant cells. Tissue biopsy of the mass was done which showed Yolk sac tumor and wedge resection of lung nodule was positive for metastatic seedings; CT abdomen and pelvis showed no intraabdominal pelvic mass or lymphadenopathy. After sperm banking, patient was started on chemotherapy with cisplatin, etoposide, ifosfamide with MESNA. DISCUSSION: Extragonadal non-seminomatous germ cell tumors (NSGCTs) primarily affect men during the third and fourth decades of life and are more aggressive than their seminomatous counterpart. Majority of patients with mediastinal NSGCTs are symptomatic at the time of diagnosis, with chest pain, hemoptysis, cough, fever, or weight loss. Superior vena cava syndrome or pericardial tamponade is occasionally present. Mediastinal NSGCT presenting as early cardiac tamponade is rarely seen in clinical practice but its early recognition and treatment by emergent pericardiocentesis can be life-saving as was done in our patient. Tumor markers including APF, b-HCG, and LDH help in the diagnosis of these tumors but the definitive diagnosis and treatment is based on the results of the biopsy of the tumor. CONCLUSIONS: One of the major causes of anterior mediastinal masses, particularly in young adult males, is an extragonadal germ cell tumor. Pericardial tamponade as a result of such tumors is rare but should always be considered in the appropriate clinical context as early recognition and management can be lifesaving. Reference #1: Nichols CR. Mediastinal germ cell tumors. Clinical features andbiologic correlates. Chest 1991;99:472–9. Reference #2: Cohn W. Anterior mediastinal mass lesions. In: Basow D, ed. UpTo-Date. Waltham, MA: UpToDate; 2012. DISCLOSURES: No relevant relationships by Taha Ahmed, source=Web Response No relevant relationships by TALHA AHMED, source=Web Response No relevant relationships by Sidra Khalid, source=Web Response No relevant relationships by Safdar Khan, source=Web Response