Case Presentation 林永傑

Patient information 8 y/o boy No. 11065953 admission date 94-7-25 Birth History: G2P2, NSD ,GA: FT weeks, Chief Complain : lung mass referred from ChiMei hospital

Transferred to Chi-Mei CxR => pneumonia => admission . 7-12 & 7-16 CxR seem improved . 7-20 A clear-margined mass lesion .7-21 Chest CT was done No fever ; Good activity ; A/B used to 7/25 2005-7-9 Intermittent fever Transferred to Chi-Mei CxR => pneumonia => admission .7-25 referred to NCKU ER 2005-7 -1 Intermittent fever 39C fever for 7 days No major symptoms LMD treated x3 No BW loss or night sweating 2005-7- 9 Chest echo was done WBC : 9.9k CRP: 23 A/B : Augmentin started fever subside soon

Development WNL Family History: Denied any systemic disease Denied any malignancy family history

Physical Exam BW: 22.9 g ( 25-50th% ) BL: 129 cm( 50-75th%) Vital sign Activity: good BW: 22.9 g ( 25-50th% ) BL: 129 cm( 50-75th%) Vital sign BT: 36.4 C, P: 　 /min, R: /min, BP: mmHg HEENT: conj: not anemic or injected ; throat : tonsil swelling mildly ; Neck: supple; No LAP Chest: left ant. chest wall : B.S. decrease / dullness ; blebing when deep inspiration RHB ; no murmur ; heart sound shifting to right side

Physical Exam Skin : no rash Abd: soft, mild distended ; Liver / spleen impalpable BS: hypomoactive ; Extremities: N.P. Skin : no rash

Lab GLU.A.C. 92 mg/dl ALK-P H 244 U/L BUN 15 mg/dl CA 10.1 mg/dl NA 138 mmol/L CL 99 mmol/L CRP <7.0 MG/L CREA L 0.5 mg/dl GOT 40 U/L LD H 202 U/L P H 5.8 mg/dl K 4.0 mmol/L GPT 18 U/L WBC 5.7 K/cmm Hb 14.3 g/dl MCV 87.2 fl MCHC 35.0 g/dl Pl H 507 K/cmm Pro . % Seg H 67 % Baso . % Lymph L 19 % NRBC . % RBC 4.70 M/cmm Hct 41.0 % MCH 30.5 pg RDW 13.0 % Blast . % Myelo . % Band . % Eos 4 % Mono H 10 % Aty-lym . %

Problem list . Mediastenum lesion . Mild URI symptoms R/O Tumor: teratoma ; lymphoma; germ cell tumor R/O congenital structural anomaly R/O lung abscess formation . Mild URI symptoms

Plan Check beta HCG ; alpha fetoprotein Arrange Cardiac echo Consult infection man If no lung abscess, consult chest surgeon

anterior mediastinal tumor Discussion anterior mediastinal tumor

Anatomy

Mediastenum mass Masses in the anterior compartment are more likely to be malignant than those found in the other mediastinal compartments. 400 patients with mediastinal tumors noted that 59, 29, and 16 percent of anterior, middle, and posterior mediastinal masses Lesions most commonly found in the anterior mediastinum are thymomas, germ cell tumors, lymphomas, intrathoracic thyroid tissue, and parathyroid lesions.

Thymoma Thymomas represent 20 percent of all mediastinal neoplasms in adults They are the most common anterior mediastinal primary neoplasm in adults but are rarely seen in children; commonly present between the ages of 30 and 50. myasthenia gravis /substernal pain, dyspnea, or cough

Lymphoma 5 to 10 % of patients with lymphoma present with primary mediastinal lesions Primary mediastinal lymphoma accounts for 10 to 20 percent of primary mediastinal masses ; and is the second most common primary anterior mediastinal mass in adults Most mediastinal lymphomas are seen in the anterosuperior mediastinum Fever, weight loss, and/or night sweats ; Neck LAP Compression of adjacent mediastinal structures are infrequent, but may include pain, dyspnea, stridor, or superior vena cava syndrome

Germ Cell tumor Germ cell tumors account for 15 percent of anterior mediastinal tumors in adults and 24 percent in children. Rarely, they are found in the posterior mediastinum Classification of germ cell tumors is based upon cell type, although many neoplasms have mixed cellularity. The most commonly used classification divides tumors into benign teratomas, seminomas, and embryonal tumors.

Benign teratomas The most common anterior mediastinal neoplasm in infants and are often seen in adults between 20 and 40 years of age M: F = 1:1 can be solid or cystic 50 to 75 percent of mediastinal teratomas contain only mature cells, without evidence of poorly differentiated or immature elements, and have little or no malignant potential Most discovered incidentally. Symptoms are generally due to compression and obstruction of surrounding organs: hest pain, cough, or dyspnea, bronchial obstruction and postobstructive pneumonia Expectoration of hair

Chest radiographs may demonstrate an anterior mediastinal mass, with calcification seen in 26 percent of benign teratomas Treatment of mediastinal teratomas, regardless of the presence or absence of immature elements, is surgical excision because malignant degeneration otherwise occurs in 25 percent of cases.

Seminomas Primary mediastinal seminomas are uncommon, representing only 2 to 4 percent of all mediastinal masses, but comprise 25 to 50 percent of malignant mediastinal germ cell tumors Neoplasms are usually located in the anterior mediastinum, and predominantly occur in young males between the ages of 20 and 40 ; rare in female beta-hCG) and alpha-fetoprotein (AFP) may allow differentiation between seminomas and nonseminomatous germ cell tumors (NSGCTs). (

Beta-hCG is increased in over 80 percent of NSGCTs, but only 34 percent of mediastinal seminomas in one large series [50]. • AFP is elevated in 80 to 85 percent of patients with NSGCTs, while in pure seminomas, serum AFP is almost never elevated [51,52]. Thus, elevated serum AFP concentrations are considered diagnostic of a nonseminomatous component of the tumor (especially yolk sac elements) or hepatic metastases

Mediastenum cyst Thyroid tissue Parathyroid tissue Pericardial cyst Enterogenous cyst : bronchogenic / enteric cyst Thymic cyst Thyroid tissue Parathyroid tissue