1. Case Presentation
林永傑

2. 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

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

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

5. Physical Exam BW: 22.9 g ( 25-50th% ) BL: 129 cm( 50-75th%) Vital sign
Activity: good
BW: g ( 25-50th% ) BL: 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

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

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

8. 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

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

10. anterior mediastinal tumor
Discussion
anterior mediastinal tumor

11. Anatomy

12. 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.

13. 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

14. 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

15. 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.

16. 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

17. 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.

18. 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). (

19. 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

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