Resection of a Giant
venous access, optimization of preload, and consider-
Mediastinal Teratoma
Sai Yendamuri, MD, FACS
Department of Thoracic Surgery, Roswell Park Cancer Institute,
Buffalo; and Department of Surgery, Jacobs School of Medicine
and Biomedical Sciences, State University of New York, Buffalo,
New York
This case report describes the surgical management of a
giant mediastinal teratoma. Perioperative considerations
and operative approach to effect good outcomes are
described.
(Ann Thorac Surg 2016;102:e401–2)
Ó 2016 by The Society of Thoracic Surgeons
T eratomas are a common pathology in the anterior
mediastinum. Because of their insidious growth, the
mediastinal structures can accommodate large teratomas
before the manifestation of symptoms. Surgical resection
is challenging because of the large size of the resultant
tumor. However, with proper surgical planning, good
outcomes can be obtained with complete resection
because of the indolent nature of these tumors. Therefore,
surgical resection of these tumors should not be denied
because of size alone.
In this brief report, we present the case of a 26-year-old
man with a giant mediastinal mass. The mass was
discovered during workup for dyspnea 9 months before
referral to our center. Computed tomography (CT)-
guided biopsy of the mass suggested a mature teratoma;
however, because of the presence of an increased alpha-
fetoprotein (AFP) level (1016 mg/mL), a diagnosis of a
non-seminomatous germ cell tumor was made at an
outside institution. Chemotherapy with three cycles of
cisplatin-based chemotherapy was administered, with no
decrease in the size of the mass or decrease in serum AFP
levels. Increasing dyspnea after the chemotherapy was
attributed to a small left-sided cystic collection diagnosed
as an empyema. A chest tube was placed in this collec-
tion, and antibiotic therapy was started. At this point, the
patient was considered too symptomatic for surgical
resection. Given the apparent lack of response to
chemotherapy, he was sent home for palliative care. At
the time of presentation to our center, the tumor was
large, occupying greater than 50% of the thoracic cavity
with a chest tube in the left chest for 6 weeks (Fig 1A, 1B).
The patient did not tolerate a supine position because of
the precipitation of hypotension, presumably the result of
cardiac compression and reduction in preload. Culture
from the chest tube grew drug-resistant Pseudomonas
aeruginosa (sensitive only to colistin).
Accepted for publication April 11, 2016.
Address correspondence to Dr Yendamuri, Department of Thoracic Sur-
gery, Roswell Park Cancer Institute, Elm and Carlton Sts, Buffalo,
NY 14263; email: sai.yendamuri@roswellpark.org.
Ó 2016 by The Society of Thoracic Surgeons
Published by Elsevier
Preoperative planning included placement of central
ation for cardiopulmonary bypass backup. In addition, a
thoracic epidural was placed. Anesthesia was induced
with the patient at 45-degree recumbency, and a double-
lumen endotracheal tube was placed. The anterior chest
was prepared and draped in this position. The patient
was then laid supine, and rapid sternotomy was made.
During the few minutes to accomplish this, the patient
experienced hypotension, with the blood pressure
reaching a nadir of 50 mm Hg despite initiation of va-
sopressors, and immediate recovery as the chest was
decompressed with completion of the sternotomy. A
plane of dissection was accomplished anterior to the
pericardium and the innominate vein, primarily by blunt
digital dissection. Using this plane, the tumor was
divided in the midline. Bleeding was controlled using
the Aquamantys device (Medtronic, Minneapolis, MN).
Blunt dissection was used to dissect the tumor off the
right lung, superior vena cava, left innominate vein, and
aorta. The tumor was removed in a piecemeal fashion
(Fig 1C). With the right chest cleared of tumor, attention
was paid to the left chest. The tumor was dissected off
the medial portion of the left lung apex and the left main
pulmonary artery. However, given the extension of the
tumor to the left costodiaphragmatic sulcus and exten-
sive adhesions to the chest wall, a decision to approach
this through a left thoracotomy was made. The sternot-
omy was closed, the patient was repositioned, and left
thoracotomy was performed. The tumor in the left chest
was then removed piecemeal without sacrificing the left
lung. After removal of the tumor, the left lung was
reinflated completely to fill the chest cavity. At the end of
the resection, no gross tumor was evident. The left-sided
chest tube was found to be in a tumor cavity and not in
the pleural space.
Postoperatively, the patient was extubated on day 1
(Fig 1D). The postoperative course was complicated by
recurrent atelectasis of the left lung from a broncho-
scopically proven malacic segment of the left mainstem
bronchus. This was treated with intermittent biphasic
positive airway pressure for a period of 2 weeks with
clinical resolution of the problem. The patient was dis-
charged on postoperative day 20. Careful pathologic ex-
amination of the specimen revealed only mature teratoma
with no malignant elements. A 2-year follow up revealed
no recurrent disease.
Comment
Some oncologic issues specific to this case require
consideration. In this case, chemotherapy administration
was initiated primarily because of increased serum AFP
level although a CT-guided core biopsy did not reveal
malignant elements. Although this raises questions of
sampling error, surgery should be considered as first-line
therapy for large tumors capable of producing cardio-
pulmonary compromise, even if they have modestly
increased serum AFP levels. Such a large tumor cannot be
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2016.04.041
e402 CASE REPORT YENDAMURI
RESECTION OF A GIANT MEDIASTINAL TERATOMA
Fig 1. Large mediastinal teratoma displacing
the mediastinum (A) and filling the left chest
(B). Resection was done piecemeal (C) and the
left lung could be salvaged (D).
taken out en bloc; therefore, piecemeal resection is inev-
itable, raising the concern for increased risk for recur-
rence. Although no specific adjuvants are recommended
for this situation, an option that can be exercised without
adding any perioperative risk is to lavage the cavity with
distilled water. Some evidence supports this approach in
other cancer sites and may be considered in cases such as
the one presented here [1].
The presence of a large mediastinal tumor with
elevated AFP level after chemotherapy can present in
three different scenarios. The first scenario is when the
response to chemotherapy is incomplete. In this situation,
Dartevelle and colleagues [2] have demonstrated good
outcomes with complete resection. The second situation
is when the there is good serum AFP response to
chemotherapy, but the mature teratoma component
continues to grow; this has been labelled the growing
teratoma syndrome. Outcomes are good with surgery [3].
This case is different from either of these presentations
because there was no response in the serum AFP levels to
chemotherapy. This difference highlights the fact that
Ann Thorac Surg
2016;102:e401–2
serum AFP level may be elevated with large teratomas
without malignant elements— phenomenon reported by
others [4]. The size of the teratoma does not predict dif-
ficulty of surgical resection, as these tumors respect
anatomic boundaries. Resection of these large tumors
with proper surgical planning often leads to satisfactory
postoperative and long-term outcomes.
References
1. Margenthaler JA. The potential role and mechanisms of
distilled water-induced hypotonic shock on malignant cells.
J Surg Res 2013;181:67–8.
2. De Latour B, Fadel E, Mercier O, et al. Surgical outcomes in
patients with primary mediastinal non-seminomatous germ
cell tumours and elevated post-chemotherapy serum tumour
markers. Eur J Cardiothorac Surg 2012;42:66–71; discussion 71.
3. Agatsuma T, Koizumi T, Kubo K, et al. Mediastinal growing
teratoma syndrome successfully treated by multiple modality
therapies. Intern Med 2011;50:607–10.
4. Petousis S, Kalogiannidis I, Margioula-Siarkou C, et al.
Mature ovarian teratoma with carcinoid tumor in a 28-year-
old patient. Case Rep Obstet Gynecol 2013;2013:108582.