内容紹介
Summary
A man in his late teens presented to our hospital with left-sided chest pain. CT showed a 12 cm sized anterior mediastinal tumor and tiny nodules in the bilateral lower lobe of the lungs. The patient also had elevated serum AFP and hCG levels. Pathological findings of the CT-guided biopsy specimen suggested a yolk sac tumor, and no testicular abnormality was seen on ultrasound. Following whole body examination, he was diagnosed with primary mediastinal non-seminomatous germ cell tumor. After sperm cryopreservation, 4 courses of BEP(bleomycin[BLM]plus etoposide[ETP]plus cisplatin[CDDP])chemotherapy were administered to normalize the tumor markers. The mediastinal tumor shrank but was still widely in contact with the left pulmonary artery. He underwent mediastinal tumor resection and segmentectomy of the left upper lobe via a median sternotomy. The maximum tumor size was 9 cm in diameter, and pathological examination of the specimen revealed only an immature teratoma with no malignant findings. At the same time, both the lower lung nodules were resected and pathologically identified as intrapulmonary lymph nodes. No recurrence was observed, but 6 months after surgery, he made an emergency visit to our department due to dyspnea. Bilateral pneumothorax was detected, and chest tube insertion was rapidly performed that improved with only right chest drainage. Cytology of the right hemorrhagic pleural effusion showed no evidence of malignancy. It was possible that a postoperative right-to-left shunt of the anterior mediastinum was present, leading to bilateral pneumothorax.
要旨
患者は10歳台後半,男性。左胸部痛にて当院を受診した。CTにて前縦隔に12 cm大の腫瘤および両肺下葉小結節を認め,AFPおよびhCG高値を伴っていた。CTガイド下生検で卵黄嚢腫瘍を疑う病理所見があり,精巣超音波検査は異常なく,縦隔原発非精上皮腫と診断した。精子保存の後,BEP[bleomycin(BLM)+etoposide(ETP)+cisplatin(CDDP)]療法4コースを施行し腫瘍マーカーは正常化した。縦隔病変は縮小したが左肺動脈に広範に接しており,胸骨正中切開縦隔腫瘍切除術に加えて左肺上葉一部合併切除を行った。病理組織学的検査にて最大腫瘍径は9 cmであり,未熟奇形腫のみで悪性所見なし。また,同時に両下葉部分切除を行ったが肺内リンパ節であった。再発なく経過していたが,術後6か月で呼吸困難を来し緊急受診となった。両側気胸発症を認めたが,右胸腔ドレナージのみで右のみならず左気胸も改善した。右血性胸水の細胞診は悪性所見なし。術後遅発性肺瘻にて右血気胸を来し,前縦隔の右左シャントが併存し両側気胸に至った可能性が考えられた。
目次
A man in his late teens presented to our hospital with left-sided chest pain. CT showed a 12 cm sized anterior mediastinal tumor and tiny nodules in the bilateral lower lobe of the lungs. The patient also had elevated serum AFP and hCG levels. Pathological findings of the CT-guided biopsy specimen suggested a yolk sac tumor, and no testicular abnormality was seen on ultrasound. Following whole body examination, he was diagnosed with primary mediastinal non-seminomatous germ cell tumor. After sperm cryopreservation, 4 courses of BEP(bleomycin[BLM]plus etoposide[ETP]plus cisplatin[CDDP])chemotherapy were administered to normalize the tumor markers. The mediastinal tumor shrank but was still widely in contact with the left pulmonary artery. He underwent mediastinal tumor resection and segmentectomy of the left upper lobe via a median sternotomy. The maximum tumor size was 9 cm in diameter, and pathological examination of the specimen revealed only an immature teratoma with no malignant findings. At the same time, both the lower lung nodules were resected and pathologically identified as intrapulmonary lymph nodes. No recurrence was observed, but 6 months after surgery, he made an emergency visit to our department due to dyspnea. Bilateral pneumothorax was detected, and chest tube insertion was rapidly performed that improved with only right chest drainage. Cytology of the right hemorrhagic pleural effusion showed no evidence of malignancy. It was possible that a postoperative right-to-left shunt of the anterior mediastinum was present, leading to bilateral pneumothorax.
要旨
患者は10歳台後半,男性。左胸部痛にて当院を受診した。CTにて前縦隔に12 cm大の腫瘤および両肺下葉小結節を認め,AFPおよびhCG高値を伴っていた。CTガイド下生検で卵黄嚢腫瘍を疑う病理所見があり,精巣超音波検査は異常なく,縦隔原発非精上皮腫と診断した。精子保存の後,BEP[bleomycin(BLM)+etoposide(ETP)+cisplatin(CDDP)]療法4コースを施行し腫瘍マーカーは正常化した。縦隔病変は縮小したが左肺動脈に広範に接しており,胸骨正中切開縦隔腫瘍切除術に加えて左肺上葉一部合併切除を行った。病理組織学的検査にて最大腫瘍径は9 cmであり,未熟奇形腫のみで悪性所見なし。また,同時に両下葉部分切除を行ったが肺内リンパ節であった。再発なく経過していたが,術後6か月で呼吸困難を来し緊急受診となった。両側気胸発症を認めたが,右胸腔ドレナージのみで右のみならず左気胸も改善した。右血性胸水の細胞診は悪性所見なし。術後遅発性肺瘻にて右血気胸を来し,前縦隔の右左シャントが併存し両側気胸に至った可能性が考えられた。