A 39-year-old man presents with chest pain and shortness of breath. CT scans are ordered, revealing the presence of an anterior mediastinal mass. The patient is sent for a consultation with a cardiothoracic surgeon. Results of cardiovascular, respiratory, and testicular exams completed during this visit are normal. Further evaluation of the mediastinal mass is conducted via MRI (Figure 1), and he is referred to interventional radiology for tissue diagnosis.
Laboratory tests were also performed at this time, which demonstrated the following: beta–human chorionic gonadotropin (beta-HCG), 0.2 mIU/mL (normal, < 5.0 mIU/mL); lactate dehydrogenase (LDH), 226 U/L (normal, 105–333 U/L); and alpha-fetoprotein (AFP), 2.8 ng/mL (normal, < 10.0 ng/mL). Core biopsy of the anterior mediastinal mass demonstrates atypical cells.
A scrotal ultrasound is obtained to assess for a potential germ cell tumor. It reveals a 7-mm mixed cystic and solid hypoechoic mass in the right testicle concerning for a testicular malignancy (Figure 2). PET/CT does not demonstrate lymphadenopathy in the retroperitoneum or elsewhere, or large amounts of increased uptake in the mediastinal mass or testicular lesion. A genital exam by the urologist at that time demonstrates a firm right testicular mass. The patient consents to a right radical inguinal orchiectomy.
Final pathology results reveal pure post-pubertal teratoma of the testis consisting of cysts lined by simple epithelium, as well as ciliated cells surrounded by smooth muscle. Stromal hyalinization and calcification are also present, suggesting the possibility of a burned-out germ cell tumor. The seminiferous tubules show spermatogenesis. Germ cell neoplasia in situ was not identified in the hematoxylin and eosin–stained sections or by immunohistochemistry (placental alkaline phosphatase and octamer transcription factor 3/4) (Figure 3).
Which of the following represents the best next step for management?
A. Obtaining additional tissue from the mediastinal mass (ie, resection)
B. Chemotherapy with bleomycin, etoposide, and cisplatin
E. Retroperitoneal lymph node dissection (RPLND)
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