A rare extra-gonadal Germ Cell Tumour mimicking ischaemic heart pain.

A rare extra-gonadal Germ Cell Tumour mimicking ischaemic heart pain. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A rare extra-gonadal Germ Cell Tumour mimicking ischaemic heart pain. Karthik Krishnan, Ahmad Zuhdi Mamat, Khairul Mustaqim Mazlan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1437880/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Mediastinal germ cell tumours (GCT) are a heterogenous group of benign and malignant neoplasms that have their origin from primitive germ cells left in the mediastinum during the prime of embryogenesis that have failed to migrate completely. Whilst GCT themselves remain rare, accounting to only about 2-4% of all cancers in children and adolescents below the age of 20, the Extra-gonadal germ cell tumours (EGGCT) represent about 5-10% of all germ cell tumours. The incidence of EGGCT is around 1 in 1,000,000 population and coincidentally, the anterior mediastinum is the most common site for EGGCT (50-70%). Case presentation: Here we detail the unusual case of a young gentleman who presented with symptoms of chest pain mimicking angina that not resolve with treatment, which turned out to be a large anterior mediastinal EGGCT. An en-bloc resection was done and the patient was thereafter subjected to adjuvant chemotherapy. Conclusion: GCT, being a rare entity coupled with an unusual presentation cause a delay in subsequent appropriate treatment which affects the prognosis of the patient. Germ Cell Tumour Mediastinal Ischaemic Heart Disease Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background Mediastinal germ cell tumours (GCT) are a heterogenous group of benign and malignant neoplasms that have their origin from primitive germ cells left in the mediastinum during the prime of embryogenesis that have failed to migrate completely. Whilst GCT themselves remain rare, accounting to only about 2–4% of all cancers in children and adolescents below the age of 20, the Extra-gonadal germ cell tumours (EGGCT) represent about 5–10% of all germ cell tumours. The incidence of EGGCT is around 1 in 1,000,000 population and coincidentally, the anterior mediastinum is the most common site for EGGCT (50–70%). Here we detail the unusual case of a young gentleman who presented with symptoms of chest pain mimicking angina that not resolve with treatment, which turned out to be a large anterior mediastinal EGGCT. An en-bloc resection was done and the patient was thereafter subjected to adjuvant chemotherapy. Case Presentation A 35 year old gentleman whom hitherto have been well presented to a district hospital with complaints of chest pain that radiated to his left shoulder. He was admitted and treated for unstable angina where he received anticoagulant therapy and initiated on Dual Antiplatelet Therapy. A week thereafter he had presented to a tertiary centre for persistent chest pain associated with non-productive cough for about a week. He also complains of loss of weight for about 1 year duration, however is unable to quantify objectively. Otherwise, he has no history of fever, loss of appetite, prolonged cough, haemoptysis or family history of malignancy. In the emergency department, point of care ultrasound was done which revealed a large pleural effusion with fibrin over the left hemithorax. Pleural tapping was performed and 1 litre of haemoserous fluid was drained, which were exudative in nature. The patient also had several episodes of tachycardic rate uncontrolled atrial fibrillation. Whilst initially responding to Amiodarone, eventually he required cardioversion twice at 50J and 100J’s respectively. Once stabilised a left pigtail catheter was inserted under radiological guidance and drained 1.5 litres of haemorrhagic effusion. At this point the patient was subjected to a computed tomography (CT) of his thorax which revealed the presence of a large heterogenous mildly enhancing hypodense mass at the anterior mediastinum measuring about 20cm x 9.4cm x 11cm. There was contrast extravasation visible which may be indicative of active intratumoral haemorrhage. The mass appears to abut the pericardium forming an indentation with pericardial effusion raising the suspicion of tumour infiltration. Features of the imaging was suggestive of an anterior mediastinal mass with high suspicion of active intratumoural haemorrhage. Possibility of GCT, Lymphoma and invasive thymoma were all considered however Tumour markers for AFP (Alpha fetoprotein) were elevated at 818.1 IU/mL narrowing it down to GCT. At this point the patient was referred to our cardiothoracic centre for further management. At our centre the patient was counselled and planned for sternotomy and resection of the tumour. Intraoperatively, it was noted that the tumour was closely abutting the sternal bone which caused some bleeding upon the sternotomy. The large tumour measuring 10x20cm was densely adhered to the medial portion of left lung parenchyma and loosely adhered to the pericardium. The sheer mass had pushed the heart infero-laterally to the right, which was restored to its original position post tumour excision. En-bloc resection of the tumour together with the portion of tumour attached to lung parenchyma was resected and sent for histopathological examination. The histopathological examination for the anterior mediastinal mass came back as mixed germ cell tumour. It was predominantly a immature teratoma, and a minor component of yolk-sac tumour. The resected let lung parenchyma showed positivity of malignancy as it was infiltrated by the yolk-sac component. Tumour markers showed an elevated AFP 818.1 IU/ml and BHCG 23.9 IU/L reading. The patient was planned for completion of staging via CT scan and started on chemotherapy with Bleomycin, Etoposide, and Platinum (BEP Regime) for 4 cycles. Discussion & Conclusion Mediastinal GCT are divided into benign and malignant neoplasms that originate from the primitive germ cells that fail to migrate during embryogenesis. The most common site of primary EGGCT is the anterior mediastinum. AFP and BHCG may be elevated in cases of malignant tumours. However, primary testicular or ovarian germ cell tumour should be excluded as the anterior mediastinum also remains as a possible site of mestastasis of Gonadal GCT. EGGCT predominantly affect young males. 30–40% of these tumours are seminomas, and the remaining is accounted by Non-seminomatous-GCT. These include yolk-sac tumours, embryonal carcinomas, choriocarcinomas, teratomas and non-teratomatous combined GCT. Besides the mediastinum (50–70%), other areas these tumours may be found are the retroperitoneum (30–40%), pineal gland (5%) and sacrococcygeal area (< 5%). The only known risk factor for EGGCT is Klinefellter Syndrome (47XXY), which is found to be associated with Non-seminomatous-GCT, characterized by their location on the midline from the pineal gland to the coccyx. The classification system developed by the International Germ Cell Collaborative Group (IGCCG) categorizes GCT on the basis of its’ histological type (seminomas have better prognosis than non-seminomas), localization of metastasis (retroperitoneal and testicular offer a better prognosis than mediastinal and intracranial), as well as the initial AFP, HCG and LDH levels. Patients receiving intensive chemotherapy have a 5-year survival rate of 40–65%. The survival rate of Seminomatous EGGCT range from 88–100% and survival of non-seminomatous EGGCT is only around 40–45%. The reason for the poor prognosis is due to the Mediastinal GCT not being as sensitive to the chemotherapy, and the bulky disease increases the risk of poorer outcomes due to issues such as respiratory and cardiac compromise. GCT remains as a rare entity, and in their presence, the anterior mediastinum appears to be the most common site it’s located in. Whilst the usual presentation may be chest pain, dyspnoea, cough and constitutional symptoms, it rarely presents as a cardiac event, mimicking angina, which is further complicated with intratumoral bleed causing pleural effusion. Generally, the symptoms vary based on the site and size of the tumour and if the tumour arises from non-vital organs, it can reach large sizes before becoming symptomatic. These unfortunately cause a delay in presentation, which affects the prognosis of the patient. Lists of Abbreviations GCT Mediastinal germ cell tumours EGGCT Extra-gonadal germ cell tumours AFP Alpha fetoprotein CT Computed Tomography BEP Bleomycin, Etoposide, and Platinum BHCG Beta Human Chorionic Gonadotropin IGCCG International Germ Cell Collaborative Group LDH Lactate dehydrogenase Declarations Ethics Approval and Consent to Participate: Not Applicable Consent for Publication: Written consent to publish the information was obtained and available. Availability of data and materials: Not Applicable as this is a case report and not a study involving recruitment of patients. Competing Interests: The authors declare that they have no competing interests Funding: No funding to declare. Code Availability: Not Applicable. Author Contribution: KK : Author of the manuscript, operating on the patient, managing the patient before, and after surgery. AZ: The primary operating surgeon, managed the patient during hospital stay, and on follow up. Corresponding author, and reviewed manuscript prior to submission. KM: Assisted in the surgery, involved in graphics creation, and contributed to the pictures and editing of the manuscript. FZ: Assisted in the surgery, co-managed the patient during hospital admission. AF: Assisted in the surgery, co-managed the patient during hospital admission. All the authors are involved in the clinical management of the patient from this case report. All authors have read and approved the manuscript. Acknowledgements: Not applicable References Karaarslan AA, Karakaşlı A, Mayda A, Karcı T, Aycan H, Kobak S. Traumatic distal ulnar artery thrombosis. Case Rep Orthop . 2014;2014:983160. doi:10.1155/2014/983160Díaz Muñoz de la Espada VM, Khosravi Shahi P, Hernández Marín B, Encinas García S, Arranz Arija JA, Pérez-Manga G. Tumores germinales mediastínicos [Mediastinal germ-cell tumours]. An Med Interna. 2008 May;25(5):241-3. Spanish. doi: 10.4321/s0212-71992008000500011. PMID: 18769749. Hainsworth JD, Greco FA. Extragonadal germ cell tumors and unrecognized germ cell tumors. Seminars in Oncology 1992;19:119-27. Lachman MF, Kim K, Koo BC. Mediastinal teratoma associated with klinefelter's syndrome. Arch Pathol Lab Med 1986;110:1067-71. Ronchi, A, Cozzolino, I, Montella, M, et al. Extragonadal germ cell tumors: Not just a matter of location. A review about clinical, molecular and pathological features. Cancer Med. 2019; 8: 6832– 6840. https://doi.org/10.1002/cam4.2195 Liu, Y., Wang, Z., Peng, ZM. et al. Management of the primary malignant mediastinal germ cell tumors: experience with 54 patients. Diagn Pathol 9, 33 (2014). https://doi.org/10.1186/1746-1596-9-33 Supplementary Files CAREchecklistEnglish2013.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1437880","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":111414806,"identity":"155de5e9-211d-4122-9658-3c8bbd232ca6","order_by":0,"name":"Karthik Krishnan","email":"","orcid":"https://orcid.org/0000-0003-0141-8380","institution":"Universiti Sains Malaysia - Kampus Kesihatan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Karthik","middleName":"","lastName":"Krishnan","suffix":""},{"id":111414807,"identity":"029af54c-4fef-41bc-aca1-fabf6c24fcea","order_by":1,"name":"Ahmad Zuhdi 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09:59:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1437880/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1437880/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":22419400,"identity":"5001395e-dc61-4773-b789-30ca4b46f4ee","added_by":"auto","created_at":"2022-06-08 16:02:02","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2899433,"visible":true,"origin":"","legend":"\u003cp\u003eChest Radiograph before (left) and after (right) the peritoneal tapping.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/dde1212f78e3f1d085227cb7.jpg"},{"id":22419409,"identity":"6329c605-7042-4162-b5c4-1be300f67a95","added_by":"auto","created_at":"2022-06-08 16:02:02","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3000633,"visible":true,"origin":"","legend":"\u003cp\u003eChest radiographs prior (left) and post (right) pleural pigtail insertion.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/e83f565fb1844b0c6f86bea1.jpg"},{"id":22419401,"identity":"a8b1897d-22fd-4ddb-8405-e922136bc68c","added_by":"auto","created_at":"2022-06-08 16:02:02","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3283325,"visible":true,"origin":"","legend":"\u003cp\u003eCT Image showing the large heterogenous mass over the anterior mediastinum abutting great vessels.\u003c/p\u003e\u003cp\u003eA: Compressed great vessels by mass\u003c/p\u003e\u003cp\u003eB: Large heterogenous mass\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/0e4a588dddab87b08fcfd003.jpg"},{"id":22419975,"identity":"f995ddf6-a409-448e-8390-b0972c6d09dd","added_by":"auto","created_at":"2022-06-08 16:07:02","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":3250502,"visible":true,"origin":"","legend":"\u003cp\u003eCT Image showing the large anterior mediastinal mass compressing the left chambers of the heart causing inferior displacement.\u003c/p\u003e\u003cp\u003eC: Compressed left heart chambers with inferior displacement\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/92ee489f9829b3b05f1e2fc2.jpg"},{"id":22419973,"identity":"ce0ad472-0a5b-4598-b0ea-7ef20e3ab83e","added_by":"auto","created_at":"2022-06-08 16:07:02","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":6533902,"visible":true,"origin":"","legend":"\u003cp\u003eTumour depicted here with bleeding from torn part adhered to sternal wall and dislocating the heart infero-laterally to the right.\u003c/p\u003e\u003cp\u003eD: Heart displacement inferolaterally to the right.\u003c/p\u003e\u003cp\u003eE: Tumour with sternal wall adherence separated\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/0fff0be3bb54b388974e2163.jpg"},{"id":22419404,"identity":"83705154-b853-4b3f-b15a-a1bb909d9069","added_by":"auto","created_at":"2022-06-08 16:02:02","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":4180961,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative Findings of the Tumour Visualized\u003c/p\u003e","description":"","filename":"Fig6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/78c76ba50adc2ff595a231cd.jpg"},{"id":22419410,"identity":"2aa9091a-9a32-4d83-a29f-c66b4f519d7c","added_by":"auto","created_at":"2022-06-08 16:02:02","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":6353314,"visible":true,"origin":"","legend":"\u003cp\u003eRestoration of normal cardiac position post tumour resection.\u003c/p\u003e\u003cp\u003eF: Heart return to normal anatomical position\u003c/p\u003e\u003cp\u003eG: Right Lung, fully able to expand\u003c/p\u003e\u003cp\u003eH: Left Lung, fully able to expand\u003c/p\u003e","description":"","filename":"Fig7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/3080cf19c8163aa993bc5938.jpg"},{"id":22419976,"identity":"8f373a73-562b-4772-9bbf-b67da0d31d2b","added_by":"auto","created_at":"2022-06-08 16:07:02","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":4033345,"visible":true,"origin":"","legend":"\u003cp\u003eTumour Specimen sent for Histopathological examination\u003c/p\u003e","description":"","filename":"Fig8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/224b11f2b82b98f05bc2d7a8.jpg"},{"id":22824595,"identity":"df5e6603-ffb8-4338-959d-dfd50d13cb6c","added_by":"auto","created_at":"2022-06-19 16:59:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1234345,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/4432def3-e20a-406c-8571-d4930b5e1699.pdf"},{"id":22419407,"identity":"c9274e09-670e-4d08-b6a1-f4c7df3b63aa","added_by":"auto","created_at":"2022-06-08 16:02:02","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":749092,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish2013.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1437880/v1/1f5277bd5d991f9c5f728a4d.pdf"}],"financialInterests":"","formattedTitle":"A rare extra-gonadal Germ Cell Tumour mimicking ischaemic heart pain.","fulltext":[{"header":"Background","content":"\u003cp\u003eMediastinal germ cell tumours (GCT) are a heterogenous group of benign and malignant neoplasms that have their origin from primitive germ cells left in the mediastinum during the prime of embryogenesis that have failed to migrate completely. Whilst GCT themselves remain rare, accounting to only about 2\u0026ndash;4% of all cancers in children and adolescents below the age of 20, the Extra-gonadal germ cell tumours (EGGCT) represent about 5\u0026ndash;10% of all germ cell tumours. The incidence of EGGCT is around 1 in 1,000,000 population and coincidentally, the anterior mediastinum is the most common site for EGGCT (50\u0026ndash;70%). Here we detail the unusual case of a young gentleman who presented with symptoms of chest pain mimicking angina that not resolve with treatment, which turned out to be a large anterior mediastinal EGGCT. An en-bloc resection was done and the patient was thereafter subjected to adjuvant chemotherapy.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 35 year old gentleman whom hitherto have been well presented to a district hospital with complaints of chest pain that radiated to his left shoulder. He was admitted and treated for unstable angina where he received anticoagulant therapy and initiated on Dual Antiplatelet Therapy.\u003c/p\u003e\n\u003cp\u003eA week thereafter he had presented to a tertiary centre for persistent chest pain associated with non-productive cough for about a week. He also complains of loss of weight for about 1 year duration, however is unable to quantify objectively. Otherwise, he has no history of fever, loss of appetite, prolonged cough, haemoptysis or family history of malignancy.\u003c/p\u003e\n\u003cp\u003eIn the emergency department, point of care ultrasound was done which revealed a large pleural effusion with fibrin over the left hemithorax. Pleural tapping was performed and 1 litre of haemoserous fluid was drained, which were exudative in nature. The patient also had several episodes of tachycardic rate uncontrolled atrial fibrillation. Whilst initially responding to Amiodarone, eventually he required cardioversion twice at 50J and 100J\u0026rsquo;s respectively.\u003c/p\u003e\n\u003cp\u003eOnce stabilised a left pigtail catheter was inserted under radiological guidance and drained 1.5 litres of haemorrhagic effusion.\u003c/p\u003e\n\u003cp\u003eAt this point the patient was subjected to a computed tomography (CT) of his thorax which revealed the presence of a large heterogenous mildly enhancing hypodense mass at the anterior mediastinum measuring about 20cm x 9.4cm x 11cm. There was contrast extravasation visible which may be indicative of active intratumoral haemorrhage. The mass appears to abut the pericardium forming an indentation with pericardial effusion raising the suspicion of tumour infiltration. Features of the imaging was suggestive of an anterior mediastinal mass with high suspicion of active intratumoural haemorrhage. Possibility of GCT, Lymphoma and invasive thymoma were all considered however Tumour markers for AFP (Alpha fetoprotein) were elevated at 818.1 IU/mL narrowing it down to GCT.\u003c/p\u003e\n\u003cp\u003eAt this point the patient was referred to our cardiothoracic centre for further management. At our centre the patient was counselled and planned for sternotomy and resection of the tumour. Intraoperatively, it was noted that the tumour was closely abutting the sternal bone which caused some bleeding upon the sternotomy. The large tumour measuring 10x20cm was densely adhered to the medial portion of left lung parenchyma and loosely adhered to the pericardium. The sheer mass had pushed the heart infero-laterally to the right, which was restored to its original position post tumour excision. En-bloc resection of the tumour together with the portion of tumour attached to lung parenchyma was resected and sent for histopathological examination.\u003c/p\u003e\n\u003cp\u003eThe histopathological examination for the anterior mediastinal mass came back as mixed germ cell tumour. It was predominantly a immature teratoma, and a minor component of yolk-sac tumour. The resected let lung parenchyma showed positivity of malignancy as it was infiltrated by the yolk-sac component. Tumour markers showed an elevated AFP 818.1 IU/ml and BHCG 23.9 IU/L reading. The patient was planned for completion of staging via CT scan and started on chemotherapy with Bleomycin, Etoposide, and Platinum (BEP Regime) for 4 cycles.\u003c/p\u003e"},{"header":"Discussion \u0026 Conclusion","content":"\u003cp\u003eMediastinal GCT are divided into benign and malignant neoplasms that originate from the primitive germ cells that fail to migrate during embryogenesis. The most common site of primary EGGCT is the anterior mediastinum. AFP and BHCG may be elevated in cases of malignant tumours. However, primary testicular or ovarian germ cell tumour should be excluded as the anterior mediastinum also remains as a possible site of mestastasis of Gonadal GCT.\u003c/p\u003e \u003cp\u003eEGGCT predominantly affect young males. 30\u0026ndash;40% of these tumours are seminomas, and the remaining is accounted by Non-seminomatous-GCT. These include yolk-sac tumours, embryonal carcinomas, choriocarcinomas, teratomas and non-teratomatous combined GCT. Besides the mediastinum (50\u0026ndash;70%), other areas these tumours may be found are the retroperitoneum (30\u0026ndash;40%), pineal gland (5%) and sacrococcygeal area (\u0026lt;\u0026thinsp;5%). The only known risk factor for EGGCT is Klinefellter Syndrome (47XXY), which is found to be associated with Non-seminomatous-GCT, characterized by their location on the midline from the pineal gland to the coccyx.\u003c/p\u003e \u003cp\u003eThe classification system developed by the International Germ Cell Collaborative Group (IGCCG) categorizes GCT on the basis of its\u0026rsquo; histological type (seminomas have better prognosis than non-seminomas), localization of metastasis (retroperitoneal and testicular offer a better prognosis than mediastinal and intracranial), as well as the initial AFP, HCG and LDH levels. Patients receiving intensive chemotherapy have a 5-year survival rate of 40\u0026ndash;65%. The survival rate of Seminomatous EGGCT range from 88\u0026ndash;100% and survival of non-seminomatous EGGCT is only around 40\u0026ndash;45%. The reason for the poor prognosis is due to the Mediastinal GCT not being as sensitive to the chemotherapy, and the bulky disease increases the risk of poorer outcomes due to issues such as respiratory and cardiac compromise.\u003c/p\u003e \u003cp\u003eGCT remains as a rare entity, and in their presence, the anterior mediastinum appears to be the most common site it\u0026rsquo;s located in. Whilst the usual presentation may be chest pain, dyspnoea, cough and constitutional symptoms, it rarely presents as a cardiac event, mimicking angina, which is further complicated with intratumoral bleed causing pleural effusion. Generally, the symptoms vary based on the site and size of the tumour and if the tumour arises from non-vital organs, it can reach large sizes before becoming symptomatic. These unfortunately cause a delay in presentation, which affects the prognosis of the patient.\u003c/p\u003e"},{"header":"Lists of Abbreviations","content":"\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.740088105726873%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGCT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.25991189427313%\"\u003e\n \u003cp\u003eMediastinal germ cell tumours\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.740088105726873%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEGGCT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.25991189427313%\"\u003e\n \u003cp\u003eExtra-gonadal germ cell tumours\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.740088105726873%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAFP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.25991189427313%\"\u003e\n \u003cp\u003eAlpha fetoprotein\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.740088105726873%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.25991189427313%\"\u003e\n \u003cp\u003eComputed Tomography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.740088105726873%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBEP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.25991189427313%\"\u003e\n \u003cp\u003eBleomycin, Etoposide, and Platinum\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.740088105726873%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBHCG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.25991189427313%\"\u003e\n \u003cp\u003eBeta Human Chorionic Gonadotropin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.740088105726873%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIGCCG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.25991189427313%\"\u003e\n \u003cp\u003eInternational Germ Cell Collaborative Group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.740088105726873%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLDH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.25991189427313%\"\u003e\n \u003cp\u003eLactate dehydrogenase\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consent to publish the information was obtained and available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable as this is a case report and not a study involving recruitment of patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode Availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKK :\u0026nbsp;\u003c/strong\u003eAuthor of the manuscript, operating on the patient, managing the patient before, and after surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAZ:\u0026nbsp;\u003c/strong\u003eThe primary operating surgeon, managed the patient during hospital stay, and on follow up. Corresponding author, and reviewed manuscript prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKM:\u0026nbsp;\u003c/strong\u003eAssisted in the surgery, involved in graphics creation, and contributed to the pictures and editing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFZ:\u0026nbsp;\u003c/strong\u003e Assisted in the surgery, co-managed the patient during hospital admission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAF:\u0026nbsp;\u003c/strong\u003eAssisted in the surgery, co-managed the patient during hospital admission.\u003c/p\u003e\n\u003cp\u003eAll the authors are involved in the clinical management of the patient from this case report.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKaraarslan AA, Karakaşlı A, Mayda A, Karcı T, Aycan H, Kobak S. Traumatic distal ulnar artery thrombosis. \u003cem\u003eCase Rep Orthop\u003c/em\u003e. 2014;2014:983160. doi:10.1155/2014/983160D\u0026iacute;az Mu\u0026ntilde;oz de la Espada VM, Khosravi Shahi P, Hern\u0026aacute;ndez Mar\u0026iacute;n B, Encinas Garc\u0026iacute;a S, Arranz Arija JA, P\u0026eacute;rez-Manga G. Tumores germinales mediast\u0026iacute;nicos [Mediastinal germ-cell tumours]. An Med Interna. 2008 May;25(5):241-3. Spanish. doi: 10.4321/s0212-71992008000500011. PMID: 18769749.\u003c/li\u003e\n \u003cli\u003eHainsworth JD, Greco FA. Extragonadal germ cell tumors and unrecognized germ cell tumors. Seminars in Oncology 1992;19:119-27.\u003c/li\u003e\n \u003cli\u003eLachman MF, Kim K, Koo BC. Mediastinal teratoma associated with klinefelter\u0026apos;s syndrome. Arch Pathol Lab Med 1986;110:1067-71.\u003c/li\u003e\n \u003cli\u003eRonchi, A, Cozzolino, I, Montella, M, et al. Extragonadal germ cell tumors: Not just a matter of location. A review about clinical, molecular and pathological features. Cancer Med. 2019; 8: 6832\u0026ndash; 6840. \u003ca href=\"https://doi.org/10.1002/cam4.2195\"\u003ehttps://doi.org/10.1002/cam4.2195\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eLiu, Y., Wang, Z., Peng, ZM. et al. Management of the primary malignant mediastinal germ cell tumors: experience with 54 patients. Diagn Pathol 9, 33 (2014). \u003ca href=\"https://doi.org/10.1186/1746-1596-9-33\"\u003ehttps://doi.org/10.1186/1746-1596-9-33\u003c/a\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Germ Cell Tumour, Mediastinal, Ischaemic Heart Disease","lastPublishedDoi":"10.21203/rs.3.rs-1437880/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1437880/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Mediastinal germ cell tumours (GCT) are a heterogenous group of benign and malignant neoplasms that have their origin from primitive germ cells left in the mediastinum during the prime of embryogenesis that have failed to migrate completely. Whilst GCT themselves remain rare, accounting to only about 2-4% of all cancers in children and adolescents below the age of 20, the Extra-gonadal germ cell tumours (EGGCT) represent about 5-10% of all germ cell tumours. The incidence of EGGCT is around 1 in 1,000,000 population and coincidentally, the anterior mediastinum is the most common site for EGGCT (50-70%). \u003c/p\u003e\u003cp\u003eCase presentation: Here we detail the unusual case of a young gentleman who presented with symptoms of chest pain mimicking angina that not resolve with treatment, which turned out to be a large anterior mediastinal EGGCT. An en-bloc resection was done and the patient was thereafter subjected to adjuvant chemotherapy.\u003c/p\u003e\u003cp\u003eConclusion: GCT, being a rare entity coupled with an unusual presentation cause a delay in subsequent appropriate treatment which affects the prognosis of the patient.\u003c/p\u003e","manuscriptTitle":"A rare extra-gonadal Germ Cell Tumour mimicking ischaemic heart pain.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-08 16:02:00","doi":"10.21203/rs.3.rs-1437880/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1e2535e-0d38-4835-90cd-d88e6bf0557e","owner":[],"postedDate":"June 8th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-06-19T16:59:27+00:00","versionOfRecord":[],"versionCreatedAt":"2022-06-08 16:02:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1437880","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1437880","identity":"rs-1437880","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}