Mediastinal seminomas with prominent cystic changes. A clinicopathologic study of 10 cases

We present 10 cases of thymic seminomas associated with prominent cystic changes. All patients were males, aged 16 to 79 years (median, 23.5). Clinically, two patients presented with chest pain/four were asymptomatic and the tumors were discovered on routine chest radiographs; one tumor was discovered incidentally at autopsy; and in three patients no clinical information was obtained. Grossly, the tumors were described as multilocular cystic lesions that ranged in size from 7 to 19 cm in greatest dimension, showing small focal areas of induration within the cyst walls. Histologically, the lesions were characterized by cystic spaces lined by squamous or cuboidal epithelium showing severe chronic inflammatory changes with areas of cholesterol cleft granulomas, lymphoid follicular hyperplasia, and scattered foci of residual thymic parenchyma within the walls of the cysts, resulting in a picture indistinguishable from acquired multilocular thymic cysts. Careful examination, however, revealed microscopic foci composed of a neoplastic proliferation of large polygonal cells with slightly eosinophilic to clear cytoplasm and large nuclei with prominent nucleoli. The atypical cells were admixed with an inflammatory background and were often accompanied by a florid granulomatous reaction. Periodic acid-Schiff histochemical reaction with diastase revealed moderate amounts of glycogen within the cytoplasm of the tumor cells. Immunohistochemical studies in five cases showed positive labeling of the tumor cells with placental alkaline phosphatase. Nine patients were treated by complete surgical excision of the mass, and additional postoperative radiation therapy was given to two patients. Follow-up information available for five patients showed all to be alive and well from 2 to 19 years after diagnosis (mean follow-up, 9 years). Four of the patients were lost to follow-up. The pathogenesis of the cystic process in these cases remained unsettled but may represent a reactive change secondary to epithelial hyperplasia of thymic epithelium. Thymic seminoma should be considered in the differential diagnosis of cystic lesions of the anterior mediastinum; extensive sampling of such lesions is therefore recommended for proper evaluation.