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J Thorac Cardiovasc Surg 2006;132:722-723
© 2006 The American Association for Thoracic Surgery

Brief Communication

Urine drug testing in an athlete leads to the diagnosis of unsuspected mediastinal germ cell tumor

Andrew E. Newcomb, MBBSa,*, C. Peter Clarke, FRACSa, Cherie Y. Chiang, MBBSb, George Jerums, FRACPb

a Department of Thoracic Surgery, Austin Hospital, Melbourne, Australia.
b Department of Endocrinology, Austin Hospital, Melbourne, Australia.

Received for publication March 14, 2006; accepted for publication April 20, 2006.

* Address for reprints: Andrew Newcomb, MBBS, Department of Thoracic Surgery, Austin Hospital, Studley Rd, Heidelberg, Victoria 3082, Australia (Email: anewcomb{at}amavic.com).

Mediastinal seminoma is an uncommon malignancy. We present the case of a 17-year-old weightlifter given a diagnosis as a result of routine urine drug screening.

Clinical Summary

This competition weightlifter was referred to an endocrinologist after a positive ß-human chorionic gonadotropin (HCG) result on routine urine screening (B sample). He was asymptomatic and denied illicit drug use. Blood tests confirmed an increase in ß-HCG levels, with decreased leutenizing hormone and follicle-stimulating hormone levels and also increased testosterone levels (Table 1). Examination, including testicular assessment with ultrasonography, was unremarkable, and an extragonadal germ cell tumor was suspected. Computed tomographic scanning of the chest, abdomen, and pelvis was performed and showed a 33-mm anterior mediastinal mass (Figure 1, A). This showed fluoro-deoxy glucose avidity on positron emission tomography (Figure 1, B). There were no extrathoracic foci.


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  		TABLE 1. Progression of the hormone markers with time
 

Figure 1
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  		Figure 1. A, Positron emission tomographic images showing the lesion in the anterior mediastinum (arrows). B, Computed tomographic images showing the same mass lateral to the ascending aorta (arrows).

 
This patient underwent video-assisted thoracoscopic excision of the lesion. This was performed through 3 port incisions in the right inframammary region. The lesion was a dense nodular mass of 50 x 35 x 20 mm with no local invasion. The histopathology was consistent with seminoma. He recovered from the operation and was referred for adjuvant treatment that he declined because of potential side effects. The markers decreased rapidly after the lesion was removed and have remained normal (Table 1). There is no evidence of recurrence on follow-up imaging, and he has returned to competition.

Discussion

Germ cell tumors are a common malignancy in young men. Less than 5% are extragonadal.1Go Seminomas are an uncommon finding in the mediastinum, although when present, they are mostly anterior. They comprise more than one third of mediastinal germ cell tumors.2Go Seminomas can be asymptomatic or associated with suspicious respiratory symptoms, depending on tumor size. They are most common in the third decade but can present earlier or later.2Go This tumor can metastasize, as do testicular seminomas, although this occurs late, and the tumors grow slowly. Because of their slow growth rate, most of these are large when diagnosed, with a median size of 5 cm.1Go Seventy-five percent of patients with these tumors have no evidence of disease recurrence at 10 years.2Go Factors associated with a poor outcome were local invasion or age greater than 37 years.3Go There was no tissue diagnosis for this young man, and therefore surgical intervention was performed first for histology and staging and to initiate treatment for this tumor.

The screening for banned substances in elite athletes is an accepted routine and is mostly restricted to urine testing. Urine samples are easier to obtain, and drug and metabolite levels are much higher in urine than in blood.3Go Urine collection commences with the chaperoned provision by the athlete. This sample is then divided into 2 bottles labeled A and B. All testing is carried out on the A sample by means of gas chromatography. A positive result requires the analysis of the second (B) sample, and if this result concurs with the first, then a potential doping offense is investigated.3Go This patient had a high level of ß-HCG on his B sample and was referred for further investigation.

HCG is a glycoprotein hormone produced in large quantities by germ cell tumors of different origins. Forty percent of extragonadal seminomas produce increased levels of ß-HCG.4Go Exogenous HCG can be used to stimulate testosterone production,5Go but the rapid decrease in ß-HCG levels after tumor removal indicates that his increase was endogenous (Table 1). Had this not been the case, he would have been banned from weightlifting, and had the lesion been a nonseminoma, with its worse prognosis, then he would have required adjuvant chemotherapy and interruption of his training.

In summary, this young weightlifter had his asymptomatic mediastinal seminoma uncovered after urine screening revealed high levels of ß-HCG. This highlights an important differential diagnosis to consider in a young male athlete.

References

  1. Bokemeyer C, Nichols CR, Droz JP, Schmoll HJ, Horwich A, Gerl A, et al. Extragonadal germ cell tumors of the mediastinum and retroperitoneum: results from an international analysis. J Clin Oncol 2002;20:1864-1873.[Abstract/Free Full Text]
  2. Moran CA, Suster S, Przygodzki RM, Koss MN. Primary germ cell tumors of the mediastinum: II. Mediastinal seminomas—a clinicopathologic and immunohistochemical study of 120 cases. Cancer 1997;80:691-698.[Medline]
  3. Corrigan B, Kazlauskas R. Drug testing at the Sydney Olympics. Med J Aust 2000;173:312-313.
  4. Mizushima Y. Extragonadal germ cell tumors. Intern Med 2004;43:1099-1100.[Medline]
  5. Cowan DA, Kicman AT, Walker CJ, Wheeler MJ. Effect of administration of human chorionic gonadotrophin on criteria used to assess testosterone administration in athletes. J Endocrinol 1991;131:147-154.[Abstract/Free Full Text]




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