Mediastinal surgery: modern treatment of primary germ cell tumor of the mediastinum

The mediastinum is the most common location of extragonadal germ cell tumors. Chemotherapy and/or surgery is the mainstay of treatment of these primary mediastinal germ cell tumors. Pure mediastinal seminomas are usually curable with chemotherapy alone, while mature teratomas are treated with surgery alone. The remaining nonseminomatous germ cell tumors are treated with neoadjuvant chemotherapy and post-chemotherapy resection regardless of tumor marker persistence. These typically anterior tumors can be found adjacent to and invading any of the major mediastinal vessels, nerves, lung, and hila. Surgery can be challenging due to tumor size, location, and adherence to important structures. Appropriate pre-surgical planning, positioning, approach, exposure, and intraoperative decision making are all integral to successful resection. We describe the work up and crucial preoperative considerations, various incisions and their applications to tumor size and location, and resectable structures and factors to consider in their removal.