Germ cell tumors always figure in the differential diagnosis of mediastinal neoplasms at any age. From the larger series, we can conclude that the whole spectrum of teratoma and germ cell malignancy occurs in the mediastinum of children and adoles-cents.50-53 Approximately half of mediastinal germ cell tumors are represented by pure teratomatous tumors, and the other half is represented by malignant mixed germ cell tumors that may include ter-atomatous tumors. Mature teratomas usually behave in a benign fashion, as reported in two large series.31,52 At least one series suggests a relationship between age greater than 15 years and recurrences with immature teratoma, emphasizing the careful exclusion of subtle components of EST and other germ cell tumor malignancy.52
These tumors are usually bulky with extensive areas of fibrosis, degenerative changes, and necrosis (Figure 22-19); aggressive tumor may invade other mediastinal organs or structures and even the lungs (Figure 22-20).
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