A mixed germ cell tumor (MGCT) in the neurohypophysis is very rare, with only a few reported cases1-4 but none with surgical videos. In this report, the endoscopic endonasal transsphenoidal approach for MGCT in the neurohypophysis is presented (Video 1). A 12-year-old girl with ocular pain, fatigue, and nausea presented with gradual onset of quadrant hemianopsia and left oculomotor palsy. Magnetic resonance imaging showed an enhanced mass in the sella turcica with multiple components involving the pituitary gland and stalk. Her endocrinological examination showed decreased levels of pituitary hormones and simultaneously elevated serum levels of alpha-fetoprotein and beta-human chorionic gonadotropin. After pituitary hormone replacement, endoscopic endonasal transsphenoidal surgery was planned. The tumor was strongly adherent to the surrounding structures, and gross total resection was achieved. The histological diagnosis was MGCT with a teratoma component. Postoperatively, her vision and oculomotor palsy improved swiftly, and adjuvant chemotherapy and radiotherapy were administered. In this case, 3-dimensional computer graphics were created from the preoperative computed tomography and magnetic resonance imaging studies. Preoperative simulation with the 3-dimensional computer graphic images and intraoperative verification with indocyanine green images facilitated our understanding of the surrounding anatomy, including the tumor components, pituitary gland, and internal carotid arteries.5 After removal of the tumor, multilayer fascial closure was performed for skull base reconstruction.6 MGCT in the neurohypophysis can be strongly adherent to the surrounding structures, requiring careful dissection and resection under endoscopy. At the last follow-up (8 months after surgery), the tumor was successfully controlled, and the patient had no neurological symptoms with pituitary hormone replacement therapy.

Spontaneous rupture and hemorrhage of mediastinal germ cell tumors is a rare occurrence. In the current report, the case of a 20-year-old male patient who was admitted with chest tightness and dyspnea is presented. An urgent chest CT scan revealed a large tumor in the right anterior mediastinum, measuring ~12 cm in diameter, with associated intratumoral hemorrhage. An emergency thoracotomy was performed to excise the lesion, which revealed that the bleeding was caused by a ruptured tumor. Postoperative pathological findings revealed a mediastinal mixed germ cell tumor consisting of four pathological types: Embryonal carcinoma, seminoma, yolk sac tumor and immature teratoma. Postoperatively, the patient showed marked improvement in the symptoms of dyspnea. However, the follow-up outcome was poor, and the patient succumbed 2 months after surgery. To the best of our knowledge, there are no reports of rupture and hemorrhage involving >4 mixed germ cell tumors. In the present report, the experience of the treatment of the patient is summarized, and literature was reviewed to improve clinicians\' awareness of the disease.

Testicular neoplasms, or testicular cancer, are not typically seen in the emergency department (ED) since their presentation involves a painless hard mass that emerges slowly over time. Uncommon presentation of testicular neoplasm to the ED with acute onset of scrotal pain may present challenges as an incomplete physical examination without supplemental imaging and laboratory workup may overlook the diagnosis of testicular neoplasm. As a result, a delay in proper treatment may occur. Early recognition of testicular neoplasm can decrease morbidity and mortality and improve overall patient survival. Here, we present a case of a 32-year-old male who presented in the ED with an acute onset of testicular pain localized on the posterior right side of the scrotum. Despite the unusual presentation, a complete physical examination, including a complete genitourinary system exam, was performed. During the physical examination, a high index of suspicion for testicular neoplasm was present. Necessary imaging and laboratory workup were ordered. Based on the findings, testicular neoplasm was highly suspected. Thus, surgical intervention was pursued to remove the suspicious mass and pathology revealed a mixed germ cell tumor. Further imaging and laboratory workup showed metastasis into other organ systems, and medical management was chosen to treat the metastatic neoplasm systemically.

Renal metastasis is a rare manifestation of germ cell tumors. Extension of malignant lesions into the renal vein can complicate the scenario.
This report presents a 35-year-old man with primary stage IS NSGCT. Fourteen months after radical orchiectomy he presented with metastasis in the lung, kidney, and para-aortic lymph nodes. He received multiple lines of salvage treatments including chemotherapy and surgery. Intraoperative exploration during radical nephrectomy and retroperitoneal lymphadenectomy revealed intra-renal vein involvement with a prominent teratomatous component.
Defining the exact extent of malignant lesions, especially endovascular lesions, is very important to clarify how advanced the malignant lesions are. The surgeons must be aware of the risk factors that predict vascular involvement, and therefore, providing intraoperative access to vascular surgery procedures when needed.

Bilateral synchronous testicular tumors are a relatively uncommon occurrence, especially when they involve germ cell tumors of different histology. In this context, we present a compelling case report of a male patient who was diagnosed with bilateral synchronous germ cell testicular tumors, with one being a seminoma and the other a non-seminomatous germ cell tumor (NSGCT). The coexistence of two distinct histological types, seminoma and NSGCT, necessitates a comprehensive diagnostic approach to accurately identify and characterize each tumor. This underscores the importance of clinical history, physical examination, imaging techniques, and histopathological analysis to establish an appropriate diagnosis. Careful consideration must be given to factors such as tumor stage, histological subtype, and individual patient characteristics to determine the most suitable treatment strategy. Treatment options may encompass a combination of surgery, chemotherapy, and radiation therapy, tailored to each tumor\'s specific characteristics and the patient\'s overall health. By highlighting this unique case, we aim to underscore the significance of meticulous evaluation and accurate diagnosis when confronted with bilateral synchronous testicular tumors of different histology.

BACKGROUND: Testicular malignancy is the most common solid organ cancer occurring in young men. The most common testicular malignancy is germ cell tumor. Extragonadal malignancies such as lymphomas are rare. Testicular fine-needle aspiration cytology (FNAC) in cancer is a bit controversial amidst fear of tumor seeding along the needle tract. Nevertheless, its largely safe, cost-effective technique providing a quick and fairly reliable diagnosis.
METHODS: A retrospective analysis of testicular malignancies on FNAC over a period of 9 years with cyto-histological correlation wherever possible was carried out. FNAC slides and cell blocks with immunocytochemistry wherever done were retrieved.
RESULTS: A total of 74 cases were obtained. The age ranged from 1 year to 65 years. Infiltration by leukemia was the most common malignancy detected in pediatric population, while germ cell tumors were common amongst young adults and middle-aged men. In elderly, metastatic carcinoma, infiltration by lymphoma were identified. On FNAC, 38 cases were of leukemic infiltration, 27 of germ cell tumors (subtyped as mixed germ cell tumors-15 cases, seminoma-11 cases, and yolk sac tumor-1 case) with two cases each of non-Hodgkin lymphoma, Leydig cell tumor, metastatic adenocarcinoma, and one case each of metastatic small cell carcinoma, rhabdomyosarcoma, and malignant neoplasm. Histological correlation was available in 15/74 cases. Only 3 cases were discordant. Seeding of tumor along the needle tract was not seen.
CONCLUSIONS: The current study deciphers the cytological spectrum of testicular malignancies on FNAC and highlights its importance as a reliable modality for a prompt diagnosis of testicular tumors guiding patient management.

UNASSIGNED: Extragonadal germ cell tumors at the mediastinum are rare and comprise of 3-4 % of all germ cell tumors. Mixed GCTs can remain asymptomatic for long periods and often present with complications. We present a case of a young male patient with a mediastinal tumor infiltrating the heart and obstructing the right ventricular outflow tract, causing cardiogenic shock.
METHODS: A 16-year-old male came with chief complain of shortness of breath and underwent an echocardiogram which revealed a mass in the right atrium and right ventricle. On CT scan, a solid mass in the mediastinum, expanding and infiltrating the right atrium was found. Our patient underwent surgical treatment. Histopathology results were consistent with mixed germ cell tumor comprised of seminoma, yolk sac, and mature teratoma at the right atrial and mediastinum.
UNASSIGNED: The pathogenesis of extragonadal GCTs has been linked to abnormal and/or incomplete migration of the primordial germ cells from the endoderm yolk sac to gonads. Mediastinum GCT can become clinically problematic through its growth patterns, especially its expansive profile, which can cause compression on surrounding mediastinal structures, including major vessels, which in turn diminish blood flow. Overall survival improvement is strongly linked with surgical resection of the tumor, which achieve removal of tumor tissue resistant to chemotherapy and provides sample for histological examination, which helps assessment of pathological response to chemotherapy and planning of further management.
CONCLUSIONS: The mediastinum is a site of different neoplasia, including germ cell tumors. Despite its low incidence, the diagnosis of a mediastinal mixed germ cell tumor should be considered in young patients with a mediastinal mass. This tumor is aggressive and often infiltrates surrounding structures and metastasis. Physicians must be aware of the difficulties and complications associated with the diagnosis.

UNASSIGNED: Primary intracranial germ cell tumors (ICGCTs) are rare and are histologically classified as germinomas and non-germinomatous with distinctive prognostic and therapeutic implications. ICGCTs, essentially due to the inherent difficulty of surgical access, pose different challenges and management connotations than their extracranial counterparts. This is a retrospective analysis of histologically verified ICGCTs, which was undertaken to evaluate various clinicopathological features and their implications on patient management.
UNASSIGNED: Eighty-eight histologically diagnosed cases (over 14 years) of ICGCT at our institute formed the study cohort and were classified into germinoma and non-germinomatous germ cell tumors (NGGCTs). Additionally, germinomas were further subdivided on the basis of 1) tumor marker (TM) levels, as germinoma with normal TM, mildly elevated TM, and markedly elevated TM and 2) radiology features, as germinomas with typical radiology and atypical radiological features.
UNASSIGNED: ICGCT with age ≤6 years (P = 0.049), elevated TM (P = 0.047), and NGGCT histology (P < 0.001) showed significantly worse outcomes. Furthermore, germinomas with markedly elevated TM and certain atypical radiological features showed prognosis akin to NGGCT.
UNASSIGNED: Analysis of our largest single cancer center Indian patient cohort of ICGCT shows that inclusion of age ≤6 years, raised TM, and certain radiological features may assist clinicians in overcoming the limitations of surgical sampling, with better prognostication of histologically diagnosed germinomas.

A 25-year-old male was admitted to the neurological intensive care unit for neurologic deterioration, likely caused by a paraneoplastic syndrome secondary to testicular malignancy. He experienced spontaneous rupture and hemorrhage of his testicular mass arising from an undescended testis while admitted. The tumor was excised, revealing a mixed germ cell tumor. Serum tumor markers began to rise after 4 cycles of chemotherapy. Surveillance scans 32 weeks after mass rupture revealed numerous tumor deposits throughout his peritoneum concerning for teratoma. We review a case of intraperitoneal metastasis of a testicular mixed germ cell tumor following intra-abdominal mass rupture.

BACKGROUND: Spontaneous rapture of a germ cell tumor (GCT) metastases causing massive hemoretroperitoneum in a patient without choriocarcinoma component who has not received previous systemic chemotherapy is an exceedingly rare event. In such a devastating case scenario, a high index of clinical suspicion for early diagnosis and appropriate management is crucial.
METHODS: We report on a 25-year-old male patient with a 4-month history of orchiectomy for testicular GCT (tGCT), who presented in the emergency department with acute abdomen and hemodynamic instability. Urgent computed tomography scan depicted a retroperitoneal mass measuring approximately 13 × 11.4 × 15 cm and massive intraperitoneal hemorrhage. Hemoperitoneum caused by spontaneous rapture of the metastatic retroperitoneal mass was suspected. COVID-19 pandemic-related deviation from the oncologic surveillance standards combined with COVID-19-related patient\'s emotional distress and self-neglect had led to loss of opportunity for appropriate adjuvant chemotherapy, obviously leading to the development of this devastating complication. An emergency, surgical exploration was decided. The bleeding mass was adequately exposed following a Cattell-Braasch maneuver and active bleeding was controlled by a challenging resection of approximately 80% of the lymph node mass volume. Pathological evaluation of the specimen revealed teratoma with low volume of yolk sac tumor component and extensive necrosis, findings compatible with the patient\'s history. Postoperative recovery was uneventful, followed by early start of adjuvant chemotherapy. Two years after the operation the patient is doing well with no evidence of recurrent disease.
CONCLUSIONS: Massive hemoperitoneum is a devastating event that exceedingly rarely can complicate the clinical course of patients with advanced tGCT. Emergency surgical intervention is usually necessary however, sound judgement and careful surgical techniques are required for a positive and uneventful outcome. During COVID-19 pandemic, first-line medical personnel push their limits further not only to ensure health care services standards but also, to manage unpredictable, life-threatening cancer-related complications, associated with COVID-19-related deviation from appropriate oncologic surveillance and care.