primary tumors of the mediastinum are generally seen in the anterior mediastinum , whereas metastatic tumors usually occur in the posterior mediastinum . particularly in young males , this is due to the fact that retroperitoneal lymphatic drainage of the testis occurs along the descending thoracic aorta towards the posterior mediastinum . the role of clinical and radiological findings in the differential diagnosis of tumors located in the mediastinum is highly limited and fine needle aspiration cytology ( fnac ) is accepted as the standard diagnostic procedure . however , the proximity of this area to the heart and major vessels decreases the usefulness of fnac and leads to a failure to adequately describe cytomorphological characteristics of the tumors . our case , a 33 year - old male patient presented with the complaints of swelling on the right side of the neck that had been gradually growing for one month , as well as shortness of breath and cough . his thoracic computed tomography ( ct ) showed a 1.5 cm lymph node on the anterior mediastinum and a mass of about 11  10  8 cm , extending from the right lung apex to the right hilus , with regular contours and without contrast enhancement . his abdominal ct revealed a hypodense , heterogeneous , and cystic necrotic mass of about 10  7  5 cm that was para - aortic at the infrarenal level . the patient was given a preliminary diagnosis of a central bronchus tumor and the lymphoma was then subjected to transthoracic fnac . cytopathological examination demonstrated pleomorphic epithelial cells , either individually or in groups , having cytoplasm with vacuoles . it was noted that these cells had eccentric located nuclei containing one or more nucleoli . in light of these findings , the patient was diagnosed with a nontypeable , malignant , epithelial tumor and was directed to undergo a genitourinary examination [ figure 1 ] . upon finding a high alpha fetoprotein ( afp ) value ( 5724 iu / ml ) , scrotal ultra sonography ( usg ) was performed and showed a mass filling the whole testis on the right side . the patient was diagnosed with a mixed germ cell tumor ( 60% mature teratoma and 40% yolk sac tumor ) by histopathological examination of the orchiectomy material . microscopic appearance of pleomorphic epithelial cells from testis with yolk sac tumor characterised with microvacuolar cytoplasm ( mgg , 1000 ) most ( almost 70% ) of the nonseminomatous germ cell tumors contain two or more germ cell components and are thus classified as mixed germ cell tumors . although pure germ cell tumors are extremely rare in adulthood , mixed tumors comprise about 33% of all germ cell tumors . , described nonseminomatous germ cell tumors as well known , aggressive , malignant tumors of the testis . the usual mode of presentation in a testicular mixed germ cell tumor is testicular enlargement which is usually associated with pain . this may change depending on the tumor components , with a greater propensity for distant metastases in tumors with high - risk histology ( e.g. , choriocarcinoma ) . pulmonary metastasis is associated with secondary hemoptysis , retroperitoneal metastasis associated with back pain , gastrointestinal system metastasis with gastrointestinal bleeding , and brain metastasis with neurological symptoms . our case presented with complaints of dyspnoea and cough associated with mediastinal metastasis . as lung and oesophageal tumors metastasise more commonly to the mediastinum , germ cell tumors of the testis are generally not considered in the differential diagnosis of mediastinal masses . a central metastatic bronchial tumor and lymphoma were initially considered in our case as well . depending on the sampling , it may not be possible to see all components of the mixed germ cell tumors with fine needle aspiration biopsy . in a study by shabb et al . , although cystic , necrotic , and fibrotic characteristics were seen in most of the mediastinal lesions by fnac , specimen adequacy was found to be 83% to diagnosis and diagnostic accuracy was 86% . it was reported in another study that cytological examination along with immunohistochemical analysis is quite reliable in the diagnosis of germ cell tumors . the cytological picture of yolk sac tumors shows pleomorphic epithelial cells with vacuolar cytoplasm , individually or in groups . however , the presence of these globules is seen in many different neoplasms , and is therefore not diagnostic . metachromatic basal membrane material with extracellular accumulation may help the diagnosis of yolk sac tumor . schiller - duval bodies which are a characteristic finding in histological investigations are rarely found in cytological examinations . cytological diagnoses is difficult due to detection of a few number of cells by aspirations of mature teratoma ; however , cytologically diagnosed few cases have been reported , previously . as cyst f luid is generally not diagnostic , repeated aspiration after evacuation may show epithelial structures , fibroblasts , or pieces of cartilage . however , signs indicating a germ cell tumor , which is the dominant component , are seen in fnac taken from the teratoma , which is usually co - existent with other germ cell tumors of the testis . chemotherapy brings about an 80% cure in cases in which nonseminomatous germ cell tumors of the testis metastasise . it has been argued that removal of residual masses after chemotherapy will increase the efficacy of treatment as well as life expectancy . fnac was taken from our cases after the administration of six cures of bleomycin , etoposide , and cisplatin . a mature teratoma was diagnosed upon seeing an abundance of flat epithelial cells , some of which had lost their nuclei , on a floor of inflammatory cells in the cytopathological examination [ figure 2 ] . histopathological examination of the mass removed thereafter , showed alterations associated with a mature teratoma and chemotherapy . a cytological picture of a teratoma , as in our case , might be helpful to guide surgery . recurrence or metastasis was not found in the follow - up of our case to date ( one year follow - up ) . multiple of flat epithelial cells belonging to teratoma component of the mixed germ cell tumor taken from the mass after chemotherapy ( a - mgg , 200 , b - pap , 200 ) in conclusion , even though metastatic lesions are mostly seen in the posterior mediastinum , our findings reveal that specimens obtained with fnab from the anterior mediastinum bear discohesive , pleomorphic , small nuclei in epithelial cells with microvacoules in the cytoplasm . these cytopathological changes in specimens from the anterior mediastinum may be responsible in promoting germ cell and yolk sac tumors .
nonseminomatous germ cell tumors of the testis are common and are very aggressive malignant tumors . 
 most of the cases have metastases at the time of diagnosis , and involvement of the posterior mediastinum in particular is well known . a 33 year - old male patient presented with complaints of a swelling on the right side of the neck that had been growing for the last month , as well as shortness of breath and cough . 
 his thoracic computed tomography ( ct ) showed a 1.5 cm lymph node on the anterior mediastinum and a mass of about 11  10  8 cm extending from the right lung apex to the right hilus , with regular contours and without contrast enhancement . 
 the patient , who was given the preliminary diagnosis of a mixture metastatic bronchial tumor plus lymphoma , was subjected to transthoracic fine needle aspiration cytology ( fnac ) . 
 his abdominal ct revealed a hypodense , heterogeneous and cystic necrotic mass of about 10  7  5 cm that was para - aortic at the infrarenal level ( initially predicted as a lymphoma ) . 
 the patient , who could not be typed in his cytopathological examination , was diagnosed with malignant epithelial tumor and was recommended to undergo a genitourinary system examination . upon finding a high alpha fetoprotein ( afp ) value , a scrotal ultra sonography was performed which showed a mass filling the right testis . 
 histopathological examination of the orchiectomy material resulted in the diagnosis of mixed germ cell tumor ( 60% mature teratoma and 40% yolk sac tumor ) . even though metastatic lesions are mostly seen in the posterior mediastinum 
 , our findings reveal that specimens obtained with fnac from the anterior mediastinum bear discohesive , pleomorphic , small nuclei in epithelial cells with microvacoules in the cytoplasm . 
 these cytopathological alterations in specimens from the anterior mediastinum might promote germ cell and yolk sac tumors .