A 24-year-old male has new onset of chest pain. Chest films demonstrate a large anterosuperior mass. Appropriate evaluation should include:

A. CT of the chest.

B. Measurement of serum alpha-fetoprotein and beta–human chorionic gonadotropin.

DISCUSSION: Elevated levels of serum alpha-fetoprotein and beta–human chorionic gonadotropin are indicative of a malignant nonseminomatous germ cell tumor. Optimal therapy for such a tumor is based on a cis-platinum-containing chemotherapeutic regimen. After normalization of serum markers, resection of residual disease is performed. Extensive surgical procedures prior to chemotherapy are not warranted. Confirmation of the diagnosis can usually be obtained using needle biopsy techniques. In some institutions patients are treated based on elevated serum markers alone. CT imaging is useful to evaluate tumor invasiveness, airway compression, vascular involvement, and the likelihood of resectability. Barium swallow may be helpful in the evaluation of enteric cysts. Myelography may be useful in patients with posterior mediastinal masses to evaluate for spinal column involvement.