Dumbbell neurogenic tumor of the mediastinum: a report of three cases undergoing single-staged complete removal without thoracotomy

Of a total thirteen patients who underwent surgery for a neurogenic tumor in the posterior mediastinum 4 (30.8 per cent) presented with dumbbell type development of the tumor. Along with a comparatively greater incidence in the number of cases of dumbbell neurogenic tumors in the posterior mediastinum, resection has also recently become more popular, necessitating the establishment of a standard operative approach for this type of tumor. We successfully removed dumbbell neurogenic tumor from the posterior mediastinum in our 3 most recent cases via a dorsal approach by virtue of a laminectomy and resection of a small portion of the neighbouring rib root without opening the parietal pleura at all. These three patients were a 14 year old female, a 54 year old male and a 68 year old female, respectively, and the largest diameter in cm and level of origin of the tumors were 5.5 at Th 1 in case 1, 3.0 at Th 2 in case 2 and 3.7 at Th 11 in case 3. The operative approach described herein was easy to perform, felt secure and was less invasive and better tolerated by the patients than the thoracotomy approach. Avoiding a thoracotomy in such cases has many advantages to enumerate, but does not seem to have been clearly aimed at by others to date. We therefore propose our technique as a standard approach for dumbbell neurogenic tumors in the posterior mediastinum.     

One-stage resected case of dumbbell type tumor of the posterior mediastinum

We reported a dumbbell type tumor of the posterior mediastinum. The patient was an asymptomatic 40-year-old male. An abnormal shadow in the right lower lung field was pointed out in a mass survey. We recognized a dumbbell type tumor in the posterior mediastinum by chest CT and MRI. The tumor invaded the intervertebral canal through the spinal foramen. It was most clearly seen by MRI myelography. Operation was performed with the patient in a prone position and with an L-shaped skin incision of the back and 11th intracostal thoracotomy and Th11 laminectomy. The dumbbell type tumor was completely removed by this operation. The pathological diagnosis was Schwannoma. The post operative course was good. The one-stage operation is useful for dumbbell type tumors of the posterior mediastinum.     

Thoracoscopic surgery combined with a supraclavicular approach for removing a cervico-mediastinal neurogenic tumor: a case report.

The neurogenic tumors in the posterior mediastinum sometimes extend into the vertebral canal, known as dumbbell tumors, but cases in which the neurogenic tumor extends to the cervical region are rare. A 19-year old female with a right-sided posterior mediastinal mass, without either Horner's syndrome or pain on the right upper extremity, was referred to our hospital. The chest computed tomography (CT) revealed a large posterior mediastinal mass, measuring 80x50x50 mm in size, which was suspected to be a neurogenic tumor, and the right vertebral artery (RVA) was involved in the tumor at the Th1 to C7 spinal level. Surgical removal of the tumor using video-assisted thoracoscopic procedures through a limited axillary route combined with a supraclavicular approach by a right semi-collar incision was successfully performed. The RVA had to be sacrificed in order to remove the tumor. She was discharged from the hospital on the 12(th) postoperative day. The combined approach using video-assisted thoracic surgery (VATS), with a limited mini-transverse axillary and supraclavicular incision was useful for the removal of a cervico-mediastinal tumor.     

Laparoscopic excision of a lower posterior mediastinal paraspinal mass: technique and feasibility of the laparoscopic approach

Paravertebral and paraspinal tumors in the posterior mediastinum are predominantly neurogenic in origin. The treatment comprises surgical extirpation. We report a case of a 40-year-old man with a 2-month history of pain epigastrium, radiating to the left scapula, and marked (10 kg) weight loss. Preoperative CT scan showed a paraspinal mass 8 cm in diameter at the level of the tenth thoracic vertebra. A CT scan-guided fine-needle aspiration cytologic analysis revealed the mass to be of neurogenic origin. Transabdominal laparoscopic excision of this lower posterior mediastinal neurogenic tumor was attempted and accomplished safely. The approach was through the left crural fibers, which were split to access the lower posterior mediastinum. Operating time was 122 minutes. Postoperatively, a left intercostal drain was inserted. The patient was discharged on the third postoperative day, after intercostal drain removal. Lower posterior mediastinal paraspinal tumors can be resected laparoscopically with careful preoperative investigation for tumor localization and a meticulous laparoscopic technique. A major advantage of transabdominal laparoscopic resection, as compared with open or thoracoscopic (VATS) excision, is that the patient recovers rapidly with minimal operative and anesthetic morbidity.     

Mediastinal neurogenic tumors and video-assisted thoracoscopy: always the right choice?

Neurogenic mediastinal tumors in adults are generally benign lesions and for this reason are ideal candidates for resection by video-assisted thoracoscopy (VAT). Usual contraindications to VAT are the dimension of the tumor (greater than 6 cm), its position (apex, posterior costodiaphragmatic angle), and/or the presence of intraspinal growth (the so-called "dumbbell tumors"). This study reviewed a single-institution 10-year experience approaching mediastinal neurogenic tumors routinely by VAT, even in cases of the above mentioned contraindications. From January 1992 to December 2002, 15 consecutive mediastinal neurogenic tumors were operated by VAT (11 females, mean age 43 years, range 16-67). Mean operating time was 99 minutes (range 60-180). No conversion thoracotomy was required. The 2 cases of "dumbbell tumor" in this series were treated by laminectomy followed by VAT. Two patients had a Claude-Bernard-Horner syndrome after removal of lesion at the level of T1-T2. Mean postoperative stay was 5.5 days. Histologic diagnosis was schwannoma in 12 cases (Antoni type A in 7 cases, type B in 4 cases, mixed type in 1 case) and neurofibroma in 3 cases. Results from this 10-year experience confirmed that VAT can be the standard approach for neurogenic tumors in adults without negative effect on radicality of resection and safety of the procedure.     

A case of dumbbell type extradural spinal meningioma

We reported a case of dumbbell type extradural spinal meningioma. The patient was a 45-year-old female. An abnormal shadow in the right middle lung field was pointed out in a mass survey. We recognized a dumbbell type tumor in the posterior mediastinum by chest CT and MRI. The tumor invaded the intervertebral canal through the spinal foramen. Operation was performed firstly with a longitudinal skin incision of the back and Th 6 laminectomy in a prone and secondly with a right posterolateral thoracotomy in a left lateral position. The dumbbell type tumor was completely removed by this operation. The pathological diagnosis was meningioma. The postoperative course was good.     

Neurogenic tumors of the posterior mediastinum

The posterior mediastinum is the potential space along each side of the vertebral column and adjacent proximal portions of the ribs--the paravertebral sulci. From the posterior mediastinal tumors, the most commonly encountered are the neurogenic tumors (75%), the remaining 25% are represented by a heterogenous group of rare tumors including teratoma, lymphoma, sarcoma and other lesions arising outside the mediastinum and projecting into the posterior compartment. Surgical excision, by thoracotomy or miniinvasive techniques, is the first line of treatment in the posterior mediastinal tumors. Tumors with extension into the spinal canal (dumbbell tumors), accounting for nearly 10% of the posterior mediastinal tumors, require a multidisciplinary approach: thoracic surgeon and neurosurgeon. We present the experience of the "Carol Davila" University of Medicine and Pharmacy Thoracic Surgery Clinic in the surgery of neurogenic posterior mediastinal tumors throughout a 9 year period (2001 - 2010). 42 cases admitted and operated in this period are being analysed.     

Surgical treatment of neurogenic tumors of the chest.

BACKGROUND: Neurogenic tumors are commonly found in the mediastinum, especially in the posterior mediastinum or in the chest wall, and have a variety of clinical and histological features. We reviewed our experience with these types of tumors and assessed diagnostic and therapeutic approaches. PATIENTS AND METHODS: A series of 60 consecutive patients with a neurogenic tumor of the chest, all seen at a single institute, was retrospectively reviewed. RESULTS: The mean age of the 60 patients was 40 years, including 32 males and 28 females. Preoperative symptoms were present in seven patients (11.7%). Median tumor size was 5.3 cm, ranging from 1.4 to 20 cm. The major location of the tumor was the posterior mediastinum in 38 cases (63.3%) and the chest wall in 16 cases (26.7%). The operative procedure performed was tumor extirpation in 58 cases (96.7%), in which video-thoracoscopic procedure was performed in nine patients and chest wall resection in two cases. The major histological type was neurilemmoma in 51 patients (85%), and malignant tumor was only diagnosed in one patient with malignant schwannoma. Tumor related death occurred in only one case with malignant schwannoma. Ten patients with neurilemmoma were precisely diagnosed by magnetic resonance imaging. CONCLUSION: Almost all cases of intrathoracic neurogenic tumors were benign in nature. Therefore, surgical indications may be carefully determined in cases with no symptom and with imaging that indicate benign neurilemmoma.     

显微手术切除及椎管固定融合治疗高颈段椎管哑铃型肿瘤

目的探讨显微手术切除高颈段椎管哑铃型肿瘤及椎管固定融合的方法及效果。方法回顾性分析11例高颈段椎管哑铃型肿瘤患者的临床资料,其中ToyamaⅡ型6例,Ⅲ型4例,Ⅴ型1例。均行显微手术切除,其中远外侧入路3例,颈后正中入路8例。同时行椎管固定融合6例。结果本组全切10例,次全切除1例。术后病理学诊断为神经纤维瘤9例,脊膜瘤2例。术后症状明显改善9例,改善2例,无感染及死亡病例。随访10例,平均时间27个月（3个月～3年）,患者的症状和神经功能均有不同程度的改善,无颈椎不稳及后凸畸形。结论高颈段椎管哑铃型肿瘤显微手术切除并椎管固定融合能明显改善症状,安全性好,并发症少。     

外科治疗纵隔原发神经源性肿瘤的手术径路评价

目的　探讨外科治疗原发纵隔神经源性肿瘤的手术径路。方法　 1963年 3月至2 0 0 3年 9月外科治疗原发纵隔神经源性肿瘤 91例。所有病例均于术前行X线胸片检查 ,其中 65例行CT或磁共振检查。根据肿瘤的大小、部位及其是否向椎管内延伸选择不同的手术入路 ,其中胸后外侧切口 84例 ,半哈壳状切口 2例 ,高位胸后侧切口 4例 ,胸后外侧加脊柱旁切口 1例。所有病例均经病理证实并行 6个月～ 15年的术后随访。结果　本组手术切除率 97.8% ( 89/91) ,术后并发症发生率 4.4% ( 4 /91) ,无手术死亡病例。术后病理诊断良性肿瘤 79例 ( 86.8% ) ,恶性肿瘤12例 ( 13 .4% )。 1例神经纤维瘤 2年后复发经再次手术切除治愈 ;恶性肿瘤平均生存 3 8.1个月。结论　适当的手术径路是提高纵隔原发神经源性肿瘤切除率的关键。     

Dumbbell type schwannoma of the posterior mediastinum: a report of two cases with different surgical approaches]

Two cases of dumbbell type schwannoma of the posterior mediastinum are reported. Case 1 involved a 16-year-old man and case 2, a 48-year-old woman. They were asymptomatic, and in both cases an abnormal mass shadow of the left mediastinum was incidentally detected on a routine chest roentogenogram. In these cases, CT and MRI revealed that dumbbell type tumors extended to the spinal canal. The operations were performed with thoracic approach cooperated with a neurosurgeon in case 1 and with combined posterior and thoracic approach cooperated with an orthopedic surgeon in case 2. Histopathologic findings indicated all benign schwannomas. The reported 25 cases in Japan sofar are reviewed.     

Robotic surgery for mediastinal tumors

BACKGROUND: The surgical approach to mediastinal tumors has changed during the last two decades. Median sternotomies and thoracotomies have been replaced in part by minimally invasive procedures. Aim of this review is to highlight applications of a robotic-assisted approach in mediastinal tumor surgery. METHODS: Review of the current literature. RESULTS: A robotic approach for thymectomy, anterior mediastinal mass resection, pericardial cyst resection, diagnostic sampling of enlarged lymph nodes in the middle mediastinum, resection of benign neurogenic tumors in the posterior mediastinum and esophageal procedures was shown to be feasible. Postoperative outcomes as well as the contraindications and limitations of a robotic approach are discussed. CONCLUSIONS: For appropriate indications minimal invasive surgery with a surgical robot can safely be performed for tumors in the anterior, middle, and posterior compartments of the mediastinum.     

Thoracoscopic removal of neurogenic mediastinal tumors: technical aspects

Background: Thoracoscopy is fast becoming the standard approach for the removal of neurogenic mediastinal tumors. However, there are risks for adjacent nervous structures (stellate ganglion, spinal cord). The aim of this study was to review the technical features of this approach.Methods: Between December 1999 and January 2003, nine patients underwent thoracoscopic resection of a mediastinal neurogenic tumor at our hospital. Five of these patients were asymptomatic with incidentally found tumor; the other four patients had compression-related syndromes. Two tumors had developed in the superior sulcus, and one had a spinal canal component (dumbell-type tumor).Results: Thoracoscopic dissection was possible in all cases. In one patient, resection of the tumor was performed via a combined neurosurgical and thoracoscopic approach. Seven tumors were benign nerve sheath tumors (schwannoma), and 2 were nerve cell tumors (ganglioneuroma). The postoperative course was uncomplicated in all patients.Conclusion: The thoracoscopic resection of mediastinal neurogenic tumors is technically easy, except for bulky tumors of the superior sulcus and dumbbell tumors, which require a combined thoracoscopic and neurosurgical approach.     

Thoracoscopic removal of intrathoracic neurogenic tumors: a combined Chinese experience

OBJECTIVE: To review the surgical and clinical results of minimally invasive resection of intrathoracic neurogenic tumors using a video-assisted thoracoscopic technique. SUMMARY BACKGROUND DATA: Thoracoscopy has emerged as a possible means for diagnosing and managing various intrathoracic disorders. Benign intrathoracic tumors often are ideal lesions for resection using a video-assisted technique. The authors report on their combined experience with the thoracoscopic resection of 143 intrathoracic neurogenic tumors. METHODS: Between March 1992 and February 1999, 143 patients with intrathoracic neurogenic tumors were diagnosed and underwent resection using video-assisted thoracoscopic techniques in three teaching centers. Case selection, surgical technique, and clinical results were reviewed. RESULTS: The average age of the patients was 40.8 years; 57.3% were male. Thirty-eight patients (27%) had symptoms attributable to the masses. Seventy-two masses were neurofibromas, 33 were neurilemmomas, 7 were paragangliomas, and 31 were ganglioneuromas. All but seven tumors were located in the posterior mediastinum. The masses were on average 3.5 cm in greatest diameter. The mean surgical time was 40 minutes, and the average hospital stay was 4.1 days. There were no major postoperative complications or recurrences to date. Nine patients reported paresthesias over the chest wall during a mean follow-up of 29 months. CONCLUSIONS: Resection of intrathoracic neurogenic tumors using a thoracoscopic technique based on standard surgical indications would seem to be appropriate. Most of these masses are benign and readily removed. For dumbbell tumors, a combined thoracic and neurosurgical approach is mandatory.     

Minimally invasive resection of extradural dumbbell tumors of thoracic spine: surgical techniques and literature review

Purpose

Dumbbell-shaped thoracic tumors represent a distinct type of tumor and involve in both the spinal canal and the posterior thoracic cavity. Successful treatment for the tumors depends on gross total resection (GTR) via an open laminectomy and facetectomy or transthoracic transpleural approach. In this case series, we report our experiments with minimally invasive method for the removal of extradural dumbbell thoracic tumor and present related literature review.

Methods

We retrospectively reviewed two patients with dumbbell-shaped thoracic tumors who underwent minimally invasive resection and unilateral transforaminal thoracic intervertebral fusion (TTIF) through unilateral paraspinal muscle approachwith a spotlight expandable tubular retractor. Clinical data, tumor characteristics, and outcomes were analyzed.

Results

Two patients underwent successful minimally invasive treatment of their spinal neoplasms. There were no procedure-related complications. The efficacy in terms of neurological recovery, pain improvement and operative variables (length of incision, operative duration, blood loss, and hospital stay) was better when compared with prior published studies. Postoperative CT image demonstrated complete resection of dumbbell tumor in the patients. The solid fusion was obtained after 3 months follow-up and there was no failure of internal fixation.

Conclusion

If the medial border of intracanal component of extradural dumbbell tumor is near the midline of canal and the pedicles of adjacent vertebrae to tumor are intact, minimally invasive resection of tumor through unilateral paraspinal muscle approach combined with unilateral TTIF is good choice.

     

Chirurgie der Mediastinaltumoren

Thymomas, lymphomas, and germ cell tumors are the most frequent lesions of the anterior mediastinum, whereas endodermal (bronchogenic) cysts and lymphomas are the most frequent lesions of the middle mediastinum. In the posterior mediastinum, neurogenic tumors and soft-tissue sarcomas are the most frequent. Depending on tumor location, mediastinoscopy, mediastinotomy, and thoracoscopy are the preferred diagnostic methods. Surgical treatment of thymoma is the gold standard, and median sternotomy is the most frequently applied approach. The decisive prognostic and therapeutic criteria are Masaoka staging, WHO classification, and R0 status. Thoracoscopy should be performed only in patients with myasthenia gravis and with very small tumors. Surgical treatment is highly recommended in patients with locally recurrent tumors. The importance of surgical treatment of germ cell tumors is determined by a negative concentration of β-HCG and α-fetoprotein and in cases of residual tumor after chemotherapy. Bronchogenic cysts always require resection because of their high complication rate (66%) after conservative treatment. In these cases complete resection is necessary due to the probability of recurrence. Ninety-eight percent of neurogenic tumors in adults are benign and usually resected via thoracoscopy or thoracotomy, depending on location and size.     

Malignant fibrous histiocytoma of the mediastinum associated with bilateral adrenal gland metastases--a case report]

A 55-year-old female underwent complete resection of left posterior mediastinal tumor and both adrenal gland tumors. Histological examination revealed malignant fibrous histiocytoma (MFH) showing a storiform pattern. Her postoperative course was uneventful and well one year after the operation. We concluded the tumor arose from the mediastinum and metastasized to the bilateral adrenal glands. No other case was reported that primary MFH of the mediastinum with distant metastases was completely resected including metastatic lesions.     

Preferred surgical approach for dumbbell-shaped tumors in the posterior mediastinum

We present the case of a 67-year-old male smoker with a posterior mediastinal hemangioma. Radiological findings revealed a dumbbell-shaped tumor with a neuroforaminal extension in the right paravertebral space. Under the preoperative diagnosis of a neurogenic tumor, surgery was performed using a combined anterior and posterior approach. During the thoracotomy, the tumor was found to be a hemangioma. We ligated the involved vessels before performing laminectomy, thus ensuring that complete tumor resection was achieved without massive bleeding in the spinal canal. Dumbbell-shaped hemangiomas are rare, and preoperative confirmation of the diagnosis is challenging. Thoracotomy before laminectomy is optimal for the resection of dumbbell-shaped tumors of the mediastinum, especially with marked vascularity, given that the initial thoracotomy procedures facilitate the subsequent laminectomy procedures.     

Ganglioneuroma : primary tumor or maturation of a suspected neuroblastoma?

Ganglioneuroma is a benign neurogenic tumor. These tumors are originating from neuroepithelium along sympathetic ganglia. Main localization is the mediastinum in children older than 10 years. An association with malignant neuroblastoma is rarely observed and it still remains a topic under current discussion. We describe the clincal course of a 17 year-old female patient with a large presacral mass causing amenorrhoea and weight loss. Eleven years before presentation, an incidental urine test showed an elevation of vanillylmandelic acid (VMA) and homovanillic acid (HMA) and a neuroblastoma was suspected. However, further investigations showed no tumor and the test results turned out to be normal within 1 year. Now, a malignant neurogenic tumor was again suspected, but a CT-guided biopsy revealed a benign tumor. The mass was originating from the left sacral nerve roots. A tumor resection via a dorsal approach was performed. Final histology showed a differentiated ganglioneuroma. This is, to our knowledge, the first report describing a patient with elevated VMA/HMA and suspected neuroblastoma who developed a ganglioneuroma 11 years later. The association of ganglioneuroma and neuroblastoma and the abnormal urine tests pointing toward a neuroblastoma 11 years ago remains unclear and the possible answers are discussed in our report.     

Combined laminectomy and thoracoscopic resection of dumbbell-type thoracic cord tumor

STUDY DESIGN: A study of five patients whose dumbbell or paraspinal tumors of the thoracic spine were managed by using thoracoscopic surgery is reported. OBJECTIVES: To report on the use of combined laminectomy and thoracoscopic resection for the management of dumbbell-type thoracic cord tumor. SUMMARY OF BACKGROUND DATA: Some posterior mediastinal tumors can be resected safely with video-assisted thoracic surgery. However, there are few reports on thoracoscopic resection of dumbbell and paraspinal tumors of the thoracic spine. METHODS: Five patients who received treatment for thoracic spine dumbbell tumors and paraspinal tumors were studied retrospectively. Three patients had dumbbell tumors, and two had paraspinal tumors of the thoracic spine. Preoperative evaluation of each patient included plain chest radiography, magnetic resonance imaging, and computed tomography. All patients underwent total resection by means of a combined posteroanterior approach, with thoracoscopic surgery for dumbbell tumors and thoracoscopic surgery alone for paraspinal tumors. In all patients, a gross total resection was achieved with this approach. All patients were observed for a minimum of 3 years. RESULTS: All patients regained their ability to walk 2 days after surgery, except for one patient who had a hemothorax. A gross total tumor resection, documented by magnetic resonance imaging, was performed on all patients. Follow-up imaging at 6 weeks, 1 year, 2 years, and 3 years after surgery did not show residual tumor or recurrence in any patient. To date, spinal instability has not developed in any patient. CONCLUSIONS: Combined laminectomy and thoracoscopic surgery may be a good alternative method for managing thoracic dumbbell tumors.