Dumbbell neurogenic tumor of the mediastinum: A report of three cases undergoing single-staged complete romoval 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 casesvia 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 aptients 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 thoractomy approach. Avoiding a thoractomy 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.     

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.     

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.     

Three surgically treated cases of spontaneous rupture of the esophagus with reference to a new surgical approach--eversion stripping and esophagogastrostomy through the posterior mediastinum

Three surgical cases of spontaneous rupture of the esophagus were reported. Case 1 was a 56-year-old man who was admitted 3 days after the onset was treated with open drainage. He had no complications whatsoever 8 years after the treatment. In case 2 (a 55-year-old man), eversion stripping of the esophagus and gastrostomy were performed 2 months after diagnosis, but esophageal reconstruction was not successful. He died of acute congestive heart failure 5 years after surgery. The Third case was a 60-year-old women whose rupture was confirmed 11 days after the onset. Cervical esophagostomy, gastrostomy and jejunostomy were performed 16 days after the rupture. Thereafter, esophageal eversion stripping and esophagogastrostomy through the posterior mediastinum were successfully carried out 2 months after the first surgery. She had no postoperative complications. Eversion stripping of the esophagus with esophagogastrostomy through the posterior mediastinum is an effective and safe method for some advanced cases of spontaneous esophageal rupture. We have not found any reports of surgical cases with spontaneous esophageal rupture treated by this approach in the literature.     

Removal of thoracic dumbbell tumors through a single-stage posterior approach: its usefulness and limitations

Background

The purpose of this study was to evaluate the surgical results of the single-stage surgery only from posterior approach for the management of thoracic dumbbell tumor and to discuss its usefulness and limitations.

Methods

Sixteen cases of large thoracic dumbbell tumor (11 men and 5 woman, mean age, 44 years) were analyzed retrospectively. Pathologic findings included schwannoma in 10 patients, neurofibroma in 2 patients (Recklinghausen in 1 patient), meningioma in 2 patients, myxolipoma in 1 and ganglioneuroma in 1. They underwent single-stage removal of dumbbell tumor using the posterior approach followed by laminectomy and often costotransversectomy combined with instrumentation. Clinical and radiologic outcomes are reviewed.

Results

The mean follow-up period for clinical and radiographic outcome variables was 66 months (range, 24–120 months). Operative time ranged from 185 to 420 min (mean, 320 min), with estimated blood loss ranging from 71 to 1830 ml (mean, 540 ml). Postoperative complications were pleural injury during the enucleation of paravertebral tumors, which could be repaired, and the chest tube was detained to prevent postoperative pneumothorax. Postoperative complications included atelectasis in one case. All patients had tumors successfully removed with no neurological deterioration. One patient underwent both posterior and anterior surgery because of attachment to and compression of an artery. We were not able to diagnose this case preoperatively, although a biopsy had been performed.

Conclusions

Single-stage surgery may be a useful method for removing thoracic dumbbell tumors without the combined anterior approach, unless they are attached to and compressing the artery and the diagnosis cannot be made preoperatively.     

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.     

Recent advances in video-assisted thoracoscopic approach to posterior mediastinal tumours

Minimal invasive video-assisted thoracic surgery can be a safe alternative technique in the assessment, diagnosis and surgical resection of posterior mediastinal tumours. Video-assisted thoracic surgery may be particularly suited for the management of posterior mediastinal tumours as most are benign. Surgical technique continues to evolve from the classic 3-port access in order to tackle more complex tumours positioned at the apical and inferior recesses of the posterior mediastinum. The preoperative identification of dumbbell tumours is important to facilitate arrangements for a single-stage combined resection for both the intra-thoracic and intraspinal tumour. Results from Video-assisted thoracic surgery posterior mediastinal tumour resection are comparable with conventional surgical techniques in terms of symptomatic improvement, recurrence and survival. Video-assisted thoracic surgery approach has been shown to result in less post-operative pain, improved cosmesis, shorter hospital stay, and more rapid recovery and return to normal activities. In over a decade, video-assisted thoracic surgery has gradually matured and is now a promising therapeutic alternative to open approach. In certain selected patients, video-assisted thoracic surgery may be considered the standard of care for conditions of the posterior mediastinum. Recent developments in robotic surgery for the management of mediastinal tumours are promising, however, long-term results are pending.     

The optimal procedure for chylothorax after operation for thoracic esophageal cancer; reasonable approaches to the thoracic duct from the point of view of routes for esophageal replacement

In general, chylothorax after esophagectomy with lymph node dissection under thoracotomy is a rare postoperative complication. We report a 71-year-old man who developed chylothorax following esophagectomy and 3-field lymph node dissection together with reconstruction using stomach through the posterior mediastinum, and discuss ideal approaches that are less invasive and make it possible to provide better exposure of the thoracic duct. In selecting the ideal approach, the most important thing is differences in routes for esophageal replacement. The anatomical relation between the location of a conduit adopted for reconstruction of the resected esophagus and the thoracic duct should be considered in each case. In the case of the retrosternal or antesternal route, a video-assisted thoracoscopic approach allows for easy detection of the thoracic duct while reducing surgical invasiveness, because there is no conduit in the posterior mediastinum. On the other hand, a conduit interrupts the visual field of thoracoscopy in the case of the posterior mediastinal or intrathoracic route. Drawing up of a conduit to gain a good operative field involves some risks in protection of the vascular pedicle. Therefore, a transabdominomediastinal approach is an optimal option. With this approach, we could easily find the thoracic duct and directly ligate it just cranial to the hiatus, resulting in a remarkable decrease in discharge through the thoracic drainage tube. In addition, we present an intelligible intraoperative photograph.     

Giant cystic hygroma of the posterior mediastinum

The case of a 5-year-old girl with a giant cystic hygroma of the posterior mediastinum is reported. Although the tumor was bilateral, it was excised by unilateral thoractomy. The unique anatomical features of this tumor suggested an embryologic origin from the cisterna chyli or the primitive paired thoracic ducts.     

Double simultaneous cysts of the mediastinum.

We describe a rare case of double mediastinal tumors in a 60-year-old male with spinocerebellar degeneration. Magnetic resonance imaging (MRI) accidentally revealed double cystic tumors in the anterior and posterior mediastinum. Surgical management by video-assisted thoracic surgery (VATS) was successfully performed. The histological diagnoses were confirmed as a thymic cyst in the anterior and a thoracic duct cyst in the posterior mediastinum, respectively.     

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。     

Mature teratoma of the posterior mediastinum: report of a case

Mediastinal teratoma generally arises in the anterior mediastinum. Posterior mediastinal teratomas have been rarely reported to date, especially in adults. We report a case of posterior mediastinal teratoma in a 57-year-old woman. The pre-operative diagnostic work-up revealed a posterior mediastinal tumor with calcification and fluid components. The tumor, adhering to the descending aorta, was radically removed through video-assisted thoracic surgery. Histological examination was concluded for a mature teratoma with cystic change. The imaging features of posterior mediastinal teratomas are identical to those in the anterior mediastinum, except for their location. To be different from anterior mediastinal teratomas, benign teratomas in the posterior mediastinum are often involved with a major surrounding structure, including aorta, chest wall, and esophagus. When a posterior mediastinal tumor has the typical features of a mature teratoma in the pre-operative findings, the adhesion to the surrounding structure should be considered.     

A case of dumbbell neurogenic tumors of the mediastinum

A 49-year-old man was admitted for the further examination of the abnormal shadow of the left posterior mediastinum, which was incidentally detected on routine chest X-ray. He has no complaints, and no abnormalities on neurological examination. Thoracic spine X-ray showed the destruction of the T12 vertebral body and the dilatation of the left intervertebral foramen between T12 and L1. Myelography showed no abnormalities, but contrast-enhanced CT scanned just after myelography revealed the extradural dumbbell-formed tumor. One stage removal of the tumor was safely performed through left posterolateral thoracotomy and transthoracic partial laminectomy. Postoperative course was uneventful. The tumor was histologically schwannoma, originated from the left thoracic sympathetic trunk. We think that this procedure is available for the operation of a kind of dumbbell tumor of the posterior mediastinum.     

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.     

A case of dumbbell neurogenic tumor in the posterior mediastinum

We have recently experienced a dumbbell tumor that developed in the posterior mediastinum in a 64-year-old male. The patient suffered from dorsalgia one year and a half previously. Chest X-ray examinations revealed a well-defined boundary in the right posterior mediastinum. Myelography followed by computerized tomographic scanning (CT) revealed that the tumor developed in a paravertebral area linked with a vertebral canal through an intervertebral foramen and destructed a rib in growing in the paraspinal muscular layer. Longitudinal incision of about 10 cm was made downward from immediately above the first thoracic spinous process, and the chest was opened by posterolateral incision extending into the muscles of the back in an arc shape. The tumor was entirely excised by additional laminectomy. Since malignant schwannoma was diagnosed histologically, Linac X-ray of 50 Gray was given. The patient is now enjoying his healthy daily life with no postoperative complication 2 years after operation. Myelography followed by CT was proved to be quite useful in evaluating a relationship between the tumor and the spinal cord in the diagnosis of this disease.     

A case of teratoma of the posterior mediastinum

We reported a case of teratoma of the posterior mediastinum, whose common location in the mediastinum is anterosuperior portion. A 10-year-old female with teratoma of the posterior mediastinum received thoracotomy in our department. Magnetic Resonance Imaging was useful in this case for the clinical diagnosis of the nature of tumorous shadow using T1-weighted, T2-weighted SE images and IR images.     

An operated case of ectopic thymic cyst of the posterior mediastinum

We reported an operated case of thymic cyst of the posterior mediastinum, whose common location in the mediastinum is anterior or antero-superior portion. A 58-year-old female was admitted because of the abnormal shadow on a routine chest radiograph. No particular symptoms and physical findings were noticed. The CT scanning and the MR Imaging of the thorax demonstrated the posterior mediastinal mass, which was removed by thoracotomy. The histopathological findings were most consistent with a diagnosis of thymic cyst. No cases of ectopic posterior mediastinal thymic cyst have been described in the recent literature.     

Robot-assisted intrathoracic procedure for dumbbell tumour in the prone position

A 24-year-old man presented with a dumbbell-shaped right posterior mediastinal mass. The patient was placed in the prone position following general anaesthesia and intubation. After laminectomy and dissection of the dorsal part of the tumour using a posterior approach were performed, the tumour was completely resected using a robotic approach in the thoracic cavity without repositioning. This is the first report of robotic resection for posterior mediastinal tumour in the prone position as well as a novel combined posterior approach and robotic resection for dumbbell tumours.     

Posterior mediastinal hemangioma successfully resected with cardiopulmonary bypass; report of a case

Mediastinal hemangioma is a rare tumor. We report a case of a 62-year-old woman with a posterior mediastinal hemangioma. She had a history of right breast cancer and a follow-up chest radiography revealed a mass located in the left posterior mediastinum. The size was about 80 mm in diameter. The tumor surrounded the descending thoracic aorta and involved intercostal arteries. Complete excision could be achieved by decompressing the descending aorta with the aid of partial cardiopulmonary bypass and the aortic cross-clamp. Histologically, the tumor was diagnosed as a benign hemangioma. It was reported that hemangioma would reccur after subtotal excision. To employ cardiopulmonary bypass was a very effective approach for the purpose of complete excision in our case.