Dumbbell type tumor of a nerve root treated surgically by vertical curvilinear approach

A 42-year-old man was admitted for further examination of an abnormal shadow on the posterior mediastinum which was incidentally detected by a routine chest X-ray. Myelography followed by computerized tomographic scanning (CT) revealed that a dumbbell shaped tumor had developed in the paravertebral area adjacent to the vertebral canal through an intervertebral foramen. A vertical curvilinear incision centered at T-6 was made with the patient in a prone position. Total laminectomy or T-5 and T-6 and resection of the left 6th rib provided sufficiently wide exposure for a one-stage resection of the tumor. The dumbbell shaped tumor originated from the root of 6th spinal nerve but did not extend to the spinal cord. The extirpated tumor was diagnosed histologically as schwannoma. Because tumor location had been determined preoperatively by CT scanning after myelography, it was possible to perform complete extirpation of the tumor while avoiding the complications of laminectomy and unnecessary thoracotomy.     

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.     

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 intrathoracic perineurial cyst

A 67-year-old man was referred to our surgical clinic for evaluation of an abnormal shadow on the chest X-ray examination. CT scan and MRI revealed a tumor in the posterior mediastinum and destruction of the pedicle and intraspinal invagination by the tumor. The tumor in a paravertebral area are linked with a vertebral canal through a destructed intervertebral foramen. MRI showed that the tumor was a cyst which contained fluid. On thoracotomy a hen's egg sized cyst was found in the posterior mediastinum, the cyst was excised. Pathological diagnosis was a perineurial cyst. This case was clearly differentiated from an intrathoracic meningocele and a neurilemmoma microscopically. This case is the first intrathoracic perineurial cyst in Japan.     

A case of dumb-bell-like neurilemmoma of the posterior mediastinum

A 56 year-old female was pointed out an abnormal shadow on chest X-ray film for the lung cancer screening study. Chest X-ray film showed a round mass shadow at the right superior mediastinum. Chest CT scan revealed the mass was in the paravertebral area abutting on the 2nd thoracic vertebral body and had extended into the intervertebral foramen. Preoperative diagnosis was a dumb-bell-like neurogenic tumor. Operation was carried out by posterior approach in the prone position. At first thoracotomy was done by removing the paravertebral portion of the 2nd and 3rd ribs, and then hemilaminectomy was added. Both the intrathoracic and intraforminal portions of the tumor were completely exposed, and excised. Pathological examination demonstrated the tumor was a typical neurilemmoma originating from the 2nd intercostal nerve. When a neurogenic tumor of the posterior mediastinum has an intraspinal extension, a posterior approach by a simultaneous thoracotomy and laminectomy will be useful to remove the tumor at one sitting.     

Unknown primary large cell neuroendocrine carcinoma (LCNEC) in the mediastinum

Unknown primary large cell neuroendocrine carcinoma (LCNEC) in the mediastinum is extremely rare. In this report, we present a case of a 53-year-old man with superior vena cava (SVC) syndrome who developed LCNEC in the middle mediastinum. His chief complaint was facial edema. Chest X-ray revealed an abnormal shadow in the right upper mediastinum. Computed tomography (CT) scan of the chest revealed a 67-mm mass in the middle mediastinum. Tumor invasion caused constriction of the SVC. The patient underwent induction chemoradiotherapy with vinorelbin and cisplatin and concurrent radiation therapy. After induction therapy, the tumor size decreased remarkably and was resected completely. The pathological diagnosis was LCNEC.     

Surgical analysis of mediastinal lymphangioma--analysis of 7 cases]

Mediastinal lymphangioma is a very rare disease. In this study, we evaluated 7 surgically treated cases of mediastinal lymphangioma. Four males and 3 females with ages ranging from 5 months to 74 years (average 31.4 years) were examined. Four patients were asymptomatic but had abnormal shadows on their chest X-ray. Of the remaining patients, one had hoarseness and another had superior vena cava syndrome and both had dyspnea. The other patient was discovered because of cervical tumor. Multiple lymphangiomas were found in only 2 patients. One patient had 4 tumors and the other had 2 tumors in the mediastinum. Of all lymphangiomas, 2 were found in the superior mediastinum, 2 in the anterior mediastinum, 3 in the median mediastinum and 3 in the posterior mediastinum. All patients had cystic lymphangioma including 1 with capillary lymphangioma and 1 with cavernous lymphangioma. Median sternotomy was performed in 3 of the patients and posterolateral thoracotomy was performed in the remainder. The cervical tumor was removed by local incision. Complete resection of the lymphangiomas was performed and no recurrence was observed after surgery.     

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.     

Cavernous hemangioma of the posterior mediastinum with bony invasion

We herein report a case of a cavernous hemangioma of the posterior mediastinum treated with surgical resection. Mediastinal hemangiomas are rare and diagnosis is difficult prior to operation. A 58-year-old female was referred to our hospital for back pain and a tumor in the left posterior mediastinum that was detected by chest computed tomography (CT). CT showed a tumor adjacent to the left side of the fifth thoracic vertebrae measuring 60 × 50 mm with invasion into and destruction of the 5th rib. The tumor was resected successfully via hemilaminectomy with costotransversectomy, and was revealed to be a cavernous hemangioma histologically. 1 year and 5 months after surgery, the patient was asymptomatic and without a recurrence. Hemangiomas are usually considered benign but sometimes behave aggressively with destruction of the neighboring structures. We consider en bloc resection to be safe and effective for aggressive cavernous hemangiomas 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.     

Erratum

Background: Rarely, a posterior mediastinal mass may mimic an adrenal tumor on preoperative computed tomography (CT) scan. The intraoperative discovery that a mass thought to be associated with the adrenal gland actually is above the diaphragm in the posteroinferior mediastinum poses a challenge for the laparoscopic surgeon. Conversion to a thoracotomy or to videothoracoscopy incurs additional morbidity and risk for the patient. Materials and Methods: We describe a technique for the transdiaphragmatic removal of a benign mass from the posterior mediastinum. A posterior mediastinal tumor was detected during a laparoscopic procedure for a suspected right adrenal tumor. Frozen section proved benign, and the mass was resected laparoscopically via transdiaphragmatic access to the posterior mediastinum. Results: No complications were noted during or after surgery. The patient was ready for discharge from the hospital postoperative day 1. Conclusions: Transdiaphragmatic resection was used successfully instead of conversion to a thoracotomy or thoracoscopic procedure for a benign posterior mediastinal tumor found incidentally during laparoscopic surgery for a presumed adrenal lesion. This transdiaphragmatic approach can be applied to selected benign mediastinal masses.     

Large malignant mesenchymoma of the left posterior mediastinum; report of a case

Malignant mesenchymoma is a soft tissue tumor arising preferentially in the extremities and retroperitoneum. We report a case of primary malignant mesenchymoma of the left posterior mediastinum. A 24-year-old woman was admitted to our hospital for complaining of cough. Chest X-ray showed a giant mass occupying the 2/3 of the left hemithorax. Chest computed tomography (CT) revealed a lobulated large mass with fat density area and calcified spot in the mediastinum and left pleural space. Chest magnetic resonance imaging (MRI) demonstrated a large solid mass consisting mainly of areas with the same intensity as fatty tissue and partly of areas with heterogenous moderate intensity. The tumor was resected completely under left posterolateral thoracotomy. The pathologic diagnosis was malignant mesenchymoma; well differentiated liposarcoma with osteocartilagenous differentiation. The patient has been well for 3 years and 3 months after surgery.     

Thoracic duct cyst--a case report

A case of thoracic duct cyst was reported. The patient, 72 year old man, was admitted with chief complaint of dysphagia. Chest X-ray film demonstrated an ovoid mass at the right upper mediastinum and the esophagus pressed by the tumor to the right. CT scan showed a round tumor with obscure margin located at the right upper mediastinum. Other laboratory data were almost within normal limits. Thoracotomy was performed on March 26, 1987 under diagnosis of leiomyoma of the esophagus. A fluid containing cyst covered with pleura was found at the upper mediastinum. The tumor was connected to the thoracic duct at its upper and lower portion. The cyst was isolated by sharp and blunt dissection without difficulties and removed. The cyst measured 7.5 X 4.5 X 4.5 cm and contained chyle. Pathological examination revealed no evidence of malignancy. Postoperative course of this patient was uneventful, and dysphagia was disappeared.     

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.     

Castleman lymphoma originated from the posterior mediastinum resected thoracoscopically: report of a case

We report thoracoscopic resection of Castleman lymphoma originated from the posterior mediastinum. The patient was a 19-year-old woman, who was pointed out to show an abnormal shadow in the left upper lung in the chest X-ray photograph. It was diagnosed as a blood-rich posterior mediastinal tumor by dynamic MRI, and thoracoscopic surgery was performed. The tumor was adjacent to the vertebral body of the fourth thoracic vertebra. Although operation involved 2 hours and 40 minutes and 670 ml of bleeding due to a strong adhesion between the tumor and the intercostal muscle and considerable bleeding from the tumor itself, it was successfully removed under thoracoscopy. The tumor was elastic and hard, and 50 x 45 x 25 mm in size. The histopathological diagnosis was a Castleman lymphoma, hyaline vascular type. The postoperative course was satisfactory, and the patient was discharged from the hospital on the 7th postoperative day. Castleman lymphoma originated from the posterior mediastinum tends to bleed considerably during its resection. If a blood-rich posterior mediastinal tumor was found preoperatively, thoracoscopic operation must be advanced carefully keeping this disease in mind.     

A case of subclavian paraganglioma in the superior mediastinum extending to the neck]

A 52-year-old female was admitted to our hospital with left anterior chest pain. On physical examination, an elastic hard mass sized in 3.0 x 2.5 cm was palpable at the left suprasternal area. Chest X-ray film showed a large mass shadow in the cervico-thoracic region, and CT films revealed a well-defined mass in the superior mediastinum which was heterogeneously enhanced by contrast medium. Operation was performed under the preoperative diagnosis of thymic tumor extending upwards. At operation, the tumor was located between the trachea and the left subclavian artery in the superior mediastinum displacing these structures and extending to the neck. Resected specimen which was 5.5 x 3.5 x 3.0 cm in size and 42 gm in weight was well encapsulated and highly vascularized. On microscopic findings, the tumor was finally diagnosed as paraganglioma. According to the classification of Glenner and Grimley, it was thought that the tumor originated from subclavian paraganglion in the superior mediastinum. Subclavian paraganglioma had rarely been reported in the literatures. As subclavian paraganglioma, our patient was the first reported case in Japan.     

Mucinous adenocarcinoma of the anterior mediastinum

The authors report are a rare case of primary mucinous adenocarcinoma of the anterior mediastinum in a 34-year-old Japanese woman. Routine chest radiography revealed an abnormal mass lesion in the left upper mediastinum. Her serum CA 19-9 level was elevated at 299 (normal < 37) U/ml. The large tumor in the anterior mediastinum, 8 cm in diameter, were made of multicystic part with thick wall and thick spetrum and solid part in chest computed tomography (CT). Teratoma was suggested by percutaneous needle biopsy under CT scanning. When the chest was opened through a median sternotomy, adding a left collar incision, we found a hard tumor occupying the superior anterior mediastinum and then resected the tumor together with the left brachiocephalic vein, the left pleura, the pericardium and the left phrenic nerve because of invaded them. Grossly, the tumor was 13 x 10 x 8 cm and weighted 400 g. Pathologic diagnosis was mucinous adenocarcinoma of the anterior mediastinum. No primary cancer lesions were found in pancreas, ovarium, gastrointestinal tract and mammary gland. Microscopic examination showed minimal atypia site in mucinous adenocarcinoma and normal thymic tissues surrounding this tumor. These findings have led this case to conclude the primary tumor of thymus.     

Myelopathy caused by hypertrophy of the posterior longitudinal ligament (HPLL): case report

A case of myelopathy caused by hypertrophy of the posterior longitudinal ligament at the cervical spine is reported. A 71-year-old man was hospitalized with myelopathy with progressed during the last two months. Plain X-ray of the cervical spine revealed only mild spondylotic change. Myelography demonstrated completely blocked contrast medium at C4 to C5 vertebral height due to epidural mass. This epidural mass was localized ventral to the spinal cord from C3 to C5. CT scan revealed slightly high density area behind the vertebral body. On surgery, no evidence of disc fragment but only hypertrophied posterior longitudinal ligament which was removed was found to be a cause of cord compression. Excellent recovery of neurological symptoms after operation was obtained. On histological study, remarkable hypertrophy, edema, hyalinoid degeneration and a little calcification of the ligament was found, which did not show any evidence of new bone formation. HPLL was characterized by thickened and broad epidural mass in the ventral side of cervical cord with Hounsfield number of 90-156 on CT scan, which is not very easy to differentiate from metastatic epidural tumor. The cause of HPLL is not well elucidated, though, this may be a new category of compression myelopathy.     

Adult neuroblastoma arising in the superior mediastinum

Adult onset neuroblastoma arising in the mediastinum, except posterior mediastinum is extremely rare. We report a case of surgically resected neuroblastoma in the superior mediastinum. A 64-year-old male was admitted to a local hospital, after an abnormal shadow had been detected on a chest radiogram on a routine medical checkup. Computed tomography (CT) examination revealed the tumor located in the superior mediastinum. Preoperatively, we suspected malignant lymphoma or lymph node metastasis from an unknown primary site. We resected the mediastinal tumor for both definitive diagnosis and local treatment. The tumor was composed of sheets of small round cells positive for CD56, NSE, chromogranin A, and vimentin, but negative for AE1/3, CK5/6, CK7, CD3, CD20, CD79a, c-kit, S-100, SMA and CD99. N-myc gene amplification was also confirmed and supported diagnosis of neuroblastoma. Chest CT seven months after surgery revealed multiple recurrences in lymph nodes.     

A case of chondrosarcoma arising from the left first rib

A 46-year-old female was admitted to our hospital because of a left supraclavicular tumor. The chest CT scan and MR imaging revealed that the tumor arose from the left first rib and developed into the supraclavicular region. In this case, we tried to resect the tumor using the so-called "trap-door" thoracotomy. Although removal of subclavian vessels and brachial plexus from the tumor was easily performed, we could not enough treat the vertebral side of the first rib through this thoracotomy without the T1 nerves injury. In cases of superior sulcus tumors developing into the posterior chest wall, a posterior incision combined with an anterior one will be useful to remove these tumors safely.