INTRATHORACIC NEUROGENIC TUMORS

The surgical approach to “dumbbell tumors” of the mediastinum

BACKGROUND

Successful management of posterior mediastinal dumbbell tumors depends on complete resection with adequate exposure. Correct preoperative assessment of neuroforaminal extension is important to avoid spinal cord injury. The surgical approach remains controversial.

METHODS

We report a retrospective analysis of posterior mediastinal dumbbell tumors over a 28-year period. All patients underwent one or more radiographic examinations available at the time of presentation and underwent a single-stage one-incision combined thoracic and neurosurgical procedure.

RESULTS

Among 16 patients aged 5 to 76 years, neuroforaminal involvement was identified before operation in 14 (87.5%) and during the procedure in 2 patients (12.5%). Computed tomography scan missed neuroforaminal involvement in 3 patients. Magnetic resonance imaging in 9 patients correctly identified neuroforaminal extension of the tumor but before MRI, myelography missed this extension in 3 patients. All patients underwent thoracotomy and posterior laminectomy was required in 10 of them. In 6 patients (38%) without laminectomy, resection required widening of the neural foramen in 3 whereas tumor was removed in 3 others through an already widened foramen. Spinal stabilization was required in 2 patients. There were 14 benign and 2 malignant lesions. Complete resection was performed in all patients without spinal cord injury or other major complication. No recurrences have been observed in a follow-up period from 2 months to 28 years (mean, 7.5 years).

CONCLUSIONS

Posterior mediastinal tumors should be evaluated for neuroforaminal involvement. A single-stage combined thoracic and neurosurgical approach is safe and leads to good long-term results. Laminectomy may be avoided in some patients.

Intrathoracic tumors of the vagus nerve

Two patients had resection of a middle mediastinal neurilemmoma of the vagus nerve. Twenty-seven other neurogenic tumors of the intrathoracic vagus are reviewed. These tumors are generally asymptomatic except for hoarseness in an occasional patient.

Intrathoracic neural tumours

The experience of one regional thoracic surgical unit in managing intrathoracic neural tumours over a 25-year period is presented. Neural tumour was diagnosed in 55 patients, of whom 41 were asymptomatic. In 11 patients complete resection was not achieved--the reasons for this and its effect on the outcome of the patient are discussed. There were 52 posterior mediastinal and three lateral chest wall tumours. The pathological distribution was as follows--benign nerve sheath tumours (neurofibroma, neurilemoma) 39, ganglioneuroma 13, and neuroblastoma 3. One neurofibroma recurred as a neurosarcoma six years after its apparently complete resection and was removed by an extensive resection at reoperation. One neuroblastoma recurred within the spinal canal four years after incomplete excision at thoracotomy--this patient died subsequently of widespread metastatic neuroblastoma. No other tumour is known to have recurred.

Intrathoracic meningocele. Its development and association with neurofibromatosis

Images

Neurogenic tumours with an intrathoracic localization

This paper is a clinicopathological review of patients suffering from intrathoracic neurogenic tumours.