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Ann Thorac Surg 1995;60:943-946
© 1995 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Videothoracoscopic Excision of Thoracic Neurogenic Tumors

Service de Chirurgie Thoracique, Hôpital Laënnec, Paris; Chirurgie Abdominale et Thoracique, Hôpital Pasteur, Nice; Clinique de Chirurgie Thoracique, Hôpital du Val de Grâce, Paris; Centre Médico Chirurgical du Cèdre, Bois-Guillaume; and Service de Chirurgie Thoracique, Hôpital Purpan, Toulouse, France

Accepted for publication April 28, 1995.

	Abstract

Top Footnotes Abstract Introduction Materials and Methods Results Comment Acknowledgments References

 
Background. Videothoracoscopic surgery is a new procedure for treating neurogenic tumors of the thorax. Feasibility and utility of this technique are not yet well defined.

Methods. Over a 26-month period, 26 neurogenic tumors of the thorax were treated in five general thoracic surgery centers performing videothoracoscopic surgery. Indications and contraindications for this new procedure and initial results were retrospectively studied.

Results. Contraindications to videothoracoscopy included intraspinal extension of the tumor (n = 3), spinal artery involvement (n = 2), tumors more than 6 cm in diameter borderline located within the thorax (n = 2), and middle mediastinal location (n = 1). Videothoracoscopy was performed in 18 patients. Conversion to thoracotomy was required in 3. In 1 patient, subsequent chest wall resection was performed because of malignancy. Postoperative hospital stay was uneventful. It was shorter after videothoracoscopy. Postsurgical pain was more acute in patients who had thoracotomy or conversion to thoracotomy.

Conclusions. Videothoracoscopy is a good alternative for managing neurogenic tumors of the thorax when deemed feasible. There is a tendency toward a shorter hospital stay with less pain in patients treated by this new procedure.

	Introduction

Top Footnotes Abstract Introduction Materials and Methods Results Comment Acknowledgments References

 
Neurogenic tumors of the thorax can originate in any neurogenic structure within the chest. Surgical resection is considered the primary treatment of such tumors [1] and is usually performed through a thoracotomy. Use of the videothoracoscopic approach was reported in 1992 to remove a posterior mediastinal neurogenic tumor 4 cm in diameter [2], in 1993 to remove a cystic schwannoma 3.5 cm in diameter located between the descending aorta and the left pulmonary artery [3], and in 1994 to remove a 7 x 4 x 2.5-cm intercostal neurilemoma presenting as a lateral chest wall tumor [4]. The purpose of this report is to define the feasibility and the utility of this new procedure for treating neurogenic tumors of the thorax.

	Materials and Methods

Top Footnotes Abstract Introduction Materials and Methods Results Comment Acknowledgments References

 
From November 1991 to January 1994, 26 neurogenic tumors of the thorax were treated in five general thoracic surgery centers. Age of the patients ranged from 13 to 78 years (average age, 46.5 years). There were 17 male and 9 female patients. Twenty tumors were discovered on routine chest roentgenogram. Five patients had symptoms: pain in 3 (1 with posterior rib deformation) and spinal cord compression in 2. In 1 patient, the tumor was associated with von Recklinghausen's disease. A computed tomographic (CT) scan was obtained in all patients and revealed intraspinal extension in 4. Angiography in search of a spinal artery near a paravertebral tumor was performed in 11 of the 18 patients and was positive in 2. A diagnosis was made for all but 1 patient with a mediastinal tumor. In the most recent 2 patients, histology was provided by fine-needle aspiration under CT scan control.

During this period, videothoracoscopic surgical intervention was attempted when deemed feasible. A similar technique was used by all the surgical teams. It included lateral decubitus positioning and double-lumen endotracheal intubation with ipsilateral lung collapse.

We retrospectively reviewed the indications and contraindications of this new procedure, particular points of the technique, perioperative and postoperative events, and the initial results (though follow-up was relatively short).

	Results

Top Footnotes Abstract Introduction Materials and Methods Results Comment Acknowledgments References

 
Eight patients underwent resection through a standard thoracotomy and 18, the videothoracoscopic approach. Contraindications to videothoracoscopy (8 patients) are shown in Table 1. In 3 there was intraspinal extension; in 2, involvement of a spinal artery; and in 1, large size and middle mediastinal location of the tumor without a precise diagnosis. Size greater than 6 cm was a contraindication only when associated with another contraindication, a thoracic sulcus, or a low paravertebral location of the tumor. In 1 patient with an apical schwannoma demonstrated by CT scan--assisted fine-needle aspiration, the goal was to preserve the integrity of the vagus nerve by dissecting the nerve fibers because the tumor seemed to have arisen from the nerve.

Videothoracoscopy was performed in 18 patients. Three trocars were used in 16 patients and two trocars with operative optics in 2. Fifteen tumors were completely removed by the videothoracoscopic procedure. They were extracted using an endobag in 11, through the trocar in 2, and without protection in 2 early in the study. In 1 patient with a ganglioneuroma 6 cm in diameter, the tumor had to be broken into pieces inside the endobag. In most of the other patients, a trocar site was slightly enlarged to allow removal. In 1 patient, the videothoracoscopic procedure was performed 2 weeks after a laminectomy, and a schwannoma 4 cm in diameter was removed after a 2-hour intervention.

Videothoracoscopic surgical intervention was the only procedure in 14 patients (Table 2). Average operating time was 92 minutes (range, 40 to 120 minutes). In 1 patient, perioperative bleeding from an intercostal artery was controlled by a clip. One chest tube drain was used in 8 patients and two chest tube drains, in 6. Quantity drained ranged from 25 to 450 mL (average amount, 170 mL). Average drainage duration was 2.5 days (range, 1 to 5 days). The average postoperative stay was 5.3 days (range, 2 to 9 days). Follow-up ranged from 2 to 24 months.

The fifteenth videothoracoscopic resection was followed by completion chest wall resection because of the discovery of malignant disease (malignant schwannoma with rhabdomyoblastic differentiation, also termed malignant ``Triton'' tumor). The tumor was 5 x 2 cm and was located at the paravertebral level of the second and third right intercostal nerves.

Conversion to thoracotomy was required in 3 patients (Table 3): in 1 patient with paravertebral schwannoma 5 cm in diameter because of rib deformation; in 1 with a juxtasternal neurofibroma 4 cm in diameter because of bleeding of the internal mammary artery; and in 1 with a schwannoma 3.5 x 3 cm because of venous bleeding at the site of a small intraspinal extension not diagnosed on CT scan. In these 3 patients, the average operating time was 200 minutes (range, 90 to 350 minutes), the quantity of drainage ranged from 280 to 1,000 mL (average amount, 460 mL), and postoperative hospital stay ranged from 4 to 7 days (average stay, 6 days). Follow-up ranged from 3 to 35 months with no late problems or residual thoracic pain. Two had deafferentation pain a few weeks after thoracotomy, which resolved rapidly.

	Comment

Top Footnotes Abstract Introduction Materials and Methods Results Comment Acknowledgments References

The diagnosis of neurogenic tumor of the thorax is most often established by CT scan. A preoperative diagnosis was established in all the patients in this report except in 1 patient with a phrenic nerve tumor. In a retrospective review [13] of 134 patients treated by thoracotomy, the radiologic diagnosis was not conclusive in 5 patients because of the median location of the tumor, and a surgical diagnosis was necessary. In a similar patient of ours, diagnosis was made by CT scan--assisted fine-needle aspiration, though a recurrent nerve origin was suspected. In this patient, thoracotomy was chosen because of the size of the tumor, its location in the thoracic sulcus, and the intention to attempt to dissect the fibers of the vagus nerve to prevent left recurrent nerve palsy, which proved unnecessary. In the patient with a phrenic nerve tumor, thoracotomy was preferred because of the absence of a diagnosis and because of the size of the tumor.

As discussed by Landreneau and associates [2], the finding of intraspinal growth is supposed to mandate an open one-stage approach to achieve complete resection of the intrathoracic and spinal component of the tumor. This contraindication to thoracoscopy was obvious in 1 patient, and thoracotomy was preferred in 2 others for less obvious reasons. One team in this collective review recently performed resection of an intrathoracic tumor through videothoracoscopy 2 weeks after neurosurgical removal of the intraspinal component. The thoracic tumor was small and easy to manage, and the result was good. This observation demonstrates that a dumbbell neurogenic tumor is perhaps not always a contraindication to a videothoracoscopic procedure.

Conversion to thoracotomy was necessary in 1 patient with tumor confined between ribs, the deformations of which were visible on the chest roentgenogram. Such tumors are not always malignant in adults. Their recognition may contraindicate videothoracoscopy. Other studies of such cases will be necessary to define this contraindication more clearly.

The presence of a spinal artery in close proximity to a paravertebral tumor prompted standard thoracotomy in 2 patients. Such caution is recommended also by others [14].

Malignant schwannoma is a contraindication to videothoracoscopy and is best treated by parietal resection when feasible. Roviaro and co-workers [11] reported the case of a patient who had videothoracoscopic removal of a tumor diagnosed postoperatively as malignant schwannoma. It was later treated by radiotherapy. In cases of malignant schwannoma with rhabdomyoblastic differentiation, local recurrence is common and the 5-year survival rate is low [15, 16]. This type of tumor is much more aggressive than sporadic malignant schwannoma. Malignant cells were discovered in the resected chest wall. A thoracic location for this tumor is rare. It is not possible to reliably predict which tumors are likely to be malignant. They are known to be extremely rare in adults. If this were not the case, the videothoracoscopic approach would be inappropriate for these patients in general.

Other contraindications we observed included the low costodiaphragmatic location of a huge neurofibroma and the location of a large schwannoma at the level of the second intercostal nerve. Size greater than 6 cm associated with such ``borderline'' locations seems to have been the reason for contraindication because of predictable difficulties in resecting such tumors using videothoracoscopy. Otherwise, these areas can be readily approached for videothoracoscopy.

Postoperative hospital stay was less eventful and shorter in the videothoracoscopic group than in the thoracotomy and conversion-to-thoracotomy groups. Postoperative pain seemed slightly more acute with thoracotomy. Our results confirm the results in most of our references but are far from significant because of the small number of patients in each group and because most of the patients not treated by videothoracoscopy had larger tumors and more advanced disease. Nevertheless, these initial results favor performing videothoracoscopy when possible.

To conclude, videothoracoscopy is a good alternative in managing neurogenic tumors of the thorax. It was used in 69% of our patients with no mortality or morbidity, though conversion to thoracotomy was mandatory in 1 of every 6 patients. Contraindications were intraspinal extension, presence of a spinal artery in the vicinity of the tumor, borderline location of the tumor within the thorax-first intercostal nerve upward, and 11th and 12th intercostal nerves downward-and, especially in these latter cases, tumors larger than 6 cm in diameter.

	Acknowledgments

Top Footnotes Abstract Introduction Materials and Methods Results Comment Acknowledgments References

 
We thank Florence Letellier for administrative assistance and preparation of the manuscript.

	Footnotes

Top Footnotes Abstract Introduction Materials and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Riquet, Service de Chirurgie Thoracique, Hôpital Laënnec, 42, rue de Sèvres, 75007 Paris, France.

	References

Top Footnotes Abstract Introduction Materials and Methods Results Comment Acknowledgments References

 

1. Shields TW, Reynolds M. Neurogenic tumors of the thorax. Surg Clin North Am 1988;68:645–67.[Medline]
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3. Facciolo F, Sposi A, Catarci M, Della Rocca G, Carboni M, Ricci C. Thoracoscopic resection of mediastinal cystic schwannoma. Surg Endosc 1993;7:447–49.[Medline]
4. Ischida T, Inoue T, Inoue K, Sugio K, Sugimashi K. Video thoracoscopic excision of an intercostal neurilemoma presenting as a lateral chest wall tumor. Surg Endosc 1994;8:402–4.[Medline]
5. Tavechio L, Alloisio M, Caniatti A, Sansonetti G, Grassi M, Ferrante F. Thoracoscopic excision of mediastinal ganglioneuroma [Abstract]. Surg Endosc 1994;8:1008.
6. Wolf RK. Cystic schwannoma [Abstract]. Surg Endosc 1994;8:521.
7. Coltharp WH, Arnold JH, Alford WC Jr, et al. Videothoracoscopy: improved technique and expanded indications. Ann Thorac Surg 1992;53:776–9.[Abstract]
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10. Shimizu N, Aoe M, Okabe K, Moriyanna S. Thoracoscopic surgery for mediastinal and chest wall masses [Abstract]. Surg Endosc 1994;8:440.
11. Roviaro G, Rebuffat C, Varoli F, Vergani C, Maciocco M, Scalambra SM. Videothoracoscopic excision of mediastinal masses: indications and technique. Ann Thorac Surg 1994;58:1679–84.[Abstract]
12. Shields TW. Benign and malignant neurogenic tumors of the mediastinum in adults. In: Shields TW, ed. Mediastinal surgery. Philadelphia, London: Lea & Febiger, 1991:240--53.
13. Ribet ME, Cardot GR. Neurogenic tumors of the thorax. Ann Thorac Surg 1994;58:1091–5.[Abstract]
14. Giudicelli R, Pellet W, Fuentes P, Heurte P, Barthelemy A, Reboud E. Danger to the spinal cord arterial blood supply during surgery for posterior mediastinal neurinomas. Ann Chir: Chir Thorac Cardio-vasc 1991;45:692–4.
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