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Ann Thorac Surg 2003;76:1650-1654
© 2003 The Society of Thoracic Surgeons

Original article: general thoracic

The surgical approach to "dumbbell tumors" of the mediastinum

M. Behgam Shadmehr, MDa, Henning A. Gaissert, MDa, John C. Wain, MDa, Ashby C. Moncure, MDa, Hermes C. Grillo, MDa, Lawrence F. Borges, MDb, Douglas J. Mathisen, MDa*

a Division of General Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA,
b Department of Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA

Accepted for publication April 22, 2003.

* Address reprint requests to Dr Mathisen, Massachusetts General Hospital, 55 Fruit St, Blake 1570, Boston, MA 02114, USA.
e-mail: dmathisen{at}partners.org


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
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.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Posterior mediastinal tumors are uncommon neoplasms [1, 2]. A small percentage of them extend into the neural foramen and may occasionally compress the spinal cord [1, 3]. The term "dumbbell tumor" has been applied to those that have both a thoracic and a spinal component. The vast majority of mediastinal dumbbell tumors are neurogenic tumors [3–5].

Radiographic evaluation of the neural foramen is performed in all posterior mediastinal tumors. Previously it was done by plain tomography and myelography and currently it is done by computed tomography (CT) scan and magnetic resonance imaging (MRI) scan. Knowledge of neuroforaminal involvement before operation may greatly minimize the disastrous complication of spinal cord injury from excessive traction or hemorrhage within the spinal canal [3, 9].

In lower thoracic posterior mediastinal tumors some have advocated spinal angiography to identify the artery of Adamkiewicz [6, 7] because loss of this artery is likely to lead to spinal cord injury [6–9]. Spinal angiography is not without risk [10] and its indication in this small group of patients is controversial.

The surgical approach to dumbbell tumors of the posterior mediastinum has been controversial for both thoracic surgeons and neurosurgeons and various approaches have been reported [1, 3, 6, 11–16]. The order of the neurosurgical versus the thoracic part of the procedure and whether they should be performed in one stage or two stages remains a matter of individual preference. The other controversy relates to the approach to the thoracic portion of the tumor, which may be through a thoracotomy, through a posterior extrapleural approach, or through thoracoscopy.

The purpose of this study is to describe the outcome after a single-stage, one-incision combined thoracic and neurosurgical approach, our preferred approach for most patients with posterior mediastinal tumors involving the neural foramen.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Acknowledgments
 References
 
Retrospective review of patients with posterior mediastinal tumors during a 28-year period (1974 to 2002) at Massachusetts General Hospital found 16 patients with neuroforaminal involvement. Hospital and office records were reviewed. Follow-up information is based on office notes and direct patient contact by letter or telephone. Massachusetts General Hospital Institutional Review Board approval was obtained on November 11, 1998. The first 4 patients were described in a previous report [6].

Patients with posterior mediastinal tumors diagnosed by chest radiographs were evaluated by plain or computerized tomography available at the time of presentation. If signs of erosion of the body or pedicle of the vertebrae or a widened intervertebral foramen were found myelography or MRI as available at the time of presentation was done. Spinal arteriography was performed in some patients whose tumors were in the lower thoracic regions (T8-L1) to identify the artery of Adamkiewicz. Neurosurgical consultation was obtained in all patients.

Our preferred surgical approach was a lateral decubitus position with slight ventral rotation to provide access to the chest and posterior spine. A standard posterolateral thoracotomy that may extend to a hockey-stick shape incision is our incision of choice. This incision as described by Grillo [6] in 1983 (Fig 1) has a vertical component over the middle of the spinous processes, beginning about 5 cm above the level of the foramen to be explored and extending for about 5 cm below, before curving sharply at this point to a sloping transverse line. A flap of skin and subcutaneous tissue is raised over the muscular fascia and the thoracotomy is completed beneath this flap.



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  		Fig 1. Skin incision. The vertical component, which permits laminectomy, is centered at the level of the involved foramen (X) and extends for about 10 cm. It curves forward to join the anterior portion of the thoracotomy incision. The dotted line indicates the thoracotomy beneath the flap. (Reprinted from Ann Thorac Surg, 36, Grillo HC, Ojemann RG, Scannell JG, Zervas NT, Combined approach to "dumbbell" intrathoracic and intraspinal neurogenic tumors, 402–7, 1983, with permission from The Society of Thoracic Surgeons.)

 
Through the thoracotomy incision the thoracic portion of the tumor is mobilized and left attached only by its intraforaminal extension to be resected later with the intraspinal portion en bloc or amputated. Resection of the intraspinal portion in some patients requires only foraminotomy, which is done with a high-speed drill through the thoracotomy incision. In other patients laminectomy is required for resection of the intraspinal portion of their tumor. In these patients the neurosurgical part of the operation that may precede or follow thoracotomy is performed through the vertical component of the incision over the middle of the spinous processes. After separating the paraspinal muscles from the spine and laminae at the desired level, laminectomy or hemilaminectomy is performed. The tumor may be entirely extradural; therefore the nerve root from which the tumor originates is divided and the tumor mobilized under direct vision. If the tumor extends intradurally, the dura is opened laterally over the tumor and its intraspinal component separated from the spinal cord using microsurgical techniques. The edges of the involved dura are resected. The dura is closed meticulously and covered with fibrin glue to avoid cerebrospinal fluid leak. A flap of pleura, pericardial fat, intercostal muscle, or a large piece of thrombin soaked absorbable gelatin sponge is used to seal the foramen from the pleural space to prevent cerebrospinal fluid leakage. Hemostasis around the neural foramen must be meticulously achieved with microbipolar coagulation. Absorbable gelatin sponges for hemostasis should not be packed and left within the foramen for hemostasis as they swell postoperatively and can cause pressure against the spinal cord.

When pedicle or facet joint resection is needed to remove the tumor and concern about spinal instability exists, an arthrodesis is performed.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Acknowledgments
 References
 
Patient characteristics and clinical manifestations
There were 10 female (63%) and 6 male patients. Age at the time of operation ranged from 5 to 76 years (mean, 43). Nine of 16 patients (56%) had at least one clinical finding (Table 1). The other 7 (44%) had chest radiographs obtained for other reasons, which showed a posterior mediastinal mass.


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  		Table 1. Clinical Manifestations in 16 Patients

 
Radiographic findings
Neuroforaminal involvement was correctly identified before operation in 14 patients (87.5%; Table 2) and during the procedure in 2 patients. One of these 2 patients (no. 5) had a normal CT scan and did not undergo any further evaluation preoperatively. The other patient (no. 6) had a CT-myelography that showed erosion of spinous process and rib but normal neuroforamen. Both these tumors had small intraforaminal extensions that were resected completely by foraminotomy through thoracotomy without the need for laminectomy.


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  		Table 2. Radiographic Findings

 
Another patient had a normal CT scan and an MRI that showed neuroforaminal involvement. Myelography missed neuroforaminal extension of the tumor in 3 patients (nos. 2, 6, 7). These three tumors again had small intraforaminal extensions that were resected completely through an already widened foramen in 2 patients (nos. 2 and 7) and by foraminotomy in 1 (no. 6) without the need for laminectomy.

After MRI became available and replaced myelography it correctly identified neuroforaminal extension of the tumor in the last 9 patients.

Among our patients there were 3 cases whose tumors were in the lower thoracic region in the critical zone (T8-L1) for the artery of Adamkiewicz. Spinal arteriography was done for 2 patients and showed that the artery of Adamkiewicz originated at least two levels below the involved intervertebral foramen.

Operative management
Fifteen of 16 patients were placed in the lateral decubitus position and did not require any intraoperative change of position. One patient was first placed in the prone position and after completion of the neurosurgical part of the operation was changed to the lateral decubitus position for thoracotomy. A "hockey-stick" incision was completed in 12 patients and a standard thoracotomy in 4.

Laminectomy was performed in 7 patients after thoracotomy and in 3 patients before thoracotomy. The order of laminectomy versus thoracotomy was based on the preference of the surgeons. The tumors in the other 6 patients had small intraforaminal extensions (4 with and 2 without radiographic findings), allowing resection of 3 by foraminotomy and 3 by careful dissection through an already enlarged foramen. All intraspinal portions of the tumors were extradural except for 1 case that required intradural dissection. Arthrodesis with autologous bone graft was done in 2 patients to prevent spinal instability.

Outcome
Complete resection was performed in all tumors. There were no deaths and no neurologic or other major complications. Minor complications occurred in 2 patients, consisting of superficial wound infection in 1 and atelectasis in the other. Two patients developed Horner's syndrome after resection of tumors attached to and arising from the sympathetic chain at the level of T1-T3. Given the anatomical position these are not considered complications.

Pathology
There were 14 benign and 1 malignant neurogenic tumors including 8 schwannomas, 4 neurofibromas, 2 ganglioneuromas, and 1 malignant schwannoma. The only tumor not of neural origin was a malignant lymphoma.

Follow-up
The patient with malignant schwannoma was treated with postoperative radiotherapy and the patient with lymphoma was treated with postoperative chemotherapy and radiotherapy. These patients have had no recurrence 20 and 7.5 years after operation respectively. Follow-up is complete except for 1 patient. All patients survived without recurrence from 2 months to 28 years (mean 7.5 years).


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Acknowledgments
 References
 
Dumbbell posterior mediastinal tumors are uncommon [1–3]. Various approaches have been recommended in the literature for these rare tumors [1, 3, 6, 11–16]. Because of the uncommon nature of these tumors a high index of suspicion must be maintained to identify neuroforaminal involvement in all posterior mediastinal tumors. To evaluate a mass found in the paraspinal region on chest roentgenogram a CT scan should be obtained as the next diagnostic procedure to determinate whether it is a mediastinal soft tissue mass or a lung mass. Computed tomography also gives valuable information about the mediastinal lymph nodes. However relying on CT scan alone for evaluation of neuroforaminal involvement may miss some of them as was seen in three of our cases. Therefore MRI is indicated as a complementary procedure in this group of patients and as shown, did not miss any neuroforaminal involvement. Accordingly all posterior mediastinal tumors should undergo evaluation by both CT (Fig 2) and MRI scans (Fig 3) to detect erosion of the body or pedicle of the vertebrae, widened neural foramen, or direct extension of tumor into the spinal canal. Identification of such involvement requires careful preoperative evaluation in collaboration with a neurosurgeon.



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  		Fig 2. Computed tomographic scan of the thorax at the level of T2 following intravenous contrast material demonstrates a soft-tissue mass in the left paravertebral region with direct extension into the left vertebral foramen. There is also slight erosion of the lateral aspect of the vertebral body.

 


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  		Fig 3. Magnetic resonance images of the thoracic spine of the same patient following gadopentetate dimeglumine enhancement with T1 images in the axial (A) and coronal (B) planes demonstrate a heterogeneous soft-tissue mass in the paravertebral region at the level of T2. The mass extends into the vertebral foramina abutting the thecal sac and encompassing the T2 nerve root.

 
Low thoracic posterior mediastinal tumors may take origin near the artery of Adamkiewicz. The radicular arteries originate from the posterior branches of intercostal arteries. The largest anterior radicular artery, arteria radicularis magna or the artery of Adamkiewicz, varies in level. It arises frequently at the T8-L1 vertebral level and 70% of times from the left side [9]. Although still controversial this artery is thought to deliver most of the blood to the thoracic and lumbar spinal cord [9]. Therefore loss of this artery may lead to spinal cord injury. Although the incidence of this complication in dumbbell tumors is unknown, consideration should be given to identify the exact origin of this artery by spinal arteriography. In a recent study by Kieffer and colleagues [10] in 480 patients, the artery of Adamkiewicz was successfully located in 419 patients with a low risk (1.6%) of major complications and mortality. Knowledge of the precise location of this artery will allow discussion with patients about the risks of removal of the tumor and special care in dissection.

A coordinated effort with neurosurgery is important for a successful outcome after removal of dumbbell tumors. A single-stage procedure is preferable to a two-stage approach to minimize complications.

Resecting the intraforaminal component as the first stage of a planned two-stage operation may result in postoperative neurologic complications due to epidural hematoma or pseudomeningocele formation [3]. Transecting the intrathoracic portion of the tumor and leaving the intraforaminal component also risks spinal cord compression due to edema of the remaining portion or bleeding [3, 17, 18].

The sequence of the surgical procedures does not matter when done in conjunction with neurosurgery. As some tumors can be removed entirely from the chest, we usually begin with a thoracotomy. As others and we observed [12, 19] laminectomy may be avoided. Occasionally the neural foramen can be widened with a high-speed drill, allowing greater access to the tumor and greater control of vascular structures. Excessive traction on the tumor must be avoided to prevent injury to the spinal cord. Hemorrhage from the neural foramen demands control even if foraminotomy or laminectomy is required. Bleeding into the spinal cord may lead to cord compression and permanent neurologic injury. The neural foramen should not be packed with hemostatic agents such as an absorbable gelatin sponge. These materials have been shown to migrate into the spinal canal resulting in swelling and cord compression [20, 21]. Packing the neural foramen with absorbably gelatin sponge may also result in cord compression because pressure increases in a closed space as fluid accumulates [22]. The combined thoracic and neurosurgical approach allows for greater flexibility and safety in dealing with these unusual tumors regardless of size and extent of the tumor. There are a few case reports describing a two-stage operation because of the large size and the extensive nature of the tumors [1, 23, 24]. The largest tumor in our series was 10 cm and involved two vertebral bodies, paraspinal muscles and chest wall. It was completely removed in a combined single-stage procedure with excellent result.

Recent reports have described combined laminectomy and thoracoscopic resection of dumbbell tumors [14, 24, 25]. Although the thoracoscopic approach is probably indicated for patients with small nonmalignant tumors [14] we do not recommend it as the procedure of choice. Laminectomy would become obligatory and some of these patients (38% in our series) do not require laminectomy. By not performing laminectomy, these patients would not be at risk of spinal destabilization after partial resection of the facet joints.

Another single-stage approach has been reported by Osada [13]. Three patients with small dumbbell tumors were successfully treated through a dorsal approach by means of a laminectomy and resection of a small portion of the neighboring rib root without opening the parietal pleura. This approach is suitable for small tumors. McCormick [16] reported a lateral extracavitary approach, which is another example of an extrapleural approach to these tumors through a posterior incision and costotransversectomy. While these approaches might be suitable for selected patients, we prefer the thoracotomy approach for optimal visualization and safe control of vascular structures. Furthermore, dissection of the large tumors in the mediastinum through a posterior approach requires extensive removal of facet bone with fusion and instrumentation.

We believe that for the majority of patients with posterior mediastinal tumors involving the neural foramen a combined single-stage thoracic and neurosurgical procedure is the procedure of choice.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
References
 
The authors thank Jo-Anne Shepard, MD, for her help in selecting the radiographic images.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 

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