Posterior Mediastinal Tumor Research Articles

Imaging features of posterior mediastinal chordoma in a child

A 5 1/2-year-old boy presented with repeated episodes of stridor and cough. Chest radiography demonstrated a widened mediastinum. Evaluation by CT revealed a low-density posterior mediastinal mass initially diagnosed as benign tumor. Histopathological analysis of the resected mass disclosed a malignant chordoma. Our radiological results are described with an analysis of the imaging findings in the medical literature. We present our suggestions for preoperative evaluation of posterior mediastinal tumors.

Remarkable response of adult-onset ganglioneuroblastoma in the advanced stage to unrelated cord blood transplantation: Case report

11524 Background: Adult-onset ganglioneuroblastoma (GNB) is a rare disease that carries the gravest prognosis. In this case report, we discuss a case of adult-onset GNB in the advanced stage which has responded favorably to unrelated cord blood transplantation (UCBT). Methods: The patient was a 22-year-old male. Posterior mediastinal tumor was excised and a diagnosis of GNB was made. The severity of GNB was classified as stage IV because bone metastasis affected the entire body. Three courses of combination chemotherapy using cisplatin (CDDP), cyclophosphamide (CY), vincristine sulfate (VCR) and pirarubicin hydrochloride-adriamycin (THP-ADR) turned out to be ineffective. Local radiation therapy to control the tumor metastasis to the right great wing of the sphenoid bone resulted in augmentation of the tumorous lesion. Then, bone marrow destructive pretreatment consisting of anticancer therapy [etoposide (VP-16) and thiotepa] and total body irradiation (TBI, 12Gy) was followed by UCBT. Cyclosporin and mycophenolate mofetil were administered to prevent graft versus host disease (GVHD). Results: The blood type compatible two-loci HLA mismatch transplant had 3.2x107 nucleated cells/kg. After the cord blood transplantation, the patient suffered complications such as acute GVHD (grade III), veno-occlusive disease (VOD) and viral hemorrhagic cystitis. Neuron-specific enolase (NSE), a GNB tumor marker, gradually decreased from 220 ng/ml to the normal level. The bone metastatic tumors were reduced in a stepwise manner. Fluorodeoxyglucose-positron-emission tomography (FDG-PET) scan demonstrated complete disappearance of abnormal accumulation. Three hundred days have passed since the unrelated cord blood transplantation. The patient is surviving and in the disease-free state. Conclusion: The remarkable response of adult-onset GNB in the advanced stage to UCBT has demonstrated the definite graft versus tumor (GVT) effect of UCBT on GNB. UCBT is regarded as a promising therapeutic intervention in solid tumors that are not associated with blood disorder. No significant financial relationships to disclose.

Preoperative diagnosis of a mediastinal granular cell tumor by EUS-FNA : A case report and review of the literature

We report the first case of a posterior mediastinal granular cell tumor initially diagnosed on cytologic material obtained via endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in a 51-year-old male with a prior history of colon cancer. Aspirates obtained were cellular and composed of polygonal cells with abundant granular cytoplasm and small, round dark nuclei. An immunoperoxidase stain performed on the cell block for antibodies to S-100 protein showed strong, diffuse staining of the cytoplasmic granules. Electron microscopy performed on the cell block revealed numerous cytoplasmic lysosomes. This is the first case report in the English literature of a definitive preoperative diagnosis of a mediastinal granular cell tumor utilizing material obtained via EUS-FNA.

Urothelial Cancer Metastasized into Mediastinal Benign Neurilemmoma: A Case Report

We report a 79-year-old male patient with urothelial cancer who underwent total cystectomy with ureterostomy 10 years earlier and right nephroureterectomy 3 years and 9 months earlier. The patient had chest complaint with posterior mediastinal tumor for 7 years and its slow growth rate suggested that the mediastinal tumor was benign but metastatic materials could not be ruled out because cytology of pleural effusion demonstrated atypical cells. He died from the progression of urothelial cancer and autopsy demonstrated that metastatic urothelial cancer was involved in the mediastinal benign neurilemmoma.

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.

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.

Thoracoscopic resection as the preferred approach to posterior mediastinal neurogenic tumors.

Traditionally, resection of posterior mediastinal neurogenic tumors (PMNTs) has been through a posterolateral thoracotomy. Although thoracoscopic resection of these tumors has been advocated, treatment guidelines have not been reported previously. The authors report a thoracoscopic resection of a PMNT and conducted a retrospective review of similar cases in the literature. Successful thoracoscopic resection was compared with tumor size and type using a nonpaired t test (alpha: P < 0.05). A total of 29 patients (13 men, 16 women), aged 26 to 68 years, who underwent a thoracoscopic resection of a PMNT were identified. Preoperative imaging included chest radiography and computed tomography in all patients and magnetic resonance imaging in 15 of 29 patients (52%). All tumors were located in the posterior mediastinum without preoperative evidence of invasion or malignancy. Conversion to an open procedure was necessitated in 12 of 29 (41%) patients ("minithoracotomy" in 11, posterolateral thoracotomy in 1). Tumor size necessitating conversion to an open procedure (mean = 4.79 cm) and tumor size amenable to thoracoscopy alone (mean = 3.84 cm) were not significantly different (P < 0.09). Pathology revealed 22 schwannomas (76%), 6 ganglioneuromas (21%), and 1 malignant schwannoma (3%) and was not associated with conversion to an open procedure (P < 0.99). Thoracoscopic resection of PMNTs can be performed successfully, regardless of tumor type or size; however, malignancy, local invasion, and tumors >5 cm may require an open procedure. Thoracoscopic resection can replace thoracotomy in the treatment of PMNTs.

Thoracoscopic Resection as the Preferred Approach to Posterior Mediastinal Neurogenic Tumors

Traditionally, resection of posterior mediastinal neurogenic tumors (PMNTs) has been through a posterolateral thoracotomy. Although thoracoscopic resection of these tumors has been advocated, treatment guidelines have not been reported previously. The authors report a thoracoscopic resection of a PMNT and conducted a retrospective review of similar cases in the literature. Successful thoracoscopic resection was compared with tumor size and type using a nonpaired t test (α:P < 0.05). A total of 29 patients (13 men, 16 women), aged 26 to 68 years, who underwent a thoracoscopic resection of a PMNT were identified. Preoperative imaging included chest radiography and computed tomography in all patients and magnetic resonance imaging in 15 of 29 patients (52%). All tumors were located in the posterior mediastinum without preoperative evidence of invasion or malignancy. Conversion to an open procedure was necessitated in 12 of 29 (41%) patients (“minithoracotomy” in 11, posterolateral thoracotomy in 1). Tumor size necessitating conversion to an open procedure (mean = 4.79 cm) and tumor size amenable to thoracoscopy alone (mean = 3.84 cm) were not significantly different (P < 0.09). Pathology revealed 22 schwannomas (76%), 6 ganglioneuromas (21%), and 1 malignant schwannoma (3%) and was not associated with conversion to an open procedure (P < 0.99). Thoracoscopic resection of PMNTs can be performed successfully, regardless of tumor type or size; however, malignancy, local invasion, and tumors >5 cm may require an open procedure. Thoracoscopic resection can replace thoracotomy in the treatment of PMNTs.

Thoracoscopic Resection of Posterior Neurogenic Tumors

Video-assisted thoracic surgery (VATS) may be used for resection of posterior mediastinal tumors to avoid thoracotomy and shorten hospital stay. Between October 1990 and June 1998, 23 patients had VATS resection of posterior neurogenic tumors. The 14 females and 9 males ranged in age from 14 months to 70 years, with a median of 35 years. Operation time ranged from 30 to 120 minutes (median, 83), and intraoperative complications were limited to minor problems as well as conversion to thoracotomy to enhance complete tumor resection in four cases. Tumor pathology included nerve sheath origin (20) and autonomic ganglia (3). There was only one malignant schwannoma. Tumor size ranged from 0.7 to 13 cm in diameter. Median chest tube days was 1 day (range, 1-4), and hospital stay was 2 days (range, 1-9). Postoperative complications included transient paresthesia (three cases), ileus (two cases), pleural effusion (one case), and transient intercostal pain (one case). Posterior neurogenic tumors may be resected safely using video-assisted techniques. Conversion to thoracotomy to enhance complete resection is both possible and encouraged. The use of VATS seems to decrease hospital stay and minimize postoperative complications. In posterior neurogenic tumors without tumor extension to the spinal canal, VATS has become our preferred method for resection.

Upper posterior mediastinal tumor supplied by an atrial branch of the left circumflex artery

We report a case of a 39-year-old woman with an upper posterior mediastinal tumor. The tumor was demonstrated by echocardiography and further defined by computerized tomography and magnetic resonance imaging. The tumor was fed by a large atrial branch of the left circumflex artery. Because of its location (adjacent to large vessels), it could not be resected by surgery. Cathet. Cardiovasc. Intervent. 47:467–468, 1999. © 1999 Wiley-Liss, Inc.

Ewing’s sarcoma presenting as a posterior mediastinal mass: a lesson learned

Thoracic vertebral body hemicorpectomy and chest wall resection was performed in a 17-year-old male patient with a posterior mediastinal tumor thought to be neurogenic in origin. No preoperative tissue diagnostic endeavor was made. Final pathologic diagnosis showed this tumor to be Ewing’s sarcoma. This communication alerts the thoracic surgeon to the need for definitive diagnosis of posterior mediastinal masses with vertebral body involvement, particularly in children. Induction chemotherapy is the accepted standard of management of these sarcomas.

Primary Mediastinal Tumors: Part ll. Tumors of the Middle and Posterior Mediastinum

Lymphoma, mediastinal cysts, and neurogenic neoplasms are the most common primary middle and posterior mediastinal tumors. Lymphoma may involve the anterior, middle and/or posterior mediastinum, frequently as lymphadenopathy or as a discrete mass. Foregut cysts are common congenital mediastinal cysts and frequently arise in the middle mediastinum. Pericardial cysts are rare. Schwannoma and neurofibroma are benign peripheral nerve neoplasms, represent the most common mediastinal neurogenic tumors, and rarely degenerate into malignant tumors of nerve sheath origin. Sympathetic ganglia tumors include benign ganglioneuroma and malignant ganglioneuroblastoma and neuroblastoma. Lateral thoracic meningocele is a rare cause of a posterior mediastinal mass.

Pediatric challenge case

This 5-year-old boy presented to the emergency department with a 3-week history of upper abdominal pain. The child was afebrile, but he had been vomiting for 2 days. Abdominal and chest radiographs were obtained (Fig. 1), and because of the findings, an ultrasound of the chest and upper abdomen was performed (Fig. 2). What is the most likely diagnosis? (A) Pneumonia with empyema (B) Congenital diaphragmatic hernia (C) Posterior mediastinal tumor with pleural effusion (D) Right middle and lower lobe atelectasis (E) Pancreatitis with pleural effusion

THORACOSCOPIC SURGERY COMBINED WITH ESOPHAGOSCOPY FOR A PARAESOPHAGEAL BRONCHOGENIC CYST-A CASE REPORT-

A 39-year-old woman was admitted to the hospital because of an abnormal shadow on chest roentgenogram, which became larger gradually since it was first detected at a medical check up 7 years before. Chest CT suggested that it was a benign posterior mediastinal tumor. Thoracoscopic surgery was performed. The tumor was cystic and 3cm in diameter, being adjacent to the descending aorta and esophagus. The tumor was extirpated by thoracoscopic procedure combined with esophagoscopy because the tumor severely adhered to the longitudinal muscle of the esophagus. The was milk-white fluid in the tumor and pathological diagnosis was bronchogenic cyst. We think that benign paraesophageal bronchogenic cyst is a candidate for the thoracoscopic surgery. Combined use of esophagoscopy, however, is useful safely and easily to extirpate a tumor which severely adhered to the esophagus like this case.

A CASE OF NEUROSCHWANNOMA OF THE ESOPHAGUS

An extremely rare case of neuroschwannoma of the esophagus in a 66-year-old woman is reported. The patient was asymptomatic and was pointed out an abnormal shadow on a chest simple X-ray film under observation for another disease. After close examinations the patient was operated on with a diagnosis of posterior mediastinal tumor. During the operation the tumor was found arising in the muscular layer of the esophageal wall. Histopathologically it presented difficulty in differential diagnosis from esophageal leiomyoma. On immunohistochemical examinations, the tumor was positive for S-100 protein. Consequently the difinite diagnosis of esophageal neuroschwannoma was made. So far only 10 cases of neuroschwannoma of the esophagus, including our case, have been reported in Japan. This rare case is reported here, together with a review of the literature.

Gastric Ganglioneuroblastoma

This report describes a female infant with stage 4 multifocal ganglioneuroblastoma with gastric involvement. The patient had a right cervical tumor, a left posterior mediastinal tumor, bilateral adrenal tumors, and bony and bone marrow metastases. The tumor cells were diploid and lacked N-myc gene amplification. The gastric involvement, which did not produce clinical symptoms, was only detected by meticulous exploration during laparotomy. Our patient achieved only a partial response to alternating cycles of cyclophosphamide, vincristine, and adriamycin; and etoposide and cisplatin. She currently has stable, unresectable disease with elevated catecholamines. Multifocal ganglioneuroblastomas may arise from either neuroblastic rests or aberrant deposits of neuroblasts. The latter mechanism may have accounted for our patient's gastric tumor. Patients with multifocal ganglioneuroblastomas warrant meticulous radiographic and surgical evaluation to completely document the full extent of disease, and to ensure appropriate staging and therapy.

Thoracoscopic surgery in the management of mediastinal masses. Indications, complications, limitations.

In recent times thoracoscopy has been used for diagnoses and treatment of mediastinal masses. This study is a preliminary review of indications, complications, and limitations in this field of surgery. Twenty-eight patients with mediastinal masses were operated in the Clinical Oncological Centre, Kazan. Twenty-two of them had anterior mediastinal growths; six had posterior mediastinal tumors. Thoracoscopy was diagnostic in 14 cases; it was therapeutic in 14 cases. The definite diagnosis was achieved in all patients. In cases of benign lesions the operations were successfully completed thoracoscopically. All patients underwent a postoperative period with low pain and short postoperative time. Video-assisted thoracoscopy is indicated in cases of mediastinal masses, both for diagnosis and treatment. It has significant advantages compared to normal thoracoscopy and mediastinoscopy.

Extramedullary hematopoiesis simulating posterior mediastinal tumors

We report the case of a patient with intrathoracic extramedullary hematopoiesis presenting as a posterior mediastinal tumor in response to chronic hemolytic anemia. Noninvasive studies including chest roentgenograms, computed tomographic scans, magnetic resonance images, and nuclear scans can establish the diagnosis in most cases. In equivocal cases, transthoracic needle biopsy and open biopsy should be considered. Surgical resection is recommended only for patients with symptoms of compression.

Chordomas of the mediastinum: Clinicopathologic, immunohistochemical, and ultrastructural study of six cases presenting as posterior mediastinal masses

Six cases of chordomas presenting as primary posterior mediastinal tumors are described. Three patients were female, and three were male between the ages of 8 and 65 years (mean, 40.6 years). In all cases, the tumors presented radiographically as relatively wellcircumscribed, encapsulated soft tissue masses that did not seem to be related to the thoracic or dorsal spine. Only in one case, focal infiltration of bone at the level of T6-T7 was observed at the time of surgery. Histologically, the lesions showed a spectrum of features that ranged from sheets and cords of large cells with abundant vacuolated cytoplasm to small, stellate cells embedded within an abundant mucoid matrix. In one case, the cell population showed more pronounced nuclear atypia with loss of cytoplasmic vacuolization, frequent mitotic figures, necrosis, and solid areas characterized by a perivascular distribution of atypical spindle cells set against a myxoid stroma. Another case showed features of chondroid chordoma, with an immature chondroid-appearing matrix surrounding the atypical tumor cells. Immunohistochemical studies in all cases showed positive staining of the tumor cells with CAM 5.2 and broad-spectrum keratin, epithelial membrane antigen (EMA) and vimentin, and, to a lesser extent, with S-100 protein. Stains for muscle actin, carcinoembryonic antigen (CEA), and desmin were negative. Ultrastructural examination in two cases showed a spectrum of features that varied from large cells with abundant cytoplasm containing scattered ribosomes, glycogen granules, Golgi apparatti, abundant intermediate filaments, and small lumen formation with immature microvilli to smaller cells with elongated cytoplasmic processes, fewer intermediate filaments, rare desmosome type intercellular junctions, and complexes of mitochondria/rough endoplasmic reticulum. On clinical follow-up, two patients died with metastases to the lungs, chest wall, and liver from 1 to 3 years after diagnosis, and two patients are alive and well without evidence of disease after 3 and 16 years. Chordoma should be entertained in the differential diagnosis of posterior mediastinal tumors. Application of immunohistochemical stains or electron microscopy will be of aid in separating them from other conditions that may histologically closely resemble these lesions.

Combined microneurosurgical and thoracoscopic removal of neurogenic dumbbell tumors

The resection of posterior mediastinal dumbbell tumors has until now required laminectomy and some form of open access to the thoracic cavity. Over a 1-year period, a novel surgical approach combining posterior microneurosurgical and anterior video-assisted thoracoscopy techniques was used in 4 patients. In 3 patients, the tumor was removed successfully with minimal postoperative discomfort and rapid recovery. In the fourth patient, limited thoracotomy became necessary to control bleeding. This new approach, which combines modern-day neurosurgical and general thoracic surgical techniques, appears safe and could become the preferred method for removing most benign posterior mediastinal dumbbell tumors.