Received: 17 September 2018 | Accepted: 3 January 2019

DOI: 10.1002/jso.25381

RESEARCH ARTICLE

Surgical treatment of posterior mediastinal neurogenic

tumors

Xiaofeng Chen MD | Qinyun Ma MD | Shaohua Wang MD | Huijun Zhang MD |

Dayu Huang MD

Department of Cardiothoracic Surgery,

Huashan Hospital, Fudan University, Shanghai,
China
Correspondence
Dayu Huang, Department of Cardiothoracic
Surgery, Huashan Hospital Fudan University
12 Wulumuqi Zhong Road, Shanghai 200040,
China.
Email: davidhuang809@126.com
Funding information
Wujieping, Grant/Award Number: 180204
Background: Posterior mediastinal neurogenic tumors are among the most
frequent mediastinal masses in adults. These tumors may be dumbbell shaped,
extending into the spinal canal, exclusively paraspinal or apical tumors extending
in the cervical region. In this report, we present our experience in the
surgical resection of these tumors and discuss the surgical strategies for such
tumors.
Methods: A retrospective analysis was performed of 121 patients who underwent
surgery for posterior mediastinal neurogenic tumors at our department during the
period 2009 to 2016. Seventy‐four tumors were excised via video‐assisted thoracic
surgery (VATS). Other approaches included thoracotomy, supraclavicular incision,
supraclavicular incision plus thoracotomy/VATS, and a posterior approach with
laminectomy combined with thoracotomy/VATS.
Results: Tumors were resected completely in 119 cases and partially in two. The
majority of the tumors were benign nerve sheath tumors. No recurrence developed
during postoperative median follow‐up period of 31 months.
Conclusion: Most posterior neurogenic tumors can be resected via VATS.
Thoracotomy is the appropriate surgical approach for large tumors. A supraclavicular
approach is recommended for tumors extending in the cervical region, and this can be
combined with VATS or thoracotomy in case of larger masses. A posterior approach
could be used for patients with dumbbell tumors.

KEYWORDS
laminectomy, mediastinum tumor, neurogenic tumors, schwannoma, thoracoscopy

1 | INTRODUCTION Although most patients are asymptomatic at presentation,7

Posterior mediastinal neurogenic tumors are among the most
frequent mediastinal masses in adults. They account for more than
75% of posterior mediastinal masses and 10% to 34% of all
mediastinal tumors.1-4 In addition, approximately 10% to 20% of
posterior mediastinal neurogenic tumors have a spinal canal
component.5 These tumors typically originate in spinal nerve roots
or sympathetic chains and are located in the paravertebral sulcus.
Malignancy is unusual in adults; most of these tumors are of benign
nerve sheath origin.6
complete removal is recommended so that the whole lesion can be
examined and malignancy can be eliminated. Patients with posterior
mediastinal tumors without intraspinal extension can be managed in
an open or a thoracoscopic approach. More complex dumbbell
tumors with an intraspinal component usually require a combined
neurosurgical and thoracic surgical approach incorporating laminect-
omy followed by thoracotomy/thoracoscopy to remove them.8 A
supraclavicular approach is used for apical neurogenic tumors
extending in the cervical region.9 The purpose of this study is to
summarize the clinical course in 121 cases of posterior mediastinal

J Surg Oncol. 2019;1-7. wileyonlinelibrary.com/journal/jso © 2019 Wiley Periodicals, Inc. | 1

2 | CHEN ET AL.

neurogenic tumors and to discuss the surgical strategies for such thoracoscopically in a straightforward manner. Tumors were placed in a
tumors. surgical glove and removed through the operative port. A single chest
tube was left in place and the incisions were closed.
For larger tumors, particularly those that occupied the thoracic
2 | MATERIALS AND METHODS
inlet and obscured the surrounding thoracic wall, posterolateral
thoracotomy was performed through an intercostal space adjacent to
2.1 | Patients
We conducted a retrospective review of 121 cases (59 males and 62 T A B L E 1 Demographic and clinical characteristics of
females) of posterior mediastinal neurogenic tumors who were patients (N = 121)
operated on at our department between 2008 and 2016. The median Variable Number
age of all patients was 47.0 ± 14.6 years (18–78 years). Approval to Age, y 47.0 ± 14.6
perform the study was obtained from the medical ethics committee in
Male/female 59/62
our hospital. Each case was reviewed for demographic data, clinical
Symptoms
presentation, tumor characteristics, surgical approach, and surgical
Asymptomatic 92(76.0%)
outcome. Patient demographics and clinical features are summarized in
Chest pain 12(9.9%)
Table 1. All patients underwent preoperative X‐ray and computed
tomography (CT) examination to determine the size, location, and Chest tightness 3(2.5%)

involvement of surrounding structures (Figure 1). Patients with the Upper extremity numbness and discomfort 4(3.3%)
suspected intraspinal extension of a tumor underwent magnetic Horner's syndrome 4(3.3%)
resonance imaging (MRI) (Figure 2). Neurologic symptoms mandate a Neck swelling 3(2.5%)
preoperative MRI. MRI is also indicated when the tumor is adjacent to Cough 2(1.7%)
or contiguous with a neural foramen, there is a widened intervertebral Dysphagia 1(0.8%)
foramen. MRI was also performed in patients with tumors located at the
Right/left 69/52
thoracic apex showing proximity to vital vessels and nerves (Figure 3).
Location
Eighty‐five patients underwent MRI scans. The preoperative evaluation
Cervicothoracic 12(9.9%)
also included electrocardiography, spirometry, and standard laboratory
Thoracic 101(83.4%)
blood tests.
Thoracolumbar 8(6.6%)
Size, cm 6.1 ± 2.4

3 | OPERATIVE AP PROAC HES Dumbbell 20(16.5%)

Operative procedure
Most of the cases (74/121) were treated through VATS. Under general VATS 74(61.2%)
anesthesia, patients were intubated with a double‐lumen endotracheal Thoracotomy 17(14.0%)
tube and were placed in the lateral decubitus position. The thoraco-
Laminectomy plus VATS 10(8.3%)
scope was introduced through the 7th intercostal space in the
Laminectomy plus thoracotomy 4(3.3%)
midaxillary line. Two operative ports were inserted through the 4th,
Supraclavicular approach 7(5.8%)
5th, and 6th intercostal space in the anterior axillary line and 6th to 7th
Supraclavicular approach plus thoracotomy 6(5.0%)
intercostal space in the posterior axillary line to make triangular
Supraclavicular approach plus VATS 3(9.9%)
configuration. The anterior axillary incision was longer to allow for
removal of the resected mass. For two‐port VATS, the thoracoscope Pathology

was introduced through the 7th intercostal space in the midaxillary line Schwannoma 88(72.7%)
and an anterior axillary incision was made in the 4th, 5th, and 6th Neurofibroma 15(12.4%)
intercostal space. The pleura covering the junction of the tumor with Ganglioneuroma 12(9.9%)
the chest wall and spine is sharply incised. Appropriate traction of the Paraganglioma 4(3.3%)
tumor with forceps allows a combination of sharp and blunt dissection Malignant schwannoma 2(1.7%)
to gradually mobilize and lift the tumor up from adjacent structures
Complications
(Figure 4). Branches from the intercostal vessels and paravertebral
Horner's syndrome 3(2.5%)
feeding vessels to the tumor were either cauterized or clipped. Excision
Brachial plexus injury 2(1.7%)
of apical chest tumors was mainly performed by intracapsular
Cerebrospinal fluid leak 1(0.8%)
enucleation techniques to avoid surrounding vascular and nerve injury.
The capsule of the tumor was opened and the mass was enucleated. The Pulmonary atelectasis 3(2.5%)

remaining tumor capsule was then carefully dissected and removed. Totals 8(6.6%)
Because most benign tumors were not invasive, they could be mobilized Abbreviation: VATS, video‐assisted thoracoscopic surgery.
CHEN ET AL.
F I G U R E 1 Transverse CT scan shows the large mass measured
7.2 cm × 6.1 cm located in the right paravertebral region. The mass
was removed using VATS and the postoperative pathological
diagnosis was a schwannoma. CT, computed tomography;
VATS, video‐assisted thoracic surgery
them. The remaining surgical procedure was identical with those in
the VATS resections. Posterolateral thoracotomy was performed in
17 patients in our series.
Laminectomy plus VATS/thoracotomy was used for posterior
dumbbell tumors with intraspinal extensions. The laminectomy was
performed by neurosurgeons before the thoracic procedure. Four-
teen patients underwent this combined thoracic and neurosurgical
approach. The involved vertebral level of the tumor was marked
preoperatively on the skin of the patient’s back. Patients were placed
in a prone position and a vertical midline incision was made to expose
the laminae at the selected levels. Enough bone was removed by a
power drill to expose the tumor and its margins, the spinal cord
tumor interface, and the affected intervertebral foramen. Whether
the dura needed to be opened depending on the presence of
F I G U R E 2 Axial MRI scan showing a paravertebral neurogenic
tumor with transforaminal intraspinal extension (dumbbell tumor).
The spinal cord was compressed and displaced by the tumor. The
tumor was removed via a posterior approach with laminectomy
combined with VATS and the postoperative pathological diagnosis
was schwannoma. MRI, magnetic resonance imaging; VATS,
video‐assisted thoracic surgery
| 3
F I G U R E 3 A, Axial MRI scan showing a large tumor occupying the
thoracic inlet and compressing the surrounding structure. B, Coronal
MRI scan shows the tumor is located in the right upper mediastinum.
The tumor shows cystic density and has a clear margin. This patient
received surgical treatment of thoracotomy and the postoperative
pathological diagnosis was schwannoma
intradural involvement of the tumor. Under the operating micro-
scope, the intraspinal component was separated from the spinal cord
and removed. The affected nerve root could be killed. We
meticulously closed the dura and covered it with fibrin glue to avoid
a cerebrospinal fluid leak. The remaining tumor was pushed into the
chest cavity via the foramen for thoracoscopic surgery or thor-
acotomy.
Superior posterior mediastinal tumors extending to the cervical
region were treated with the supraclavicular approach or a combined
supraclavicular and transthoracic approach. A supraclavicular trans-
verse incision was made over the tumor. This approach allowed a safe
and accurate exposure of the cervical component of the tumor from the
trunks of the brachial plexus and from the subclavian or cervical vessels.
To avoid serious complications, intraoperative stimulation, and neuro-
monitoring were performed throughout the procedure to ensure that
no vital nerves were injured. When the deep side of the tumor was
exposed by blunt dissection, the supraclavicular wound and thoracic
cavity were communicated, and sometimes the tumor could be pulled
out from the supraclavicular wound. If the tumor was too large to be
excised completely, the cervical component of the tumor was resected
first and the remaining thoracic component was left for VATS or
4 |
F I G U R E 4 Intraoperative photo of VATS. (A) The pleura covering
the junction of the tumor with the chest wall and spine is sharply
incised. (B) Traction of the tumor with sponge‐holding forceps allows
a combination of sharp and blunt dissection and mobilization of the
tumor. (C) Intraoperative photograph of the tumor bed after
resection. The tumor (asterisk), the rib (black arrowhead), and the
junction of the tumor with the chest wall (white arrowhead) are
clearly seen. VATS, video‐assisted thoracoscopic surgery [Color
figure can be viewed at wileyonlinelibrary.com]
thoracotomy. After tumor resection, branches of the brachial plexus
were identified and stimulated, confirming its integrity.
4 | RES U LTS
Preoperative symptoms are shown in Table 1. In this series, 92 (76%)
of the patients were asymptomatic, and their lesions were discovered
CHEN ET AL.
incidentally on chest radiography or CT. Chest pain was the most
common complaint (n = 12, 9.9%). Eight patients complained of
Horner's syndrome or numbness in the upper extremities that were
affected by the tumor. Three patients presented with swelling on the
neck. The lesion was right‐sided in 69 patients and left‐sided in
52 patients. The tumor sizes were between 2.5 and 13 cm. The sites
of the tumors were the thoracic tract in 97 cases (80.1%), the
cervicothoracic junction in 16 cases (13.2%), and the thoracolumbar
junction in 8 cases (6.6%). In 20 (16.5%) patients, the tumors had
neuroforaminal or intraspinal extension (dumbbell tumor).
The operative approaches are presented in Table 1. Gross total
resection was achieved in all cases except two patients for whom
MRI scan results were unclear, and the tumors had extensive soft
tissue invasion with the subclavian artery involvement in one and
brachial plexus invasion in the other. Subtotal resection was only
possible in patients where malignancy was later proved. Surgical
excision was performed by VATS in 74 patients (61.2%), with no
conversions to open thoracotomy. Open thoracotomy was performed
in 17 patients (14.0%). Dumbbell tumors of the thoracic tract were
treated with laminectomy plus VATS/thoracotomy in 14 patients and
VATS alone in 2 patients. In cases involving cervicothoracic junction,
9 patients underwent supraclavicular plus VATS /thoracotomy, and
the remaining 7 patients were treated with a supraclavicular
approach.
Operative time for tumor excision, estimated blood loss (EBL),
postoperative chest drain duration，postoperative length of hospital
stay, and complications were recorded (Table 2). Postoperative
neurologic complications were considered present if patients newly
developed nervous injury after surgery or postoperative aggravation
of pre‐existing neurologic symptoms. There was no operative
mortality but minor postoperative complications occurred in
9 patients. Among them, nerve injury was most common. Five
patients had postoperative aggravation of pre‐existing neurological
symptoms (Horner's syndrome or brachial plexus injury). In one of
the patients with intraspinal extension, cerebrospinal fluid leakage
persisted for 10 days postoperatively.
The pathology diagnoses are presented in Table 1. The majority
were benign, but a few malignant lesions (2/121) were seen.
Preoperative chest pain and neurological symptoms were signifi-
cantly improved and resolved postoperatively within one year. At a
mean follow‐up of 31 months (range = 6‐68 months) no patients
showed recurrence of the tumor. Two patients with malignant
T A B L E 2 Operative data of the patients of the posterior
mediastinal neurogenic tumor (N = 121)
Variable Measurement (mean ± SD)
Operation time 105.2 ± 83.4 min
Estimated blood loss 163.0.5 ± 139.4 mL
Postoperative drain 1.5 ± 0.9 d
duration (n = 114)
Postoperative hospital stay 2.8 ± 1.2 d
Follow‐up 31.0 ± 13.2 mo
CHEN ET AL.
schwannoma were treated with postoperative radiotherapy. These
patients had no recurrence 1 and 1.5 years after the operation,
respectively.
5 | D IS C U S S IO N
Neurogenic tumors of the posterior mediastinum are uncommon
neoplasms but account for 10% to 34% of all mediastinal tumors.1
They typically arised from the spinal nerve roots, sympathetic chains,
and branches of the intercostal nerves.10 According to the neural
tissue‐based classification, they are classified as nerve sheath tumors,
such as schwannoma and neurofibroma; nerve cell tumors, such as
1
ganglioneuroma, and paraganglionic tumors. These tumors are
usually benign and asymptomatic and are often detected on imaging
for other reasons.7 Around 10% to 20% of posterior neurogenic
tumors have a spinal canal component, which is called dumbbell
tumors.5,6,11 It has been reported that 12% to 37% of posterior
neurogenic tumors could produce symptoms, which are mainly
related to neurologic compromise of the spinal cord or intrathoracic
2,3,7,12
mass local compression. Back and chest pain may be present
from the involvement of ribs or intercostal nerves. Tumors involving
the stellate ganglion or sympathetic trunk can cause Horner's
syndrome and tumor compression of the brachial plexus would lead
to referred neurologic symptoms. The presence of neurologic
symptoms correlates with the likelihood of intraspinal tumor
involvement. Between 60% and 80% of patients with dumbbell tu-
mors will have neurologic symptoms.13,14 In our series, 29 (24.0%)
patients have clinical symptoms at presentation. We encountered 20
(16.5%) patients with dumbbell‐type out of 121 patients with
neurogenic tumors, and 5 of them had complaints of neurologic
symptoms.
All patients with a posterior mediastinal tumor, even if asympto-
matic, should be evaluated for the possibility of intraspinal tumor
extension. CT scans are routinely performed to determine the
characteristics, location, and margins of the tumor. CT scans can also
aid in showing an enlarged intervertebral foramen or the presence of
an intraspinal extension. However, relying on CT scan alone for
evaluation of neuroforaminal involvement may miss a minority of
14
them. MRI is the most sensitive method to define the presence and
extent of the intraspinal component of the tumor. MRI is indicated
whenever the tumor is continuous to a neural foramen, there is a
widened intervertebral foramen or erosion of a vertebral body or
pedicle. 15
Neither CT nor MRI scan can accurately differentiate
between benign and malignant nature of the tumor. 16
In our series,
MRI is indicated as a complementary procedure in 85 patients and
we did not miss any neuroforaminal involvement in 20 patients.
Preoperative needle biopsy of posterior mediastinal tumors is not
required because it may not provide a definitive histologic classifica-
tion of such a tumor. Furthermore, the histologic type of benign
tumor has no impact on clinical management.
The radiographic appearance suspicious for a posterior mediast-
inal tumor is sufficient to warrant surgical treatment. Early surgical
| 5
exploration and resection is usually advised because of doubt about
the diagnosis, the continued growth of the tumor, and the possibility
of malignancy.17 In most cases, posterior neurogenic tumors without
evidence of intraspinal extension can be easily removed by VATS or
thoracotomy.2,7 VATS has gradually gained acceptance as a safe and
reliable minimal access alternative to thoracotomy for the manage-
ment of posterior neurogenic tumor. The minimal invasive approach
permits good exposure of the mediastinum, reduction of surgical
trauma, and a shorter hospital stay.17,18 The open approach may be
more appropriate for cases where the tumor is larger, suspicious of
malignancy, and located at the costophrenic angle or thoracic
apex.12,17 It has been reported that VATS is not appropriate for
tumors more than 6 cm in diameter, tumors located at the
costophrenic angle and tumors at the thoracic apex. Of 121 patients
in our series, 74 underwent VATS resection of posterior neurogenic
tumors and 17 had thoracotomy, all with satisfactory results. VATS
was performed in cases where the tumor was smaller than 8 cm,
which was also reported by Liu et al.17 None of VATS needed
conversion to open thoracotomy. Yang has reported that VATS is
associated with an increased incidence of brachial plexus injury.19 In
our study, excision of apical chest tumors without extension to the
cervical region was mainly performed by VATS using intracapsular
enucleation techniques without major complications. This is a safer
alternative to manipulation of a large tumor adjacent to important
structures.20 We considered that this technique could reduce the risk
of vessel and neurologic injury.
Patients with dumbbell tumors require special consideration. The
presence of intraspinal extension, tumor dimension, and its location
have made the resection of these types of neoplasms difficult. It is
crucial to fully assess the presence and degree of intraspinal
extension before planning the surgical procedure. A multidisciplinary
team combined of thoracic surgeons and neurosurgeons should
collaborate to determine the appropriate approach for individual
patients. Various approaches have been recommended including a
single‐stage posterior approach by laminectomy, hemilaminectomy
with partial costotransversectomy,21,22 costotransversectomy with
extension to a posterolateral thoracotomy,23 and through a
combined posterior and transthoracic approach performed either in
one or two stages.8 In our series, 14 of 20 dumbbell tumors were
removed by a single‐stage operation performed through a combined
neurosurgical and thoracic surgical approach. Advocates claim that
this approach avoids traction on the spinal cord during manipulation
of the intrathoracic component and allows a water‐tight dural closure
to be performed.24,25 Furthermore, the segmental stability may be
less compromised.25,26 Either an open or a VATS approach can be
used to excise the thoracic component, with the decision depending
on the principles described earlier. Lesions that are completely
intrathoracic, with minimal extension into the spinal canal, may be
removed by thoracotomy or thoracoscopy alone. Perioperative and
long‐term results of resection of dumbbell tumors with these
procedures were very good; only one complication occurred.
Occasionally posterior neurogenic tumors located at the thoracic
apex extend to the cervical region. These tumors have always posed
6 |
particular challenges to surgeons because of their close association
with important nervous and vascular structures of the thoracic inlet,
along with the difficulty in exposing the superior border of the tumor.
Various approaches have been reported, including a standard
thoracotomy,27 thoracoscopy,28 a lateral cervical approach,29 ante-
30 31
rior chest approach, and a combination of these approaches. In
both thoracotomy and thoracoscopic surgery, the superior portion of
the tumor is observed in a posterosuperior direction and the
anatomic relation may not be visualized adequately, which could
increase the risk of vascular and nervous injury during resection.19
Some reports showed that the transcervical approach had a high rate
9 Sugarbaker DJ, Bueno R, Krasna MJ, Mentzer SJ, Zellos L, eds. Adult
of postoperative neurologic complications. Yamaguchi and Akashi
described the surgical excision of superior mediastinal tumor by
means of combined procedures of a thoracoscopic approach and a
supraclavicular approach.31,32 In our cases, a combined approach
using VATS/thoracoscopy and supraclavicular incision or a supracla-
vicular approach was successfully performed to remove the tumor at
the cervicothoracic junction in 16 patients. Despite intraoperative
stimulation and neuromonitoring, 5 patients had postoperative
neurological complications. We believe that some of these complica-
tions were inevitable because the tumors originated from these
nerves in most cases. The supraclavicular approach afforded an
excellent exposure of cervical structures, allowing direct dissection
of the superior portion of the thoracic inlet tumors which facilitate
the thoracic procedure later. We considered that this approach could
minimize the severity of the neurologic injury, thus maximizing
preservation of the functions of the important nerves.
Posterior neurogenic tumors can be resected successfully with
few complications. Unrecognized tumor extension into the spinal
foramen or canal can lead to incomplete resection, retraction of the
nerve root, and intratumoral bleeding. All 20 dumbbell tumors in our
series were identified preoperatively thanks to the liberal use of MRI.
Five patients developed Horner’s syndrome or brachial plexus injury
due to the unavoidability of the originating nerve injury or malignant
invasion. Unrepaired perforation of the dura mater will result in
leakage of CSF and may require reoperation. The leak in one of our
patients resolved with several days of bed rest.
6 | CONC LU SION
Excellent results can be achieved with resection of posterior mediastinal
neurogenic tumors. Surgical approach should be tailored to the tumor
size, location, and extent of intraspinal/neuroforaminal involvement.
Most benign neurogenic tumors without neuroforaminal involvement
can be completely resected via VATS. Thoracotomy is the appropriate
surgical approach for large tumors. A supraclavicular approach or
combined with the transthoracic approach is recommended for tumors
extending in the cervical region. Finally, a posterior approach with
laminectomy plus thoracotomy/VATS can be used for patients with
dumbbell tumors. Careful evaluation and preoperative diagnosis are
essential, and intraoperative attention to avoid neurologic complications
can lead to a successful operation with excellent results.
CHEN ET AL.
CON F LI CTS OF I NTERE ST
The authors declare that they have no conflicts of interests.
ORCI D
Dayu Huang http://orcid.org/0000-0002-1246-7666
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