European Journal of Cardio-thoracic Surgery 25 (2004) 509–514
www.elsevier.com/locate/ejcts
One step removal of dumb-bell tumors by postero-lateral
thoracotomy and extended foraminectomyq
Witold Rzymana,*, Jan Skokowskia, Radosław Wilimskia,
Krzysztof Kurowskia, Mirosław Stempniewiczb
a
Department of Thoracic Surgery, Medical University of Gdańsk, 7 De˛binki St., 80-211 Gdańsk, Poland
b
Department of Neurosurgery, Medical University of Gdańsk, Poland
Received 9 November 2003; received in revised form 3 December 2003; accepted 15 December 2003
Abstract
Objective: Thoracic dumb-bell tumors are rare, usually benign tumors in the posterior mediastinum, consisting of intrathoracic and
intraspinal parts. Surgical removal is the treatment of choice, performed by two teams – neurosurgeons and thoracic surgeons operating in a
prescribed order. Methods: Between 1994 and 1997 five patients had dumb-bell tumors removed in a one-step operation involving posterolateral thoracotomy and extended foraminectomy. This operating method, rarely described in the medical literature, consists of intrathoracic
and intraspinal parts being performed by a thoracic team independently or with the assistance of a neurosurgeon. Initially the intrathoracic
part is resected, followed by an extensive widening of the intervertebral foramen to an appropriate extension and the removal of the
remaining intraspinal part of the tumor. Results: Four postero-lateral thoracotomies and one incision over a huge tumor in the thoraco-lumbal
region, without entering the pleural cavity, were performed. In one patient postoperative, transient leakage of the cerebral fluid was observed.
No form of late complications or neurologic sequelae have been reported within a 5-year follow-up. Conclusions: One-step removal of a
dumb-bell tumor by postero-lateral thoracotomy and extended foraminectomy is a safe surgical procedure that can be performed by the
thoracic team alone. Early and late surgical results confirm the appropriateness and usefulness of the method.
q 2004 Elsevier B.V. All rights reserved.
Keywords: Dumb-bell tumor; Surgery; Neurogenic neoplasm; Thoracotomy
1. Introduction
Tumors of the posterior mediastinum arising from the
nervous system and penetrating through the intervertebral
foramen into the spinal canal are called dumb-bell or
sandglass tumors [1]. In the majority of cases they are
neurogenic benign tumors which have their origin in the
neuron sheath (68%), parasympathic ganglion (30%)
or paraganglionic cells (2%) [2]. Only 3 – 19% of such
tumors, usually in children, are malignant. Akawari [1]
reported that 10% of all the mediastinal tumors of
neurogenic origin extended from the thorax through the
spinal foramen into the neural canal. The intraforaminal
q
Part of the paper was presented at the 6th ESTS Conference on General
Thoracic Surgery, Portoroz, Slovenia, October 22–24, 1998. One stage
removal of dumbbell tumor in the thoracic region. Abstracts book, p. 17.
* Corresponding author. Tel.: þ 48-58-349-2400; fax: þ48-58-349-2429.
E-mail address: [email protected] (W. Rzyman).
1010-7940/$ - see front matter q 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcts.2003.12.022
growth may cause destruction of the vertebral body, while
its intraspinal component may cause spinal cord damage by
compression or when malignant infiltration with neurological sequelae [3]. Weber in 1856 was the first scientist to
describe such tumors but, in 1952, Love and Dodge [4] first
introduced the name ‘dumb-bell’ tumors reporting the
ingrowths of a neurogenic tumor into the spinal canal.
Patients usually present neurological symptoms but some
asymptomatic dumb-bell tumors have appeared during a
routine chest X-ray [3].
We present a method of removing thoracic dumb-bell
tumors in a one-step operation through postero-lateral
thoracotomy and extensive widening of the intravertebral
foramen—foraminectomy. Our experience regarding the
removal of dumb-bell tumors presented in this report is
based on five patients operated during the period from 1994
to 1997. In all of these cases we applied a one-stage removal
by postero-lateral thoracotomy and extended foraminectomy. A team of thoracic surgeons operated on all the patients
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assisted by a neurosurgeon both at the beginning and
whenever the extension of the intraspinal part was expected
to be widespread.
2. Materials and methods
Between 1994 and 1997 five patients were admitted for a
thoracic dumb-bell tumor removal at the Department of
Thoracic Surgery in the Medical University of Gdańsk.
Three men and two women, between 35 and 70 years old
(mean age of 51) were operated on by applying
foraminectomy to remove the intraspinal parts of the
tumors. In four of these cases postero-lateral thoracotomy
was performed and in the remaining one patient, an incision
over the tumor in thoraco-lumbal region. Four patients had
symptoms of the spinal compression, while one was
asymptomatic and the tumor mass was diagnosed
coincidentally. During a preoperative assessment only
patient no. 3 had a fine needle biopsy with the diagnosis
of a benign neural tumor. All of these patients before being
admitted into the Department of Thoracic Surgery had
undergone computed tomography (CT) scans and two of
them, in addition, magnetic resonance imaging (MRI) scans
of the thorax (Figs. 1 and 2). The diagnostic protocol for the
patient with dumb-bell tumor in our institution includes
chest radiograph, CT thorax and neurological examination.
If intraspinal tumor extension is significant and/or
Fig. 1. Magnetic resonance imaging of the thoracic dumb-bell tumor—axial
reconstruction (patient no. 3).
Fig. 2. Magnetic resonance imaging of the thoracic dumb-bell tumor—
normal scan (patient no. 3).
infiltration of the surrounding structures including spinal
cord is suspected, MRI and fine needle biopsy is performed.
Patients were followed up in our outpatient clinic every
3 months in the first year and then once a year after the
operation. CT scans were performed in two of them
postoperatively.
2.1. Description of the operation
The patient is placed on the side in the lateral decubitus
position. Postero-lateral thoracotomy is performed through
the intercostal space corresponding with the level of tumor
penetration to the spinal canal.
After the opening of the pleural cavity, the lung is moved
forward to reveal the intrathoracic neurogenic mass.
The parietal pleura over the tumor is incised and detached.
The dissection of the tumor extends into the intervertebral
foramen. At this stage, the decision is made whether the
intrathoracic part of the tumor should be removed or left
until the resection of the tumor’s intraspinal part is
complete. If the manipulation of the tumor is difficult and
the view into the intravertebral foramen insufficient we
either cut the intrathoracic part off completely or we leave
only a small portion of it to be held with the artery
forceps. Now, blunt and sharp dissections in the proximity
of the foramen permit the lifting of the tumor, exposing the
narrowed part placed in the foramen. The tumor is gradually
dissected off its surroundings, while being lifted up by hand
or the artery forceps. This maneuver affords a good view
into the foramen. When the tumor has a wide penetration to
the neural canal, one can begin to widen the foramen in a
chosen direction: upwards, downwards or both. If necessary,
the processus tranversus is removed allowing a better view
into the structures of the spinal canal (Fig. 3). After the
opening of the vertebral canal, one proceeds with a very
delicate dissection, with either the scissors or coagulation,
of the remaining tumor tissue from the dura mater. In case of
a hemorrhage, coagulation, hydroxide peroxide or a sponge
W. Rzyman et al. / European Journal of Cardio-thoracic Surgery 25 (2004) 509–514
511
patients postero-lateral thoracotomy and in one (patient
no. 3) an incision over the tumor at the back, without
entering the pleura itself, was performed. Three of the
tumors had a wide intraspinal part, it was smaller in the case
of the remaining two, requiring only a 3-cm widening of the
foramen. In two patients an opening of 4 –5 cm was enough,
but in patient no. 3 a length of 8 cm along the lateral part of
the vertebral body between two foramina (Th11/12 and
Th12/L1)—that extended additionally in the opposite
directions—had to be excised (Fig. 3).
In one patient with a huge tumor in the lowest part of the
thoracic cavity, intraoperative bleeding from the venous
plexus of the spinal canal followed by a leakage of the
cerebral fluid, occurred postoperatively. He had neurological sequelae in the form of transient meningitis-like
symptoms (4 days) with a minimal Babinski symptom on
the left side, a bilateral Kernig symptom and neck stiffness.
All were successfully treated with bed rest and fluid balance
in 7 days. All of the patients are monitored once a year in an
outpatient clinic, and no late neurological sequelae have
been noted.
4. Discussion
Fig. 3. Extended foraminectomy. The opening connecting three foramina.
Dashed line around the processus transversus illustrates possibility of its
removal.
were used. No sealing material was applied to fill the
opening after foraminectomy.
3. Results
The details concerning the patients’ symptoms,
preoperative radiological and postoperative pathological
findings are listed in Table 1, while a description of each
patients’ operation has been included in Table 2. Four of the
five tumors gave symptoms usually associated with pressure
on the surrounding structures. Three patients had no findings
in a neurological examination. The CT was done in all
patients and demonstrated intraforaminal growth of the
tumor and its intraspinal extension. When infiltration of the
surrounding structures including spinal cord was considered
after CT, MRI of suspected region was employed. In four
A surgical excision of the dumb-bell tumor, which is the
treatment of choice, is a challenge to the thoracic surgeon
mainly because it covers two surgical fields: thoracic and
neurosurgical. Therefore surgical techniques and
approaches vary widely. Some surgeons, depending on the
institution, prefer a two-stage operation, where the removal
of the intrathoracic and intraspinal tumor mass is done
separately and in different sequences. In the late 1970s,
however, some surgeons introduced a one-stage removal of
the dumb-bell tumor. Akawari, for example, combined two
approaches in a single session. The first step was posterior
laminectomy, done by neurosurgeons, and the second step
was postero-lateral thoracotomy, performed by a thoracic
team. This method, in the opinion of the authors, avoids the
risk of bleeding from remnant tumor tissue, compression of
the spinal cord, leakage of the cerebral fluid or damage to
the spinal cord encountered in a two-stage procedure [1,3].
Grillo, in 1983, demonstrated a one-approach technique, i.e.
through a band skin incision at the back. The first step
consisted of removal by a neurosurgeon of the intraspinal
part by laminectomy, with the rest of the tumor being
removed by a thoracic surgeon through thoracotomy [3,8,9].
The only difference between these two methods is the skin
incision. Ricci et al. [10] concluded that Grillos method only
allows the removal of dumb-bell tumors whose intraspinal
part does not exceed 3 cm. Lately, a combined approach
involving laminectomy by a neurosurgeon followed by a
videothoracoscopic removal of the intrathoracic part has
been the focus of interest [11 – 14].
In a preoperative diagnosis, a fine needle biopsy is rarely
successful due to the consistency (hard and solid) and
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Table 1
Symptoms, radiological findings and histopathological diagnosis in all patients
Symptoms
Radiological examinations
Pathology
Patient 1, SJ, 46, male
Tremor of lower right extremity,
paresthesis in the lower right
extremity, reduced sensitivity
Ganglioneuroma
Patient 2, DJ, 65, male
Asymptomatic
Patient 3, FS, 41, male
Slowly growing tumor, backache
Patient 4, NZ, 70, female
General weakness, backache
Patient 5, RL, 35, female
Backache, headache
and dizziness
Myelography and CT thorax. Intrathoracic tumor
mass: 2 £ 1.5 cm in the left poserior mediastinum;
intraspinal part: 5 £ 2 cm epidural mass filling
almost completely the lumen of the spinal canal;
penetration to the spinal canal: destructed
intervertebral foramen between Th5 and Th6
CT thorax. Intrathoracic tumor mass: 3.5 £ 4.0 cm
in the left posterior mediastinum; intraspinal part:
2.5 £ 1.5 cm, no dislocation of the spinal cord;
penetration to the spinal canal: widened intervertebral
foramen between Th4 and Th5
CT and MRI of the tumor. Extraspinal tumor: in the left
paravertebral region 12 £ 17 cm mass, displacing
latissimus dorsi, from the level of Th8 to L3 (tumor
dislocates the left kidney); intrathoracic part:
tumor penetration into the left hemithorax
through the diaphragm (partial destruction of the
vertebral body, lamina and processus transversus
of Th11); intraspinal part: 5 £ 1.5 cm, dislocation
of dura mater to the right; penetration to the spinal
canal: two intervertebral foramina, Th11/Th12 and
Th12/L1
CT of the thorax. Intrathoracic tumor mass:
5.7 £ 4.6 cm in the right posterior mediastinum;
intraspinal part: one-third of the tumor mass,
dislocation of the dura mater; penetration to
the spinal canal: widened intervertebral foramen
Th3/Th4
CT and MRI of the thorax
and spine. Intrathoracic tumor mass: 3.5 £ 3 cm
in the left posterior mediastinum; intraspinal
part: 2 £ 2 cm (dislocation and compression
of the medulla); penetration to the spinal canal:
intervertebral foramen Th4/Th5; !: on the level of Th1/Th2
another tumor 2 £ 2 cm without penetration to the spinal canal
location (aorta, vertebral structures) of neurogenic tumors.
Since almost all such tumors are benign in adults [1,5] and
they need to be removed anyway, it is performed on very
rare occasions. Nor is the use of MRI obligatory in the
diagnosis, in our opinion. Its advantage over a CT scan lies
mostly in the accuracy of describing the longitudinal
extension of the intraspinal component of the tumor [10].
Either method is capable of visualizing the morphologic
features of the neural mass, but infiltration of soft tissues
including neural structures is better seen on MRI images.
Although Shadmehr et al. [9] reports that CT missed to
show intraforaminal growth in three of 16 reported cases in
their series we have never been surprised by such accidental
findings while operating neurogenic tumors at our institution. Myelography is only of historical significance [15].
Arteriography is rarely, if ever necessary, and maybe
helpful when considering proximity of Adamkiewicz artery
in the lower portion of the posterior mediastinum, infiltration of aorta or major aortic branches [9]. Although the
majority of dumb-bell tumors are of benign origin, careful
Neurilemmoma
Neurilemmoma
Neurilemmoma
(Antoni type)
Ganglioneuroma
(both tumors)
diagnosis with CT, MRI, or biopsy is mandatory in the rare
cases of their being malignant.
Dumb-bell tumors of the thoracic region comprise 10% of
all the neurogenic mass in the posterior mediastinum [1,5].
Most of the neurinomas are easy to remove by subtle
dissection in the proximity of the foramen followed by slow
and deliberate extraction of the tumor from the spinal canal.
In the majority of ‘true’ dumb-bell tumors, however, a
good view over the medulla is necessary. In such cases,
postero-lateral thoracotomy with widening of the intervertebral foramen by the resection of its bony structure is
preferable [6]. If necessary, the processus transversus can be
excised, affording an excellent overview of the medulla.
Five patients have been operated on in this manner and
subjected to long-term follow up. We have been able to find
in the literature only one case report concerning the
removal of dumb-bell tumor in the cervical region by
foraminectomy [7].
Our technique of one stage dumb-bell tumor resection
through postero-lateral thoracotomy and extended
W. Rzyman et al. / European Journal of Cardio-thoracic Surgery 25 (2004) 509–514
Table 2
Detailed description of operations in all patients
Operation
Patient 1 LPLT. The foramen was widely excised up- and downward
(4– 5 cm) with rongeur and the intraspinal part was dissected
from the dura mater with coagulation
Patient 2 LPLT through the 4th IS. Tumor with 4 £ 3 cm intrathoracic
part penetrating through the foramen between Th4 and Th5
into the spinal canal was excised after dissection from the
surrounding tissues, pleura and dura mater and widening
of intravertebral foramen (3 cm)
Patient 3 Patient placed in a prone position with a slight dorsal rotation.
Skin incision over the tumor on the back. Bulky tumor mass
consisted of three parts was found: external, under spine
muscles; internal, in the spinal canal and intrathoracic—that
was located subpleural. Dissection of the muscles over the
tumor mass in the lumbal region. The external, lumbar tumor
mass was cut off proximal to the foramina. Penetration to the
spinal canal through the two destructed intervertebral foramina
(Th11/Th12 and Th12/L1) was found. The spinal canal was
opened by the excision of the bony structures between both
foramina in the opposite directions (together 8 cm length) with
the rongeur and the tumor was dissected from the dura mater
that was not infiltrated. After removing processus transversus
10 and 11 with a concomitant ribs, intrathoracic part of the
tumor mass was excised without entering pleural cavity. Two
suction drains were placed in the operation bed. During skin
suture significant hemorrhage occurred. The incision was
reopened and bleeding from the spinal plexi was stopped
with coagulation and hydrogen peroxide sponges
Patient 4 RPLT through third IS. After incision of the pleura, tumor
7 £ 5 cm, was dissected from the surrounded tissues and cut
off on the level of foramen which was than widely excised
with rongeur (4 cm) and the intraspinal part of tumor with
dimension of 1 £ 2 cm was dissected under direct vision
Patient 5 LPLT through third IS. Dissection of the tumor from
surrounded tissues. Widening of the intervertebral foramen
with the rongeur (3 cm) and dissection from dura mater.
The tumor on the level of Th1/ Th2 was excised without
foraminectomy
RPLT, right posterolateral thoracotomy; LPLT, left posterolateral
thoracotomy; IS, intercostal space.
foraminectomy can be regarded as a safe procedure leading
to satisfying early and long-term results without neurological sequelae. The intervertebral foramen could be excised
very extensively. In patient no. 3 the extensions of the
opening exceed the distance between two foramina. We find
the operative technique easy in the hands of an experienced
thoracic surgeon who has good control over the tumor and
the surrounded structures at all stages of the operation.
Earlier on, we used to ask neurosurgeons for assistance
during the intraspinal part of the operation, but in the last
three patients the thoracic team alone performed the
operation. When the tumor is malignant, naturally, it is
preferable to have a neurosurgeon in the operation room
while operating dumb-bell tumor with this technique.
Absence of instability of the spine or neurologic symptoms
of neural compression or destruction confirms, however, the
usefulness and effectiveness of the applied operative
513
method. In two operated patients we have used gelatin
sponges (Surgicel and Spongostan) to stop bleeding from
the resected foramen. Due to recent case reports of
paraplegia caused by swelled sponges in the postoperative
period we advise to avoid application of similar materials or
to use them with appropriate caution [16,17]. An interesting
alternative to our technique is a dorsal approach, proposed
by Osada et al. [2], involving laminectomy and resection of
a small portion of the adjacent rib without opening the
parietal pleura. The avoidance of thoracotomy helps in
postoperative pain control.
Due to limited series of dumb-bell tumors with wide
extension in the spinal canal no institution sees a lot of such
neoplasms. Therefore, the appropriate method should be
applied concerning the variety of anatomic situation and
experience of the operating team. In our opinion extended
foraminectomy has its place in surgical treatment of
thoracic dumb-bell tumors but it should be performed by
highly experienced thoracic surgeons.
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