192
Thoracoscopic Resection of Benign Schwannoma W Weder. R. Schlumpf, R. Schimm er; T. Kotulek ", and F Larqiader
Summary
Thorakosko pische Resektion cines ben ign en Schwan no ms
The recent impr ovement of endosco pic surgical instrumen ts allows new th erap eut ical application of thora coscopy. We re port a thoracoscopic resection of a benign schwa nnoma of th e 6th inter costal nerve in a 35-yea r-old patient. The operative technique a nd extrac tion of the tumor fro m the chest is described. Postoperative morbid ity was minor. We consider th e thoracoscopic resection as first choice of tr eatment.
In der letzt en Zeit haben wesentliche Verbesse rungen des Instru menta riums fur die endoskopische Chirur gie den Indika tionsbereich der opera tiven Thorakoskop ie deutlich erwe ite rt. Wir reseziert en bei einem 35jah rigen Patienten ein gutartiges Schwa nnom des 6. Interko sta lnerven thorakoskopis ch. Die postoperative Morbidltat war minimal. Die Operationstechnik sowie auch die Technik der Extraktion des Tumors aus dem Thorax wird beschri eben .
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Department of Surgery, Univers ity Hospit al, Zurich 'Institute of Radi ology, Sta dtspita l Waid , Zur ich, Switzerland
Key wo r ds Thoracoscopic resection - Schwannoma
Intr oduction Schwannomas (neuril emomas) are most often benign tumors originating from the sheath of peripheral nerves. In th e chest th ey can arise from spinal nerve roots, intercostal nerves, th e sympathetic chain, phrenic or vagus nerve, or brachial plexus . Most are asymptomatic and detected incidentally on a ch est radiograph . The diagnosis is suggest ed by th e typica l radiographic app earance and location . Treatment is resection , traditionally through a thoracotomy to confirm the diagnosis . We perform ed a r esection of su ch a tumor thoracoscopically in a 35-year-old patient. Case report A 35-year-old constr uction work er was admitted with a tumor in th e left chest identified on a check-up radiograph. He was as ymptomatic and the clinical examination wa s normal. Th e chest radiograph (Fig. 1) showed a well defined egg-shaped tumor in the left dorsal chest betwe en the 6th and 7th rib. Computed tomography (Fig. 2) showed a circumscribed 5 x 3 em mass with areas of inhomog eneity covere d by a thick en ed pleura. The ribs wer e slightly sca lloping without signs of infiltration. From th e rad iographic app earance a schwannoma was susp ected , and a surgical rem oval was indi cat ed.
L Fig. 1 Chest radiograph showing a tumor on the left side
Thorac. cardiovasc. Surgeon 40 (1992) 192 -1 94 © Georg Thieme Verlag Stuttga rt - New York
Received for Publication : May 6. 1992
•
Thorac. cardiovasc. Surgeon 40 (1992)
Thoracoscopic Resection ojBenign S chwannoma
193
Operative procedure The pati ent was an esth esized in a full lateral right position and the chest prepared for a possible thoracotomy. He was ventilated through a double-lumen endotracheal tube with a non -ventilated left lung. A first trocar was insert ed at the 8th inter costal spac e in left mid-axillary line and the video camera (Wolf CCD- Endocam 5370) inserted. The tum or was located between the 6th and 7th rib covered completely by the pleura and showed a sm ooth surface. Ther e wer e no adh esions and the thoracoscopic insp ection of the chest was normal. A second tro car (lO-mm) was inserted in the 6th inter costal space in the anterior axillary line and a third tro car (5-mm) in the posterior axillary line. These two openings were used for the operative pro cedure. The pleura ar ound the tumor was opened with a hook electrode (unipolar) . The ventral part of the tumor was grasped with a forceps and the tumor freed from the chest wall with the hook ca utery under slight tension. The 6th intercostal nerve was in direct contact with the tumor and was resected. There were no signs of infiltration of the chest wall and the tumor could be freed completely. The camera was now changed to the ventral trocar. The midline incision was enlarged to 3.5 em, and a bab y sternal retractor insert ed. A sterile plastic bag with a cut in the lateral wall was inserted into the chest. The main opening was extrathora cally. The tumor was drawn with a forceps into this plasti c bag through the side hole (Fig. 3). This enabled safe extrac tion of the tumor by pulling through the narrow opening without contaminating the chest cavity.A drainage tube (Charr. 20) was inserted thr ough the dors al trocar and placed dorsally. The incisions wer e closed. Operation time was 40 minutes. The histological examination confirmed the diagn osis of a benign schwannoma. The postoperati ve course was uneventful and the drainage was removed on the 2nd day. The pati ent left the hospital on the 3rd day. One week later he was asymptomati c and returned to work .
Fig. 3 After resection from the chest wall the tumor was brought into a plastic bag via a side cut and extracted.
Comment Schwannomas (neurilemomas) originate from the sheath of a periph eral nerve or a nerve root. In the chest they ar e most commonly located in the posterior mediastinum wh ere they originate from the spinal nerve root , the intercostal nerve or rarely from the sympathetic trunk (2, 4). Exceptionally they can arise from the vagus (3) or ph renic nerve. They are typically benign, solitary, and asymptomatic . In the chest they are most often detected incidentally on a routin e radiograph as in this case . In the CT appearan ce it is a well-defined tumor with areas of inhomogeneity. This mixed CT attenuation may relate to the pathologic finding of ar eas with cellular adjac ent to collagenous regions and large areas of xanthomatous changes and cystic degenerations. The pattern of central necr osis is not a sign of malignancy (l ). The therapy is resection of the tumor classically thr ough a thorac otomy. Recent improvem ents of endoscopic surgical instrum ents allows new therapeutic application of the old technology of thoracoscopy. The thoracoscopic resection of a schwannoma has not been describ ed yet. It was in this case easy and time-sa ving to perform . We believe the extraction of an y tum or should be done in a protecting plastic bag especially if the tumor has to be squeezed slightly through the narrow opening . The described technique is both practical and safe. The postop er ative morbidity was negligible. Thoracoscopic extraction of schwannomas of peripheral nerves should be consider ed as first choice of treatment.
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Fig. 2 Contrast-enhanced CTscan of the chest demonstrating a well· circumscribed extrapleural tumor between the 6th and 7th rib.
Thora c. cardiovas c. Surg eon 40 (1992)
References 1
2
3
4
Cohen. L. M.. A. M. Schwartz. and S. D. Rockoff Benign Schwannoma s: Path ologic Basis for CT. Inhomogeneities. AIR 147 (1986) 141-143 Das Gupta. T. K.. R. D. Brasfi eld. E. W. Strong . and S. I. Haj du: Benign solitary schwa nnomas (neurilemo mas) . Cancer 24 (1979) 355 - 366 Heitmiller; R. F.. 1. D. Labs. and P. A. Lipsett : Vagal Schwannorna. Ann. Thorac . Surg. 50 (1990) 811 - 813 Whitaker. W. G.. and C. Droulias: Benign encapsulated neurilemom a . A report of 76 cases . Ann. Surg. 42 (1976) 675-678
W Weder. R. Schlumpf, R. Schimmer, T. Kotulek, and F. Largiad er Dr. W. Weder Department of Surgery University Hospital CH-8091 Zurich Switzerland
Downloaded by: University of British Columbia. Copyrighted material.
194
Thoracoscopic Resection of Benign Schwannoma W Weder. R. Schlumpf, R. Schimm er; T. Kotulek ", and F Larqiader
Summary
Thorakosko pische Resektion cines ben ign en Schwan no ms
The recent impr ovement of endosco pic surgical instrumen ts allows new th erap eut ical application of thora coscopy. We re port a thoracoscopic resection of a benign schwa nnoma of th e 6th inter costal nerve in a 35-yea r-old patient. The operative technique a nd extrac tion of the tumor fro m the chest is described. Postoperative morbid ity was minor. We consider th e thoracoscopic resection as first choice of tr eatment.
In der letzt en Zeit haben wesentliche Verbesse rungen des Instru menta riums fur die endoskopische Chirur gie den Indika tionsbereich der opera tiven Thorakoskop ie deutlich erwe ite rt. Wir reseziert en bei einem 35jah rigen Patienten ein gutartiges Schwa nnom des 6. Interko sta lnerven thorakoskopis ch. Die postoperative Morbidltat war minimal. Die Operationstechnik sowie auch die Technik der Extraktion des Tumors aus dem Thorax wird beschri eben .
Downloaded by: University of British Columbia. Copyrighted material.
Department of Surgery, Univers ity Hospit al, Zurich 'Institute of Radi ology, Sta dtspita l Waid , Zur ich, Switzerland
Key wo r ds Thoracoscopic resection - Schwannoma
Intr oduction Schwannomas (neuril emomas) are most often benign tumors originating from the sheath of peripheral nerves. In th e chest th ey can arise from spinal nerve roots, intercostal nerves, th e sympathetic chain, phrenic or vagus nerve, or brachial plexus . Most are asymptomatic and detected incidentally on a ch est radiograph . The diagnosis is suggest ed by th e typica l radiographic app earance and location . Treatment is resection , traditionally through a thoracotomy to confirm the diagnosis . We perform ed a r esection of su ch a tumor thoracoscopically in a 35-year-old patient. Case report A 35-year-old constr uction work er was admitted with a tumor in th e left chest identified on a check-up radiograph. He was as ymptomatic and the clinical examination wa s normal. Th e chest radiograph (Fig. 1) showed a well defined egg-shaped tumor in the left dorsal chest betwe en the 6th and 7th rib. Computed tomography (Fig. 2) showed a circumscribed 5 x 3 em mass with areas of inhomog eneity covere d by a thick en ed pleura. The ribs wer e slightly sca lloping without signs of infiltration. From th e rad iographic app earance a schwannoma was susp ected , and a surgical rem oval was indi cat ed.
L Fig. 1 Chest radiograph showing a tumor on the left side
Thorac. cardiovasc. Surgeon 40 (1992) 192 -1 94 © Georg Thieme Verlag Stuttga rt - New York
Received for Publication : May 6. 1992
•
Thorac. cardiovasc. Surgeon 40 (1992)
Thoracoscopic Resection ojBenign S chwannoma
193
Operative procedure The pati ent was an esth esized in a full lateral right position and the chest prepared for a possible thoracotomy. He was ventilated through a double-lumen endotracheal tube with a non -ventilated left lung. A first trocar was insert ed at the 8th inter costal spac e in left mid-axillary line and the video camera (Wolf CCD- Endocam 5370) inserted. The tum or was located between the 6th and 7th rib covered completely by the pleura and showed a sm ooth surface. Ther e wer e no adh esions and the thoracoscopic insp ection of the chest was normal. A second tro car (lO-mm) was inserted in the 6th inter costal space in the anterior axillary line and a third tro car (5-mm) in the posterior axillary line. These two openings were used for the operative pro cedure. The pleura ar ound the tumor was opened with a hook electrode (unipolar) . The ventral part of the tumor was grasped with a forceps and the tumor freed from the chest wall with the hook ca utery under slight tension. The 6th intercostal nerve was in direct contact with the tumor and was resected. There were no signs of infiltration of the chest wall and the tumor could be freed completely. The camera was now changed to the ventral trocar. The midline incision was enlarged to 3.5 em, and a bab y sternal retractor insert ed. A sterile plastic bag with a cut in the lateral wall was inserted into the chest. The main opening was extrathora cally. The tumor was drawn with a forceps into this plasti c bag through the side hole (Fig. 3). This enabled safe extrac tion of the tumor by pulling through the narrow opening without contaminating the chest cavity.A drainage tube (Charr. 20) was inserted thr ough the dors al trocar and placed dorsally. The incisions wer e closed. Operation time was 40 minutes. The histological examination confirmed the diagn osis of a benign schwannoma. The postoperati ve course was uneventful and the drainage was removed on the 2nd day. The pati ent left the hospital on the 3rd day. One week later he was asymptomati c and returned to work .
Fig. 3 After resection from the chest wall the tumor was brought into a plastic bag via a side cut and extracted.
Comment Schwannomas (neurilemomas) originate from the sheath of a periph eral nerve or a nerve root. In the chest they ar e most commonly located in the posterior mediastinum wh ere they originate from the spinal nerve root , the intercostal nerve or rarely from the sympathetic trunk (2, 4). Exceptionally they can arise from the vagus (3) or ph renic nerve. They are typically benign, solitary, and asymptomatic . In the chest they are most often detected incidentally on a routin e radiograph as in this case . In the CT appearan ce it is a well-defined tumor with areas of inhomogeneity. This mixed CT attenuation may relate to the pathologic finding of ar eas with cellular adjac ent to collagenous regions and large areas of xanthomatous changes and cystic degenerations. The pattern of central necr osis is not a sign of malignancy (l ). The therapy is resection of the tumor classically thr ough a thorac otomy. Recent improvem ents of endoscopic surgical instrum ents allows new therapeutic application of the old technology of thoracoscopy. The thoracoscopic resection of a schwannoma has not been describ ed yet. It was in this case easy and time-sa ving to perform . We believe the extraction of an y tum or should be done in a protecting plastic bag especially if the tumor has to be squeezed slightly through the narrow opening . The described technique is both practical and safe. The postop er ative morbidity was negligible. Thoracoscopic extraction of schwannomas of peripheral nerves should be consider ed as first choice of treatment.
Downloaded by: University of British Columbia. Copyrighted material.
Fig. 2 Contrast-enhanced CTscan of the chest demonstrating a well· circumscribed extrapleural tumor between the 6th and 7th rib.
Thora c. cardiovas c. Surg eon 40 (1992)
References 1
2
3
4
Cohen. L. M.. A. M. Schwartz. and S. D. Rockoff Benign Schwannoma s: Path ologic Basis for CT. Inhomogeneities. AIR 147 (1986) 141-143 Das Gupta. T. K.. R. D. Brasfi eld. E. W. Strong . and S. I. Haj du: Benign solitary schwa nnomas (neurilemo mas) . Cancer 24 (1979) 355 - 366 Heitmiller; R. F.. 1. D. Labs. and P. A. Lipsett : Vagal Schwannorna. Ann. Thorac . Surg. 50 (1990) 811 - 813 Whitaker. W. G.. and C. Droulias: Benign encapsulated neurilemom a . A report of 76 cases . Ann. Surg. 42 (1976) 675-678
W Weder. R. Schlumpf, R. Schimmer, T. Kotulek, and F. Largiad er Dr. W. Weder Department of Surgery University Hospital CH-8091 Zurich Switzerland
Downloaded by: University of British Columbia. Copyrighted material.
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