ORIGINAL ARTICLE Mediastinal Neurogenic Tumors and Video-Assisted Thoracoscopy Always the Right Choice? Nicolas Venissac, MD,* Francesco Leo, MD,* Paul Hofman, MD, PhD,† Philippe Paquis, MD,‡ Je´rome Mouroux, MD* Summary: Neurogenic mediastinal tumors in adults are generally benign lesions and for this reason are ideal candidates for resection by video-assisted thoracoscopy (VAT). Usual contraindications to VAT are the dimension of the tumor (greater than 6 cm), its position (apex, posterior costodiaphragmatic angle), and/or the presence of intraspi- nal growth (the so-called “dumbbell tumors”). This study reviewed a single-institution 10-year experience approaching mediastinal neuro- genic tumors routinely by VAT, even in cases of the above mentioned contraindications. From January 1992 to December 2002, 15 con- secutive mediastinal neurogenic tumors were operated by VAT (11 females, mean age 43 years, range 16–67). Mean operating time was 99 minutes (range 60–180). No conversion thoracotomy was re- quired. The 2 cases of “dumbbell tumor” in this series were treated by laminectomy followed by VAT. Two patients had a Claude-Bernard- Horner syndrome after removal of lesion at the level of T1-T2. Mean postoperative stay was 5.5 days. Histologic diagnosis was schwannoma in 12 cases (Antoni type A in 7 cases, type B in 4 cases, mixed type in 1 case) and neurofibroma in 3 cases. Results from this 10-year experience confirmed that VAT can be the standard approach for neurogenic tumors in adults without negative effect on radicality of resection and safety of the procedure. Key Words: video-assisted thoracoscopy, neurogenic tumor (Surg Laparosc Endosc Percutan Tech 2004:14:20–22) N eurogenic mediastinal tumors occurring in adults are generally benign lesions. 1,2 The risk of malignancy is very low for schwannomas and neurofibromas, except in pa- tients with Von Recklinghausen’s disease. 3 This favorable on- cologic behavior makes the neurogenic tumors ideal candi- dates for resection by video-assisted thoracoscopy (VAT). After the first report of Landrenau in 1992, 4 the treat- ment by VAT of mediastinal neurogenic tumors has been widely accepted. 5,6 Contraindications to the video- thoracoscopic approach of neurogenic tumors have changed over the years and are mainly linked to the dimension of the tumors and/or the presence of intraspinal growth. Tumors with a diameter greater than 6 cm have been considered not amenable for thoracoscopic removal, mainly when located in the apex or in the costodiaphragmatic angle. 7 Less than 10% of paravertebral neurogenic tumors have an extension inside the spinal canal, the so-called “dumbbell tumors.” 8 The assumption that intraspinal growth is a contra- indication to an endoscopic approach was questioned by the demonstration that a combined thoracoscopic and neurosurgi- cal approach is feasible and safe. 9,10 The aim of the study was to review the experience of a single institution over a period of 10 years approaching medi- astinal neurogenic tumors routinely by VAT, regardless of their dimension and/or of the presence of intraspinal growth. MATERIALS AND METHODS From September 1992 to November 2002, 18 neuro- genic tumors were operated at the Thoracic Surgery Division of the University Hospital of Nice, France. Three of them were operated by thoracotomy due to the position of the lesion (bra- chial plexus neurofibroma) or the radiologic features, suspi- cion of malignancy (2 cases). These patients were excluded from the analysis. The study focused on the 15 patients operated by VAT. Information on clinical presentation, surgical operation, and postoperative complications were retrospectively recorded. All patients were evaluated by a CT scan of the thorax. MRI was performed when an intracanalar extension was an- ticipated on CT scan. When the tumor was located between T9 and T12, an angiography was performed to detect the position of the Adamkiewitz artery. In patients with a “dumbbell tumor,” the dissection of endospinal tumor was done first by laminectomy though a pos- terior approach. Videothoracoscopy was performed under Received for publication March 11, 2003; accepted August 14, 2003. From the *Departments of Thoracic Surgery, †Pathology, and ‡Neurosurgery, Pasteur Hospital, University of Nice, France. Reprints: Nicolas Venissac, MD, Thoracic Surgery Department, Pasteur Hos- pital, 30 Ave de la Voie Romaine, 06002 Nice, France (e-mail: venissac.n@ chu-nice.fr). Copyright © 2004 by Lippincott Williams & Wilkins 20 Surg Laparosc Endosc Percutan Tech • Volume 14, Number 1, February 2004