PMC6302558_01
Preoperative and postoperative neuroradiological studies. (a) Preoperative computed tomography: axial (a1), sagittal (a2), and coronal (a3) scans showing an irregular tumor with pleural (tp) and spinal (ts) components. Note that the vertebral foramen is slightly enlarged (arrow) and the adjacent bone structures are not infiltrated. T8: Eighth thoracic vertebrae. (b) Preoperative MRI: axial (b1) and coronal (b2) MRI scans demonstrating a dumbbell-shaped mass along the course of the right eighth nerve root. The spinal cord (asterisk) is displaced to the left. (c) Postoperative MRI shows an adequate decompression of the spinal cord (asterisk) and persistence of the pleural tumor component (tp)
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F1
The patient was referred to our institution at the time radiographic spinal cord compression at T8-T9 level was discovered in addition to pleural thickening involving both hemithoraces [Figure 1a]. Postoperative MRI confirmed complete removal of the spinal tumor component [Figure 1c].
Intraoperative photographs and neurophysiologic monitoring. (a) The patient is placed in a prone position. A vertical midline incision was made centered at the T8 level. (b) Following a one-level laminectomy and extensive foraminotomy, the intraspinal (ts) and foraminal (tf) components of the tumor were exposed. Observe the notable spinal cord compression (yellow arrows). White arrow points to the D-wave cable placed in the epidural space below the tumor. (c) The spinal cord has been decompressed. Two nonabsorbable stitches (arrowhead) were placed at the anatomical area of the T8's right exiting nerve root, where a small dural hole was found after tumor removal. Motor evoked potentials to transcranial electrical stimulation (d1) and D-wave (d2) monitoring. No changes were observed between basal recordings (green waves) and those measured at the end of tumor removal (black waves)
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F2
T8-T9 facetectomy [Figure 2a]. The right T8 root was encased by an epidural solid tumor mass [Figure 2b]. Following gross total resection, a small dural hole was repaired at the right-sided T8 exiting nerve root [Figure 2c]. Intraoperatively, neurophysiologic recordings remained stable [Figure 2d].
Photomicrographs of the surgical specimen. Hematoxylin-eosinstain ((a) 10x, (b) 40x). The neoplasm consisted of a mixture of poligonal (oval) and spindle-shaped epithelial cells (arrowhead), small-to-medium sized, arranged in nests, and surrounded or intermingled with nonneoplastic small mature-appearing lymphocytes (asterisk). The epithelial cells show vesicular oval nuclei with nucleoli and pale cytoplasms. Immunohistochemistry stains (c-f): The epithelial nature of the polygonal and spindle-shaped cells was supported by their immunostaining for low- and high-molecular weight cytokeratin markers CKAE1-AE3 (c) and CK5-6 (d). The nonneoplastic, immature lymphoid population intermingled with the epithelial cells showed positivity for CD3 (e) and TdT (f)
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F3
The morphological and immunostaining features of the tumor corresponded to metastatic thymoma [Figure 3].