PMC10291177_01
Imaging before surgery. (A) CT scan of the chest showing a 33 mm mass with clear boundaries located beside the mediastinum of the upper lobe of the left lung. Calcified nodules within the mass are slightly enhanced. Coronal (C) and sagittal (D) chest CT images reveal no abnormal changes in the adjacent thoracic vertebrae and ribs. (B) MRI of the thoracic vertebrae showing an equal-length T1, and long T2 mainly mixed signal shadows on the left side of the upper mediastinum (around the level of the T1-T2 vertebrae), low-signal shadows are observed on T2WI.
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Contrast-enhanced computed tomography (CT) of the patient's chest revealed a well-defined mass, measuring approximately 33mm in diameter, adjacent to the mediastinum of the upper lobe of the left lung ( Figures 1A, C, D ). CT of the tumor blood vessels displayed a distinct boundary between the tumor and the left subclavian artery, with vascular branches visible at the posterior margin of the tumor ( Figure 2A ). Contrast-enhanced magnetic resonance imaging (MRI) of the thoracic vertebrae revealed an equal-length T1 and long T2 signal lesion predominantly located on the left side of the upper mediastinum (approximately at the level of T1-T2 vertebrae), low-signal shadows were detected on T2WI ( Figure 1B ).
Three-dimensional reconstruction CT scans of tumor vessels were obtained preoperatively (A) and postoperatively (B).
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CT of the tumor blood vessels displayed a distinct boundary between the tumor and the left subclavian artery, with vascular branches visible at the posterior margin of the tumor ( Figure 2A ). Contrast-enhanced magnetic resonance imaging (MRI) of the thoracic vertebrae revealed an equal-length T1 and long T2 signal lesion predominantly located on the left side of the upper mediastinum (approximately at the level of T1-T2 vertebrae), low-signal shadows were detected on T2WI ( Figure 1B ). Three-dimensional reconstruction CT revealed the disappearance of the mass ( Figure 2B ).
(A) The cervical approach incision. (B-F) The procedure begins with a horizontal incision along the left supraclavicular area, followed by the sequential removal of tissue layers including the platysma muscle, deep cervical fascia, and carotid sheath, exposing the left recurrent laryngeal nerve, venous horn, lymphatic vessels, and left subclavian artery. The tumor was then carefully separated from the surrounding tissue and the upper pole of the tumor was excised. (G-I) The ultrasonic scalpel was utilized to carefully remove the mass from the root of the brachial plexus.
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The procedure began with the upper pole of the tumor, and an approximately 8 cm curved incision was made horizontally along the left supraclavicular, extending from the midfront of the neck to the anterior edge of the left sternocleidomastoid muscle ( Figure 3A ). Meticulous dissociation of the platysma muscle, deep cervical fascia, and carotid sheath was performed, exposing the left recurrent laryngeal nerve, venous horn, lymphatic vessels, and left subclavian artery ( Figures 3B-E ). The tumor was then carefully separated from the surrounding tissue and the upper pole of the tumor was excised ( Figure 3F ), revealing its origin from the left brachial plexus. The mass was carefully removed from the root of the brachial plexus using an ultrasonic scalpel to minimize the risk of peripheral nerve and vascular injury ( Figures 3G-I ).
(A) The tumor's anatomical relationship with the subclavian artery and surrounding tissues was visualized from the neck perspective. (B) The location of the lesion under uniportal VATS. (C) The superior aspect of the thoracic cavity following successful lesion resection. (D) The tumor measuring 3.3 x 3.3 cm in diameter after being removed. (E) Post-pathology results reveal that the mass was a mediastinal brachial plexus schwannoma. Immunohistochemical analysis revealed positive staining for CD34 (vessel), Ki-67 (approximately 1%), S-100, Vimentin, and SOX-10, whereas staining for CK-P, Desmin, and NSE was negative.
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Bleeding was carefully managed, and a thin drainage tube was placed in the neck ( Figure 4A ). The mass was located in the uppermost mediastinum, adjacent to the spine ( Figure 4B ). Ultimately, successful removal of the tumor was achieved ( Figures 4C, D ), and the wound was meticulously closed layer by layer. The postoperative pathology results revealed that the mass located in the left upper mediastinum was a schwannoma ( Figure 4E ).