Ann Thorac Surg 1995;59:1586-1587
© 1995 The Society of Thoracic Surgeons
Case Report
Thoracoscopic Excision of a Malignant Schwannoma of the Intrathoracic Vagus Nerve
Raymond L. Singer, MD
Division of Cardiothoracic Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania
Accepted for publication November 3, 1994.
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Abstract
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Malignant schwannomas of the intrathoracic vagus nerve are rare tumors. A patient underwent resection of a mediastinal malignant schwannoma of the vagus nerve using video-assisted thoracoscopy, with no recurrence at 18 months.
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Introduction
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Although intrathoracic neurogenic tumors are the most common mediastinal tumor, they usually are located posteriorly and the site of origin is an intercostal nerve or the sympathetic chain. Primary tumors of the intrathoracic vagus nerve are rare and usually benign [1]. A case is presented in which a malignant schwannoma was removed from the right intrathoracic vagus nerve using video-assisted thoracoscopic techniques with no recurrence at 18 months.
A 61-year-old woman with Sjogren's syndrome was evaluated for recent onset of cough. Her cough was nonproductive and she denied fever, night sweats, and weight loss. She had no evidence or family history of Von Recklinghausen's disease.
A chest film revealed a right paratracheal mass. Magnetic resonance imaging delineated the mass as being well-encapsulated and separate from the mediastinal vascular structures (Fig 1
).
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Fig 1.. T1-weighted magnetic resonance image shows a well-encapsulated mass, separate frommediastinal vascular structures.
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Operation was advised and right video-assisted thoracoscopy was performed using a 0-degree thoracoscope and a three-chip camera system (Stryker Endoscopy, San Jose, CA). When the thorax was entered, a solitary mediastinal tumor was readily apparent, posterior and lateral to the superior vena cava, originating from the vagus nerve (Fig 2). The tumor was firm and rubbery, measuring 6 x 3.5 x 2 cm. Complete excision was performed with proximal and distal division of the vagus nerve.
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Fig 2.. Operative photograph shows a solitary mediastinal mass, posterior and lateral to the superior venacava, originating from the vagus nerve.
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Histologically, the diagnosis of a malignant nerve sheath tumor with glandular differentiation was made by the appearance of predominately spindle cells with elongated nuclei and multiple mitotic figures (Fig 3A). The glandular differentiation was complex, with a cribriform pattern and large nuclei, consistent with malignant-appearing glands (Fig 3B).
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Fig 3.. (A) Microscopic findings of a malignant nerve sheath tumor showing spindle cells with elongatednuclei and multiple mitotic figures. (B) Microscopic findings of malignant glandular differentiationwithin the same tumor. (Both, hematoxylin and eosin; x400 before 28% reduction.)
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The patient's postoperative recovery was uneventful, and she was discharged on the second postoperative day. She received a total of 60 Gy of postoperative radiation therapy. At 18 months she has no clinical or radiographic evidence of recurrence.
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Comment
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Vagal nerve sheath tumors are rare, occurring usually along the proximal, thickest part of the nerve before the origin of its major intrathoracic branches [2]. The fact that the recurrent laryngeal nerve arises lower in the thoracic cavity on the left is believed to account for the observation that vagal nerve tumors occur twice as often on the left as on the right. Schwannomas (neurilemmomas) are typically solitary and encapsulated, whereas neurofibromas may be multiple and usually are not encapsulated. Malignant nerve sheath tumors are common in Von Recklinghausen's disease (50%); however, that leaves 50% to occur sporadically [3].
A review of the literature in 1990 by Dabir and associates [1] found 27 reported cases of intrathoracic vagal nerve tumors, mostly benign, to which the authors added 2 cases. In 1991, Davis and associates [4] reported an additional case of a (benign) schwannoma of the intrathoracic vagus nerve. To these, I wish to add this rare case of a malignant schwannoma of the right intrathoracic vagus nerve, which was completely excised using video-assisted thoracoscopic techniques.
Malignant nerve sheath tumors have a poor prognosis, with patients rarely surviving 1 year [5]. The patient presented received postoperative irradiation and was free of recurrence at 18 months.
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Addendum
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Twenty months after the operation, a recurrence developed in the mini-thoracotomy wound used to extract the tumor during thoracoscopy. No protective container had been used before the tumor was removed through the wound. The recurrent tumor was excised locally. There has been no evidence of recurrence at 24 months. This finding is important in light of recent published reports concerning tumor implantation after thoracoscopic operations [6, 7].
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Footnotes
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Address reprint requests to Dr Singer, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA 18103.
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References
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- Dabir RR, Piccione W, Kittle CF. Intrathoracic tumors of the vagus nerve. Ann Thorac Surg 1990;50:494–7.[Abstract]
- Strickland B, Wolverson MK. Intrathoracic vagus nerve tumors. Thorax 1974;29:215–22.[Abstract/Free Full Text]
- Schoene WC. The nervous system. In: Robbins SL, Cotran RS, eds. Pathologic basis of disease, 2nd ed. Philadelphia: Saunders, 1979:1530–98.
- Davis CJ, Butchart EG, Gibbs AR. Neurilemmoma of the intrathoracic vagus nerve. Eur Respir J 1991;4:508–10.[Abstract]
- Shields TW, Reynolds M. Neurogenic tumors of the thorax. Surg Clin North Am 1988;68:645–68.[Medline]
- Fry WA, Siddiqui A, Pensler JM, et al. Thoracoscopic implantation of cancer with a fatal outcome. Ann Thorac Surg 1995;59:42–5.[Abstract/Free Full Text]
- Walsh GL, Nesbitt JC. Tumor implants after thoracoscopic resection of a metastatic sarcoma. Ann Thorac Surg 1995;59:215–6.[Abstract/Free Full Text]
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Abstract
Introduction
