Ann Thorac Surg 2004;78:713-714
© 2004 The Society of Thoracic Surgeons
Case report
Peripheral tumors of the intercostal nerves
James H. McClenathan, MDa*,
Richard J. Bloom, MDa
a Department of Surgery, Kaiser Permanente Medical Center, Santa Clara, California, USA
Accepted for publication September 4, 2003.
* Address reprint requests to Dr McClenathan, Department of Surgery, Kaiser Permanente Medical Center, 900 Kiely Blvd, Santa Clara, CA 95051-5386, USA
e-mail: james.mcclenathan{at}kp.org
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Abstract
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Fewer than 10% of primary neural tumors of the chest originate peripherally from intercostal nerves; most neural tumors of the chest arise in the mediastinum. Most patients with primary tumors of the intercostal nerve are asymptomatic. We report a case of neurilemmoma arising from an intercostal nerve in a woman seen for severe pain in the chest wall. Resecting the tumor relieved the pain. Recent medical literature describing peripheral tumors of thoracic nerves is reviewed.
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Introduction
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Primary neural tumors can affect any peripheral nerve—including peripheral branches of cranial nerves—and can be benign, malignant, symptomatic, or asymptomatic. We recently treated a patient with an intrathoracic neurilemmoma that originated from an intercostal nerve.
A 62-year-old woman was admitted to the hospital for removal of a neurilemmoma in the right side of the chest wall after a decade of intermittent sharp discomfort across the right side of the chest wall. The pain had become more severe in the 2 years before the surgical procedure. Preoperative physical examination showed point tenderness above the right seventh rib laterally. Preoperative chest radiography (Fig 1) and computed tomography (Fig 2) showed a 2-cm tumor located laterally in the right side of the chest. Computed tomography-guided needle biopsy was performed, and results of pathology examination of the aspirate showed cellular neurilemmoma. Video-assisted minithoracotomy showedan extrapleural mass, which was then excised completely (Fig 3). The patient's chest pain resolved postoperatively.
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Fig 3. Photograph of a bivalved operative specimen showing intercostal nerve at both ends of the specimen.
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Comment
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Three large case series [1–3] described 326 patients with thoracic neural tumors, 308 (90%) of which originated in the mediastinum and only 18 (5%) of which arose laterally from intercostal nerves [1–3]. No information about patient demographics or clinical presentation, examination (clinical or laboratory), or treatment was available for these 18 tumors. Additional individual case reports (citations available from the authors) bring the number of neural tumors arising from intercostal nerves to 33 tumors in 32 patients—neurilemmoma in 22, neurofibroma in 6, malignant neurilemmoma in 2, paraganglioma in 2, and primitive neuroectodermal tumor in 1 patient. Patient data included age of patients (range, newborn to 67 years), tumor location on right or left side of thorax (nearly equal distribution), tumor size (range, 1 to 12 cm), and symptoms (intractable or chronic pain, 3 patients; bleeding into chest, 1 patient; no symptoms, 8 patients; not reported, 1 patient). Analysis of medical records at our medical center identified no additional patients with this condition.
During treatment for an intercostal neural tumor, a 7-cm malignant neurilemmoma and a small adjacent neurofibroma were found in a patient with neurofibromatosis [4]. A report of familial neurilemmomatosis [5] described multiple neurilemomas in a woman and in her 16-year-old daughter, who had 1 neurilemmoma removed from the vagus nerve, 1 from an intercostal nerve, and 1 from an area adjacent to the serratus anterior muscle.
In our previous review of nonmediastinal neural tumors (ie, those originating in the diaphragm), 30% of patients had clubbing of the fingers. Intercostal nerve tumors do not cause clubbing of the fingers.
All patients in our series underwent plain chest radiography, but patients examined during the early part ofthe study period also received tomograms or diagnostic pneumothorax. Currently, most patients are studied with either computed tomographic scanning or magnetic resonance imaging or with both. Either fine-needle cytology or incisional biopsy is sometimes used to establish the diagnosis and to determine extent of necessary resection.
All patients in this study were treated with surgical resection. The patients with primitive neuroectodermal tumor [6], malignant neurilemmoma [4, 7], and paraganglioma [8] were treated with chest wall resection which included a wide margin around the tumor; nonetheless, primitive neuroectodermal tumor caused death in 1 patient [6]. One patient with malignant neurilemmoma had local recurrence of the disease, which later resolved after treatment with wider excision and radiotherapy [7]. Most of the smaller tumors in the patients studied were treated with thoracoscopic surgery. No patients treated for neurilemmoma or neurofibroma had recurrence of tumor.
Peripheral tumors of the intercostal nerves are less common than neural tumors arising in the mediastinum, occur in persons of any age, and often cause no symptoms. When symptomatic, these tumors usually cause radicular pain distributed along the course of the affected nerve. For most patients with persistent chest pain of obscure etiology, examination should include plain chest radiography and either computed tomographic or magnetic resonance imaging scanning to rule out or identify peripheral tumors of intercostal nerves. Fine-needle cytology can often establish the diagnosis. Local resection is sufficient treatment for most of the smaller peripheral tumors of intercostal nerve. Thoracoscopy is usually the preferred surgical approach. Larger or more aggressive tumors require resection of the chest wall.
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Acknowledgments
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The Kaiser Foundation Hospitals, Inc, Medical Editing Department provided editorial assistance.
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References
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- Oosterwijk W.M., Swierenga J. Neurogenic tumours with an intrathoracic localization. Thorax 1968;23:374-384.[Abstract/Free Full Text]
- Reed J.C., Hallet K.K., Feigin D.S. Neural tumors of the thorax: subject review from the AFIP. Radiology 1978;126:9-17.[Abstract]
- Davidson K.G., Walbaum P.R., McCormack R.J. Intrathoracic neural tumours. Thorax 1978;33:359-367.[Abstract/Free Full Text]
- Molenaar W.M., Ladde B.E., Schraffordt Koops H., Dam-Meiring A. Two epithelioid malignant schwannomas in a patient with neurofibromatosis. Cytology, histology and DNA-flow-cytometry. Pathol Res Pract 1989;184:529-534.[Medline]
- Iwabuchi S., Tanita T., Koike K., Fujimura S. Familial neurilemmomatosis: report of a case. Surg Today 1993;23:816-819.[Medline]
- Das L., Chang C.H., Cushing B., Jewell P. Congenital primitive neuroectodermal tumor (neuroepithelioma) of the chest wall. Med Pediatr Oncol 1982;10:349-358.[Medline]
- Chen K.T., Latorraca R., Fabich D., Padgug A., Hafez G.R., Gilbert E.F. Malignant schwannoma: a light microscopic and ultrastructural study. Cancer 1980;45:1585-1593.[Medline]
- Smalley J.J., Gallagher W.B., Nichols C.P. Paraganglioma simulating primary rib tumor. Arch Surg 1977;112:323-325.[Abstract/Free Full Text]
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Abstract
Introduction
