Ann Thorac Surg 2006;82:e26
© 2006 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Asymptomatic Giant Thoracic Schwannoma
Sanjay Kumar, MCh, FRCS,
Muhammad U. Rafiq, MBBS,
Imthiaz Ahamed, MBBS,
Junaid Ansari, FRCS, CTh,
Michael E. Cowen, FRCS*
East Yorkshire Heart Centre, Castle Hill Hospital, Hull, United Kingdom
* Address correspondence to Mr Cowen, East Yorkshire Heart Centre, Castle Hill Hospital, Hull HU16 5JQ, United Kingdom (Email: sanjaykr33{at}hotmail.com).
Schwannoma is the most common nerve sheath tumor in the posterior mediastinum. The majority of patients with this type of tumor are asymptomatic. Up to 11.7% of patients have been reported to be symptomatic based on the size and location of the tumor [1]. Magnetic resonance imaging (MRI) accurately describes the extension and any intraspinal component of the tumor and assists in choosing the appropriate surgical approach [2]. We illustrate a case of the largest thoracic schwannoma reported in the English literature, to our knowledge.
A 59-year-old woman was incidentally found to have a large soft tissue opacity in the right hemithorax obliterating the right cardiac border on chest x-ray postero-anterior view (Fig 1). A chest computerized axial tomography (CT) scan with contrast showed a 14 cm x 15 cm x 19 cm heterogeneous mass with a thin capsule and flecks of calcification arising from within the right hemithorax. After the CT scan, a MRI scan was done. The MRI thorax axial T2 and sagittal T2 (respectively) showed an enormous well-circumscribed, heterogeneous, and encapsulated soft tissue mass filling the right hemithorax. The lesion abutted the right T6 exit foramen containing soft tissue, suggestive of a nerve sheath tumor. There was no evidence of invasion of the epidural space, vertebral pedicle, or ribs (Fig 2
[A] FH = foot and head; L = left; SI = slice; [B] P = posterior). A CT-guided needle biopsy of the tumor had the appearance of a neural tumor favoring a schwannoma with no convincing features of malignancy.
The patient underwent right posterolateral thoracotomy. A well-encapsulated mass weighing 2040 g and measuring 14 cm x 15 cm x 19 cm was excised. The tumor had a large vascular pedicle derived from the 5th right posterior intercostal artery. The right lower lobe of the lung was collapsed and densely adherent to the capsule of the tumor. Hence, right lower lobectomy was performed. The medium power view (hematoxylin and eosin) section of the mass showed an encapsulated lesion of variable cellularity containing interlacing fascicles of spindle cells, nuclear palisading, and a whorled organoid appearance (Fig 3). Occasional pleomorphic nuclei were present with extremely low mitotic rate. The features were those of a neurilemmoma (schwannoma). The immunohistochemistry (Fig 3, inset) showing strong positive staining for S100 protein confirmed this. Her postoperative recovery was uneventful.
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References
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- Yamaguchi M, Yoshino I, Fukuyama S, et al. Surgical treatment of neurogenic tumors of the chest Ann Thorac Cardiovasc Surg 2004;10:148-151.[Medline]
- Takeda S, Miyoshi S, Minami M, Matsuda H. Intrathoracic neurogenic tumors—50 years' experience in a Japanese institution Eur J Cardiothorac Surg 2004;26:807-812.[Abstract/Free Full Text]
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