- Email: [email protected]
Schwannoma of the Sternum
1280
CASE REPORT MIZUNO ET AL PRIMARY SHWANNOMA OF THE STERNUM
tumors are very rare. A careful preoperative evaluation of patients is crucial. Complete surgical resection and careful hilar and mediastinal lymph node dissection should be preferred, especially in atypical carcinoid tumors. In typical carcinoid tumors, as in our case, anatomical resection is not possible, and a limited resection, together with a lymphadenectomy may be preferred. Postoperative follow-up should be more careful and frequent in such cases.
References
FEATURE ARTICLES
1. Hage R, Brutel de la Rivière A, Seldenrijk CA, Van den Bosch JMM. Update in pulmonary carcinoid tumors: a review article. Ann Surg Oncol 2003;10:697–704. 2. Rea F, Zuin A, Callegaro D, Bortolotti L, Guanella G, Sartori F. Surgical results for multiple primary lung cancers. Eur J Cardiothorac Surg 2001;20:489 –90. 3. Scott WJ. Surgical treatment of other bronchial tumors. Chest Surg Clin North Am 2003;13:111–28. 4. Nguyen BD, Roarke MC, Umfrid RP, Dutton N. Technetium99m sestamibi SPECT imaging of bilateral pulmonary carcinoid tumors. Clin Nucl Med 2000;25:546 –7. 5. DeCaro LF, Paladugu R, Benfield JR, Lovisatti L, Pak H, Teplitz RL. Typical and atypical carcinoids within the pulmonary APUD tumor spectrum. J Thorac Cardiovasc Surg 1983; 86:528 –36. 6. Beshay M, Roth TR, Stein R, Schmid AR. Synchronous bilateral typical pulmonary carcinoid tumors. Eur J Cardiothorac Surg 2003;23:251–3. 7. Sivrikoz MC, Tulay CM, Döner E, Özkan R. Synchronous bilateral typical carcinoid tumors of the lung. Thorac Cardiov Surg 2008;56:60 – 4. 8. Camargo SM, Machuca TN, Moreira ALS, Schio SM, Moreira JS, Camargo JJP. Multiple synchronous bronchial carcinoid tumors: report of a case. Thorac Cardiov Surg 2009;57:57– 62.
Schwannoma of the Sternum Tetsuya Mizuno, MD, Noriyasu Usami, MD, Tetsuo Taniguchi, MD, Koji Kawaguchi, MD, Takehiko Okagawa, MD, and Kohei Yokoi, MD Division of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
A primary sternal tumor is rare, and it is difficult to make an accurate diagnosis. We herein report a case of inAccepted for publication Sept 8, 2009. Address correspondence to Dr Yokoi, Division of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan; e-mail: [email protected].
Ann Thorac Surg 2010;89:1280 –1
traosseous schwannoma of the sternum, which was associated with various difficulties in regard to making an accurate preoperative diagnosis. A 38-year-old woman underwent a surgical resection for a sternal tumor. Preoperative radiologic images showed a well-defined, dumbbell-shaped and solid nodule in her sternum. However, a definitive diagnosis could not be obtained before the operation. The pathologic findings of the resected specimen revealed schwannoma, Antoni type A. No recurrence has been observed during her postoperative course. (Ann Thorac Surg 2010;89:1280 –1) © 2010 by The Society of Thoracic Surgeons
A
mong primary bone tumors, intraosseous schwannoma accounts for less than 0.2% [1]. These tumors typically develop in the mandible, sacrum, maxilla, fibula, ulnar, femur, vertebrae, and so forth [2]. The sternum is a considerably rare site, and only one case of sternal intraosseous schwannoma has been reported [3]. The preoperative diagnosis of the intraosseous schwannoma is challenging because of its rarity and the fact that it is not readily acknowledged by physicians. Herein we report a resected case of intraosseous shwannoma of the sternum. An asymptomatic 38-year-old woman underwent physical examinations for her ovarian cyst and the screening of her entire body. A chest computed tomographic scan showed a dumbbell-shaped, well-defined, and lowdensity nodule measuring 2.6 ⫻ 1.6 cm, which was located at the left parasternum and expanded forward into the left thoracic cavity, as well as into the bone marrow. No tumor enhancement was identified in a contrast study (Fig 1A). A magnetic resonance image showed an iso-intensity signal on T1-weighted images and a high-intensity signal on a T2-weighted image in the nodule (Fig 1B). We evaluated this tumor as most likely being a benign sternal tumor, but we could not achieve a further detailed diagnosis. A surgical resection was planned and performed for radical treatment and to obtain a definitive diagnosis. A solid, lobulated tumor was located at the back of the patient’s sternum and the second left costal cartilage, and it was attached strongly to them. An extirpation of the tumor and a partial resection of the episternum and the second costal cartilage were performed. Frozen sections
Fig 1. (A) Axial chest computed tomographic scan showing a dumbbell-shaped nodule in the patient’s left parasternum. The margin of the nodule was well-defined and smooth. (B) Axial chest magnetic resonance image demonstrating a highintensity nodule on T2-weighted image.
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.09.016
Ann Thorac Surg 2010;89:1281–3
CASE REPORT HOLLOWAY ET AL ENDOGENOUS ENDOPHTHALMITIS AFTER MRSA INFECTION
1281
Fig 2. (A) The pathological findings of a tumor that had destroyed the sternal cortex and developed forward both inside and outside of the sternum. (Hematoxylin and eosin; ⫻40). (B) The spindle-shaped cells were seen as a typical palisading pattern formation, and the tumor was diagnosed as benign schwannoma, Antoni type A. (Hematoxylin and eosin; ⫻200).
Comment In a report by Turk and colleagues [2], 3,987 primary bone tumors were collected, and in this series, intraosseous schwannoma accounted for only 0.2% of the tumors. Only one case of schwannoma developed in the sternum [3]. Although it is difficult to achieve a definitive diagnosis before surgery, some characteristic radiologic findings were suggested. At computed tomographic study, tumors may be identified as a poorly enhanced soft tissue mass accompanying a bone lytic or erosive lesion. Partial defects of the bone cortex were observed (ie, the destructive growth pattern of the tumor). A magnetic resonance image demonstrated that the tumor had iso-intense or moderately intense signals on T1-weighted images and highly intense signals on T2-weighted images. The findings of our radiologic studies were almost consistent with the patterns in previous reports regarding intraosseous schwannoma [3, 4]. The hypotheses of the development of intraosseous schwannoma by de la Monte and colleagues [5] were as follows: (1) an extraosseous tumor can cause secondary erosion of the bone; (2) a tumor can arise in the nutrient canal, (3) a tumor can arise inside the bone. In our pathologic findings, the tumor had developed excluding and destroying the cortex of the sternum, which was not suggestive of an invasive proliferation. Although the tumor was dumbbell-shaped, we could not distinguish the intraosseous tumor from the extraosseous one. In addition, we did not recognize any findings that the tumor had developed from the intercostal nerve. In making a differential diagnosis of sternal tumors, we should therefore also be aware of this benign tumor. It is commonly believed that the prognosis of patients with © 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
this tumor is favorable after a complete resection. When the clinical and radiologic findings suggest a sternal schwannoma, it may thus be reasonable to proceed to a surgical resection without a preoperative histologic examination to make a definitive diagnosis and to perform radical treatment.
References 1. Fawcet KJ, Dahlin DC. Neurilemmoma of bone. Am J Clin Pathol 1967;47:759 – 66. 2. Turk PS, Peters N, Libbey NP, Wanebo HJ. Diagnosis and management of giant intrasacral schwannoma. Cancer 1992; 70:2650 –7. 3. Tanaka K, Okuda K, Ochi M. Intraosseous neurilemoma of the sternum. Ann Thorac Surg 1999;67:1474 – 6. 4. Mutema GK, Sorger J. Intraosseous schwannoma of the humerus. Skeltal Radiol 2002;31:419 –21. 5. de la Monte SM, Dorfman HD, Chandra R, Malawer M. Intraosseous schwannoma: Histologic feature, ultrastructure, and review of the literature. Hum Pathol 1984;15:551– 8.
Endogenous Endophthalmitis After Methicillin-Resistant Staphylococcus aureus Sternal Wound Infection Edward S. Holloway, MRCS, Richard W. D. Pilling, MRCS, and Ralph W. White, FRCS(CTh) Department of Cardiothoracic Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, United Kingdom
Endogenous endophthalmitis is an extremely rare but sight-threatening complication of cardiac surgery. A high index of suspicion, prompt diagnosis and treatment, and early involvement of the ophthalmic surgeon is essential. We describe what we believe is the first case of endophthalmitis in a cardiac surgical patient with a methicillinresistant Staphylococcus aureus wound infection. (Ann Thorac Surg 2010;89:1281–3) © 2010 by The Society of Thoracic Surgeons
Accepted for publication Aug 26, 2009. Address correspondence to Dr Holloway, 26 Kirkstall Ave, Leeds, Yorkshire, LS5 3DW, United Kingdom; e-mail: [email protected].
0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.08.065
FEATURE ARTICLES
of the resected specimen demonstrated that it was schwannoma. Pathologic examination revealed that the tumor was not encapsulated while excluding any neighboring tissues. No signs of invasion were observed. Microscopically, the tumor was predominantly composed of spindle-shaped cells arranged in a typical palisading pattern that was compatible with schwannoma, Antoni type A. The tumor was found to have destroyed the cortex of the sternum and proceeded forward to the bone marrow and outside of the bone (Figs 2A, 2B). A microscopic observation indicated no involvement of the intercostal nerve. The patient is alive without relapse 3 years after the operation.
CASE REPORT MIZUNO ET AL PRIMARY SHWANNOMA OF THE STERNUM
tumors are very rare. A careful preoperative evaluation of patients is crucial. Complete surgical resection and careful hilar and mediastinal lymph node dissection should be preferred, especially in atypical carcinoid tumors. In typical carcinoid tumors, as in our case, anatomical resection is not possible, and a limited resection, together with a lymphadenectomy may be preferred. Postoperative follow-up should be more careful and frequent in such cases.
References
FEATURE ARTICLES
1. Hage R, Brutel de la Rivière A, Seldenrijk CA, Van den Bosch JMM. Update in pulmonary carcinoid tumors: a review article. Ann Surg Oncol 2003;10:697–704. 2. Rea F, Zuin A, Callegaro D, Bortolotti L, Guanella G, Sartori F. Surgical results for multiple primary lung cancers. Eur J Cardiothorac Surg 2001;20:489 –90. 3. Scott WJ. Surgical treatment of other bronchial tumors. Chest Surg Clin North Am 2003;13:111–28. 4. Nguyen BD, Roarke MC, Umfrid RP, Dutton N. Technetium99m sestamibi SPECT imaging of bilateral pulmonary carcinoid tumors. Clin Nucl Med 2000;25:546 –7. 5. DeCaro LF, Paladugu R, Benfield JR, Lovisatti L, Pak H, Teplitz RL. Typical and atypical carcinoids within the pulmonary APUD tumor spectrum. J Thorac Cardiovasc Surg 1983; 86:528 –36. 6. Beshay M, Roth TR, Stein R, Schmid AR. Synchronous bilateral typical pulmonary carcinoid tumors. Eur J Cardiothorac Surg 2003;23:251–3. 7. Sivrikoz MC, Tulay CM, Döner E, Özkan R. Synchronous bilateral typical carcinoid tumors of the lung. Thorac Cardiov Surg 2008;56:60 – 4. 8. Camargo SM, Machuca TN, Moreira ALS, Schio SM, Moreira JS, Camargo JJP. Multiple synchronous bronchial carcinoid tumors: report of a case. Thorac Cardiov Surg 2009;57:57– 62.
Schwannoma of the Sternum Tetsuya Mizuno, MD, Noriyasu Usami, MD, Tetsuo Taniguchi, MD, Koji Kawaguchi, MD, Takehiko Okagawa, MD, and Kohei Yokoi, MD Division of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
A primary sternal tumor is rare, and it is difficult to make an accurate diagnosis. We herein report a case of inAccepted for publication Sept 8, 2009. Address correspondence to Dr Yokoi, Division of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan; e-mail: [email protected].
Ann Thorac Surg 2010;89:1280 –1
traosseous schwannoma of the sternum, which was associated with various difficulties in regard to making an accurate preoperative diagnosis. A 38-year-old woman underwent a surgical resection for a sternal tumor. Preoperative radiologic images showed a well-defined, dumbbell-shaped and solid nodule in her sternum. However, a definitive diagnosis could not be obtained before the operation. The pathologic findings of the resected specimen revealed schwannoma, Antoni type A. No recurrence has been observed during her postoperative course. (Ann Thorac Surg 2010;89:1280 –1) © 2010 by The Society of Thoracic Surgeons
A
mong primary bone tumors, intraosseous schwannoma accounts for less than 0.2% [1]. These tumors typically develop in the mandible, sacrum, maxilla, fibula, ulnar, femur, vertebrae, and so forth [2]. The sternum is a considerably rare site, and only one case of sternal intraosseous schwannoma has been reported [3]. The preoperative diagnosis of the intraosseous schwannoma is challenging because of its rarity and the fact that it is not readily acknowledged by physicians. Herein we report a resected case of intraosseous shwannoma of the sternum. An asymptomatic 38-year-old woman underwent physical examinations for her ovarian cyst and the screening of her entire body. A chest computed tomographic scan showed a dumbbell-shaped, well-defined, and lowdensity nodule measuring 2.6 ⫻ 1.6 cm, which was located at the left parasternum and expanded forward into the left thoracic cavity, as well as into the bone marrow. No tumor enhancement was identified in a contrast study (Fig 1A). A magnetic resonance image showed an iso-intensity signal on T1-weighted images and a high-intensity signal on a T2-weighted image in the nodule (Fig 1B). We evaluated this tumor as most likely being a benign sternal tumor, but we could not achieve a further detailed diagnosis. A surgical resection was planned and performed for radical treatment and to obtain a definitive diagnosis. A solid, lobulated tumor was located at the back of the patient’s sternum and the second left costal cartilage, and it was attached strongly to them. An extirpation of the tumor and a partial resection of the episternum and the second costal cartilage were performed. Frozen sections
Fig 1. (A) Axial chest computed tomographic scan showing a dumbbell-shaped nodule in the patient’s left parasternum. The margin of the nodule was well-defined and smooth. (B) Axial chest magnetic resonance image demonstrating a highintensity nodule on T2-weighted image.
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.09.016
Ann Thorac Surg 2010;89:1281–3
CASE REPORT HOLLOWAY ET AL ENDOGENOUS ENDOPHTHALMITIS AFTER MRSA INFECTION
1281
Fig 2. (A) The pathological findings of a tumor that had destroyed the sternal cortex and developed forward both inside and outside of the sternum. (Hematoxylin and eosin; ⫻40). (B) The spindle-shaped cells were seen as a typical palisading pattern formation, and the tumor was diagnosed as benign schwannoma, Antoni type A. (Hematoxylin and eosin; ⫻200).
Comment In a report by Turk and colleagues [2], 3,987 primary bone tumors were collected, and in this series, intraosseous schwannoma accounted for only 0.2% of the tumors. Only one case of schwannoma developed in the sternum [3]. Although it is difficult to achieve a definitive diagnosis before surgery, some characteristic radiologic findings were suggested. At computed tomographic study, tumors may be identified as a poorly enhanced soft tissue mass accompanying a bone lytic or erosive lesion. Partial defects of the bone cortex were observed (ie, the destructive growth pattern of the tumor). A magnetic resonance image demonstrated that the tumor had iso-intense or moderately intense signals on T1-weighted images and highly intense signals on T2-weighted images. The findings of our radiologic studies were almost consistent with the patterns in previous reports regarding intraosseous schwannoma [3, 4]. The hypotheses of the development of intraosseous schwannoma by de la Monte and colleagues [5] were as follows: (1) an extraosseous tumor can cause secondary erosion of the bone; (2) a tumor can arise in the nutrient canal, (3) a tumor can arise inside the bone. In our pathologic findings, the tumor had developed excluding and destroying the cortex of the sternum, which was not suggestive of an invasive proliferation. Although the tumor was dumbbell-shaped, we could not distinguish the intraosseous tumor from the extraosseous one. In addition, we did not recognize any findings that the tumor had developed from the intercostal nerve. In making a differential diagnosis of sternal tumors, we should therefore also be aware of this benign tumor. It is commonly believed that the prognosis of patients with © 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
this tumor is favorable after a complete resection. When the clinical and radiologic findings suggest a sternal schwannoma, it may thus be reasonable to proceed to a surgical resection without a preoperative histologic examination to make a definitive diagnosis and to perform radical treatment.
References 1. Fawcet KJ, Dahlin DC. Neurilemmoma of bone. Am J Clin Pathol 1967;47:759 – 66. 2. Turk PS, Peters N, Libbey NP, Wanebo HJ. Diagnosis and management of giant intrasacral schwannoma. Cancer 1992; 70:2650 –7. 3. Tanaka K, Okuda K, Ochi M. Intraosseous neurilemoma of the sternum. Ann Thorac Surg 1999;67:1474 – 6. 4. Mutema GK, Sorger J. Intraosseous schwannoma of the humerus. Skeltal Radiol 2002;31:419 –21. 5. de la Monte SM, Dorfman HD, Chandra R, Malawer M. Intraosseous schwannoma: Histologic feature, ultrastructure, and review of the literature. Hum Pathol 1984;15:551– 8.
Endogenous Endophthalmitis After Methicillin-Resistant Staphylococcus aureus Sternal Wound Infection Edward S. Holloway, MRCS, Richard W. D. Pilling, MRCS, and Ralph W. White, FRCS(CTh) Department of Cardiothoracic Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, United Kingdom
Endogenous endophthalmitis is an extremely rare but sight-threatening complication of cardiac surgery. A high index of suspicion, prompt diagnosis and treatment, and early involvement of the ophthalmic surgeon is essential. We describe what we believe is the first case of endophthalmitis in a cardiac surgical patient with a methicillinresistant Staphylococcus aureus wound infection. (Ann Thorac Surg 2010;89:1281–3) © 2010 by The Society of Thoracic Surgeons
Accepted for publication Aug 26, 2009. Address correspondence to Dr Holloway, 26 Kirkstall Ave, Leeds, Yorkshire, LS5 3DW, United Kingdom; e-mail: [email protected].
0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.08.065
FEATURE ARTICLES
of the resected specimen demonstrated that it was schwannoma. Pathologic examination revealed that the tumor was not encapsulated while excluding any neighboring tissues. No signs of invasion were observed. Microscopically, the tumor was predominantly composed of spindle-shaped cells arranged in a typical palisading pattern that was compatible with schwannoma, Antoni type A. The tumor was found to have destroyed the cortex of the sternum and proceeded forward to the bone marrow and outside of the bone (Figs 2A, 2B). A microscopic observation indicated no involvement of the intercostal nerve. The patient is alive without relapse 3 years after the operation.