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Thoracoscopic excision of a malignant schwannoma of the intrathoracic vagus nerve
1586
CASEREPORT SINGER MALIGNANTSCHWANNOMA
Ann Thorac Surg 1995;59:1586-7
amyloidoma: histologic proof yielded by transthoracic coaxial fine needle biopsy. Chest 1992;102:1597-8. 6. Cathcart E, Ritchie R, Brandt K. Immunoglobulins and amyloidosis: an immunologic study of 62 patients with biopsy proven disease. Am J Med 1972;52:93-101.
Thoracoscopic Excision of a Malignant Schwannoma of the Intrathoracic Vagus Nerve R a y m o n d L. Singer, MD Division of Cardiothoracic Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania Malignant s c h w a n n o m a s of the intrathoracic vagus nerve are rare tumors. A patient u n d e r w e n t resection of a mediastinal malignant s c h w a n n o m a of the vagus nerve using video-assisted thoracoscopy, w i t h no recurrence at 18 months. (Ann Thorac Surg 1995;59:1586-7)
lthough intrathoracic neurogenic t u m o r s are the most c o m m o n mediastinal tumor, they usually are located posteriorly a n d the site of origin is an intercostal nerve or the sympathetic chain. Primary t u m o r s of the intrathoracic vagus nerve are rare a n d usually benign [1]. A case is p r e s e n t e d in which a m a l i g n a n t s c h w a n n o m a was r e m o v e d from the right intrathoracic vagus nerve using video-assisted thoracoscopic techniques with no recurrence at 18 months.
A
Fig 1. Tl-weighted magnetic resonance image shows a well-encapsulated mass, separate from mediastinal vascular structures.
the a p p e a r a n c e of p r e d o m i n a t e l y spindle cells with elongated nuclei a n d multiple mitotic figures (Fig 3A). The glandular differentiation was complex, with a cribriform pattern a n d large nuclei, consistent with malignanta p p e a r i n g glands (Fig 3B). The p a t i e n t ' s postoperative recovery was uneventful, a n d she was discharged on the second postoperative day. She received a total of 60 G y of postoperative radiation therapy. At 18 m o n t h s she has no clinical or radiographic evidence of recurrence. Comment
A 61-year-old w o m a n with Sjogren's s y n d r o m e was evalu a t e d for recent onset of cough. Her cough was n o n p r o ductive a n d she d e n i e d fever, night sweats, and weight loss. She h a d no evidence or family history of Von Recklinghausen's disease. A chest film revealed a right paratracheal mass. Magnetic resonance i m a g i n g d e l i n e a t e d the mass as b e i n g w e l l - e n c a p s u l a t e d a n d separate from the mediastinal vascular structures (Fig 1). O p e r a t i o n was advised a n d right video-assisted thoracoscopy was p e r f o r m e d using a 0-degree thoracoscope a n d a three-chip camera system (Stryker Endoscopy, San Jose, CA). W h e n the thorax was entered, a solitary mediastinal t u m o r was readily apparent, posterior a n d lateral to the s u p e r i o r vena cava, originating from the vagus nerve (Fig 2). The t u m o r was firm a n d rubbery, m e a s u r i n g 6 × 3.5 × 2 crn. Complete excision was p e r f o r m e d with proximal and distal division of the vagus nerve. Histologically, the diagnosis of a m a l i g n a n t nerve sheath t u m o r with glandular differentiation was m a d e by
Vagal nerve sheath t u m o r s are rare, occurring usually along the proximal, thickest part of the nerve before the origin of its major intrathoracic b r a n c h e s [2]. The fact that the recurrent laryngeal nerve arises lower in the thoracic cavity on the left is b e l i e v e d to account for the observation that vagal nerve tumors occur twice as often on the
Accepted for publication Nov 3, 1994. Address reprint requests to Dr Singer, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA 18103.
Fig 2. Operative photograph shows a solitary mediastinal mass, posterior and lateral to the superior vena cava, originating from the vagus nerve.
© 1995 by The Society of Thoracic Surgeons
0003-4975/95/$9.50 0003-4975(94)00972-A
Ann Thorac Surg 1995;59:1586-7
CASE REPORT SINGER MALIGNANT SCHWANNOMA
1587
A r e v i e w of t h e literature in 1990 b y D a b i r a n d associates [1] f o u n d 27 r e p o r t e d cases of i n t r a t h o r a c i c v a g a l n e r v e t u m o r s , m o s t l y b e n i g n , to w h i c h the a u t h o r s a d d e d 2 cases. In 1991, D a v i s a n d associates [4] r e p o r t e d an a d d i t i o n a l case of a (benign) s c h w a n n o r n a of t h e intrathoracic v a g u s nerve. To these, I w i s h to a d d this rare case of a m a l i g n a n t s c h w a n n o m a of the right i n t r a t h o racic v a g u s nerve, w h i c h was c o m p l e t e l y excised u s i n g video-assisted thoracoscopic techniques. Malignant nerve sheath tumors have a poor prognosis, w i t h p a t i e n t s rarely s u r v i v i n g 1 y e a r [5]. The p a t i e n t p r e s e n t e d r e c e i v e d p o s t o p e r a t i v e i r r a d i a t i o n a n d was free of r e c u r r e n c e at 18 m o n t h s . A
Addendum 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].
References
B Fig 3. (A) Microscopic findings of a malignant nerve sheath tumor showing spindle cells with elongated nuclei and multiple mitotic figures. (B) Microscopic findings of malignant glandular differentiation within the same tumor. (Both, hematoxylin and eosin; ×400 before 28% reduction.) left as on the right. S c h w a n n o m a s ( n e u r i l e m m o m a s ) are typically solitary a n d e n c a p s u l a t e d , w h e r e a s n e u r o f i b r o m a s m a y be m u l t i p l e a n d u s u a l l y are n o t e n c a p s u l a t e d . M a l i g n a n t n e r v e s h e a t h t u m o r s are c o m m o n in V o n R e c k l i n g h a u s e n ' s d i s e a s e (50%); h o w e v e r , that l e a v e s 50% to occur sporadically [3].
1. Dabir RR, Piccione W, Kittle CF. Intrathoracic tumors of the vagus nerve. Ann Thorac Surg 1990;50:494-7. 2. Strickland B, Wolverson MK. Intrathoracic vagus nerve tumors. Thorax 1974;29:215-22. 3. Schoene WC. The nervous system. In: Robbins SL, Cotran RS, eds. Pathologic basis of disease, 2nd ed. Philadelphia: Saunders, 1979:1530-98. 4. Davis CJ, Butchart EG, Gibbs AR. Neurilemmoma of the intrathoracic vagus nerve. Eur Respir J 1991;4:508-10. 5. Shields TW, Reynolds M. Neurogenic tumors of the thorax. Surg Clin North Am 1988;68:645-68. 6. Fry WA, Siddiqui A, Pensler JM, et al. Thoracoscopic implantation of cancer with a fatal outcome. Ann Thorac Surg 1995;59:42-5. 7. Walsh GL, Nesbitt JC. Tumor implants after thoraeoscopic resection of a metastatic sarcoma. Ann Thorac Surg 1995;59: 215-6.
CASEREPORT SINGER MALIGNANTSCHWANNOMA
Ann Thorac Surg 1995;59:1586-7
amyloidoma: histologic proof yielded by transthoracic coaxial fine needle biopsy. Chest 1992;102:1597-8. 6. Cathcart E, Ritchie R, Brandt K. Immunoglobulins and amyloidosis: an immunologic study of 62 patients with biopsy proven disease. Am J Med 1972;52:93-101.
Thoracoscopic Excision of a Malignant Schwannoma of the Intrathoracic Vagus Nerve R a y m o n d L. Singer, MD Division of Cardiothoracic Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania Malignant s c h w a n n o m a s of the intrathoracic vagus nerve are rare tumors. A patient u n d e r w e n t resection of a mediastinal malignant s c h w a n n o m a of the vagus nerve using video-assisted thoracoscopy, w i t h no recurrence at 18 months. (Ann Thorac Surg 1995;59:1586-7)
lthough intrathoracic neurogenic t u m o r s are the most c o m m o n mediastinal tumor, they usually are located posteriorly a n d the site of origin is an intercostal nerve or the sympathetic chain. Primary t u m o r s of the intrathoracic vagus nerve are rare a n d usually benign [1]. A case is p r e s e n t e d in which a m a l i g n a n t s c h w a n n o m a was r e m o v e d from the right intrathoracic vagus nerve using video-assisted thoracoscopic techniques with no recurrence at 18 months.
A
Fig 1. Tl-weighted magnetic resonance image shows a well-encapsulated mass, separate from mediastinal vascular structures.
the a p p e a r a n c e of p r e d o m i n a t e l y spindle cells with elongated nuclei a n d multiple mitotic figures (Fig 3A). The glandular differentiation was complex, with a cribriform pattern a n d large nuclei, consistent with malignanta p p e a r i n g glands (Fig 3B). The p a t i e n t ' s postoperative recovery was uneventful, a n d she was discharged on the second postoperative day. She received a total of 60 G y of postoperative radiation therapy. At 18 m o n t h s she has no clinical or radiographic evidence of recurrence. Comment
A 61-year-old w o m a n with Sjogren's s y n d r o m e was evalu a t e d for recent onset of cough. Her cough was n o n p r o ductive a n d she d e n i e d fever, night sweats, and weight loss. She h a d no evidence or family history of Von Recklinghausen's disease. A chest film revealed a right paratracheal mass. Magnetic resonance i m a g i n g d e l i n e a t e d the mass as b e i n g w e l l - e n c a p s u l a t e d a n d separate from the mediastinal vascular structures (Fig 1). O p e r a t i o n was advised a n d right video-assisted thoracoscopy was p e r f o r m e d using a 0-degree thoracoscope a n d a three-chip camera system (Stryker Endoscopy, San Jose, CA). W h e n the thorax was entered, a solitary mediastinal t u m o r was readily apparent, posterior a n d lateral to the s u p e r i o r vena cava, originating from the vagus nerve (Fig 2). The t u m o r was firm a n d rubbery, m e a s u r i n g 6 × 3.5 × 2 crn. Complete excision was p e r f o r m e d with proximal and distal division of the vagus nerve. Histologically, the diagnosis of a m a l i g n a n t nerve sheath t u m o r with glandular differentiation was m a d e by
Vagal nerve sheath t u m o r s are rare, occurring usually along the proximal, thickest part of the nerve before the origin of its major intrathoracic b r a n c h e s [2]. The fact that the recurrent laryngeal nerve arises lower in the thoracic cavity on the left is b e l i e v e d to account for the observation that vagal nerve tumors occur twice as often on the
Accepted for publication Nov 3, 1994. Address reprint requests to Dr Singer, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA 18103.
Fig 2. Operative photograph shows a solitary mediastinal mass, posterior and lateral to the superior vena cava, originating from the vagus nerve.
© 1995 by The Society of Thoracic Surgeons
0003-4975/95/$9.50 0003-4975(94)00972-A
Ann Thorac Surg 1995;59:1586-7
CASE REPORT SINGER MALIGNANT SCHWANNOMA
1587
A r e v i e w of t h e literature in 1990 b y D a b i r a n d associates [1] f o u n d 27 r e p o r t e d cases of i n t r a t h o r a c i c v a g a l n e r v e t u m o r s , m o s t l y b e n i g n , to w h i c h the a u t h o r s a d d e d 2 cases. In 1991, D a v i s a n d associates [4] r e p o r t e d an a d d i t i o n a l case of a (benign) s c h w a n n o r n a of t h e intrathoracic v a g u s nerve. To these, I w i s h to a d d this rare case of a m a l i g n a n t s c h w a n n o m a of the right i n t r a t h o racic v a g u s nerve, w h i c h was c o m p l e t e l y excised u s i n g video-assisted thoracoscopic techniques. Malignant nerve sheath tumors have a poor prognosis, w i t h p a t i e n t s rarely s u r v i v i n g 1 y e a r [5]. The p a t i e n t p r e s e n t e d r e c e i v e d p o s t o p e r a t i v e i r r a d i a t i o n a n d was free of r e c u r r e n c e at 18 m o n t h s . A
Addendum 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].
References
B Fig 3. (A) Microscopic findings of a malignant nerve sheath tumor showing spindle cells with elongated nuclei and multiple mitotic figures. (B) Microscopic findings of malignant glandular differentiation within the same tumor. (Both, hematoxylin and eosin; ×400 before 28% reduction.) left as on the right. S c h w a n n o m a s ( n e u r i l e m m o m a s ) are typically solitary a n d e n c a p s u l a t e d , w h e r e a s n e u r o f i b r o m a s m a y be m u l t i p l e a n d u s u a l l y are n o t e n c a p s u l a t e d . M a l i g n a n t n e r v e s h e a t h t u m o r s are c o m m o n in V o n R e c k l i n g h a u s e n ' s d i s e a s e (50%); h o w e v e r , that l e a v e s 50% to occur sporadically [3].
1. Dabir RR, Piccione W, Kittle CF. Intrathoracic tumors of the vagus nerve. Ann Thorac Surg 1990;50:494-7. 2. Strickland B, Wolverson MK. Intrathoracic vagus nerve tumors. Thorax 1974;29:215-22. 3. Schoene WC. The nervous system. In: Robbins SL, Cotran RS, eds. Pathologic basis of disease, 2nd ed. Philadelphia: Saunders, 1979:1530-98. 4. Davis CJ, Butchart EG, Gibbs AR. Neurilemmoma of the intrathoracic vagus nerve. Eur Respir J 1991;4:508-10. 5. Shields TW, Reynolds M. Neurogenic tumors of the thorax. Surg Clin North Am 1988;68:645-68. 6. Fry WA, Siddiqui A, Pensler JM, et al. Thoracoscopic implantation of cancer with a fatal outcome. Ann Thorac Surg 1995;59:42-5. 7. Walsh GL, Nesbitt JC. Tumor implants after thoraeoscopic resection of a metastatic sarcoma. Ann Thorac Surg 1995;59: 215-6.