336
CASE REPORT ISHIBASHI ET AL A GIANT SCHWANNOMA CAUSING TRACHEAL STENOSIS
Ann Thorac Surg 2014;98:336–8
Fig 3. Immunohistochemical staining 200: (A) Melan A was diffusely positive; (B) S-100 was diffusely positive.
Therefore, histopathologic and clinical findings are important for characterizing a tumor as primary pleural malignant melanoma.
References
FEATURE ARTICLES
1. Ohata Y, Haga T, Ogata S, Nakanishi K, Kawai T. Malignant amelanotic melanoma of the pleura without primary skin lesion: an autopsy case report. Acta Med Okayama 2009;63: 379–84. 2. Um SW, Yoo CG, Lee CT, Han SK, Shim YS, Kim YW. Apparent primary pleural melanoma: case report and literature review. Respir Med 2003;97:586–7. 3. Smith S, Opipari MI. Primary pleural melanoma.A first reported case and literature reivew. J Thorac Cardiovasc Surg 1978;75:827–31. 4. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74–108. 5. Wilson RW, Moran CA. Primary melanoma of the lung: a clinicopathologic and immunohistochemical study of eight cases. Am J Surg Pathol 1997;21:1196–202. 6. Dountsis A, Zisis C, Karagianni E, Dahabreh J. Primary malignant melanoma of the lung: a case report. World J Surg Oncol 2003;1:26. 7. Biddle DA, Evans HL, Kemp BL, et al. Intraparenchymal nevus cell aggregates in lymph nodes: a possible diagnostic pitfall with malignant melanoma and carcinoma. Am J Surg Pathol 2003;27:673–81.
Successful Excision of a Giant Mediastinal Vagal Schwannoma Causing Severe Tracheal Stenosis Through a Median Sternotomy Hironori Ishibashi, MD, PhD, Ken Takahashi, MD, Sachiko Kumazawa, MD, and Kenichi Okubo, MD, PhD Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
Vagal nerve schwannomas that compress the trachea are extremely rare. We report a case in which a giant middle Accepted for publication Sept 5, 2013. Address correspondence to Dr Ishibashi, Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
mediastinal schwannoma accompanied by severe tracheal stenosis was excised. A 70-year-old woman had a 30-year history of hoarseness and paralysis of the left recurrent laryngeal nerve. She presented with chronic cough and dyspnea, which she had experienced for several months. Computed tomography indicated a middle mediastinal mass (8.3 3 7.1 3 4.9 cm) that directly compressed the lower trachea, carina, both bronchi, and the left main pulmonary artery. The trachea was 4 mm in diameter at the narrowest point. Through a median sternotomy, the superior vena cava, ascending aorta, right pulmonary artery, and trachea were dissected, and the tumor was excised by gentle dissection. Histologic examination indicated a benign schwannoma. (Ann Thorac Surg 2014;98:336–8) Ó 2014 by The Society of Thoracic Surgeons
S
chwannomas are benign neurogenic tumors that arise from perineural nerves. Although schwannomas are the most common neurogenic thoracic tumors, vagal nerve schwannomas that compress the trachea are extremely rare. We report a case of successful excision of a giant middle mediastinal vagal schwannoma that caused severe tracheal stenosis. A 70-year-old woman had presented with hoarseness and paralysis of the left recurrent laryngeal nerve when she was 40 years old. She had undergone excision of schwannomas that caused neurothlipsia 7 times since the age of 47 years. The middle mediastinal tumor had been detected 2 years earlier and was monitored as a suspected schwannoma. The patient presented with chronic cough and dyspnea of several months’ duration. A chest roentgenogram showed an abnormal shadow in the mediastinum. A computed tomographic scan showed a middle mediastinal mass (8.3 7.1 4.9 cm) that directly compressed the lower trachea, carina, and both bronchi (Fig 1A). The trachea was 4 mm in diameter at the narrowest point. Bronchoscopic findings revealed severe stenosis of the lower trachea with a smooth surface, and the bronchoscope could not pass the stenosis (Fig 1B). After a team consultation among thoracic, cardiovascular, and anesthesia clinicians, a final scheduled operation was performed through a median sternotomy. The 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.028
Ann Thorac Surg 2014;98:336–8
CASE REPORT ISHIBASHI ET AL A GIANT SCHWANNOMA CAUSING TRACHEAL STENOSIS
337
Fig 1. (A) Chest computed tomographic scan showed a middle mediastinal tumor, measuring 8.3 7.1 4.9 cm, which caused severe stenosis of the trachea and left pulmonary artery. (B) Bronchoscopic findings revealed severe stenosis of the lower trachea with a smooth surface and stenosis of both bronchi. The bronchoscope could not pass the stenosis.
remains well and has no evidence of recurrence or tracheal stenosis.
Comment Schwannomas are benign nerve sheath tumors that arise from perineural Schwann cells. The tumors, which comprise Schwann cells and collagen fibers, can occur in any region of the body and are the most common neurogenic thoracic tumors [1]. Although schwannomas can involve any thoracic nerve [2], vagal nerve schwannomas are rare; moreover, there is only 1 previous case report of a vagal nerve schwannoma that compressed the trachea [3]. Direct compression of the trachea or main bronchi, or both, by a tumor can lead to total airway occlusion, whereas external compression of major blood vessels or even the heart can result in a cardiovascular catastrophe. Tracheal stenosis occurs with malignant tumors such as
Fig 2. (A) The tumor comprised compact bundles of spindle-shaped cells, and mitotic events were rare (hematoxylin and eosin, 100 magnification). (B) Immunohistochemical staining was positive for S-100 (100 magnification).
FEATURE ARTICLES
superior vena cava, ascending aorta, right main pulmonary artery, and trachea encircled the tumor, which was dissected from these structures. Finally, the tumor was divided posterior to the aorta; the right half was excised through a space between the superior vena cava and the aorta and the left half was excised through a space between the aorta and the main pulmonary artery. The tumor measured 8.0 7.5 6.0 cm and was homogeneous and hard and elastic. Microscopically, the tumor comprised compact bundles of spindle-shaped cells and rare mitotic figures. Immunohistochemical staining was positive for S-100 and negative for CD34, desmin, c-kit, and a-smooth muscle actin (Fig 2). The histologic diagnosis was benign schwannoma. The patient recovered uneventfully and was discharged on the sixth day after the operation. Bronchoscopy, performed 3 weeks after the operation, showed that there was almost no stenosis in the trachea and bronchus, and no collapse was observed during coughing (Fig 3). At 5 months after excision, she
338
CASE REPORT ICHIKI ET AL IDIOPATHIC AZYGOS VEIN ANEURYSM
Ann Thorac Surg 2014;98:338–40
schwannoma with severe tracheal stenosis through a sternotomy.
References 1. Reed JC, Hallet KK, Feigin DS. Neural tumors of the thorax: subject review from the AFIP. Radiology 1978;126:9–17. 2. Aughenbaugh GL. Thoracic manifestations of neurocutaneous diseases. Radiol Clin North Am 1984;22: 741–56. 3. Katoh J, Yoshii S, Osamu S, Hosaka S, Hashimoto R, Tada Y. Mediastinal vagal neurilemmoma causing tracheal stenosis. J Thorac Cardiovasc Surg 1995;109: 184–5. 4. Chen HC, Huang HJ, Wu CY, Lin TS, Fang HY. Esophageal schwannoma with tracheal compression. Thorac Cardiovasc Surg 2006;54:555–8.
An Idiopathic Azygos Vein Aneurysm Mimicking a Mediastinal Mass Fig 3. Findings of bronchoscopy performed 3 weeks after the operation. Almost no stenosis was noted in the trachea and bronchus, and no collapse was observed during coughing.
FEATURE ARTICLES
lung cancer, esophageal cancer, thyroid cancer, lymphoma, and thymic tumors. A benign mediastinal tumor that compresses the trachea is often an intrathoracic huge goiter. Tracheal stenosis from a benign mediastinal tumor is rare because mediastinal tumors tend to extend into the pleural cavity and thus do not usually cause tracheal stenosis. In the present case, the tumor was considered to have originated in the aortopulmonary window, because the patient had experienced left recurrent laryngeal nerve paralysis since she was 40 years old. We determined that the tumor could not extend into the pleural cavity because it was surrounded by the trachea, aorta, left pulmonary artery, and the vertebrae. Therefore, we established that our patient’s tumor compressed the lower trachea, thus causing severe dyspnea. Schwannomas are generally treated with surgical resection, usually through a thoracotomy with enucleation or excision. The prognosis of schwannomas after complete excision is generally excellent, and recurrence is rare [4]. We determined that tumor excision through a right thoracotomy would be difficult and instead successfully performed complete tumor excision through a median sternotomy. One reason for our choice was that the use of standard double-lumen tubes was difficult because of the severe tracheal stenosis, and thus a single-lumen spiral tube was used for intubation with fiberoptic bronchoscope guidance. The other reason was that the tumor might have invaded the left pulmonary artery, and thus a cardiopulmonary bypass was prepared in case pulmonary artery replacement was required. In conclusion, this is the first report, to our knowledge, of successful excision of a giant middle mediastinal vagal Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Yoshinobu Ichiki, MD, PhD, Takayuki Hamatsu, MD, PhD, Taketoshi Suehiro, MD, PhD, Makiko Koike, MD, PhD, Fumihiro Tanaka, MD, PhD, and Keizo Sugimachi, MD, PhD Departments of Chest Surgery, Surgery, Emergency, and Radiology, Onga Nakama Medical Association, Onga Hospital, Onga-gun, and Second Department of Surgery, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
Azygos vein aneurysms are very rare causes of mediastinal masses and are usually accidental findings on chest roentgenography. Most are detected in patients with portal hypertension or venous malformations. An idiopathic azygos vein aneurysm is assumed to be congenital and is much more exceptional. We present the case of a 76-year-old man who underwent excision of an idiopathic azygos vein aneurysm by video-assisted thoracoscopic surgery (VATS). (Ann Thorac Surg 2014;98:338–40) Ó 2014 by The Society of Thoracic Surgeons
A
n aneurysm of the azygos vein is a rare cause of a mediastinal mass. They typically result from venous dilatation resulting from abnormal vascular drainage in patients with portal hypertension or venous malformations. An idiopathic azygos vein aneurysm is much more exceptional. Approximately 30 cases have been reported in the literature to date. We present another rare case of idiopathic azygos vein aneurysm.
Accepted for publication Sept 4, 2013. Address correspondence to Dr Ichiki, Department of Chest Surgery, Onga Nakama Medical Association Onga Hospital, Onga-gun, Japan, 1725-2 Ooaza-Ozaki Ongacho, Onga-gun, Fukuoka 811-4342, Japan; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.024
CASE REPORT ISHIBASHI ET AL A GIANT SCHWANNOMA CAUSING TRACHEAL STENOSIS
Ann Thorac Surg 2014;98:336–8
Fig 3. Immunohistochemical staining 200: (A) Melan A was diffusely positive; (B) S-100 was diffusely positive.
Therefore, histopathologic and clinical findings are important for characterizing a tumor as primary pleural malignant melanoma.
References
FEATURE ARTICLES
1. Ohata Y, Haga T, Ogata S, Nakanishi K, Kawai T. Malignant amelanotic melanoma of the pleura without primary skin lesion: an autopsy case report. Acta Med Okayama 2009;63: 379–84. 2. Um SW, Yoo CG, Lee CT, Han SK, Shim YS, Kim YW. Apparent primary pleural melanoma: case report and literature review. Respir Med 2003;97:586–7. 3. Smith S, Opipari MI. Primary pleural melanoma.A first reported case and literature reivew. J Thorac Cardiovasc Surg 1978;75:827–31. 4. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74–108. 5. Wilson RW, Moran CA. Primary melanoma of the lung: a clinicopathologic and immunohistochemical study of eight cases. Am J Surg Pathol 1997;21:1196–202. 6. Dountsis A, Zisis C, Karagianni E, Dahabreh J. Primary malignant melanoma of the lung: a case report. World J Surg Oncol 2003;1:26. 7. Biddle DA, Evans HL, Kemp BL, et al. Intraparenchymal nevus cell aggregates in lymph nodes: a possible diagnostic pitfall with malignant melanoma and carcinoma. Am J Surg Pathol 2003;27:673–81.
Successful Excision of a Giant Mediastinal Vagal Schwannoma Causing Severe Tracheal Stenosis Through a Median Sternotomy Hironori Ishibashi, MD, PhD, Ken Takahashi, MD, Sachiko Kumazawa, MD, and Kenichi Okubo, MD, PhD Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
Vagal nerve schwannomas that compress the trachea are extremely rare. We report a case in which a giant middle Accepted for publication Sept 5, 2013. Address correspondence to Dr Ishibashi, Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
mediastinal schwannoma accompanied by severe tracheal stenosis was excised. A 70-year-old woman had a 30-year history of hoarseness and paralysis of the left recurrent laryngeal nerve. She presented with chronic cough and dyspnea, which she had experienced for several months. Computed tomography indicated a middle mediastinal mass (8.3 3 7.1 3 4.9 cm) that directly compressed the lower trachea, carina, both bronchi, and the left main pulmonary artery. The trachea was 4 mm in diameter at the narrowest point. Through a median sternotomy, the superior vena cava, ascending aorta, right pulmonary artery, and trachea were dissected, and the tumor was excised by gentle dissection. Histologic examination indicated a benign schwannoma. (Ann Thorac Surg 2014;98:336–8) Ó 2014 by The Society of Thoracic Surgeons
S
chwannomas are benign neurogenic tumors that arise from perineural nerves. Although schwannomas are the most common neurogenic thoracic tumors, vagal nerve schwannomas that compress the trachea are extremely rare. We report a case of successful excision of a giant middle mediastinal vagal schwannoma that caused severe tracheal stenosis. A 70-year-old woman had presented with hoarseness and paralysis of the left recurrent laryngeal nerve when she was 40 years old. She had undergone excision of schwannomas that caused neurothlipsia 7 times since the age of 47 years. The middle mediastinal tumor had been detected 2 years earlier and was monitored as a suspected schwannoma. The patient presented with chronic cough and dyspnea of several months’ duration. A chest roentgenogram showed an abnormal shadow in the mediastinum. A computed tomographic scan showed a middle mediastinal mass (8.3 7.1 4.9 cm) that directly compressed the lower trachea, carina, and both bronchi (Fig 1A). The trachea was 4 mm in diameter at the narrowest point. Bronchoscopic findings revealed severe stenosis of the lower trachea with a smooth surface, and the bronchoscope could not pass the stenosis (Fig 1B). After a team consultation among thoracic, cardiovascular, and anesthesia clinicians, a final scheduled operation was performed through a median sternotomy. The 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.028
Ann Thorac Surg 2014;98:336–8
CASE REPORT ISHIBASHI ET AL A GIANT SCHWANNOMA CAUSING TRACHEAL STENOSIS
337
Fig 1. (A) Chest computed tomographic scan showed a middle mediastinal tumor, measuring 8.3 7.1 4.9 cm, which caused severe stenosis of the trachea and left pulmonary artery. (B) Bronchoscopic findings revealed severe stenosis of the lower trachea with a smooth surface and stenosis of both bronchi. The bronchoscope could not pass the stenosis.
remains well and has no evidence of recurrence or tracheal stenosis.
Comment Schwannomas are benign nerve sheath tumors that arise from perineural Schwann cells. The tumors, which comprise Schwann cells and collagen fibers, can occur in any region of the body and are the most common neurogenic thoracic tumors [1]. Although schwannomas can involve any thoracic nerve [2], vagal nerve schwannomas are rare; moreover, there is only 1 previous case report of a vagal nerve schwannoma that compressed the trachea [3]. Direct compression of the trachea or main bronchi, or both, by a tumor can lead to total airway occlusion, whereas external compression of major blood vessels or even the heart can result in a cardiovascular catastrophe. Tracheal stenosis occurs with malignant tumors such as
Fig 2. (A) The tumor comprised compact bundles of spindle-shaped cells, and mitotic events were rare (hematoxylin and eosin, 100 magnification). (B) Immunohistochemical staining was positive for S-100 (100 magnification).
FEATURE ARTICLES
superior vena cava, ascending aorta, right main pulmonary artery, and trachea encircled the tumor, which was dissected from these structures. Finally, the tumor was divided posterior to the aorta; the right half was excised through a space between the superior vena cava and the aorta and the left half was excised through a space between the aorta and the main pulmonary artery. The tumor measured 8.0 7.5 6.0 cm and was homogeneous and hard and elastic. Microscopically, the tumor comprised compact bundles of spindle-shaped cells and rare mitotic figures. Immunohistochemical staining was positive for S-100 and negative for CD34, desmin, c-kit, and a-smooth muscle actin (Fig 2). The histologic diagnosis was benign schwannoma. The patient recovered uneventfully and was discharged on the sixth day after the operation. Bronchoscopy, performed 3 weeks after the operation, showed that there was almost no stenosis in the trachea and bronchus, and no collapse was observed during coughing (Fig 3). At 5 months after excision, she
338
CASE REPORT ICHIKI ET AL IDIOPATHIC AZYGOS VEIN ANEURYSM
Ann Thorac Surg 2014;98:338–40
schwannoma with severe tracheal stenosis through a sternotomy.
References 1. Reed JC, Hallet KK, Feigin DS. Neural tumors of the thorax: subject review from the AFIP. Radiology 1978;126:9–17. 2. Aughenbaugh GL. Thoracic manifestations of neurocutaneous diseases. Radiol Clin North Am 1984;22: 741–56. 3. Katoh J, Yoshii S, Osamu S, Hosaka S, Hashimoto R, Tada Y. Mediastinal vagal neurilemmoma causing tracheal stenosis. J Thorac Cardiovasc Surg 1995;109: 184–5. 4. Chen HC, Huang HJ, Wu CY, Lin TS, Fang HY. Esophageal schwannoma with tracheal compression. Thorac Cardiovasc Surg 2006;54:555–8.
An Idiopathic Azygos Vein Aneurysm Mimicking a Mediastinal Mass Fig 3. Findings of bronchoscopy performed 3 weeks after the operation. Almost no stenosis was noted in the trachea and bronchus, and no collapse was observed during coughing.
FEATURE ARTICLES
lung cancer, esophageal cancer, thyroid cancer, lymphoma, and thymic tumors. A benign mediastinal tumor that compresses the trachea is often an intrathoracic huge goiter. Tracheal stenosis from a benign mediastinal tumor is rare because mediastinal tumors tend to extend into the pleural cavity and thus do not usually cause tracheal stenosis. In the present case, the tumor was considered to have originated in the aortopulmonary window, because the patient had experienced left recurrent laryngeal nerve paralysis since she was 40 years old. We determined that the tumor could not extend into the pleural cavity because it was surrounded by the trachea, aorta, left pulmonary artery, and the vertebrae. Therefore, we established that our patient’s tumor compressed the lower trachea, thus causing severe dyspnea. Schwannomas are generally treated with surgical resection, usually through a thoracotomy with enucleation or excision. The prognosis of schwannomas after complete excision is generally excellent, and recurrence is rare [4]. We determined that tumor excision through a right thoracotomy would be difficult and instead successfully performed complete tumor excision through a median sternotomy. One reason for our choice was that the use of standard double-lumen tubes was difficult because of the severe tracheal stenosis, and thus a single-lumen spiral tube was used for intubation with fiberoptic bronchoscope guidance. The other reason was that the tumor might have invaded the left pulmonary artery, and thus a cardiopulmonary bypass was prepared in case pulmonary artery replacement was required. In conclusion, this is the first report, to our knowledge, of successful excision of a giant middle mediastinal vagal Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Yoshinobu Ichiki, MD, PhD, Takayuki Hamatsu, MD, PhD, Taketoshi Suehiro, MD, PhD, Makiko Koike, MD, PhD, Fumihiro Tanaka, MD, PhD, and Keizo Sugimachi, MD, PhD Departments of Chest Surgery, Surgery, Emergency, and Radiology, Onga Nakama Medical Association, Onga Hospital, Onga-gun, and Second Department of Surgery, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
Azygos vein aneurysms are very rare causes of mediastinal masses and are usually accidental findings on chest roentgenography. Most are detected in patients with portal hypertension or venous malformations. An idiopathic azygos vein aneurysm is assumed to be congenital and is much more exceptional. We present the case of a 76-year-old man who underwent excision of an idiopathic azygos vein aneurysm by video-assisted thoracoscopic surgery (VATS). (Ann Thorac Surg 2014;98:338–40) Ó 2014 by The Society of Thoracic Surgeons
A
n aneurysm of the azygos vein is a rare cause of a mediastinal mass. They typically result from venous dilatation resulting from abnormal vascular drainage in patients with portal hypertension or venous malformations. An idiopathic azygos vein aneurysm is much more exceptional. Approximately 30 cases have been reported in the literature to date. We present another rare case of idiopathic azygos vein aneurysm.
Accepted for publication Sept 4, 2013. Address correspondence to Dr Ichiki, Department of Chest Surgery, Onga Nakama Medical Association Onga Hospital, Onga-gun, Japan, 1725-2 Ooaza-Ozaki Ongacho, Onga-gun, Fukuoka 811-4342, Japan; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.024
