Peripheral tumors of the intercostal nerves

Carbon-Assisted Minimally Invasive Transtubular Approach for Intercostal Nerve Schwannoma

BACKGROUND AND OBJECTIVES

The intraoperative localization of an intercostal nerve schwannoma (INS) is extremely difficult because the lesion is generally not palpable, and the fluoroscopic visualization of anatomic landmarks in the ribs is unsatisfactory. Using activated carbon suspension to mark the soft-tissue approach could improve INS localization. We present a novel, simple, reproducible carbon-assisted minimally invasive transtubular approach for an INS.

METHODS

The patient was a 57-year-old man with a painful 12th left INS arising below the floating rib. A computed tomography image-guided, tumor-to-skin marking with aqueous carbon suspension was performed 48 hours before surgery. A minimally invasive transtubular approach following the carbon path allowed a precise tumor location.

RESULTS

The INS was completely removed. The patient's thoracic radicular pain was immediately relieved after surgery. He was discharged the following day with residual numbness on the left thoracic side. At the 5-year follow-up, no tumor recurrence was noted in the control MRI.

CONCLUSION

This article presents an alternative novel technique for resecting an intercostal schwannoma. Using a transtubular approach with carbon-marking assistance allowed a tumor gross total resection with immediate pain relief and a successful outcome.

Preoperative Wire Localization: A Simple Guidance Technique for Excision of Deep, Painful, Small, Soft Tissue Neurofibromas

A novel use of preoperative wire localization to aid in the removal of small deep-seated soft tissue nerve sheath tumors is described. Wire localization is commonly used in breast surgery, and applying this technique in neurosurgery will enable the surgeon to directly reach the lesion with smaller incisions and prevent unnecessary soft tissue dissection.

[Benign primitive schwannoma of the pleura]

Le schwannome est une tumeur neurogène développée à partir des cellules de Schwann. Dans la région thoracique, le médiastin est le principal site d'apparition du schwannome. Le plus souvent, il s'agit d'une lésion solitaire et la localisation pleurale est extrêmement rare. Nous rapportons un cas de schwannome pleural bénin primitif chez une femme âgée de 44 ans chez qui la lésion a été découverte suite à la réalisation d'un bilan radiologique pour une douleur thoracique et une dyspnée. Le patient a eu résection chirurgicale complète de cette tumeur sous vidéo thoracoscopie. L'étude anatomopathologique a conclu à un schwannome bénin primitif de la plèvre.

Giant intercostal nerve schwannoma in a patient with neurofibromatosis type 2

PURPOSE

To describe a case of giant intercostal nerve schwannoma successfully resected in a patient with neurofibromatosis type 2.

METHODS

A 44-year-old woman, with a history of neurofibromatosis type 2, presented with chest discomfort and mild dyspnea. She had undergone a recent resection of a large frontal parasagittal benign meningioma. Radiologic examinations showed a large lesion (9×12×9 cm) of the left hemithorax causing a complete atelectasis of left upper lobe. Bronchoscopy did not show any endobronchial alterations, apart from an ab estriseco compression of the left upper bronchial tree. A transthoracic needle biopsy was then performed and microscopic examination revealed a mesenchymal tumor composed of spindle-like cells.

RESULTS

A video-assisted thoracoscopic surgery procedure was proposed. The tumor mass appeared to be tenaciously adherent to the parietal pleura in its anterolateral aspect, confirming the radiologic appearance. No invasion of the lung parenchyma or parietal pleural metastases were visible. Therefore, a left posterolateral thoracotomy at the fifth intercostal space was performed and a macroscopic complete resection was carried out. The recovery was uneventful and the patient was discharged on postoperative day 5. The histologic examination revealed a moderate cellular proliferation of spindle-shaped and oval to polygonal cells with frequent Verocay bodies; mitotic figures were rare. The tumor cells were strongly S-100 positive. The microscopic features were consistent with benign intercostal schwannoma. Eight years later, the patient is disease-free and asymptomatic.

CONCLUSIONS

An unusual case of giant intercostal nerve schwannoma successfully resected in a patient with neurofibromatosis type 2 is described.

Thoracic Radiculopathy Resulting From Retrograde Neuronal Degeneration

We report a case of thoracic radiculopathy caused by retrograde degeneration from an intercostal nerve mass. A 74-year-old woman presented with thoracic radicular pain in the T4 dermatome. Needle electromyography revealed abnormal spontaneous activity in the left paraspinal muscle. Magnetic resonance imaging of the thoracic spine showed no signs of a herniated thoracic disk or root compression but revealed a mass along the intercostal space. The pathologic findings included perineural infiltration. A mass located along the intercostal space approximately 1.8 cm from the dorsal root ganglion may cause thoracic radiculopathy via retrograde degeneration.

Dumbbell Shaped Schwannoma of the Lateral Chest Wall masquandering as a soft tissue sarcoma

Schwannomas are benign, slow growing nerve sheath tumours of Schwann cell origin. They predominantly are known to involve the head, neck and the flexor surfaces of the extremities, retroperitoneum and the posterior spinal roots. The chest wall is a relatively uncommon location for a schwannoma, the vast majority of which are intra-thoracic, which are usually located in the posterior mediastinum and bulge into the thoracic cavity. Schwannomas arising from the lateral chest wall are relatively uncommon (<5 %). Dumbbell shaped schwannomas of the lateral chest wall i.e. with an intra-thoracic and extra-thoracic component, is extraordinarily rare and to the best of our knowledge only one case has been reported prior. We report possibly the second case of a dumbbell shaped lateral chest wall schwannoma in a 33-year-old female patient which masquandered as a case of soft tissue sarcoma.

Intercostal neurinoma: a rare cause of persistent thoracic pain

Persistent thoracic pain with no history of trauma demands diagnostic workup. In this case, the patient complained of right thoracic continuous belt-like pain, sometimes experienced as shooting pain, over several months. The symptoms were first treated conservatively with painkillers, which was rather ineffective. A magnetic resonance imaging scan of the thorax surprisingly showed an unclear piston-like enlargement near the seventh rib closely above the spinal canal. Video thoracoscopy was performed to provide further clarification. This showed two lesions of the intercostal nerves of the seventh and eighth ribs. The intercostal nerves were resected in these areas. Histological examination revealed two neurinomas of the intercostal nerves with focal outgrowth of a neural cyst measuring 1.6 cm on the seventh intercostal nerve. The patient was free of any pain after the operation.

Schwannomatozis of the Chest Wall: FDG PET Findings

Authors present a rare case of bifocal schwannoma of thoracic wall showing metabolic activity on FDG PET images. A 43-year-old male with palpable mass on lateral chest wall was referred for F-18 FDG PET/CT imaging for differential diagnosis. His medical history and basic laboratory results were unremarkable. PET/CT images revealed a mild FDG uptake in the solid soft tissue mass in the left lateral chest wall that was growing outside of the thorax. It was located in 7th intercostal space and adjacent ribs were intact. Incidentally, second mass lesion was detected in the right posterior seventh intercostal space protruding to the pleural space and showing higher FDG uptake on PET/CT images. The lesions were surgically removed at the same session for definite diagnosis and treatment. Histopathologic evaluation of both lesions revealed benign schwannoma.

Primary pleural benign myxoid schwannoma in an 18-year-old female: a case report and literature review

Pleural schwannomas are exceedingly rare neoplasms of the thoracic cavity. To the best of our knowledge, less than 20 cases have been reported in the medical English literature. Herein, we report the case of primary pleural benign myxoid schwannoma in an 18-year-old female. The patient was originally referred to our tertiary care hospital for further management of right adrenal gland mass. Physical examination and all laboratory tests were normal. Contrast-enhanced computed tomography scan showed a 4.2 × 3.2 cm, heterogeneous noncalcified mass involving the right adrenal gland region. The right renal vein and inferior vena cava were intact. There was no pleural effusion, ascites, or lymphadenopathy. No pelvic masses were identified. Patient was scheduled for surgical resection. On laparotomy, the mass was not found in its radiologically expected location, and the right kidney and right adrenal gland were intact. The right-sided lower part of diaphragm was opened, and the mass was interestingly found inside the thorax attached to the pleura, and resected successfully. A final histopathological diagnosis of primary pleural benign myxoid schwannoma was established. At a postoperative 6-month followup, there was no radiological evidence of tumor recurrence. Furthermore, literature review on pleural schwannomas is also presented.

Human pulmonary dirofilariasis coexisting with intercostal neurilemmoma: a case report and literature review

Human pulmonary dirofilariasis (HPD) is a rare zoonotic infection caused by Dirofilaria immitis. Dogs are the definite hosts and humans are infected occasionally via a vector, generally a mosquito. Most thoracic neurilemmoma arise in the mediastinum and fewer tumors originate peripherally from the intercostal nerves. Most patients with HPD or thoracic neurilemmoma are asymptomatic and these diseases are often discovered incidentally. We present a 53-year-old female who was found to have a pulmonary nodule and a chest wall nodule during a routine health examination. She underwent a video-assisted thoracoscopic surgery (VATS) with partial lung resection and local excision of the chest wall. The pathological examination revealed a coiled, degenerating Dirofilariasis immitis worm surrounded by granulomatous inflammation with caseous necrosis and a neurilemmoma composed of S-100 protein immunoreactive but smooth muscle actin negative spindle cells. Because these diseases are self-limiting and make further treatment unnecessary, video-assisted thoracoscopic surgery (VATS) is considered preferable and less invasive for definitive diagnosis and management.

Clinical and CT manifestation of pleural schwannoma

BACKGROUND

A schwannoma arising from the pleura is rare. The computer tomography (CT) features, however, have seldom been disclosed in the English literature.

PURPOSE

To retrospectively assess the role of CT in the diagnosis of pleural schwannomas.

MATERIAL AND METHODS

Eleven patients with pathologically confirmed pleural schwannomas were included in the study. CT images and clinical data were analyzed. The CT features emphasized included the location of the neoplasm, as well as its diameter, origin, margin, shape, attenuation, enhancement pattern, and extent and invasion into adjacent structures, all of which were observed and recorded.

RESULTS

Seven patients were men, while four were women; patients were aged 21-60 years, with a mean age of 45 years. Most cases were incidentally detected. Seven cases involved neoplasms located in the right hemithorax whereas four cases involved neoplasms in the left hemithorax. The mean tumor diameter was 4.4 cm (range, 2.3-6.4 cm). All of the tumors were solitary and well-defined ovoid (n = 7) or round (n = 4) in shape. The schwannomas showed isoattenuation (four cases) or mild hypoattenuation (seven cases) to the chest wall muscle on unenhanced CT. All cases showed minimal enhancement on contrast-medium-enhanced CT. Two bony erosions of the rib were also observed.

CONCLUSION

CT findings may suggest the diagnosis of pleural schwannoma preoperatively. Pleural schwannoma should be included in the differential diagnosis of solid, solitary, and well-defined pleural tumors.

Tandem intercostal thoracic schwannomas resected using a thoracoscopic nerve-sparing technique: case report

BACKGROUND AND IMPORTANCE

To describe a novel nerve-sparing technique for the resection of intercostal nerve schwannomas. This case demonstrates that intercostal neuralgia can be caused by intercostal schwannomas and that it can be relieved by their removal.

CLINICAL PRESENTATION

A young woman with schwannomatosis had progressively worsening intercostal neuralgia caused by compression of the intercostal nerve against the rib by tandem intercostal schwannomas. After the tumors were removed, her symptoms were completely relieved. A thoracoscopic technique was used to define the involved fascicles and to facilitate removal of the tumors while sparing the uninvolved nerve.

CONCLUSION

The patient's radicular pain was relieved completely by the tumor resection. Thoracoscopic surgery offers a safe and minimally invasive technique for removal of intercostal schwannomas and is a valid alternative to open thoracotomy. Removal of thoracic schwannomas can relieve intercostal neuralgia.

Multiple schwannomas in a single costal interval: report of two cases

Schwannomas of the intercostal nerve, typically, are solitary and rarely originate from the mediastinum. Here, we describe two cases of multiple schwannomas occurring within a single costal interval. Both patients were misdiagnosed prior to surgery, and the correct diagnosis was made by pathological examination following surgery. Upon retrospective review of the preoperative radiographic examination, we found that such misdiagnoses may be avoided by performing 3-dimensional reconstruction.

Schwannomatosis of a single intercostal nerve: a case report

Schwannomatosis is a rare form of neurofibromatosis and is characterized by more than one schwannoma without any sign of neurofibromatosis. We report a case of a 60-year-old male patient admitted with progressive chest discomfort who was found to have six encapsulated tumors along the seventh intercostal space with a maximum tumor size of 3x2x1 cm.

MR imaging evaluation of disorders of the chest wall

Chest wall lesions constitute a diverse group of thoracic diseases, including those of soft tissue and osseous origin. MR imaging, with its superior tissue-resolving capability and multiplanar image acquisition, is an important tool for assessing chest wall lesions. In this article, the authors review common and uncommon diseases of the chest wall, with an emphasis on the MR imaging characteristics of these diseases. Among the diseases they discuss are diseases of the soft tissue including lipoma, hibernoma, liposarcoma, hemangioma, and lymphoma. They also examine diseases of the osseous thorax, including benign osseous tumors, fibrous dysplasia, and aneurysmal bone cyst. In addition, they discuss such malignant osseous tumors as osteosarcoma and Ewing's sarcoma.

An unusual case of abdominal pain in a patient with cystic fibrosis

We report the case of a 19 year old man with cystic fibrosis (CF) who presented with atypical abdominal pain precipitated by pressing his ribs. This was subsequently discovered to be referred pain from an intercostal schwannoma. Surgical resection led to a resolution of his symptoms.

Intercostal nerve mononeuropathy: study of 14 cases

This retrospective study describes 14 cases of intercostal nerve mononeuropathy (INM) found in 5,560 electromyography (EMG) exams performed between January 1991 and June 2004 in our University Hospital. Medical charts of all patients with history of thoracic pain and EMG diagnosis of intercostal mononeuropathy were reviewed. INM was detected in 14 patients; etiology was thoracic surgery in 6 (43%), post-herpetic neuropathy in 4 (28%), probable intercostal neuritis in 2 (14%), lung neoplasia in 1 (7%), and radiculopathy in 1 (7%). From this study, trauma and infection were the main etiologies in intercostal neuropathic pain development. Tricyclic antidepressants and anticonvulsants were the most common therapeutic drugs used.