This article has Open Peer Review reports available.
Schwannoma of the vagus nerve, a rare middle mediastinal neurogenic tumor: case report
© K Rammos et al; licensee BioMed Central Ltd. 2009
Received: 28 August 2009
Accepted: 26 November 2009
Published: 26 November 2009
Schwannoma originating from the vagus nerve within the mediastinum is a rare, usually benign tumor. A 44-year old male was presented with chest pain. Chest radiography, CT scan and MRI showed a well circumscribed mass, 5 × 4 cm located in the aortopulmonary window. The mass was found at surgery to be in close proximity with the aortic arch and the left pulmonary hilum, alongside the left vagus nerve. The encapsulated tumor was completely resected through a left thoracotomy incision and it was found to be a benign schwannoma in pathology. The patient is free of recurrence 6 years after surgery.
Neurogenic tumors represent approximately 20% of all adult and 25% of all pediatric primary mediastinal neoplasms. They are divided into nerve sheath, ganglion cell and paraganglionic cell neoplasms . Neurogenic tumors are benign mediastinal tumors with rare exceptions [1–3]. Schwannomas or neurilemmomas originating from the vagus nerve are rare mediastinal tumors, accounting for 2% of all mediastinal neurogenic tumors, arising typically from the nerve sheath and extrinsically compressing the nerve fibers [1, 4].
Scwannomas are lobulated, encapsulated spherical masses, different from neurofibromas in that matter. Men and women are equally affected in their third and fourth decades . Usually, they are asymptomatic and benign, and very rarely malignant or multiple [2–5]. Shwannomas usually arise from a spinal nerve root, indeed they may arise from any other intrathoracic nerve [1, 4]. Radiologically they are sharply demarcated with rare calcifications. CT contrast enhanced scan of the chest shows in accordance, a sharply demarcated mass with low densities and mild enrichment, rarely with calcifications and no fat. On MRI the schwannomas have low - to intermediate signal intensity on T1-weighted images and may have intermediate - to high - signal intensity on T2-weighted sequences [6, 7].
The patient had no postoperative complications and he is free of recurrence 73 months later.
Comment and Conclusion
Benign schwannomas of the vagus nerve are very rare middle mediastinal neurogenic tumors of nerve sheath origin [1, 2]. Schwannomas of the vagus nerve occur usually on the left hemithorax while they may reach huge dimensions in rare instances [1, 2]. Thoracotomy instead of VATS was preferred in the presented case because of the location of the tumor in the middle mediastinal compartment, close to the aortic arch and the hilum of the left lung. VATS resection is an alternative option for resection of mediastinal neurogenic tumors however the location of the tumor in the middle mediastinum and especially in the aortopulmonary window may necessitate thoracotomy for safe isolation of the tumor from the vital mediastinal structures and further, in order to avoid damage to the recurrent nerve during dissection of the tumor within the aortopulmonary window [8–10].
The tumor was confirmed to be a schwannoma because microscopically it showed spindle cells in fascicles in a loose stroma. Strong positivity of the tumor cells for S-100 protein confirmed the diagnosis of schwannoma [3–7]. Malignant schwannomas are rare and they are distinguished from benign schwannomas on microscopic examination because they show atypia, mitoses, pleomorphism and necrosis [3, 4, 11]. More than fifty percent of malignant schwannomas are found in patients with neurofibromatosis .
Written informed consent was obtained from the patient for publication of this case-report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Strollo DC, Rosado-de-Christenson ML, Jett JR: Tumors of the middle and posterior mediastinum. Chest. 1997, 112: 1344-1357. 10.1378/chest.112.5.1344.View ArticlePubMedGoogle Scholar
- Dabir RR, Piccione W, Kittle FC: Intrathoracic tumors of the vagus nerve. Ann Thorac Surg. 1990, 50: 494-497.View ArticlePubMedGoogle Scholar
- Shoji F, Maruyama R, Okamoto T, Wataya H, Nishiyama K, Ichinose Y: Malignant schwannoma of the upper mediastinum originating from the vagus nerve. World Journal of Surgical Oncology. 2005, 3: 65-68. 10.1186/1477-7819-3-65.View ArticlePubMedPubMed CentralGoogle Scholar
- Kaneko M, Matsumoto I, Oda M, Watanabe G: Multiple schwannoma of the intrathoracic vagal nerve; report of a case. Jap J Thorac Surg. 2008, 61: 820-823.PubMedGoogle Scholar
- Cohen L, Schwartz A, Rockoff S: Benign schwannomas: Pathologic basis for CT inhomogeneities. Am J Roentgenol. 1986, 147: 141-143.View ArticleGoogle Scholar
- Sakai F, Sone S, Kiyono K, Maruyama A, Ueda H, Aoki J, Kawai T, Ishii K, Morimoto M, Haniuda M, Koizumi T: Intrathoracic neurogenic tumors: MR-pathologic correlation. Am J Roentgenol. 1992, 159: 279-283.View ArticleGoogle Scholar
- Price KL, Rainer WG, Ratzer E, Muckleroy SK: Right posterolateral thoracotomy for excision of a left intrathoracic vagus nerve schwannoma. Am J Surg. 2006, 192: 255-256. 10.1016/j.amjsurg.2005.12.008.View ArticlePubMedGoogle Scholar
- Yamaguchi N, Yoshino I, Fukuyama S, Osoegawa A, Kameyama T, Tagawa T, Maehara Y: Surgical treatment of neurogenic tumors of the chest. Ann Thorac Cardiovasc Surg. 2004, 10: 148-151.PubMedGoogle Scholar
- Singer RL: Thoracoscopic excision of a malignant schwannoma of the intrathoracic vagus nerve. Ann Thorac Surg. 1995, 59: 1586-1587. 10.1016/0003-4975(94)00972-A.View ArticlePubMedGoogle Scholar
- Sasaki K, Kohto T, Mun M, Yoshiya T: Thoracoscopic removal of middle mediastinal schwannoma originating from the recurrent nerve. Thorac Cardiovasc Surg. 2008, 56: 375-377. 10.1055/s-2008-1038471.View ArticlePubMedGoogle Scholar
- Lioulias AG, Foroulis CN, Fotinou M, Lazopoulos G: Malignant melanocytic schwannoma: a rare tumor of the posterior mediastinum. Eur J Cardiothorac Surg. 2003, 23: 105-10.1016/S1010-7940(02)00673-5.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.