Disorders of the Mediastinum: Student/Resident Case Report Poster - Disorders of the Mediastinum |

Rare Presentation of an Intrathoracic Phrenic Nerve Schwannoma FREE TO VIEW

Shintaro Chiba, MD; Michael Sperling, BA; Trevor DerDerian, MD; Igor Brichkov, MD
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St. George's University School of Medicine, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):557A. doi:10.1016/j.chest.2016.08.645
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SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Mediastinum

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: We present a 32-year-old female found to have a left phrenic nerve schwannoma who underwent successful video assisted thoracoscopic (VAT) resection.

CASE PRESENTATION: This is a 32-year-old female patient, who presented with a 6-month history of persistent upper back pain radiating to the left. A CT-scan, revealed a 3.1 X 2.2 cm left paracardiac mass (Figure 1). The patient was brought to the operating theatre for biopsy and excision of the mass. Upon careful evaluation, the mass was found to be arising from the phrenic nerve which is an atypical site (Figure 2). After multiple unsuccessful attempts to delineate a plane between the nerve and mass, the lesion was resected en bloc with the phrenic nerve. Final pathology demonstrated a partially capsulated yellow adipose tissue measuring 5.5 X 3 X 0.9 cm, with a cellular pattern of dense avascular spindle cell pattern with numerous thin cytoplasmic processes, consistent with Antoni type A cellular pattern. Immunohistochemical analysis demonstrated tissue to be S100 positive and CD34 negative. Paraffin sections were analyzed by immunochemistry and known positive tissues were tested with each antibody and examined to ensure reactivity. These findings were consistent with the diagnosis of schwannoma of the phrenic nerve.

DISCUSSION: Schwannoma is commonly a solitary encapsulated mass composed of groups of nerve sheath cells or schwann cells arising from a spinal nerve root or any thoracic nerve. Thoracic schwannomas are unusual, most commonly arising from the intercostal or sympathetic nerves and are located in the posterior mediastinum. The majority of intrathoracic phrenic nerve schwannomas are reported to be asymptomatic (92% to 94%) (1). Sparring of the phrenic nerve has been described for benign lesions of the phrenic nerve when achievable, but is contraindicated in malignancy. The majority of patients with adequate pulmonary function preoperatively, remain asymptomatic after unilateral phrenic nerve resection. Patient’s who have poor pulmonary function or demonstrate postoperative symptoms from eventration after nerve resection, may benefit from diaphragmatic plication (1,2,3).

CONCLUSIONS: The en bloc resection using the VATs technique in combination with intrathoracic CO2 insufflation is a safe and minimally invasive method for the diagnosis and resection of the rare intrathoracic phrenic nerve schwannoma. Intraoperative frozen section can be useful in tailoring resection margins.

Reference #1: Shields TW. Overview of primary mediastinal tumors and cyst. In: Shields TW, LoCicero J, Ponn RB, Rusch VW, editors. General thoracic surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. P. 2489-94.

Reference #2: Gurkok S, Onur G, Gozubuyuk A, Caylak H, Kavakli K. Schwannoma arising from the right phrenic nerve. Turk Gogus Kalp Damar Cer Derg 2009;17(1):49-50.

Reference #3: Gilani SM, Danforth RD. Intactable hiccups: a rare presentation of phrenic nerve schwannoma. Eur Ann Otorhinolatyngol Head Neck Dis 2012 Dec;129(6):331-3.

DISCLOSURE: Shintaro Chiba: Employee: Surgical Resident The following authors have nothing to disclose: Michael Sperling, Trevor DerDerian, Igor Brichkov

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