University of South Florida, Tampa, FL
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Lung Pathology I
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Endobronchial lesions arise in a wide range of benign and malignant pathologies. Schwannomas are benign nerve sheath tumors which rarely present in visceral organs. We present a case of sporadic endobronchial schwannoma presenting as cough and chest pain.
CASE PRESENTATION: A 58-year-old male lifelong nonsmoker with no known past medical history presented to the emergency department with new onset right-sided pleuritic back pain in the setting of one week of subjective fever, malaise and a cough productive of clear sputum. Physical exam revealed decreased breath sounds in the right base, dullness to percussion of the right chest base, and no palpable cervical, supraclavicular or axillary lymphadenopathy. Initial chest x-ray showed blunting of the right costophrenic angle and volume loss. Laboratory data was significant for leukocytosis with neutrophilia, and the patient was admitted to the hospital for treatment of community acquired pneumonia with intravenous antibiotics. On hospital day one, his leukocytosis was improving and he remained afebrile. A lateral decubitus film failed to show a layering effusion and ultrasound confirmed absence of a fluid collection. CT of the chest identified an abrupt occlusion of the bronchus intermedius with associated complete consolidation of the right lower lobe. A fiberoptic bronchoscopy was performed demonstrating an obstructive mass of the bronchus intermedius where forceps biopsies were obtained. Pathology revealed S100 positive spindle cell tumor consistent with schwannoma. The patient was referred to cardiothoracic surgery for thoracotomy with resection.
DISCUSSION: Schwannomas are benign nerve sheath tumors which occur sporadically or as the familial tumor syndromes schwannomatosis and neurofibromatosis. These tumors carry a low propensity for malignant transformation and most commonly arise in the head, neck and extensor surfaces of the extremities. Peripheral nerve sheath tumors, which include schwannomas, neurofibromas and perineuromas rarely occur intrathoracically. Collectively, these tumors constitute 75% of tumors of the posterior mediastinum. However, pulmonary involvement is rare. Together, peripheral nerve sheath tumors make up only 0.2% of pulmonary neoplasms, a fraction of which are Schwann Cell origin.
CONCLUSIONS: We present a case of endobronchial tumor presenting with post obstructive pneumonia. Fiberoptic bronchoscopy guided biopsy demonstrated an exceptionally rare endobronchial schwannoma. Definitive management for this patient was referral for surgical resection.
Reference #1: Boland, J, Colby, T and Folpe, A. Intrathoracic peripheral nerve sheath tumors—a clinicopathological study of 75 cases. Human Pathology 2015; 46, 419-425.
Reference #2: Roviaro, G, Montorsi, M, Varoli, F, Binda, R, and Cecchetto, A. Primary pulmonary tumours of neurogenic origin. Thorax 1983; 38, 942-945.
Reference #3: Hilton, D and Hanemann, C. Schwannomas and tfheir pathogenesis. Brain Pathology 2014; 24, 205-220.
DISCLOSURE: The following authors have nothing to disclose: Vanessa Ohleyer, Stephen Clum, Kondi Wong
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