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LETTER TO EDITOR
Year : 2011  |  Volume : 48  |  Issue : 3  |  Page : 366-368
 

A case of carinal schwannoma resected under cardiopulmonary bypass


1 Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
3 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication14-Sep-2011

Correspondence Address:
A Kumar
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.84915

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How to cite this article:
Dutta R, Kumar A, Kaushal S, Choudhary S K. A case of carinal schwannoma resected under cardiopulmonary bypass. Indian J Cancer 2011;48:366-8

How to cite this URL:
Dutta R, Kumar A, Kaushal S, Choudhary S K. A case of carinal schwannoma resected under cardiopulmonary bypass. Indian J Cancer [serial online] 2011 [cited 2019 Aug 22];48:366-8. Available from: http://www.indianjcancer.com/text.asp?2011/48/3/366/84915


Sir,

Schwannoma is a benign, slowly growing neoplasm of Schwann cells that may arise in any nerve, including cranial nerves, spinal roots, or peripheral nerves. These tumors usually are seen in adults. Schwannoma of the endobronchial origin is extremely rare and only few cases have been reported previously in the literature.

A 15-year-old male presented with fever, dry cough, and chest pain for 2 years. There was no history of hemoptysis, dyspnea, and weight loss. Clinical examination of chest revealed drooping of the left shoulder with wheeze in the left mammary area on auscultation. Contrast enhanced computed tomography (CECT) of chest showed a left-sided endobronchial, polypoidal soft tissue mass projecting into carina, and lower trachea [Figure 1]. The left lung was collapsed with bronchiectatic changes. Fiber optic bronchoscopy-guided biopsy and bronchoalveolar lavage findings were inconclusive on two occasions. The patient was taken up for surgery with a provisional diagnosis of the left bronchial tumor with involvement of carina with destroyed left lung. Median sternotomy was performed and lower trachea and carina were approached through the aortocaval space. He was placed into cardiopulmonary bypass and the lower trachea and left bronchus were opened to document the origin and extent of the tumor. The tumor was completely occupying the lumen of the left bronchus with involvement of the posterior tracheal wall and carina. The carina with distal 2 cm of trachea, proximal 1 cm of right and whole of left bronchus with the tumor inside was excised [Figure 2]a. The tumor was sessile with a wide area of contact in the left bronchus, carina and distal trachea [Figure 2]b. The frozen section biopsy of the resection margin of trachea and right main bronchus was negative for the tumor cell. The left lung was collapsed, fibrotic, and densely adherent to the chest wall. Left pneumonectomy was completed after intrapericardial ligation and division of the left main pulmonary artery, superior, and inferior pulmonary veins. The right main bronchus was anastomosed with the trachea end-to-end with interrupted 3-0 vicryl stitches. The anastomosis was covered with vascularised pericardial fat pad. The tumor was immunohistochemically and histopathologically compatible with benign schwannoma [Figure 2]d and e.
Figure 1: CECT chest axial section (a and b) shows tumor in the lumen of trachea (arrow) with involvement of its posterior wall. Lung window (a) and coronal reconstruction (c) show collapsed and bronchiectatic changes in the left lung

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Figure 2: Excised carina with tumor (a). (b) Tumor involving the carina, lower trachea, and left main bronchus (arrow is pointing to the right main bronchus). Microphotograph (c) is showing spindle cell tumor arranged in a palisading fashion (verocay bodies) and the prominence of blood vessels without necrosis or mitosis (H and E, ×200). Microphotograph (d) shows positivity of tumor cells for S-100 (Immunoperoxidase, ×200)

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Schwannoma have an equal distribution in trachea, central bronchus, and pulmonary parenchyma. [1] They usually have a long natural history, causing symptoms only after they have attained a large size. The resultant lung collapse and pneumonia is responsible for the symptoms of the patient. The tracheobronchial tumors can present with respiratory wheeze, dry, or productive cough and hemoptysis. [2],[3] The CECT of chest is helpful in assessing lung parenchyma distal to obstruction and delineation of the tumor inside the lumen as well as outside the wall of the respiratory tract. The definitive treatment is surgical resection with a healthy margin of tissue. [3],[4] Endoscopic transbronchial electrical snaring and Nd-YAG laser abrasion are reported for histopathologically proven benign lesions. [5] An endoscopic approach was not ideal for our patient due to inconclusive preoperative histology. Moreover, it was not possible to carry out lung parenchyma preserving surgery due to unhealthy left lung. We preferred the median sternotomy approach as it provides access to carina and helps in performing left pneumonectomy through the same incision. The other approach used commonly is right posterolateral thoracotomy through the fourth or fifth intercostal space which provides excellent access to the carina and trachea. [6] This approach requires selective right lung collapse which was not possible in our patient due to collapsed and destroyed left lung. For left carinal pneumonectomy, a left thoracotomy approach is used for limited resections, and either a bilateral thoracotomy or "clamshell" (bilateral submammary, transsternal) incision through the fourth intercostal space for more extensive resections. [6] He is doing well at 2 years follow-up. With careful patient selection and meticulous surgical techniques, a favourable clinical outcome can be achieved with carinal resection.

 
  References Top

1.Kasahara K, Fukuoka K, Konishi M, Hamada K, Maeda K, Mikasa K, et al. Two Cases of Endobronchial Neurilemmoma and Review of the Literature in Japan. Intern Med 2003;42:1215-8.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Horovitz AG, Khalil KG, Verani RR, Guthrie AM, Cowan DF. Primary intratracheal neurilemoma. J Thorac Cardiovasc Surg 1983;85:313-7.  Back to cited text no. 2
[PUBMED]    
3.Dorfman J, Jamison BM, Morin JE. Primary Tracheal Schwannoma. Ann Thorac Surg 2000;69:280-1.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Righini CA, Lequeux T, Laverierre MH, Reyt E. Primary tracheal schwannoma: One case report and a literature review. Eur Arch Otorhinolaryngol 2005;262:157-60.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Suzuki H, Sekine Y, Motohashi S, Chiyo M, Suzuki M, Haga Y, et al. Endobronchial neurogenic tumors treated by transbronchial electrical snaring and Nd-YAG laser abrasion: Report of three cases. Surg Today 2005;35:243-6.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Mitchell JD, Mathisen DJ, Wright CD, Wain JC, Donahue DM, Moncure AC, et al. Clinical experience with carinal resection. J Thorac Cardiovasc Surg 1999;117:39-52.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  


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