Eur J Cardiothorac Surg 2006;29:625-626
© 2006 Elsevier Science NL
Chest wall mass with double pathology
Murugu Sundara Pandiyan
a
,
*
,
Alpha Mathew Kavunkal
a
,
Vijit Koshy Cherian
a
,
Devasahayam J. Christopher
b
a Department of Cardiothoracic Surgery Unit-I, Christian Medical College and Hospital, Vellore 632 004, Tamil Nadu, India
b Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
Received 24 November 2005;
received in revised form 13 December 2005;
accepted 15 December 2005.
* Corresponding author. Tel.: +91 416 2282029; fax: +91 416 2232035. (Email: murugusp{at}yahoo.com).
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Abstract
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Intrathoracic neurogenic tumors arising from chest wall are generally rare tumors. The benign soft tissue tumors may produce compression effect on the chest wall but are generally free. The presence of unusual adherence raises the suspicion of malignancy. Our case report describes the clinical features of a young male who underwent excision of a left posterosuperior chest wall mass with a portion of the fourth rib. Histopathological examination unexpectedly revealed the existence of two different pathologies. The mass was found to be benign schwannoma and the rib showed features of tuberculous osteomyelitis. Inflammatory response and fibrous reaction mimicked the features of malignancy.
Key Words: Chest wall • Mediastinal • Neurogenic • Tumors
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1. Introduction
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Intrathoracic neurogenic tumors arising from chest wall are rare tumors [1]. Primary chest wall tumors have an almost equal chance of being benign or malignant [2]. It is often difficult preoperatively to be sure if these tumors are benign or malignant. Our case report describes the condition of a young male who presented with a left intrathoracic tumor adjacent to the posterior chest wall. The presence of adhesions of the tumor to the fourth rib intraoperatively created a suspicion of malignancy. He underwent wide excision of the tumor along with a portion of adjacent chest wall. Histopathological examination identified the tumor as being schwannoma and tuberculous osteomyelitis in the adjacent rib. The features of malignancy are probably due to the proximity of the benign tumor with the tuberculous rib.
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2. Clinical summary
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A 31-year-old male presented with a history of recurrent hemoptysis and left-sided chest pain of 6 months duration. A thorough physical examination did not reveal any positive finding and a clinical diagnosis of probable bronchogenic carcinoma was made.
Chest radiology showed a 79 mm x 75 mm lobulated soft tissue density mass region in the left upper zone posteriorly (Fig. 1
). Computed tomography of the thorax revealed an extraparenchymal intrathoracic chest wall mass, which was cystic and multilobulated, posterior to the left upper lobe. The demarcation between the mass and the adjacent fourth rib was not very well defined (Fig. 2
). There were no features of pulmonary tuberculosis radiologically. Smears and culture of the sputum and bronchoalveolar lavage fluid for acid fast bacilli and malignant cells were negative. Computed tomography guided-needle biopsy of the mass was non-diagnostic.
He underwent surgery through a left fourth intercostal space posterolateral thoracotomy. We found a 6 cm x 5 cm x 4 cm lobulated cystic mass, loosely adherent to the left upper lobe but densely stuck to the fourth rib only. The cyst wall was thickened and highly vascular with multiple feeders from the intercostal vessels. As there were adhesions only to the fourth rib and the rest were free, excision of the tumor was carried out along with a wide margin of the fourth rib. The postoperative biopsy report revealed the tumor to be schwannoma and the rib showed granulomatous inflammation suggestive of tuberculosis.
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3. Discussion
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Primary chest wall tumors are rare and constitute 1–2% of all thoracic tumors [2]. Most series report an almost equal incidence of benign and malignant tumors [2,3]. In one study, 5 out of 41 (12%) patients were found to have neurogenic tumors, 4 of them were benign and 1 was malignant [2]. Intrathoracic neurogenic tumors occurs predominantly (90%) in the mediastinum and about 10% originate peripherally from the intercostal nerves [4]. Ninety-five percent of the neurogenic tumors are nerve sheath tumors and of these 75% are neurilemmomas [4]. The risk of malignancy in a nerve sheath tumor is very small (2–5%) unless there is a history of Von Recklinghausen's disease or radiation exposure when the risk increases to 10–20% [1,5,4]. Nerve sheath tumors can produce intercostal nerve irritation, rib displacement, and bone erosion owing to pressure effect [5]. It is often impossible to establish the benign or malignant nature of these tumors before surgery preoperatively [2,3,5].
In certain cases, the computed tomography scan can demonstrate central areas of low attenuation consistent with necrosis, hemorrhage, or cystic degeneration, which are suggestive of malignancy [5]. Benign tumors can produce thinning and scalloping of the adjacent rib but are generally free from it. The presence of unusual adherence indicates malignancy [5]. Therefore, a wide surgical resection remains the cornerstone of treatment and often requires the cooperative effort of thoracic, plastic, and neurosurgeons.
In the case of our patient, the presence of dense adhesions and increased vascularity were in favor of malignancy. This could have been secondary to the extension of inflammation from the tuberculous osteomyelitis of the fourth rib onto the capsule of the tumor. Postoperatively he was treated with antituberculous chemotherapy. At 6 months follow-up he was doing well. Chest X-ray did not reveal any recurrence of tumor or any fresh lesion.
On reviewing the literature, we did not find any report of chest wall schwannoma occurring in close proximity with tuberculosis of the rib, thus mimicking a malignant primary chest wall tumor.
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Acknowledgments
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We thank Mrs. I. Famitha Banu for her secretarial assistance.
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References
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Abstract
1. Introduction
