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J Thorac Cardiovasc Surg 1995;109:184-185
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

Mediastinal vagal neurilemmoma causing tracheal stenosis

Junya Katoh, MD, Shinpei Yoshii, MD, Osamu Suzuki, MD, Shigeru Hosaka, MD, Ryoichi Hashimoto, MD, Yusuke Tada, MD


Yamanashi, Japan

From the Second Department of Surgery, Yamanashi Medical University, Yamanashi, Japan.

Neurogenic tumors of the mediastinum are common and constitute the majority of neoplasms of the posterior mediastinum.Go 1 Usually such tumors arise from the intercostal nerve or the sympathetic chain. However, tumors originating from the vagus nerve are rare. A review of the literature revealed no patient with vagal neurilemmoma causing severe tracheal stenosis. We report here a case of vagal neurilemmoma in which hemosputum resulted from compression of the membranous trachea.

A 68-year-old man was admitted with a 6-month history of feeling pressure on swallowing and recent onset of frequent hemosputum. He had retired from his post as a public official 8 years previously, did not smoke, and had no history of serious illness. Physical examination showed no abnormalities, and results of laboratory findings including urinalysis, complete blood count, blood chemistry, arterial blood gases, and tumor makers were within normal limits. A spirogram also showed no abnormalities. Posteroanterior and lateral roentgenograms of the chest showed a mass compressing the trachea from behind. A computed tomographic scan revealed a well-circumscribed, heterogeneously enhanced mass, which was causing tracheal stenosis. Magnetic resonance imaging was performed for further anatomic definition of the mass (Fig. 1). Examination with a fiberoptic bronchoscope disclosed severe extrinsic pressure on the distal trachea and mucosal injection (Fig. 2). Transtracheal biopsy was impossible because the mucosa had a tendency to bleed. It was difficult to establish a definite preoperative diagnosis computed tomography and magnetic resonance imaging suggested a benign tumor, such as neurilemmoma or neurofibroma, but we could find no case report of benign mediastinal tumor associated with frequent hemosputum, and a pathologic diagnosis could not be obtained because of bleeding from the tracheal mucosa.



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  		Fig. 1. Magnetic resonance imaging showing a well-circumscribed mass compressing the membranous trachea.

 


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  		Fig. 2. View through a fiberoptic bronchoscope showing severe extrinsic pressure on the distal trachea from behind. Tracheal mucosa is injected and has a tendency to bleed.

 
With the preoperative diagnosis of mediastinal neurogenic tumor, which was most likely a neurilemmoma but possibly a malignant tumor, a right thoracotomy incision was made. A smooth, encapsulated tumor with the dimensions of 4 x 4 x 3 cm was encountered behind the trachea, and careful observation revealed that it was originating from the right vagus nerve. Inasmuch as examination of frozen sections of the mass showed that the tumor was a neurilemmoma originating from the vagus nerve, we decided to resect the tumor completely. Because the tumor could not be dissected from the nerve, the tumor was extirpated with proximal and distal ligation and division of the vagus nerve. At that time, a 2 cm defect in the membranous trachea of the carina occurred, and a double-lumen endobronchial tube was placed into the left main bronchus to ventilate the left lung selectively. A pedicled pericardial flap was harvested and sutured to the membranous trachea with interrupted Maxon sutures (Davis & Geck, Danbury, Conn.). In addition, a pedicled omentum was harvested through a median incision of the upper part of the abdomen and wrapped around the repaired defect to avoid anastomotic leakage. Pathologically this tumor was characterized as an encapsulated neurilemmoma. The tissue was composed of compactly arranged spindle cells and the nuclei were arranged in palisades that were designated Antoni type A. No postoperative complications developed. A bronchoscopic study performed 8 weeks after the operation showed complete epithelialization of the pericardial patch.

Tumors originating from the vagus nerve are rare Besznyak, Toth, and SzendeGo 2 observed two intrathoracic vagal tumors among 741 mediastinal tumors seen in a 25-year period. Das Gupta and colleaguesGo 3 identified two cases of vagal tumor from 303 benign solitary schwannomas. Usually vagal tumors are recognized at the paramedian portion of the mediastinum because of the anatomic situation of the vagus nerve. Intrathoracic neurilemmomas are usually detected as incidental findings at chest radiography. Symptoms, such as hoarseness, chest pain, or cough, however, may occur by involvement of the recurrent laryngial nerve or from compression of the trachea or bronchi.Go 4 This is the first reported case of a vagal neurilemmoma that grew behind the trachea and compressed it, thereby causing frequent hemosputum.

Benign vagal tumor with hemosputum is rare, but it may be of benefit for the thoracic surgeon to establish methods of diagnosis and treatment of this disease

Footnotes

J THORAC CARIOVASC SURG 1995; 109:184-5 Back

References

  1. Shields TW, Reynolds M. Neurogenic tumors of the thorax. Surg Clin North Am 1988;68:645-68.[Medline]
  2. Besznyák I, Tóth L, Szende B. Intrathoracic vagus nerve tumors: a report of two cases and review of the literature. J Thorac Cardiovasc Surg1985;89:462-65.
  3. Das Gupta TK, Brasfield RD, Strong EW, Hajdu SI. Benign solitary schwannomas (neurilemmomas). Cancer 1979;24:355-66.
  4. Stickland B, Wolverson MK. Intrathoracic vagus nerve tumors. Thorax 1974;29:215-22.[Abstract/Free Full Text]




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