Interactive Cardiovascular and Thoracic Surgery 2:483-485(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Port site recurrence after video-assisted thoracoscopic resection of chest wall schwannoma
Masaki Anraku,
Rie Nakahara,
Haruhisa Matsuguma and
Kohei Yokoi*
Division of Thoracic Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi 320-0834, Japan
* Corresponding author. Tel.: +81-28-658-5151; fax: +81-28-658-5488
kyokoi{at}tcc.pref.tochigi.jp
Received January 9, 2003;
received in revised form March 25, 2003;
accepted May 29, 2003
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Abstract
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Schwannoma is a benign neurogenic tumor, and no cases of metastasis or implantation from this tumor have been reported. We first describe a case of port site recurrence after video-assisted thoracoscopic resection of chest wall schwannoma. She has been well with no evidence of disease for 2 years after resection of the recurrent tumor. We stress the importance of using a specimen bag and careful manipulation during video-assisted thoracic surgery, even for benign tumors.
Key Words: Port site recurrence; Schwannoma; Video-assisted thoracoscopic surgery
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1. Introduction
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Port site recurrence (PSR) of malignant tumor is known as a complication of video-assisted thoracoscopic surgery (VATS). However, PSR of schwannoma has not been reported to our knowledge.
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2. Case report
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A 63-year-old woman was referred to our hospital with an abnormal shadow in her annual chest X-ray films. Computed tomographic (CT) scanning was performed for further evaluation of the abnormal shadow suspected chest wall tumor. CT scans showed a 2.7x1.6 cm hemispheric homogeneous mass in the right lateral chest wall (Fig. 1a). CT guided transcutaneous needle biopsy of the mass revealed schwannoma. Because the tumor was considered benign and non-invasive from those findings, she subsequently underwent VATS for tumor removal. Three port sites were placed. The tumor under the parietal pleura was identified at the sixth intercostal space. The direct connection of the tumor with the intercostal nerve was uncertain at the operation. A firm, encapsulated mass was resected in pieces because of capsule laceration. Tumor pieces were removed from one of the port sites without using a specimen bag. The tumor specimen was pathologically diagnosed as schwannoma. She was discharged on the seventh post-operative day with no complications.
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Fig. 1 (a) Computed tomogram before the initial operation showing a smooth mass in the lateral chest wall. (b) Computed tomogram 2 years after the initial operation demonstrating a subcutaneous mass (arrow) under the port site scar.
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Two years after the operation, a small subcutaneous mass sensation on the chest wall led her to visit our hospital. On palpation, there was a well-defined, smooth, firm mass of 1.5 cm in diameter beneath the port site scar. The port wound was used for the tumor removal at the operation. CT scans revealed a subcutaneous round mass at the same site (Fig. 1b). The mass was excised with the surrounding muscle under topical anesthesia. There was no connection between the mass and the intercostal nerve. Pathological examination demonstrated the areas with patterns of Antoni A and B. Spindle cells without mitotic figures or nuclear atypia composed short bundles, and tumor cells arranged nuclear palisading (Fig. 2). S-100 protein, which distinguishes schwannoma from neurofibroma, was widely detected in the tumor cells by immunohistochemical method, as the primary tumor was. The pathological findings that were identical to the primary tumor confirmed the diagnosis of benign schwannoma. The resected margin was free of the tumor. Within 2 years follow-up period after PSR resection, she is alive with no evidence of disease.
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3. Discussion
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VATS has become a useful procedure for the diagnosis and treatment of various thoracic diseases, especially for selected early stage lung cancer, metastatic lung tumor, and benign chest wall tumor. On the other hand, PSR is known as a rare complication of videoscopic surgical procedures for malignancy [1]. While the mechanism of PSR has not been clarified, tumor implantation in the trocar wound is considered to be the most likely cause. Downey and colleagues described 16 PSR cases after VATS, and pointed out tumor implantation could result from pulling the tumor mass through a small wound [2]. The Ad Hoc Committee for Cardiothoracic Surgical Practice Guidelines of the Society of Thoracic Surgeons recommended the use of a specimen bag during VATS in suspected malignancy [3]. In any case, to our best knowledge, PSR of schwannoma has not yet been reported.
Schwannoma is a benign nerve sheath tumor consisting of two components alternating Antoni A and B areas [4]. In Antoni A areas, spindle cells are arranged in short bundles or fascicles with focal nuclear palisading. Antoni B areas show less cellular with loose myxoid patterns composed of spindle or oval cells. S-100 protein is commonly present in the nucleus and cytoplasm of Schwann cells and can be demonstrated in the tumor derived from them. Uniformly intense immunostaining for S-100 protein is a feature of schwannoma, particularly in Antoni A areas. Schwannoma behaves in benign fashion, and malignant change is rare [5]. In this case, no malignant cell population was demonstrated in the recurrent tumor. Besides, there were no mitotic figures or nuclear atypia. While it seemed unlikely, PSR resulting from benign tumor implantation occurred in this patient. The disruption of the solid tumor by thoracoscopic handling, and the tumor retrieval without a specimen bag would have been responsible for viable cells seeding.
In conclusion, although benign tumor recurrence in a port wound is uncommon, careful manipulation and the use of a specimen bag should be considered to prevent tumor cells spillage that may result in PSR.
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Appendix A
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ICVTS on-line discussion
Author: Dr. Luciano Solani, Thoracic Surgeon, S. Maria delle Croci Hospital Thoracic Surgery Unit, V. le Randi, 5, Ravenna 48100, Italy
Date: 18-Sep-2003
Message: It is very important, in all cases, to avoid contact between the specimen and the chest wall, therefore we believe that a plastic bag must be used in all cases during its extraction from the pleural cavity in VATS procedure. In addition to the well-known implant of the malignant tumor, the Authors showed that also tissue from benign tumors can implant in the port site. Moreover, I would like to stress the use of the plastic bag also when inflammatory tissue is resected. Problems can occur when the specimen is bigger than the chest hole: in these cases it is preferable to enlarge the hole rather than risk the hazard of breaking the bag.
In the case reported by the Authors the recurrence could also have been helped by the fragmentation of the specimen during the endoscopic procedure. In conclusion, I recommend the complete resection of the specimen in a single block and its removal from the chest cavity in a plastic bag in all cases of VATS procedure.
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Acknowledgements
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We thank Yukio Tsuura, MD, for his pathological review.
doi:10.1016/S1569-9293(03)00116-6
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References
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Abstract
1. Introduction