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  Table of Contents    
CASE REPORT
Year : 2015  |  Volume : 32  |  Issue : 3  |  Page : 271-273  

Tracheal schwannoma: Completely resected with therapeutic bronchoscopic techniques


1 Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of General Pathology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication5-May-2015

Correspondence Address:
Dr. Barney Thomas Jesudason Isaac
Department of Pulmonary Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.156252

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   Abstract 

Tracheal schwannomas are rare benign tumors of the trachea. There are only a few reported cases in the literature. Surgeons have generally resected these tumors, whereas bronchoscopists have attempted to remove them bronchoscopically. We report a case of tracheal schwannoma which was completely resected using bronchoscopic techniques.

Keywords: Electrocautery, endobronchial treatment, tracheal neoplasms, tracheal tumor, schwannoma


How to cite this article:
Isaac BT, Christopher DJ, Thangakunam B, Gupta M. Tracheal schwannoma: Completely resected with therapeutic bronchoscopic techniques. Lung India 2015;32:271-3

How to cite this URL:
Isaac BT, Christopher DJ, Thangakunam B, Gupta M. Tracheal schwannoma: Completely resected with therapeutic bronchoscopic techniques. Lung India [serial online] 2015 [cited 2019 Sep 15];32:271-3. Available from: http://www.lungindia.com/text.asp?2015/32/3/271/156252


   Introduction Top


Tracheal schwannomas are extremely rare. Since there have been only a few case reports of these, there is no consensus on the correct approach to treatment. There are not many reports of the use of bronchoscopic techniques to resect such tumors, and generally surgical options seem to have been adopted more often, with curative intent. We report a case of tracheal schwannoma, which was completely resected using bronchoscopic techniques.


   Case Report Top


A 24-year-old man presented with dry cough and shortness of breath for 1 year and noisy breathing for 2 months. He had been on several medications for asthma for the past 1 year with no response. On examination, he had a monophonic inspiratory and expiratory wheeze, heard bilaterally.

His spirometry revealed reduction in maximum mid expiratory flow rate (MMEF) with flattening of both inspiratory and expiratory limbs of the flow volume loop, suggestive of a fixed upper airway obstruction [Figure 1]a. His chest x-ray was reported as being normal. Hence, he underwent a computed tomography (CT) of the neck [Figure 2]a, which revealed a well-defined, lobulated, mildly enhancing soft tissue density lesion arising from the right lateral and posterior wall of the trachea, projecting into the tracheal lumen and causing luminal narrowing at C7-T1 level.
Figure 1: Flow volume loop. (a) Pre-operative; (b) Post-operative

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Figure 2: (a) Pre-operative computed tomography (b) Post-operative magnetic resonance imaging

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He was then subjected to a flexible bronchoscopy through a laryngeal mask airway (LMA) under general anesthesia, with an intent of de-bulking the tumor. There was a smooth vascular tumor seen, almost completely occluding the tracheal lumen, arising from its right lateral and posterior walls, with its proximal extent 2 cm from the vocal cords [Figure 3]a. Adrenaline (1 ml of 1 in 10,000) was injected at its base, through a conventional TBNA (trans-bronchial needle aspiration) needle to prevent severe endo-bronchial bleeding. The tumor was then resected using an electrocautery snare as two large pieces. Since the pieces were large, with the help of a head down tilt of the operating table, they were delivered into a foreign body basket and successfully removed along with the LMA [Figure 3]c. There was no residual tumor [Figure 3]b. The location of its pedicle was 9.5 cm from the carina and 3.5 cm from the vocal cords, at the right postero-lateral wall of the trachea.
Figure 3: (a) Bronchoscopy showing tumor completely occluding the trachea. (b) Post-bronchoscopic resection showing a completely patent trachea. (c) Picture of the tumor removed within a foreign body basket along with the laryngeal mask airway (LMA)

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Post procedure, he became asymptomatic and the spirometry and flow volume loop reverted to normal [Figure 1]b. Histopathological examination revealed fibrovascular tissue lined by respiratory epithelium. The fibrovascular tissue was replaced by a tumor, composed of fascicles of spindle cells arranged in a palisading fashion forming verocay bodies [Figure 4]. Infiltrates of lymphocytes, plasma cells and hemosiderin laden macrophages were seen. There was no evidence of malignancy. Spindle cells were diffusely and strongly positive for S-100 [Inset of [Figure 4]. CD34 and epithelial membrane antigen (EMA) were negative. This was consistent with a schwannoma.
Figure 4: (a) Tumor with palisading arrangement of spindle cells is seen, H and E (hematoxylin and eosin), 20× magnification. (b) Tumor cells staining for S-100, immunohistochemistry, 10× magnification

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Since there was a doubt on the pre-procedure CT of a posterior extra-luminal extension, an MRI (magnetic resonance imaging) was done post bronchoscopy, which showed minimal mucosal thickening along the right lateral and posterior wall of the trachea and minimal hyperintensity in the paratracheal soft tissue at the same level, which were consistent with post-operative changes [Figure 2]b. Since there was no residual tumor, it was decided to keep the patient on bronchoscopic surveillance. At the sixth month review, bronchoscopy revealed no recurrence.


   Discussion Top


Primary tracheal tumors are rare and comprise only 1% of all neoplasms. Among these only a quarter are benign. [1] Schwannoma is an uncommon benign tracheal tumor, [1] and thus tracheal schwannomas are extremely rare. Till date, there are around 35 reported cases of tracheal schwannomas.

Since schwannomas are slow growing tumors of the trachea, they produce symptoms only when they are large enough to cause obstructive symptoms. Since they present with cough and breathlessness, they are often mistreated for years as asthma [2] or COPD, until one suspects an endotracheal lesion due to unresponsiveness to inhaled medications or by the appearance of the flow volume loop or when the symptoms progress to stridor, like it did in our subject.

Bronchoscopic biopsy will yield the diagnosis, but when the tumor is large, as in this case, it is better done under general anesthesia, to reduce complications and mortality. This also gives the opportunity to do therapeutic debulking, which by itself is curative as noted in the literature, [3],[4],[5],[6] provided there is no significant extraluminal component. The literature seems to suggest that when these patients have been managed surgically, [7],[8],[9],[10],[11],[12] the primary approach has been surgical removal with limited resection of the trachea with preservation of the lung, except in a case of carinal schwannoma, [7] when the patient had to undergo a carinal pneumonectomy, since one lung had been significantly damaged due to post obstructive collapse. Among the cases which have been dealt with bronchoscopically, [3],[4],[5],[6] there have been no recurrence reported during the follow up period, ranging from one to five years. It may be desirable to keep these patients on bronchoscopic surveillance, at least yearly to tackle recurrence if at all they occur.

 
   References Top

1.
Grillo HC, Mathisen DJ. Primary tracheal tumors: Treatment and Results. Ann Thorac Surg 1990;49:69-77.  Back to cited text no. 1
    
2.
Thomas R, Christopher DJ, Thangakunam B, Samuel R. Tracheal schwannoma as a mimic of bronchial asthma. Singapore Med J 2012;53:e95-6.  Back to cited text no. 2
    
3.
Melendez J, Cornwell L, Green L, Casal RF. Treatment of large subglottic tracheal schwannoma with microdebrider bronchoscopy. J Thorac Cardiovasc Surg 2012;144:510-2.  Back to cited text no. 3
    
4.
Rusch VW, Schmidt RA. Tracheal schwannoma: Management by endoscopic laser resection. Thorax1994;49:85-6.  Back to cited text no. 4
    
5.
Weiner DJ, Weatherly RA, DiPietro MA, Sanders GM. Tracheal schwannoma presenting as status asthmaticus in a sixteen-year-old boy: Airway considerations and removal with the CO2 laser. Pediatr Pulmonol 1998;25:393-7.  Back to cited text no. 5
    
6.
Ikeda T, Nakanishi T, Ito G, Takagi Y. A case of tracheal schwannoma resected by bronchoscopic electrocautery and argon plasma coagulation. J Jpn Soc Respir Endoscopy 2006;28:426-30.  Back to cited text no. 6
    
7.
Dutta R, Kumar A, Kaushal S, Choudhary SK. A case of carinal schwannoma resected under cardioplulmonary bypass. Indian J Cancer 2011;48:366-8.  Back to cited text no. 7
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8.
Bagheri R, Kalantari M, Noorshafiee S. Primary tracheal schwannoma. Tanaffos 2010;9:64-8.  Back to cited text no. 8
    
9.
Muzaffar MS, Umair B, Ali MZ, Hanif MS. Tracheal schwannoma: A rare tracheal tumour. J Coll Physicians Surg Pak 2010;20:410-1.  Back to cited text no. 9
    
10.
Dincer SI, Demir A, Kara HV, Fener N, Altin S. Primary tracheal schwannoma: A case report. Acta Chir Belg 2006;106:254-6.  Back to cited text no. 10
    
11.
Dorfman J, Jamison BM, Morin JE. Primary tracheal schwannoma. Ann Thorac Surg 2000;69:280-1.  Back to cited text no. 11
    
12.
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. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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