Scientific Letter
Pleural Schwannoma Mimicking Metastatic Rectal Carcinoma
Schwannoma pleural que simula metástasis pleural de un carcinoma de recto
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B) TC con contraste intravenoso en ventana de mediastino. C) RMN con secuencia GRE-T1 tras la administración de contraste paramagnético. D) Ecografía con sonda lineal siguiendo un espacio intercostal. Las flechas blancas señalan una lesión con características extrapulmonares en todas las imágenes. En la imagen ecográfica se puede apreciar una imagen lineal de localización inferior a la lesión correspondiente a la línea pleuropulmonar y que, en la exploración dinámica mostraba movimiento preservado por lo que no sugeriría infiltración de la hoja visceral. E) Celularidad fusiforme, con patrón arremolinado, con músculo y vasos atrapados. F) Se observa moderado pleomorfismo celular, con ocasional cariomegalia, alternando áreas hipercelulares (+) o Antoni A e hipocelulares (*) o Antoni B, sin que se visualicen figuras mitóticas. 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(B) CT with intravenous contrast in mediastinum window. (C) MRI with GRE-T1 sequence after the administration of paramagnetic contrast medium. (D) Ultrasound with linear probe following an intercostal space. The white arrows show a lesion with extrapulmonary features in all images. In the ultrasound image, a linear image can be seen below the lesion corresponding to the pleuropulmonary line that, in the dynamic examination, showed normal movement suggesting no infiltration of the visceral layer. (E) Spindle-shaped cells in a whirling pattern, with trapped muscle and blood vessels. (F) Moderate cellular pleomorphism is observed, with occasional karyomegaly, alternating Antoni A hypercellular areas (+) and Antoni B hypocellular areas (*), with no visualization of mitotic figures. (G) Positivity for S100 protein.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Neuroblastoma-like schwannomas or neurilemomas arising from the Schwann cells of the nerve sheath are extremely uncommon benign tumors, first described by Goldblum in 1994.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> They mainly affect the head, particularly the jaw and neck, the flexor surface of limbs and the posterior root of the spinal nerve.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> Tumors tend to be solitary, and in exceptional circumstances occur in the chest wall,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> but they can occasionally be multiple in neurofibromatosis type 2 (NF2) or in the entity known as schwannomatosis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 57-year-old man with an 80 pack-year smoking history, prostate cancer treated with transurethral resection, and rectal cancer in the lower middle third of the rectum, treated surgically, with subsequent chemotherapy and radiation therapy (RT). The patient was clinically stable and asymptomatic from a respiratory point of view. Chest computed tomography (CT) was performed as part of the extension study, revealing well-defined, nonspecific oval pleural nodular thickening in the posterolateral portion of the 8th right intercostal arch measuring 35×11<span class="elsevierStyleHsp" style=""></span>mm. The same lesion was visualized on magnetic resonance imaging (MRI). The patient was referred to our clinic to rule out the existence of pleural metastases. We performed a chest ultrasound, which showed a poorly defined, anechoic, homogeneous lesion in the right chest wall, about 4.3<span class="elsevierStyleHsp" style=""></span>cm long and 1.8<span class="elsevierStyleHsp" style=""></span>cm thick. No infiltration was observed in the visceral pleura located medially to this lesion. Ultrasound-guided biopsy was performed using 14<span class="elsevierStyleHsp" style=""></span>G Acecut<span class="elsevierStyleSup">®</span> needles with 75<span class="elsevierStyleHsp" style=""></span>mm and 22<span class="elsevierStyleHsp" style=""></span>mm penetration depth (TSK, Japan). The pathology study showed spindle cell proliferation, with no characteristic pattern, swirling cellularity, moderate pleomorphism, occasional karyomegaly, and few mitotic figures, as well as more hypocellular areas with less compact stroma. Immunohistochemistry results were as follows: S100-positive, vimentin-positive, and Sox-10 positive, consistent with schwannoma with focal degenerative changes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The majority (approximately 95%) of pleural tumors are malignant, and mostly metastatic,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> while benign pleural tumors are unusual. Among the benign tumors, schwannomas usually occur in the posterior mediastinum, especially in a paravertebral site. Schwannomas located in the lateral chest wall are uncommon, and account for less than 5% of these tumors.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> Pathological findings are characteristic and consist of a proliferation of tumor cells growing eccentric to the nerve with a spindle-like appearance; there are densely cellular areas (Antoni A) in which the nuclei are may occasionally palisade to form Verocay bodies, and less compact areas (Antoni B).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> They are almost always positive for S100.</p><p id="par0020" class="elsevierStylePara elsevierViewall">From a clinical point of view, schwannomas may be asymptomatic or cause cough, chest pain, or dyspnea.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Malignancy is exceptional and has been described primarily in patients who have received RT.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Chest ultrasound usually shows anechoic tumors and can generally discriminate well between benign and malignant tumors.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> However, in our case, the image lacked well-defined borders, and given that the existence of pleural metastasis could have therapeutic implications, we decided to perform an ultrasound-guided biopsy of the lesion.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Other imaging techniques should clarify the differential diagnosis between solitary pleural lesions, such as lipomas, single metastatic lesions, mesotheliomas, fibrous tumors, and other neurogenic tumors. In schwannoma, CT with contrast can distinguish heterogeneous lesions with different cellularity demarcating the Antoni type A or B areas, with enhancement of the former suggesting areas of cystic degeneration.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> On MRI, schwannomas usually display an isointense image in T1, similar to muscle, sometimes called the “split fat sign” that appears as a peripheral margin of displaced fat in the neurovascular bundle,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> with hyperintense signal in T2, although the cystic regions may have a low signal intensity. MRI is also useful for visualizing vascular involvement. Positron emission tomography/computed tomography (PET/CT), however, is of limited utility, given that often shows high uptake,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> even in benign tumors, preventing the differential diagnosis with metastases of tumors from another source.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment is usually surgical and recurrence after treatment is unusual.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> However, in view of the lack of symptoms and the accompanying underlying disease of our patient, we decided to maintain a conservative attitude, while monitoring his clinical and radiological progress.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López González FJ, García Alfonso L, Enríquez Rodríguez AI, Torres Rivas HE. Schwannoma pleural que simula metástasis pleural de un carcinoma de recto. Arch Bronconeumol. 2019;55:110–111.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1379 "Ancho" => 2000 "Tamanyo" => 380193 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Posteroanterior chest X-ray. (B) CT with intravenous contrast in mediastinum window. (C) MRI with GRE-T1 sequence after the administration of paramagnetic contrast medium. (D) Ultrasound with linear probe following an intercostal space. The white arrows show a lesion with extrapulmonary features in all images. In the ultrasound image, a linear image can be seen below the lesion corresponding to the pleuropulmonary line that, in the dynamic examination, showed normal movement suggesting no infiltration of the visceral layer. (E) Spindle-shaped cells in a whirling pattern, with trapped muscle and blood vessels. (F) Moderate cellular pleomorphism is observed, with occasional karyomegaly, alternating Antoni A hypercellular areas (+) and Antoni B hypocellular areas (*), with no visualization of mitotic figures. (G) Positivity for S100 protein.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Retroperitoneal schwannoma: case series and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Cury" 1 => "R.F. Coelho" 2 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 41 | 23 | 64 |
| 2024 September | 73 | 25 | 98 |
| 2024 August | 98 | 50 | 148 |
| 2024 July | 68 | 32 | 100 |
| 2024 June | 63 | 28 | 91 |
| 2024 May | 95 | 31 | 126 |
| 2024 April | 50 | 32 | 82 |
| 2024 March | 43 | 24 | 67 |
| 2024 February | 30 | 17 | 47 |
| 2023 March | 4 | 5 | 9 |
| 2023 February | 43 | 15 | 58 |
| 2023 January | 39 | 19 | 58 |
| 2022 December | 87 | 24 | 111 |
| 2022 November | 69 | 21 | 90 |
| 2022 October | 65 | 41 | 106 |
| 2022 September | 42 | 19 | 61 |
| 2022 August | 46 | 43 | 89 |
| 2022 July | 37 | 37 | 74 |
| 2022 June | 51 | 33 | 84 |
| 2022 May | 62 | 38 | 100 |
| 2022 April | 92 | 37 | 129 |
| 2022 March | 98 | 43 | 141 |
| 2022 February | 96 | 36 | 132 |
| 2022 January | 89 | 32 | 121 |
| 2021 December | 77 | 42 | 119 |
| 2021 November | 89 | 42 | 131 |
| 2021 October | 91 | 36 | 127 |
| 2021 September | 40 | 47 | 87 |
| 2021 August | 69 | 36 | 105 |
| 2021 July | 35 | 18 | 53 |
| 2021 June | 68 | 39 | 107 |
| 2021 May | 59 | 60 | 119 |
| 2021 April | 122 | 125 | 247 |
| 2021 March | 54 | 15 | 69 |
| 2021 February | 21 | 16 | 37 |
| 2020 March | 25 | 2 | 27 |
| 2020 February | 75 | 9 | 84 |
| 2020 January | 76 | 11 | 87 |
| 2019 December | 40 | 11 | 51 |
| 2019 November | 27 | 17 | 44 |
| 2019 October | 20 | 15 | 35 |
| 2019 September | 19 | 13 | 32 |
| 2019 August | 20 | 8 | 28 |
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