Schwannoma of the Intercostal Nerve Manifesting as Chest Pain Wei-Hsiang Feng, MD, Tung Liu, MD, Tsai-Wang Huang, MD, PhD, and Ying-Yi Chen, MD Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; and Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan Many different benign and malignant tumors develop in the chest wall and pose a diagnostic and therapeutic challenge to clinicians. Chest wall schwannomas of the intercostal nerve are rare. This report describes the clinical and imaging findings of a patient who presented with persistent and progressive chest pain. The inter- costal tumor was treated using wide excision with chest wall reconstruction and titanium plate fixation. Schwannoma was diagnosed on the basis of histopatho- logic examination. (Ann Thorac Surg 2020;110:e281-3) Ó 2020 by The Society of Thoracic Surgeons T umors of the thoracic skeleton are uncommon and are rarely encountered in thoracic surgery. More than one-half of such tumors are malignant and result from metastasis or direct invasion of tumors of adjacent structures, including the thorax, mediastinum, and soft tissue. Wide surgical resection is the most effective treatment for most chest wall tumors. However, it is one of the most challenging operations for thoracic and reconstructive surgeons and can lead to significant post- operative pulmonary dysfunction. 1 Neurogenic tumors, although common in the medias- tinum, rarely occur in the chest wall. 2 A schwannoma is a benign, encapsulated, neurogenic tumor arising from the Schwann cells of the nerve sheath. It is a type of peripheral nerve sheath tumor. 3 These tumors often occur in the spinal nerve roots. 4 Most benign tumors of the chest wall, including schwannomas, manifest as slow-growing, painless, and palpable masses. 4 Several thoracic neurogenic tumors tend to arise in the posterior mediastinum. A chest wall schwannoma is a rare entity that arises from the intercostal nerves. 5 Men and women are equally affected in the third and fourth de- cades of life. 6 Here we present a rare case of refractory chest pain and describe the methods used to establish the challenging diagnosis. A 42-year-old man experienced intermittent left chest wall pain for 6 years. This pain progressively worsened over the months leading up to admission. He did not have any relevant medical history. The pain was aggravated by movement. Physical examination revealed a firm, un- movable but tender mass measuring approximately 5 2 cm at the left ninth rib. We performed a series of in- vestigations, including blood tests, chest roentgenograms, chest computed tomography (CT), and technetium-99m methylene diphosphonate whole body bone scan, to evaluate the lesion. Blood tests and plain chest roent- genograms failed to reveal any remarkable findings. Chest CT revealed a poorly enhancing tubular lesion along the left ninth rib (Figure 1), which indicated a neurogenic tumor or fibrous dysplasia. No markedly abnormal uptake was observed over the left ninth rib on the bone scan. After providing the patient with an explanation and obtaining consent, we performed wide excision of the left ninth rib with chest wall reconstruction and titanium plate fixation. A 15-cm linear incision was made along the ninth costal region from the anterior axillary to the pos- terior axillary line. The rib tumor was excised, and the ninth rib and parietal pleura were partially resected (Figure 2). The defect in the left ninth rib was recon- structed with an 18-hole titanium plate and 8-mm screws. The pleural defect was repaired using a mesh, and two Jackson-Pratt drains were placed, both within the sub- cutaneous layer and within the left pleural space. Sub- sequently, the patient reported that the pain in his chest wall was significantly reduced; he was discharged on postoperative day 4. Figure 1. A poorly enhanced tubular lesion (arrow) identified along the left ninth rib on chest computed tomography. (A, anterior; L, left; P, posterior; R, right.) Accepted for publication Feb 17, 2020. Address correspondence to Dr Chen, Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, 325, Section 2, Cheng-Kung Rd, Taipei 114, Taiwan, Republic of China; email: [email protected]. Ó 2020 by The Society of Thoracic Surgeons 0003-4975/$36.00 Published by Elsevier Inc. https://doi.org/10.1016/j.athoracsur.2020.02.044
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