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• W2890031317 abstract "Cellular schwannoma is a rare variant of schwannoma, showing high cellularity and a low mitotic index. A 64-year-old man was admitted to our hospital with a 2-month history of productive cough. Chest computed tomography showed an endobronchial tumor with complete atelectasis of the right lower lobe. Bronchoscopy showed an endobronchial tumor occluding the intermediate bronchus that was diagnosed as a cellular schwannoma on biopsy and was successfully excised with a right lower sleeve lobectomy to preserve the middle lobe. The postoperative course was uneventful, and the patient remains well with no sign of recurrence at the 7-year follow-up. Cellular schwannoma is a rare variant of schwannoma, showing high cellularity and a low mitotic index. A 64-year-old man was admitted to our hospital with a 2-month history of productive cough. Chest computed tomography showed an endobronchial tumor with complete atelectasis of the right lower lobe. Bronchoscopy showed an endobronchial tumor occluding the intermediate bronchus that was diagnosed as a cellular schwannoma on biopsy and was successfully excised with a right lower sleeve lobectomy to preserve the middle lobe. The postoperative course was uneventful, and the patient remains well with no sign of recurrence at the 7-year follow-up. Schwannoma may occur in any peripheral nerve and is often found in the chest wall and posterior mediastinum. Cellular schwannoma is a variant of schwannoma that shows high cellularity and a low mitotic index. It is difficult but important to distinguish schwannoma from malignant peripheral nerve sheath tumor (MPNST) or malignant fibrous histiocytoma (MFH). Here, we report a case of endobronchial cellular schwannoma occluding the intermediate bronchus that was successfully excised by performing a right lower sleeve lobectomy. A 64-year-old man was referred to our hospital with a 2-month history of productive cough and atelectasis of the right lower lobe on a chest roentgenogram (Fig 1A ). Chest computed tomography showed a 20-mm endobronchial tumor arising from the right lower lobe into the intermediate bronchus with complete atelectasis of the right lower lobe (Fig 1B). A bronchoscopic examination revealed that the right intermediate bronchus was almost occluded because of the polyp from the right lower bronchus, and the tumor was diagnosed as a cellular schwannoma by using transbronchial biopsy (Fig 1C). Fluorine-18-fluorodeoxyglucose (FDG)–positron emission tomography showed that the mass exhibited high-level FDG accumulation, with a maximum standardized uptake ratio of 3.5 (Fig 1D). We performed a 6-cm lateral thoracotomy through the fifth intercostal space. The right lower lobe showed complete atelectasis, with the tumor arising from the B6 bronchus, and the right middle bronchus was not occluded because of the tumor (Fig 2). The patient underwent a right lower sleeve lobectomy, and both the distal and proximal margins were negative on frozen section. We accomplished an interrupted 4-0 PDS-II (Ethicon Inc, Johnson & Johnson, Somerville, NJ) suture without a covering flap. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. The resected tumor arising from the parenchymal B6 bronchus into the intermediate bronchus measured 45 mm × 20 mm and consisted of a solid component (Fig 3A ). Histologically, the tumor consisted of randomly arranged spindle cells with hyperchromatic and atypical nuclei (Fig 3B). An immunohistochemical study showed positive staining for S100 protein and negative staining for smooth muscle actin, CD34, and epithelial membrane antigen. There was a 16% positive staining for MIB-1 (Ki-67). Results from the histologic and immunohistochemical studies yielded a definitive diagnosis of a low-grade malignant cellular schwannoma (Fig 3C). The patient has remained well, with no sign of tumor recurrence at the 7-year follow-up. Schwannoma is a type of encapsulated neoplasm within the human body and is almost always solitary. It is most commonly located on the flexor surfaces of the extremities, neck, mediastinum, retroperitoneum, posterior spinal roots, and cerebellopontine angle [1Ackerman L. Rosai J. Ackerman’s Surgical Pathology.8th ed. Mosby Inc, St. Louis, MO1996Google Scholar]. Intrapulmonary or bronchial schwannoma account for 0.2% of all pulmonary neoplasms and originate within the tissue in the proximity of the terminal segmental bronchus in 55% of these patients [2Ohtsuka T. Nomori H. Naruke T. Orikasa H. Yamazaki K. Suemasu K. Intrapulmonary schwannoma.Jpn J Thorac Cardiovasc Surg. 2005; 53: 154-156Crossref PubMed Scopus (20) Google Scholar]. Cellular schwannoma is a variant of schwannoma and was first described by Woodruff and colleagues in 1981 [3Woodruff J.M. Godwin T.A. Erlandson R.A. Susin M. Martini N. Cellular schwannoma: a variety of schwannoma sometimes mistaken for a malignant tumor.Am J Surg Pathol. 1981; 5: 733-744Crossref PubMed Scopus (207) Google Scholar]. The tumor occurs predominantly among women, at a median age of 55 years (range: 15 to 79 years), and most tumors are located in the retroperitoneum or mediastinum [4Casadei G.P. Scheithauer B.W. Hirose T. Manfrini M. Van Houton C. Wood M.B. Cellular schwannoma: a clinicopathologic, DNA flow cytometric, and proliferation marker study of 70 patients.Cancer. 1995; 75: 1109-1110Crossref PubMed Scopus (109) Google Scholar]. Histologic features include a distinct predominance of cellular Antoni A tissue composed of interlacing fascicles of spindle cells with variable mitotic activity, absence of Verocay bodies, nuclear hyperchromasia, and pleomorphism. Although the outcome of cellular schwannoma is favorable without metastatic spread, it is important to distinguish it from MPNST or MFH. Cellular schwannoma is a highly cellular nerve sheath benign tumor with a low mitotic index and, because of its atypical features, may lead to an erroneous diagnosis of malignancy in approximately 28% of the surgical biopsy and resection specimens [4Casadei G.P. Scheithauer B.W. Hirose T. Manfrini M. Van Houton C. Wood M.B. Cellular schwannoma: a clinicopathologic, DNA flow cytometric, and proliferation marker study of 70 patients.Cancer. 1995; 75: 1109-1110Crossref PubMed Scopus (109) Google Scholar]. Immunohistochemical staining of S100 protein has been detected in all schwannomas with strong and diffuse reactivity, including cellular schwannomas but has been partly or not detected in MPNST and MFH [5Takahashi K. Isobe T. Ohtsuki Y. Akagi T. Sonobe H. Okuyama T. Immunohistochemical study on the distribution of alpha and beta subunits of S-100 protein in human neoplasm and normal tissues.Virchows Arch B Cell Pathol Incl Mol Pathol. 1984; 45: 385-396Crossref PubMed Scopus (254) Google Scholar]. In this case, histologic features, including a distinct predominance of cellular Antoni A spindle cells with variable mitotic activity, absence of Verocay bodies, nuclear hyperchromasia, pleomorphism, and an immunohistochemical study of positive staining for S100 protein, confirmed the diagnosis of the tumor as a cellular schwannoma. The utility of Ki-67, a tumor cell proliferation marker, has been reported in determining malignant potential [6Kindblom L.G. Ahlden M. Meis-Kindblom J.M. Stenman G. Immunohistochemical and molecular analysis of p53, MDM2, proliferating cell nuclear antigen and Ki67 in benign and malignant peripheral nerve sheath tumors.Virchows Arch. 1995; 427: 19-26Crossref PubMed Scopus (120) Google Scholar]. Kindblom and colleagues [6Kindblom L.G. Ahlden M. Meis-Kindblom J.M. Stenman G. Immunohistochemical and molecular analysis of p53, MDM2, proliferating cell nuclear antigen and Ki67 in benign and malignant peripheral nerve sheath tumors.Virchows Arch. 1995; 427: 19-26Crossref PubMed Scopus (120) Google Scholar] compared Ki-67 expression in 26 MPNSTs and 24 schwannomas. In 23 of 26 MPNSTs, from 5% to 65% of the tumor cell nuclei were immunoreactive for Ki-67, whereas none of the 24 schwannomas had nuclear staining exceeding 5%. The present cellular schwannoma showed a Ki-67 labeling index of 16%, higher than that of ordinary schwannomas. Surgical removal or intrabronchial resection with endoscopy has been performed to treat primary pulmonary schwannoma. Tumor enucleation or partial lung resection are thought to be adequate for this tumor because of its low malignant potential. Malignant transformation of solitary schwannoma is extremely rare [7Bartley T.D. Arean V.M. Intrapulmonary neurogenic tumors.J Thorac Cardiovasc Surg. 1965; 50: 114-123Abstract Full Text PDF PubMed Google Scholar]; however, Casedei and colleagues [4Casadei G.P. Scheithauer B.W. Hirose T. Manfrini M. Van Houton C. Wood M.B. Cellular schwannoma: a clinicopathologic, DNA flow cytometric, and proliferation marker study of 70 patients.Cancer. 1995; 75: 1109-1110Crossref PubMed Scopus (109) Google Scholar] reported 23.4% of local recurrence of cellular schwannoma, but no patient experienced distant metastasis or died as a result of the tumor. We consider, therefore, that a lobectomy or a segmentectomy should be chosen without hesitation to secure adequate margins, depending on the location of the tumor, and that careful follow-up should be considered. For our patient, a right lower sleeve lobectomy was required to accomplish complete excision, and the patient has remained well, with no sign of tumor recurrence at 7-year follow-up. In conclusion, we reported a rare case of endobronchial cellular schwannoma presenting as an occlusion of the intermediate bronchus that was successfully treated through complete excision by means of a right lower sleeve lobectomy to preserve the middle lobe." @default.
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• W2890031317 title "Successful Excision of Endobronchial Cellular Schwannoma With Right Lower Sleeve Lobectomy" @default.
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