A Case of Benign Esophageal Schwannoma Causing Life-threatening Tracheal Obstruction

Total removal of a large esophageal schwannoma by submucosal tunneling endoscopic resection: A case report and review of literature

BACKGROUND

Primary schwannoma is a rare submucosal tumor of the esophagus, which is most often benign, and surgery is the only effective treatment. So far, only a few cases have been reported. Herein, we reported a single case diagnosed with primary esophageal schwannoma that was totally removed by submucosal tunneling endoscopic resection (STER).

CASE SUMMARY

A 62-year-old man presented to the hospital with a history of resection of a malignant gastric tumor and mild dysphagia. Endoscopic examination revealed a large submucosal elevated lesion in the esophagus 25-30 cm from the incisors. Endoscopic ultrasonography detected a 45 mm × 35 mm × 31 mm hypoechoic lesion; chest computed tomography showed a mass of approximately 55 mm × 35 mm × 29 mm. A preliminary examination showed features suggestive of a stromal tumor. Pathological findings indicated esophageal schwannoma. Next, STER alone was performed to completely resect the mass, and the patient recovered well post-surgery. Afterward, the patient was discharged and showed no tumor recurrence at 33 mo of follow-up.

CONCLUSION

Endoscopic resection is still an effective treatment for large esophageal schwannomas (> 30 mm) under meticulous morphological evaluation.

Thoracoscopic resection of a large lower esophageal schwannoma: A case report and review of the literature

BACKGROUND

Esophageal schwannomas originating from Schwann cells are extremely rare esophageal tumors. They commonly occur in the upper and middle esophagus but less frequently in the lower esophagus. Herein, we report a rare case of a large lower esophageal schwannoma misdiagnosed as a leiomyoma. We also present a brief literature review on lower esophageal schwannomas.

CASE SUMMARY

A 62-year-old man presented with severe dysphagia lasting 6 mo. A barium esophagogram showed that the lower esophagus was compressed within approximately 5.5 cm. Endoscopy revealed the presence of a large submucosal protuberant lesion in the esophagus at a distance of 32-38 cm from the incisors. Endoscopic ultrasound findings demonstrated a 4.5 cm × 5.0 cm hypoechoic lesion. Chest computed tomography revealed a mass of size approximately 53 mm × 39 mm × 50 mm. Initial tests revealed features indicative of leiomyoma. After multidisciplinary discussions, the patient underwent a video-assisted thoracoscopic partial esophagectomy. Further investigation involving immunohistochemical examination confirming palisading spindle cells as positive for S100 and Sox10 led to the final diagnosis of a lower esophageal schwannoma. There was no tumor recurrence or metastasis during follow-up.

CONCLUSION

The final diagnosis of esophageal schwannoma requires histopathological and immunohistochemical examination. The early appropriate surgery favors a remarkable prognosis.

Esophageal Schwannoma: A Rare Benign Esophageal Tumor

Benign primary tumors are uncommon, with the majority of these tumors being leiomyomas; schwannomas of the esophagus are rare. Here, we present a case of a 78-year-old woman referred for complaints of intermittent dysphagia with a chest computed tomography scan showing a homogenous mass, compressing the esophagus. Upper gastrointestinal endoscopy revealed a submucosal mass, which was eventually diagnosed as a schwannoma after an endoscopic ultrasound with fine-needle aspiration and subsequent pathologic and immunohistochemical examination. Schwannomas could be managed conservatively.

Clinicopathological features of esophageal schwannomas in mainland China: systematic review of the literature

OBJECTIVE

Esophageal schwannoma (ES) are rare and mostly benign neurogenic tumors. The clinical misdiagnosis rate of it is high. In this study, the clinicopathologic features of ES in mainland China were studied to better understand the disease and improve the diagnosis and treatment rate.

METHODS

A systematic review was conducted in accordance with PRISMA guidelines. The keywords "esophageal schwannoma", "esophageal neurinoma" and "esophageal neurilemoma" were searched for databases such as Pubmed, EMbase, Wanfang Database and Chinese National Knowledge Infrastructure. The search time frame for database was until July 2019. Combined with our patient, the clinicopathological data and the diagnosis and treatment of ES were summarized.

RESULTS

ES occurs in the upper part of the mediastinum and in the thoracic esophagus in most patients in the neck, upper and middle segments. CT and PET/CT examinations can be used for diagnosis, but the differentiation value of both benign and malignant ES is similar. The histopathological findings of forceps biopsy specimens are often difficult to diagnose, and deep tissue biopsies may increase pathological accuracy. EUS-FNA is also recommended for ES diagnosis, but it may also be misdiagnosed. Pathological features include a fusiform arrangement in a palisade-like structure or a tumor cell arranged in a network to form a loose structure. ES characteristic immunohistochemistry results showed that S-100 protein has strong immunological activity.

CONCLUSION

The definitive diagnosis requires immunohistochemistry, especially immunological reaction with S-100 protein. The appropriate treatment plan should be selected according to the diameter of the lesion. The overall prognosis of ES is good, but attention should be paid to follow-up.

Benign esophageal schwannoma: A case report and brief overview

RATIONALE

Schwannoma is a tumor of the peripheral nervous system that originated in the Schwann cells of the neural sheath. Esophageal schwannomas are rare esophageal submucosal tumors, comprising approximately 2% of esophageal tumors. Since the symptoms, signs, and images of esophageal schwannoma are not specific, its preoperative diagnosis remains challenging.

PATIENT CONCERNS

A 67-year-old woman visited our department with complaints of gradually developed dysphagia and dyspnea for 4 years. A chest computed tomography scan showed a well-demarcated, enhancing homogeneous tumor measuring 61 × 46 × 60 mm in the upper third of the esophagus. Upper gastrointestinal endoscopy revealed a smooth elevated lesion located 19 to 24 cm from the incisor teeth. An endoscopic ultrasound-guided fine-needle aspiration demonstrated the presence of benign spindle cells.

DIAGNOSES

Histopathologic examination revealed spindle-shaped cells in a fasciculated and disarrayed architecture. The immunohistochemical study showed positivity for S-100 protein antibody and absence of staining for CD117, CD34, smooth muscle actin, and Desmin. These findings confirmed the diagnosis of benign esophageal schwannoma.

INTERVENTIONS

The tumor was considered to be difficult to repair the esophagus by direct anastomosis after tumor resection. Therefore, subtotal esophagectomy and esophagogastrostomy in the right thorax were performed.

OUTCOMES

The patient has been doing well with no recurrence at 36 months after the operation.

LESSONS

The symptoms and surgical procedures for benign esophageal schwannoma depend on the size and location of the tumor, proper and timely treatment is essential. A definitive diagnosis is confirmed by histology, and complete excision should yield good results.

Clinical characteristics and surgical treatment of schwannomas of the esophagus and stomach: A case series and systematic review

BACKGROUND

Gastrointestinal schwannomas are slow-growing benign mesenchymal neoplasms that originate from Schwann cells of the nerve sheath of Auerbach´s plexus or less frequently from Meissner´s plexus. The main differential diagnosis of gastric schwannomas are the gastrointestinal stromal tumors (GISTs), which are classified by their immunohistochemistry. The treatment of choice for gastric schwannomas is surgery where laparoscopy plays an important role. Wedge resection, subtotal or total gastrectomy can be done. In its counterpart, esophageal schwannomas are benign tumors of the esophagus that are very uncommon since they comprise less than 2% of all esophageal tumors. The main differential diagnosis is the leiomyoma which corresponds to the most common benign esophageal tumor, followed by GIST. The treatment consists on tumoral enucleation or esophagectomy.

AIM

To review the available literature about gastrointestinal schwannomas; especially lesions from de stomach and esophagus, including diagnosis, treatment, and follow up, as well as, reporting our institutional experience.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. The following databases were used for reviewing process: PubMed, Ovid, MEDLINE, and Scopus. Only English language manuscripts were included. All gastrointestinal schwannomas specifically located in the esophagus and stomach were included. Cases that did not report long-term follow-up were excluded.

RESULTS

Gastric localization showed a higher prevalence in both, the literature review and our institution: 94.95% (n = 317) and 83% (n = 5) respectively. With a follow-up with disease-free survival greater than 36 mo in most cases: 62.01% (n = 80) vs 66.66% (n = 4). In both groups, the median size was > 4.1 cm. Surgical treatment is curative in most cases

CONCLUSION

Schwannoma must be taken into account in the differential diagnosis of gastrointestinal mesenchymal tumors. It has a good prognosis, and most are benign. A disease-free survival of more than 36 mo can be achieved by surgery.

Esophageal schwannoma: Case report and epidemiological, clinical, surgical and immunopathological analysis

INTRODUCTION

Schwannoma is a tumor of the peripheral nervous system originated in the Schwann cells of the neural sheath.

PRESENTATION OF CASE

A 43-years-old male complained of odynophagia, dysphagia and hemoptysis. The upper gastrointestinal endoscopy showed a smooth elevated lesion, 20 cm from the incisor teeth, occupying the entire lumen of the esophagus. The chest computed tomography (CT) scan showed a lesion of 7 cm and superior mediastinal, lower paraesophageal and cardiac enlarged lymph nodes. A posterolateral thoracotomy was performed with total esophagectomy without intraoperative complications. The anatomopathological analysis revealed fusocellular mesenchymal neoplasia of low malignancy potential. The immunohistochemical study showed positivity for S-100 protein and KI67 antibodies and absence of staining for CD117, CD34, ALK protein, SMA and Desmin. Thus, the morphological and immunohistochemical findings pointed to the diagnosis of esophageal Schwannoma.

DISCUSSION

Although rare and indolent, Schwannoma occurs in the peripheral nervous system, being uncommon in the esophagus.

CONCLUSION

The immunohistochemical study is essential for the diagnosis, which is based on the positivity for S-100 protein and absence of staining for CD34 and CD117.

Strategy for esophageal non-epithelial tumors based on a retrospective analysis of a single facility

BACKGROUND

Although most esophageal non-epithelial tumors are benign tumors, such as leiomyomas, they also include gastrointestinal tumors (GISTs); thus, a histopathological diagnosis is indispensable to determine the optimal treatment strategy. However, no consensus has been reached as to the diagnostic methods and treatments for esophageal non-epithelial tumors. The purpose of this study was to evaluate the reliability of the diagnostic methods and treatments for esophageal non-epithelial tumors in our hospital.

METHODS

All 28 cases of esophageal non-epithelial tumors at Kobe University Hospital from 2008 to 2016 were analyzed retrospectively with respect to the diagnostic methods, histopathological diagnosis, and treatments.

RESULTS

Three diagnostic methods, endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA), endoscopic incisional biopsy, and endoscopic submucosal dissection (ESD)/endoscopic mucosal resection (EMR), were performed in our hospital. All GIST cases could be correctly diagnosed by EUS-FNA. Tumors less than approximately 20 mm in diameter and located in the superficial layer are good indications for ESD/EMR, which both play roles in diagnosis and treatment. The final diagnoses by these methods consisted of the following: 13 leiomyomas, 5 GISTs, 3 schwannomas, 2 liposarcomas, 3 cysts, 1 reactive lymphoid hyperplasia, and 1 granulosa cell tumor. Fifteen cases underwent surgery. Enucleation or partial resection was performed for leiomyomas, schwannomas and liposarcomas, while esophagectomy was performed for GISTs. Thus, sufficient management of non-epithelial tumors is achieved.

CONCLUSIONS

Improved endoscopic procedures, including EUS-FNA and ESD/EMR, enabled the appropriate diagnosis and treatment of esophageal non-epithelial tumors.

Benign esophageal schwannoma: a brief overview and our experience with this rare tumor

Background

Benign esophageal tumors are uncommon, comprising approximately 2% of esophageal tumors. Esophageal schwannomas constitute an even rarer entity, with few cases reported in the literature.

Case presentation

We present a 66-year-old male who was referred for dysphagia. A computed tomography scan showed a well-demarcated, enhancing, and homogenous esophageal tumor measuring 50 mm. The tumor was hypermetabolic on positron emission tomography, and an endoscopic ultrasound-guided fine needle aspiration demonstrated the presence of benign spindle cells. We performed an uncomplicated, simple, tumor enucleation through a cervical approach. Histology revealed spindle-shaped cells in a fasciculated, disarrayed pattern. Immunohistochemistry demonstrated positive staining for S-100 protein and negative staining for KIT, CD34, desmin, and α-smooth muscle actin. These findings were consistent with a benign esophageal schwannoma.

Conclusions

We report our experience with esophageal schwannoma, a rare but benign diagnosis of the esophagus.

Vagus nerve schwannoma in the right upper mediastinum

A 35‐year‐old woman was admitted to our hospital with an abnormal shadow on her chest roentgenogram. Computed tomography showed that a tumor was located in the right upper mediastinum. Resection of the tumor by video‐assisted thoracoscopic surgery was performed. Operative findings determined that the tumor originated from the right vagus nerve and was diagnosed as schwannoma by pathological examination.