Adjacent schwannomas originating from two different nerves!
The following case has been reported in BMJ.

Schwannomas are the most frequent type of intrathoracic neurogenic tumour, but the presence of multiple simultaneous schwannomas is a rare occurrence. The authors share their experience of a patient initially thought to have a single schwannoma based on preoperative imaging, but was subsequently found to have two adjacent schwannomas arising from different nerves.

A 48-year-old woman showed an abnormal shadow on chest X-ray during a medical examination. CT-guided biopsy did not provide a definitive diagnosis, and she was therefore referred to our department. Her general condition was good and her neurological findings were normal. No skin pigmentation or subcutaneous nodules were observed. Chest CT revealed a 5.5 cm segmental lobular tumour in the right posterior mediastinum (figure 1A) and chest MRI showed that the tumour continued from the right intervertebral foramina (figure 1B).

The authors suspected schwannoma of the intercostal nerve, and performed video-assisted thoracoscopic surgery in the left lateral decubitus position. A lobular tumour was present in the 10th intercostal space. However, while peeling the parietal pleura, the lesion was seen to comprise two distinct tumours rather than a single tumour; one continuous with the intercostal nerve and the other continuous with the sympathetic nerve trunk.

Neither of the tumours invaded the surrounding tissue and both were isolated from the nerves and removed. Both tumours were schwannomas. There was no nerve resection in the high intercostal space, and no obvious neurological deficit symptoms including abnormal perspiration were observed after surgery.

However, wound pain accompanied by intercostal neuralgia, as a common result of video-assisted thoracoscopic surgery, was observed for 2 weeks. The patient showed no signs of recurrence 2 years after surgery.

Learning points
• The presence of multiple schwannomas in the thoracic cavity is a rare occurrence.

• Multiple schwannomas can occur even in patients with no history of neurofibromatosis.

• The possibility of multiple adjacent schwannomas in the same intercostal space but derived from different nerves should be considered in patients who present with lobular tumours, even if initial imaging suggests that the lesion is a single tumour.

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