General Medicine

2013, vol. 14, no. 1, p. 67-71.

Case Report

Bronchial Schwannoma Masquerading as Cause of Hemoptysis in

a Patient with Pulmonary Embolism
1)

1)

1)

Tomoko Nagatomo, Takeshi Saraya, Masuo Nakamura, Yasutaka Tanaka,

1)

1)

1)

Akira Nakajima, Atsuko Yamada, Yukari Ogawa , Naoki Tsujimoto,

1)

1)

1)

1)

1)

Erei Sohara, Toshiya Inui, Mitsuru Sada, Manabu Ishida, Miku Oda,
1)

3)

4)

1)

1)

2)

Ichiro Hirukawa, Masachika Fujiwara, Teruaki Oka, Hidefumi Takei ,

2)

1)

Tomoyuki Goya, Hajime Takizawa, Hajime Goto

1)

Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City Tokyo 181-8611, JAPAN
1)

Department of Respiratory Medicine

2)

Department of Surgery

3)

Department of Pathology

4)

Kanto Central Hospital of the Mutual Aid Association of Public School Teachers, Japan,
Division of Pathology andCentral Clinical Laboratory, Kamiyoga, Japan

A 78-year-old woman who had a history of left deep venous thrombosis was referred to our hospital with a sudden
hemoptysis. Thoracic computed tomography showed a solitary pulmonary nodule in the right lower lobe. Based on
her medical history of deep venous thrombosis, she was tentatively diagnosed as having pulmonary embolism and
successfully treated by inserting an inferior vena cava filter and anticoagulant therapy with warfarinPlease
confirm whether previous sentence is correct]. However, the lung nodule on thoracic computed tomography was still
depicted four months later. With suspicion of a malignant tumor, including possible lung cancer, a right
segmentectomy was performed. Pathological assessment of the resected specimen showed the tumor was derived
from the right bronchial wall, but was not ruptured into the intratracheal lumen, as well as coexistence with
intraalveolar hemorrhage near the tumor. The lung nodule was diagnosed as bronchial schwannoma. Thus, the origin
of the hemoptysis was found to be pulmonary embolism due to deep vein thrombosis, and not by bronchial
schwannoma, which was also present in the lung.
Key words: bronchial schwannoma, solitary pulmonary nodule, pulmonary embolism, hemoptysis, deep venous
thrombosis
Radiological and Pathological Findings in a Patient with Bronchial Schwannoma Presented with Hemoptysis
Abbreviations; PE: pulmonary embolism, DVT: deep venous thrombosis, CT: computed tomography

Corresponding Author : Hajime Goto, MD, PhD, Professor and Chair,

Department of Respiratory Medicine, Kyorin University School of Medicine
e-mail h510@ks.kyorin-u.ac.jp
Received for publication 20 Februry 2012 and accepted in revised form 1 December 2012

67

General Medicine

INTRODUCTION

2013, vol. 14, no. 1

perfusion scintigraphy scan showed solid, new consoli-

The incidence of primary neurogenic tumors of the

dation in her right middle lung and a wedge shaped

lung has been estimated to be 0.2% of all pulmonary

defect in the same area, as well as the disappearance

neoplasms. Primary pulmonary schwannoma is a

of left DVT on contrast enhanced CT, which was

benign, asymptomatic tumor, and is usually located

previously seen on ultrasound Doppler technique at

within the pulmonary parenchyma. The bronchial

her local hospitalFigure not shown). In addition to

is also an

the imaging findings, the patients Wells and Geneva

extremely rare, benign bronchial tumor that is usually

score10 points and 11 points, respectivelyshowed a

accompanied by such clinical symptoms as a produc-

high probability of PE. Thus we concluded that DVT,

schwannoma, first reported in 1951,

tive cough, pyrexia, and shortness of breath. Herein,

subsequently followed by a pulmonary embolism

we present a case of bronchial schwannoma with a

PE), was the source of her hemoptysis. An inferior

hemoptysis that was due to a concurrent pulmonary

vena cava filter was inserted and the hemoptysis

embolismPE). Until today, only five cases have been

gradually disappeared. The patient was discharged

reported with a chief complaint of hemoptysis, and

uneventfully.

this is a first report of brochial schwannoma masquer-

Four months later, the patient had another broncho-

ading as the cause of hemoptysis in a patient with PE.

scopy, which revealed a protruding submucosal

We recognized the tumor as a solitary pulmonary

tumor with a smooth surface. The tumor measured 25

nodule, and, after retrieving a resected specimen,

mm at the right B10b orificeFig. 1-B), which was

compared the findings from a pathological finding

consistent with the patients CT findings on admission

with those from computed tomographyCT).

Fig. 1-A). Afterward, a right segmentectomy was

performed, and a specimen was taken from the right

CASE

S10. The tumor, originating from the right B10b

A 78-year-old woman was referred to our emer-

bronchial wall, measured 25 mm, revealed cystic

gency department due to a sudden onset of hemopty-

changeFig. 1-C, arrowhead), and protruded to the

sis. The patient had a medical history of left deep

bronchial lumenFig. 1-C), compressing the right

venous thrombosisDVT), which was confirmed by

B10c. Upon hematoxylin and eosin staining, the

ultrasound Doppler technique at her local hospital,

resected tumor was found to be composed of spindle-

and had been taking warfarin for the past year. Her

shaped cells showing both Antoni A and B type

vital signs showed blood pressure of 14098

mmHg, a

histologiesFig. 1, D-1, D-2), which were positive for

pulse rate of 102min,

body temperature of 36.3, a

immunohistochemical upon S-100 protein staining

respiratory rate of 24 breathsmin,

and an oxygen

Fig. 1, D-3), implying bronchial schwannoma.

saturation level of 88%. The physical examination was

Although the tumor was accompanied by an intraal-

normal except for coarse crackles in her bilateral

veolar hemorrhage that was localized in the peribron-

lower lung fields, as well as gradual edema in both

chiolar areaFig. 1, D-4), the bronchial schwannoma

legs. A chest roentgenogram revealed ground-glass

showed no bleeding or necrotic components, and

opacity in the right middle lung, and a non-enhanced

there was no rupture into the intratracheal lumen

thoracic CT showed a tiny, smooth, solitary nodule

Fig. 1-E). Taken together, the patient was thus

measuring 25 mm at the peripheral area between

diagnosed with bronchial schwannoma concurrent

right B10b and B10cFig. 1-A). On day 2, the patient

with PE caused by DVT.

had moderate hemoptysis. Although a bronchoscopy

was performed four days after admission, the tracheal

DISCUSSION

lumen was entirely occluded by a clot in the right

Schwannomas frequently arise from the intercos-

proximal portion, and the cause of the hemoptysis was

tals nerves and sympathetic trunk in the thorax, while

unknown. Hemoptysis occurred again on day 13, and 3

primary intrapulmonary or bronchial schwannomas

days later a chest roentgenogram and a lung

are uncommon. They are an extremely uncommon

68

Bronchial Schwannoma Masquerading as Cause of Hemoptysis in a Patient with Pulmonary Embolism

Figure. 1-ANon-enhanced thoracic CT depicted a tiny, solitary, smooth nodule 25 mm in

size at the peripheral area between right B10b and B10c.
Figure. 1-BRepeated bronchoscopy 4 months after commencing treatment revealed a
protruding submucosal 25 mm tumor with a smooth surface at the right B10b orificeFig. 1B).
Figure. 1-Cmacroscopic view of resected tumor
Resected specimen from thoracotomy
revealed that the tumor was derived from the right bronchial wallright B10band had a
cystic componentFig. 1-C, arrowheadthat protruded into the lumen, and compressed the
right B10c.
Figure. 1-Dmicroscopic view of resected tumor
After hematoxylin and eosinHEstaining,
we concluded that the tumor was composed of typical spindle-cell proliferation with Antoni
AFig. 1, D-1, 200and Antoni B patternFig. 1, D-2, 200). These cells were positive
for immunohistochemical staining of S-100 proteinFig. 1, D-3, 200and could easily
delineate the focal area of the intraalveolar hemorrhage on HE stainFig. 1, D-4, 40).
Figure. 1-EOn HE stain40), the tumor, which had not ruptured into the intratracheal
lumen, was easily visible between its border, the bronchiole, and tumorasterisk).
B10c

B10b
D1
1

D2
2

D3
3

D4
4

B10b
A

B10b

B10c
E
B

B10b

B10c

69

General Medicine

cause of intratracheal tumor, and rarely cause

2013, vol. 14, no. 1

CONCLUSION

respiratory symptoms, particularly if the lesion is

The hemoptysis of our case was not caused by

located in the lung parenchyma andor

distal bron-

bronchial schwannoma itself, but PE. The present

chiole. However, if the lesion is in the proximal portion,

case reminds us that bronchial schwannoma is rarely

such as the trachea or bronchus, it might produce

the cause of hemoptysis, which needs to be given

obvious symptoms, such as a productive cough,

consideration for diverse differential diagnosis.

pyrexia, and dyspnea upon effort. To the best of our

knowledge, the present case was one of only 58 cases

Disclosures: None

of bronchial schwannoma that have been reported in

4

We have nothing to report regardingWDisclosure of

Japan, and the hemoptysis that occurred in this

financial interestXand declare that we are not

disease seemed to be a rare clinical presentation as an

thinking of redundant or duplicate publication.

1,58

initial onset

. Therefore, we should pay attention to

diverse differential diagnosis for hemoptysis.

Although the tumor in our case was located in the

References
1

Roviaro, G.; Montorsi, M.; Varoli, F.; Binda, R.;

distal bronchiole, there was a sudden onset of

Cecchetto, A. Primary pulmonary tumours of neuro-

hemoptysis. High values of Wells and Geneva scores

genic origin. Thorax. 1983, vol. 38, p. 942-945.

led us to a diagnosis of PE together with the presence

of DVT. In addition, the pathological findings revealed

tracheobronchial tree. A case report. Ann Otol Rhinol

that an intraalveolar hemorrhage easily delineated a

Laryngol. 1951, vol. 60, p. 242-246.

tumor with loose connective tissuesFig. 1, D-4;

however, there was no fistula between the tumor and

Ishikawa, S.; Noro, M. A case of bronchial neurinoma.

bronchioleFig. 1-E). Thus, in our present case, the

GTCS. 1996, vol. 44, p. 820-825.

moderate hemoptysis was due to a PE, not bronchial

schwannoma, which was also present in the lung.

cases of endobronchial neurilemmoma and review of

Upon treatment, the PE symptoms subsided over

Straus, G. D.; Guckien, J. L. Schwannoma of the

Yodonawa, S.; Mitsui, K.; Akaogi, E.; Onizuka, M.;

Kasahara, K.; Fukuoka, K.; Konishi, M. et al. Two

literature in Japan. Intern Med. 2003, vol. 42, p. 1215-

three months. The present case showed a unique

1218.

clinical presentation in that thoracic CT incidentally

depicted a small solitary nodule measuring 25 mm in

L. Dieulafoys disease of the bronchus in association

right S10 together with the ground-glass opacity in

with a paravertebral neurilemoma. Chest. 2001, vol.

the right middle lobe in a patient with hemoptysis

119, p. 292-294.

who had been treated as DVT. Based on the

pathological findings of resected specimens obtained

Chang, S. C. Massive hemoptysis caused by endobron-

from right segmentectomy, the nodule in right S10

chial schwannoma in a patient with neurofibromatosis

was diagnosed as bronchial schwannoma, which was

2. Am J Med Sci. 2003, vol. 325, p. 299-302.

known as an extremely rare cause of all pulmonary

neoplasms. On the other hand, the ground-glass

Tracheal schwannoma: a rare tracheal tumor. J Coll

opacity in right middle lobe was considered to be the

Physicians Surg Pak. 2010, vol. 20, p. 410-411.

cause of PE.

Stoopen, E.; Baquera-Heredia, J.; Cortes, D.; Green,

Chen, S. R.; Chen, M. H.; Ho, D. M.; Lin, F. C.;

Muzzaffar, M. S.; Umair, B.; Ali, M. Z.; Hanif, M. S.

Ondo, K.; Sugio, K.; Yano, T.; Kase, S.; Yamazaki,

This case was diagnosed with bronchial schwanno-

K.; Yamaguchi, M. et al. Cystic schwannoma present-

ma incidentally-detected by PE of which the radiolog-

ing as massive hemoptysis in an adult. Respiration.

icalFig. 1-Aand pathological findingsFig. 1-C,

2000, vol. 67, p. 327-329.

1-D, 1-Ewere successfully compared, and was a

first report of brochial schwannoma coinciding with

Endobronchial schwannoma with massive hemopty-

PE presented as hemoptysis.

sis. Tuberk Toraks. 2009, vol. 57, p. 89-92.

10

70

Onal, M.; Ernam, D.; Atikcan, S.; Memi, L.

Fujioka, S.; Nakamura, H.; Miwa, K. et al.

Bronchial Schwannoma Masquerading as Cause of Hemoptysis in a Patient with Pulmonary Embolism

Intrapulmonary schwannoma in the right middle lobe:

Yamazaki, K.; Suemasu, K. Intrapulmonary schwan-

A case report. Asian J Endosc Surg. 2011, vol. 4, p.

noma. Jpn J Thorac Cardiovasc Surg. 2005, vol. 53, p.

147-149.

154-156.

11

14

Ushiyama, T.; Katsuda, E.; Tanaka, M. et al. 18F-

Fujikawa, T.; Shiono, S.; Abiko, M. et al.

fluorodeoxyglucose uptake and apparent diffusion

Pulmonary schwannoma with hypervascularity; re-

coefficient in lung. Clin Imaging. 2012, vol. 36, p. 65-67.

port a case. GTCS. 2008, vol. 61, p. 1075-1077.

12

15

Domen, H.; Iwashiro, N.; Kimura, N. et al.

Suzuki, H.; Sekine, Y.; Motohashi, S. et al.

Intrapulmonary cellular schwannoma. Ann Thorac

Endobronchial neurogenic tumors treated by trans-

Surg. 2010, vol. 90, p. 1352-1355.

brochial electrical snaring and Nd-YAG laser abra-

13

sion. Surg Today. 2005, vol. 35, p. 234-246.

Ohtsuka, T.; Nomori, H.; Naruke, T.; Orikasa, H.;

71