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A Case of Incidental Schwannoma Mimicking Necrotic Metastatic Lymph Node from Bladder Cancer

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A Case of Incidental Schwannoma Mimicking Necrotic Metastatic Lymph Node from Bladder Cancer medicina Case Report A Case of Incidental Schwannoma Mimicking Necrotic Metastatic Lymph Node from Bladder Cancer Jeong-Hyouk Choi 1, Koo-Han Yoo 1 , Dong-Gi Lee 1, Gyeong-Eun Min 1 , Gou-Young Kim 2 and Tae-Soo Choi 1,* 1 Department of Urology, College of Medicine, Kyung Hee University, Seoul 05278, Korea; [email protected] (J.-H.C.); [email protected] (K.-H.Y.); [email protected] (D.-G.L.); [email protected] (G.-E.M.) 2 Department of Pathology, College of Medicine, Kyung Hee University, Seoul 05278, Korea; [email protected] * Correspondence: [email protected]; Tel.: +82-2-440-6271; Fax: +82-2-440-7744 Abstract: Background and Objectives: Retroperitoneal schwannoma is a very rare case of schwan- noma which commonly occurs in the other part of the body. However, it is difficult to distinguish schwannoma from other tumors before pathological examination because they do not show specific characteristics on imaging study such as ultrasound, computed tomography (CT), and magnetic reso- nance image (MRI). Case summary: A 60-year-old male showed a retroperitoneal cystic tumor which is found incidentally during evaluation of coexisted bladder tumor. Neurogenic tumor was suspicious for the retroperitoneal tumor through pre-operative imaging study. Finally, a schwannoma was diagnosed by immunohistochemical examination after complete surgical excision laparoscopically. Conclusion: As imaging technology is developed, there may be more chances to differentiate schwan- Citation: Choi, J.-H.; Yoo, K.-H.; Lee, noma from other neoplasm. However, still surgical resection and histopathological examination is D.-G.; Min, G.-E.; Kim, G.-Y.; Choi, feasible for diagnosis of schwannoma. T.-S. A Case of Incidental Schwannoma Mimicking Necrotic Keywords: neurilemmoma; retroperitoneal space; urinary bladder neoplasm Metastatic Lymph Node from Bladder Cancer. Medicina 2021, 57, 728. https://doi.org/10.3390/ medicina57070728 1. Introduction Schwannoma (neurilemmomas) are benign tumors that originate from nerve sheath Academic Editor: Andrea Mingoli cells along peripheral nerves [1]. They generally form a tumor that is solitary, well- circumscribed, and encapsulated in appearance [2]. Retroperitoneal schwannoma are Received: 28 May 2021 extremely rare, comprising only 1% of all schwannoma [3]. They are often found inci- Accepted: 15 July 2021 dentally in solid form but frequently undergo cystic degeneration [2]. Surgical excision Published: 19 July 2021 of the tumor allows for diagnosis and is associated with effective, long-term therapeutic outcomes [4]. We report a case involving successful laparoscopic resection of a pelvic Publisher’s Note: MDPI stays neutral schwannoma. with regard to jurisdictional claims in published maps and institutional affil- 2. Case History iations. A 60-year-old male presented with a two-week history of intermittent gross hematuria. There was a 2.5 cm-sized papillary tumor at the left anterolateral wall of the urinary bladder on cystoscopy. A contrast-enhanced abdominal computed tomography (CT) scan incidentally revealed a 4.8 cm cystic mass with septa at the left pelvic wall. Lymphangioma Copyright: © 2021 by the authors. or cystic changes of the neurogenic tumor were suspicious for a cystic tumor. Magnetic Licensee MDPI, Basel, Switzerland. resonance image (MRI) was recommended for differential diagnosis of a necrotic metastatic This article is an open access article distributed under the terms and lymph node, which was the least-likely suspected diagnosis. MRI revealed that the bladder conditions of the Creative Commons tumor was likely muscle-invasive with Vesical Imaging-Reporting And Data System (VI- Attribution (CC BY) license (https:// RADS) category 4, and the pelvic mass exhibited cystic changes, suggestive of a neurogenic creativecommons.org/licenses/by/ tumor (Figure1)[ 5]. There was no evidence of metastases on chest CT and bone scan. 4.0/). The patient was scheduled for transurethral resection of bladder tumor (TURBT) with Medicina 2021, 57, 728. https://doi.org/10.3390/medicina57070728 https://www.mdpi.com/journal/medicina Medicina 2021, 57, 728 2 of 4 Medicina 2021, 57, x FOR PEER REVIEW 2 of 5 laparoscopic(TURBT) with pelvic laparoscopic mass excision. pelvic mass TURBT excision. alone TURBT was alone performed was performed to confirm to confirm the presence of musclethe presence invasion of asmuscle an initial invasion diagnostic as an initial plan. diagnostic plan. A B Figure 1.Figure(A) A 1. T1-weighted(A) A T1-weighted magnetic magnetic resonance resonance image image shows shows a homogenous a homogenous low-signal low-signal-intensity-intensity mass, while mass, (B) the while T2- (B) the weighted MR image reveals several cysts with septa within the tumor. T2-weighted MR image reveals several cysts with septa within the tumor. First, TURBT was performed under general anesthesia with the patient in a lithotomy position.First, TURBT The bladder was performed tumor was underhistologically general confirmed anesthesia as witha high the-grade patient papillary in a lithotomy position.urothelial The carcinoma, bladder tumor Ta. One was month histologically later, laparoscopic confirmed pelvic as mass a high-grade excision was papillary com- urothe- lialpleted carcinoma, under general Ta. One anesthesia month using later, four laparoscopic trocars with pelvicthe patient mass placed excision in the wassupin completede underposition. general A 12 anesthesia-mm incision using port fourfor the trocars laparoscope with plus the patientthree other placed working in theports supine were position. A 12-mmplaced. incision The left retroperitoneal port for the laparoscope space was exposed plus three after otheran incision working of the ports left abdomen were placed. The leftperitoneum. retroperitoneal The plane space was was developed exposed by aftera combination an incision of sharp of the and left blunt abdomen maneuvers. peritoneum. The left ureter and left common iliac vessels adherent to the pelvic mass were identified Theand plane dissected was developed carefully. Finally, by a combination the mass was gently of sharp separated and blunt from maneuvers.the pelvic wall The and left ureter andextracted left common into a laparoscopic iliac vessels specimen adherent bag. to The the specimen pelvic masswas sent were to th identifiede pathologic and de- dissected carefully.partment Finally, for routine the mass staining was and gently sectioning separated (Figure froms 2 and the 3). pelvic Suction wall drainage and extracted was into a laparoscopicplaced near the specimen resection bag.site. Four The days specimen after surgery, was sent he was to thedischarged pathologic without department any for routinecomplications. staining andThere sectioning were no significant (Figures lesions2 and on3). follow Suction-up drainagecystoscopy, was or on placed the ab- near the resectiondominal site. CT Fourtaken daysthree aftermonths surgery, after discharge. he was discharged without any complications. There Medicina 2021, 57, x FOR PEER REVIEWwere no significant lesions on follow-up cystoscopy, or on the abdominal3 of CT 5 taken three months after discharge. FigureFigure 2. 2. LowerLower magnification magnification shows shows a well- adefined well-defined and capsulated and capsulated round mass round with intratumoral mass with intratumoral cystic changes (arrow) and hemorrhage (arrowhead) (H-E stain, 20× magnification). cystic changes (arrow) and hemorrhage (arrowhead) (H-E stain, 20× magnification). Figure 3. The immunohistochemical study shows diffuse strong-positive signaling for the S-100 pro- tein (200× magnification). 3. Discussion Schwannoma most commonly occur in the head and neck [6]. Although the propor- tion of retroperitoneal schwannoma is very low, there have been several reports of their occurrence. Schwannoma are usually less than 5 cm in diameter, while those in the retro- peritoneal region tend to be much larger [7]. Symptoms are typically absent or nonspecific; however, abdominal pain can manifest as the tumor grows and adjacent structures are compressed [4]. Cystic changes happen when the tumor overgrows its blood supply [8]. Over half of schwannoma appear as cystic lesions on radiography [9]. In this case, a pre-op CT scan showed that the cystic lesion was likely a neurogenic tumor, and the MRI confirmed it to be clear. Although ultrasound, CT, and MRI can visualize the tumor’s features and are helpful; however, they cannot definitively distinguish schwannoma because of the lack of Medicina 2021, 57, x FOR PEER REVIEW 3 of 5 Medicina 2021, 57, 728 3 of 4 Figure 2. Lower magnification shows a well-defined and capsulated round mass with intratumoral cystic changes (arrow) and hemorrhage (arrowhead) (H-E stain, 20× magnification). FigureFigure 3.3. The immunohistochemical immunohistochemical study study shows shows diffuse diffuse strong strong-positive-positive signaling signaling for forthe theS-100 S-100 pro- proteintein (200 (200× magnification× magnification).). 3.3. DiscussionDiscussion SchwannomaSchwannoma most commonly occur occur in in the the head head and and neck neck [6] [6. ].Although Although the the propor- pro- portiontion of retroperitoneal of retroperitoneal schwannoma schwannoma is very is very low, low, there there have have been been several several reports reports of their of theiroccurrence. occurrence. Schwannoma Schwannoma are usually are usually less than less 5 than cm 5in cm diameter, in diameter, while while those thosein the in retro- the retroperitonealperitoneal
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