Case report - Thoracic general Sudden onset of thoracic pain: neurofibroma with intracystic haemorrhage A. Campione * , M. Di Bisceglie, M. Lonzi, G. Gotti Department of Cardiothoracic Surgery, Thoracic Surgery Unit, University Hospital of Siena, Viale Bracci 1, 53100 Siena, Italy Received 19 December 2003; received in revised form 5 April 2004; accepted 15 April 2004 Abstract Intercostal nerve sheath tumors are normally benign and asymptomatic. Nevertheless surgical resection can eliminate the risk of malignant transformation and also achieve complete remission in case of symptoms. q 2004 Elsevier B.V. All rights reserved. Keywords: Mediastinal tumor; Neurofibroma; Thoracoscopy 1. Introduction The nerve sheath tumours in the thorax often occur in either costovertebral sulcus. Schwannoma and neuro- fibroma are benign peripheral nerve neoplasm, which represent the most common mediastinal neurogenic tumors, and rarely deteriorate into malignancy [1]. According to some reports, patients with malignant schwannomas have very poor prognoses, especially when associated with Von Recklinghausen’s disease [2]. On the other hand, surgical resection is generally curative in benign neoplasm and eliminate the risk of malignant transformation. Intercostals nerve sheath tumors are rare and normally benign tumors. Though thoracoscopic approach can be the first attempt to cure them [3], when intervertebral foramen or adjacent structures seem to be involved, open thoracotomy is mandatory. These neoplasm are most often asymptomatic, but some of them can cause symptoms because of pressure on adjacent nerve with paresthesia or back pain. Here, we present a case with a sudden onset of symptoms probably related to intracystic haemorrhage. 2. Case report We present a case of a 37-year-old healthy white man who complained a sudden onset of radicular thoracic pain, involving the right hemithorax from spine to sternum. He was referred to our hospital and he underwent routine clinical assessment. Roentgenograms showed evidence of a paravertebral mass, which was further detected with chest CT scan. The lesion was diagnosed on imaging as a neurogenic tumor (Fig. 1). Under video-assisted thoracoscopy, we found a spherical smooth-featured neoplasm of the right paravertebral sulcus. The mass was confirmed as having arised from an enlarged XI intercostal nerve, which was dissected posteriorly up to the intervertebral foramen, where it was ligated and transected. A minimal muscle-sparing lateral thoracotomy was performed and the adjacent rib was removed. A cystic cavity with sign of internal recent haemorrhage was noted. Postoperative course was uneventful and the patient was discharged with complete remission from symptoms. Histopathologic examination confirmed a cystic neoplasm, which was identified as neurofibroma. 3. Discussion Schwannoma and neurofibroma represent the most common mediastinal neurogenic tumors. Most of the neurogenic tumors are asymptomatic, although a small percentage of patients experience paresthesia or back pain from compression of adjacent structures or from intraspinal tumor extension. 1569-9293/$ - see front matter q 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.icvts.2004.04.008 Interactive CardioVascular and Thoracic Surgery 3 (2004) 533–534 www.icvts.org * Corresponding author. Tel.: þ 39-0328-742-1444. E-mail address: campioneandrea@libero.it (A. Campione).