Journal of Veterinary Cardiology (2015) 17, 149e153

www.elsevier.com/locate/jvc

CASE REPORT

Pulmonary edema secondary to a cardiac

schwannoma in a dog*
Justin D. Thomason, DVM a,*, Gregg Rapoport, DVM a,
Tiffany Fallaw, RVT a, Clay A. Calvert, DVM a,
Kaori Sakamoto, DVM, PhD b

a
Department of Small Animal Medicine and Surgery, College of Veterinary Medicine,
University of Georgia, 501 DW Brooks Drive, Athens, GA 30602, USA
b
Department of Pathology, College of Veterinary Medicine, University of Georgia,
501 DW Brooks Drive, Athens, GA 30602, USA

Received 3 September 2014; received in revised form 24 January 2015; accepted 27 January 2015

KEYWORDS Abstract A 4-year-old castrated labrador retriever presented for cardiac evalua-
Congestive heart fail- tion to determine the etiology of cardiogenic pulmonary edema diagnosed 1 month
ure; prior. A large pedunculated mass involving the ventral aspect of the mural mitral
Mitral regurgitation; valve leaflet and the endocardial surface of the left ventricular free wall, resulting
Intracardiac mass in severe mitral regurgitation, was identified on echocardiogram. Histopathology
and immunohistochemistry of this mass and other endocardial masses identified
at necropsy for S-100 protein were consistent with a diagnosis of schwannoma.
To the authors’ knowledge, this is the first case of a benign intracardiac schwanno-
ma described in the left heart of a dog.
ª 2015 Elsevier B.V. All rights reserved.

*
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* Corresponding author. Current address: Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University,
USA.
E-mail address: jthomason11@vet.k-state.edu (J.D. Thomason).

http://dx.doi.org/10.1016/j.jvc.2015.01.006
1760-2734/ª 2015 Elsevier B.V. All rights reserved.
150
A 4-year-old, castrated, 35-kg Labrador retriever
was referred to the University of Georgia’s College
of Veterinary Medicine for cardiac evaluation to
determine the etiology of cardiogenic pulmonary
edema diagnosed 1 month prior. The referring vet-
erinarian had treated the patient with maintenance
furosemide (1 mg/kg PO q12 h), and he was
asymptomatic at the time of presentation. The dog
had been adopted 1 year earlier, was current on
vaccinations, and was receiving monthly heartworm
preventative. He had a history of hypoadrenocor-
ticism and was being managed with monthly des-
oxycorticosterone pivalate (2.2 mg/kg IM) and
prednisone (0.25 mg/kg PO q12 h). There was no
other significant medical history.
Salient features on physical examination were a
heart rate of 120 bpm with a regular rhythm, a
grade II/VI left apical systolic heart murmur, a
respiratory rate of 48 rpm with eupnea, and nor-
mal synchronous pulses.
Two-dimensional echocardiographic evaluation
revealed a pedunculated nodular mass involving the
ventral aspect of the mural mitral valve leaflet and
the endocardial surface of the left ventricular free
wall (Fig. 1). No effusions or spontaneous echo-
cardiographic contrast were noted. The left atrium
appeared severely dilated (absolute left atrial
diameter on right parasternal long axis ¼ 54 mm;
Figure 1 Transthoracic echocardiogram recorded from the right parasternal long axis view. A pedunculated nodular
mass involving the ventral aspect of the mural mitral valve leaflet and the endocardial surface of the left ventricular
free wall is present. Due to severe mitral regurgitation (not evident on image), severe left atrial and ventricular
dilation is present.
J.D. Thomason et al.
left atrial to aortic diameter ¼ 2.0). There was
incomplete coaptation of the mitral valve appara-
tus secondary to the intracardiac mass. Sub-
jectively, the left ventricular chamber size was
increased and the interventricular septum and left
ventricular free wall were mildly decreased in
thickness. Left ventricular wall motion appeared
normal. All other cardiac structures appeared sub-
jectively normal. Color-flow Doppler evaluation
revealed severe mitral regurgitation, trivial tricus-
pid regurgitation, trivial pulmonic regurgitation,
trivial aortic regurgitation, laminar flow within the
left ventricular outflow tract, and laminar flow
within the right ventricular outflow tract. Other
findings included a normal sinus rhythm throughout
the echocardiogram, mildly increased preload (as
assessed by peak velocity of early diastolic trans-
mitral flow to peak velocity of late transmitral flow,
peak velocity of early diastolic transmitral flow to
peak velocity of early diastolic mitral annular
motion, peak velocity of early transmitral flow to
isovolumic relaxation time, and deceleration time
of the early diastolic transmitral flow velocity) and a
systolic blood pressure of 100 mmHg.
Differential diagnosis for the intracardiac mass
included neoplasia, thrombus and infective endo-
carditis. Given the appearance of the mass, history
of normal complete blood counts, and absence of
Cardiac schwannoma in a dog
Figure 2 H & E Stain (200). The neoplasm is composed
of spindle cells forming streams, bundles, and palisades.
These cells are elongated, with moderate amounts of
eosinophilic, fibrillar cytoplasm, and oval to polygonal
nuclei, with finely to coarsely stippled chromatin, and
inapparent nucleoli.
pyrexia, neoplasia and thrombus were entertained
as likely possibilities. Hemostatic assays, including
thromboelastography and D-dimers were normal
suggesting against the diagnosis of thrombus. Ther-
apeutic recommendations at that time were: furo-
semide (0.9 mg/kg PO q12 h), enalapril (0.4 mg/kg
PO q12 h), pimobendan (0.3 mg/kg PO q12 h). Sur-
gical mass resection was offered to the client but
was declined. Serial monitoring, every 3e6 months
or sooner if sleeping respiratory rate >8 respirations
per 15 s, was recommended. Serial echocardiograms
demonstrated progressive enlargement of the
intracardiac mass and left heart chambers. Due to
recurrent pulmonary edema, development of atrial
fibrillation, and poor quality of life, the owners
elected euthanasia approximately 19 months after
the initial diagnosis.
A necropsy was performed. On gross observa-
tion, the lungs were slightly firm and mottled pink,
light red, and pale brown. Pale yellow froth was
present in the mainstem bronchi. A multinodular,
firm, dark red mass, measuring 2.5 cm  2 cm, was
adhered to the mitral valve. Several round,
smooth, pale tan nodules measuring up to 1 cm in
diameter were scattered along the endocardium of
both ventricles. The peritoneal cavity contained
2.5 L of serous fluid. The liver was swollen, roun-
ded, nodular, and light brown.
On histopathology, sections of the valvular mass
consisted of abundant fibrin surrounding a loosely
cellular neoplasm composed of spindle cells
forming streams, bundles, and palisades (Fig. 2),
151
supported by a fine to moderate, fibrous stroma.
These cells were elongated, with moderate
amounts of eosinophilic, fibrillar cytoplasm, and
oval to polygonal nuclei, with finely to coarsely
stippled chromatin, and inapparent nucleoli. Ani-
socytosis and anisokaryosis were moderate. No
mitotic figures were noted. Multiple foci of hem-
orrhage, necrosis, fibrin, and infiltrates of lym-
phocytes and hemosiderin-laden macrophages
were scattered throughout the neoplasm. In some
areas of the mass, the spindle cells were noted to
exhibit nuclear palisading with adjacent fibrillar,
eosinophilic material (Verocay-like bodies, Antoni
A pattern). A section through one of the nodular
endocardial masses consisted of a more mono-
morphic population of these neoplastic cells and
large numbers of infiltrating degenerate neu-
trophils. The mass was adhered to the endocar-
dium via granulation tissue and fibrosis that was
infiltrated by moderate numbers of lymphocytes
and plasma cells. Immunohistochemistry of the
valvular neoplasm for S-100 protein revealed faint
to strong, cytoplasmic staining, consistent with a
schwannoma (Fig. 3).
Discussion
Cardiac tumors are relatively uncommon in
dogs.1,2 In one study, the incidence of cardiac
tumors was 0.19%.1 The most common cardiac
tumors reported are hemangiosarcoma, aortic
body tumors, lymphoma, and ectopic thyroid car-
cinoma.1,2 Other tumors rarely reported are myx-
oma, myxosarcoma, mesothelioma, fibroma,
fibrosarcoma, rhabdomyoma, rhabdomyosarcoma,
leiomyoma, and malignant peripheral nerve sheath
tumor. Although an intracardiac malignant
peripheral nerve sheath tumor has been described
in the dog, to the authors’ knowledge, this is the
first case of multiple benign intracardiac
schwannomas.3
Neurogenic cardiac tumors are extremely rare
and are almost always primary and benign,
although malignant and metastatic neurogenic
tumors have been reported.4e13,16 Schwannoma,
also called peripheral nerve sheath tumor or neu-
rofibroma, is most common in people 20e50 years
of age.11e13 It frequently arises from the nervous
system of the heart, primarily on the right side,
especially from the right atrium.3,4,11,12,16 The
reason postulated for this location is that the ori-
gins of cardiac schwannomas are from cardiac
152
Figure 3 Immunohistochemistry of the valvular neo-
plasm for S-100 protein (400). Faint to strong cyto-
plasmic staining is present, consistent with
schwannoma.
branches of the vagus nerve and cardiac
plexus.4,11,16 Schwannomas can occasionally be
found in the left atrium or near the left ven-
tricle.12,13,16 The presence of multiple intracardiac
schwannomas in this case is unusual. It is possible
that these could represent metastases; however,
malignancy was not supported by cell morphology
or invasion, and a primary mass was not noted
elsewhere in the patient.
The clinical signs of cardiac schwannoma are
related to their location. When located on the
right atrium or in the pericardial sac, external
compression of structures and pericardial effusion
may occur.16 In people, this often results in the
symptoms of chest pain, dyspnea, or syncope.14,15
When located inside the cardiac chambers, as in
our case, valvular obstruction or regurgitation may
lead to clinical signs of congestive heart failure.16
Echocardiography is a useful tool for the diag-
nosis of cardiac tumors including cardiac schwan-
noma.4,16 Magnetic resonance imaging and
computed tomography are sometimes used in
people for more detailed evaluation.4,16 In the
case described here, we were able to define tumor
size, shape, attachment, and mobility with trans-
thoracic echocardiography; therefore, additional
imaging modalities were not performed.
Surgical excision, when possible, is considered
the treatment of choice of cardiac schwan-
noma.4,11,12,15 If malignant schwannoma is pres-
ent, partial resection, followed by radiation or
chemotherapy, is a palliative option.4 In our case,
J.D. Thomason et al.
inflow occlusion with mass resection was recom-
mended; however, the owner elected conservative
medical management.
Histopathologic features of schwannoma
include the biphasic architecture of Antoni A and B
patterns, as well as nuclear palisading (Verocay
bodies) and fibrous capsules containing the cells
derived from the nerves.4,15,17 The Antoni A pat-
tern contains elongated fascicles in the areas of
moderate to high cellularity with a small stromal
matrix.4,15,17 In the Antoni B pattern, the tumor is
less densely cellular with a loose meshwork of cells
along with microcysts and myxoid changes.4,15,17 A
benign schwannoma was diagnosed in this case due
to the presence of an Antoni A and B pattern,
Verocay-like bodies, and S-100 immunopositivity,
with only moderate cell pleomorphism, no evi-
dence of invasion, and no mitotic activity. The
fibrin and hemorrhage deposited primarily on the
surface of the neoplasm is likely a reflection of
turbulent blood flow and damage to the neoplasm.
The inflammatory infiltrate was likely a response
to this damage; however, bacteriology was not
performed in this case due to the clear presence of
a neoplasm. Secondary bacterial endocarditis is a
possible consequence of abnormally structured
and/or functioning valves.
Immunohistochemistry is useful for confirmation
of the diagnosis of schwannoma. The S-100 protein
is used as a marker for schwannoma.4,15 It is
obtained from the neural crest origin tumors from
which the melanocytes and Schwann cells are
derived.4,15 It can, however, stain non-specifically.
In our case, S-100 immunopositivity, combined
with cell morphology and arrangement supported a
diagnosis of benign valvular and endocardial
schwannoma.
Conflict of interest
None.
Supplementary data
Supplementary videos related to this article
can be found online at http://dx.doi.org/10.
1016/j.jvc.2015.01.006.
Cardiac schwannoma in a dog 153

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