The British Journal of Radiology, 75 (2002), 624626

2002 The British Institute of Radiology

Case report

Gastric schwannoma: MRI findings

N KARABULUT, MD, D R MARTIN, MD, PhD and M YANG, MD
Department of Radiology, West Virginia University Hospitals, Morgantown, WV, USA

Abstract. MRI features are described in a case of gastric schwannoma. A large, discretely
marginated, multilobular mass was seen adjacent to the gastric antrum with the epicentre of the
mass in the gastrocolic ligament. The overall signal pattern was low on T1 weighted images and
moderate to markedly elevated on T2 weighted images. Post-gadolinium sequences demonstrate
slow but fairly uniform enhancement throughout the mass.

Schwannomas are rare among the spindle

cell mesenchymal tumours of the digestive
tract, arising from the Schwann cells of the
neural plexus of the gastrointestinal wall. Gastric
schwannomas, most commonly sited in the
stomach, account for only 0.2% of all gastric
tumours [1] and have received little attention in
radiological literature. These tumours are usually
asymptomatic or may present as upper gastrointestinal bleeding or as mass lesions [17]. Upper
endoscopy is important in the initial evaluation
of these patients, but it may not be helpful in
the diagnosis of submucosal tumours growing
exophytically. Cross-sectional imaging findings
may be useful in the detection and characterization of the tumour and its relation with
surrounding organs. We describe here the MRI
features of gastric schwannoma in a 46-year-old
patient. To our knowledge, this case is the first to
be reported with MRI documentation.

Case report
A 46-year-old White male was seen in surgery
clinic with the complaint of inguinal hernia. On
physical examination the patient was found to
have a large abdominal mass in his right upper
quadrant. The patient denied any complaints or
any symptoms related to the mass. Laboratory
findings were within normal limits. Upper endoscopy showed large extrinsic bulges from both the
anterior and posterior walls in the gastric antrum.
Multiple biopsies taken from the site of extrinsic
mass revealed marked chronic active gastritis
without evidence of a malignancy. The patient
subsequently underwent abdominal MRI in order
to evaluate the mass, which showed a large,
Received 24 January 2002 and accepted 19 March 2002.
Address correspondence to N Karabulut, MD, Hastane
Cad. Umut Apt 5/3, 20010, Denizli, Turkey.
624

discretely marginated mass with innumerable

lobulations centered in the region of the gastrocolic ligament (Figure 1). The overall signal
pattern was low on T1 weighted images and
moderate to markedly elevated on T2 weighted
images (Figure 1a, b). Each of these lobulations
appeared to be encapsulated with moderately
well defined borders, which were seen as markedly
hypointense on T1 weighted images and hypointense, isointense and hyperintense on T2 weighted
images. Post-gadolinium sequences demonstrate
slow but fairly uniform marked enhancement
throughout the internal aspect of each of the
lobules (Figure 1c, d). However, the hypointense
borders around the lobulations remained unenhanced. There was no evidence of necrosis within
the tumour mass. The inferior aspect of the mass
was pushing on the transverse colon with the
transverse colon draped around the mass. The
superior aspect of the mass was seen extending
over the anterior aspect of the gastric antrum,
pylorus, duodenal cap and proximal part of the
second segment of the duodenum towards the
gall bladder fossa and porta hepatis. The distal
stomach appeared to be squeezed by the mass
(Figure 1a, b, d). The pancreas was pushed
posteriorly and inferiorly but was clearly separate
from the mass. The remainder of the abdomen
was unremarkable without evidence of direct
organ invasion, lymphadenopathy or solid organ
metastases. The celiac artery and major branches,
as well as the superior mesenteric artery and
major branches, were clearly identified but a
vascular supply to the mass was not well
demonstrated.
At exploratory laparatomy, the abdominal
mass was found to be adhered to the greater
curvature in the anterior wall of the distal
stomach. Since the mass was arising from the
distal portion of the stomach, a partial gastrectomy with Billroth I gastroduodenostomy was
The British Journal of Radiology, July 2002

Case report: MRI of gastric Schwannoma

(a)

(b)

(c)

(d)

Figure 1. 46-year-old man with gastric schwannoma. (a) Axial fat-suppressed T1 weighted fast spoiled gradient
echo MR image (FLASH: TR/TE, 258/5.9 msec) at the level of the gall bladder shows a hypointense mass in the
region of gastrocolic and gastrohepatic ligaments squeezing the gastric antrum (arrows). (b) Coronal T2 weighted
fast steady state MR image (True FISP: TR/TE 4.6/2.3 msec) through the stomach shows a multilobulated mass
centred in the gastrocolic ligament exhibiting areas of moderate to markedly elevated signal. Note the close relation of the mass to gastric antrum. (c) Axial fat-suppressed T1 weighted fast spoiled gradient echo MR image
(FLASH: TR/TE, 168/5.9 msec) after iv administration of gadolinium demonstrates fairly uniform intense
enhancement throughout the internal aspect of each of the lobules. The hypointense borders surrounding the
lobules remain unenhanced. (d) Axial fat-suppressed T1 weighted volumetric three-dimensional gradient echo MR
image (TR/TE, 3.7/1.7 msec) at the level of the gastric antrum after iv administration of gadolinium delineates the
relationship between the mass and the stomach to a better degree.

performed in order to remove the mass. Macroscopic examination revealed a yellowtan bosselated tumour, which measured 15 cm612 cm6
11 cm in size. The cut surface of this tumour
was yellowtan and focally haemorrhagic with a
fish flesh appearance. Sections from the gastric
tumour showed a spindle cell neoplasm arranged
in a palisading fashion with numerous Verocay
bodies. In addition, more cellular Antoni type A
patterns were seen alternating with looser Antoni
type B areas. Mitoses were not seen and cytologic
atypia was not appreciated. The tumour cells
were strongly positive for S100 and vimentin, and
negative for smooth muscle actin, keratin and
The British Journal of Radiology, July 2002

CD34. The histological and immunohistochemical features were consistent with a benign
Schwannoma.

Discussion
Schwannomas, also known as neurinoma and
neurilemmoma, are benign, slow growing neoplasms originating in any nerve that has a
Schwann cell sheath. They rarely occur in the
digestive tract, but when they do the most
common site is the stomach, and represent 0.2%
of all gastric tumours [1]. Gastric schwannomas
occur more frequently in the third to fifth decade
of life and are usually solitary tumours arising
625

N Karabulut, D R Martin and M Yang

from the fundus, body or antrum of the stomach

[17]. However, they can occur in children and,
rarely, can be malignant [8]. Commonly they are
intramural, although they can be extraluminal
or endoluminal [2]. Gastric schwannomas are
usually covered by intact mucosa and principally
involve the submucosa and muscularis propria.
Tumours vary from 0.5 cm to 11 cm diameter
and are spherical or ovoid, occasionally with a
multinodular pattern [37]. They can be distinguished from other gastric mesenchymal tumours
based on immunohistochemical or ultrastructural
findings [6, 7]. Patients are usually asymptomatic, however, they may present with the symptoms of abdominal pain or discomfort, occult
or overt upper gastrointestinal bleeding from
the ulceration of the overlying mucosa. A palpable mass may be present when the tumour is
larger and predominantly exophytic. Diagnosis
is usually delayed owing to subclinical tumour
growth. Endoscopic evaluation may be normal
or only show non-specific secondary findings
such as extrinsic mass effect or ulceration if the
schwannoma is mainly exophytic. Furthermore,
as occurred in this case, endoscopic biopsy may
not be adequate for definite diagnosis because
schwannomas are submucosal tumours and
mucosal abnormality may be minimal.
In this case, the abdominal mass appeared to
be centred in the gastrocolic ligament and its
site of origin could not be confirmed initially,
although close relation of the tumour with the
gastric antrum was depicted, particularly on threedimensional volumetric MRI. When a large
intraabdominal mass is present next to several
organs, its exact site of origin cannot be determined based on the location of its epicentre on
cross-sectional imaging, as in this case. However,
the benign nature of the tumour and its relation
to adjacent structures are well delineated on MRI.
Although definite diagnosis of digestive tract
schwannoma is made by microscopic examination and immunohistochemical staining, crosssectional imaging, particularly MRI with direct
multiplanar imaging capability, is important in
defining the exact location and extent of the
tumour with displacement of surrounding organs
or vessels, providing valuable information for
surgical planning. The imaging findings of gastric
schwannoma have rarely been documented [6,
8]. Usually they appear as spherical, ovoid or

626

multilobulated solid masses adjacent to gastric

wall, hypoechoic on ultrasound, hypodense on
CT and show contrast enhancement. They
rarely appear cystic, although large tumours
may undergo cystic degeneration. Calcification
is uncommon.
The MRI appearance of schwannomas arising from cranial or spinal nerves has been well
described in the literature, but that of a gastric
schwannoma has not been reported previously.
Typically, these lesions are sharply demarcated,
strongly enhancing tumours, having low to
medium signal intensity on T1 weighted images
and high signal intensity on T2 weighted images.
The MRI findings in our case are consistent
with the literature on cranial or spinal nerve
schwannomas, except for unenhanced borders
surrounding the lobules. Schwannomas should
be included in the differential diagnosis of
intramural or exophytic gastric masses when
imaging findings show a well defined multilobulated solid mass adjacent to the stomach.

References
1. Melvin WS, Wilkinson MG. Gastric Schwannoma.
Clinical and pathologic considerations. Am Surg
1993;59:2936.
2. Bruneton JN, Drouillard J, Roux P, Ettore F,
Lecomte P. Neurogenic tumors of the stomach.
Report of 18 cases and review of the literature.
ROFO Fortschr Geb Rontgenstr Nuklearmed 1983;
139:1928.
3. Miettinen M, Lasota J. Gastrointestinal stromal
tumorsdefinition, clinical, histological, immunohistochemical, and molecular genetic features and
differential diagnosis. Virchows Arch 2001;438:112.
4. Daimaru Y, Kido H, Hashimoto H, Enjoji M.
Benign schwannoma of the gastrointestinal tract: a
clinicopathologic and immunohistochemical study.
Hum Pathol 1988;19:25764.
5. Sarlomo-Rikala M, Miettinen M. Gastric schwannomaa clinicopathological analysis of six cases.
Histopathology 1995;27:35560.
6. Rymarczyk G, Hartleb M, Boldys H, Kajor M,
Wodolazski A. Neurogenic tumors of the digestive
tract: report of two cases. Med Sci Monit 2000;
6:3835.
7. Prevot S, Bienvenu L, Vaillant JC, de Saint-Maur
PP. Benign schwannoma of the digestive tract: a
clinicopathologic and immunohistochemical study of
five cases, including a case of esophageal tumor. Am
J Surg Pathol 1999;23:4316.
8. Bees NR, Ng CS, Dicks-Mireaux C, Kiely EM.
Gastric malignant schwannoma in a child. Br
J Radiol 1997;70:9525.

The British Journal of Radiology, July 2002