A nerve sheath tumour inside the chest is benign in the great majority of cases. What varies from one person to the next is not the pathology but the anatomy — which nerve the tumour sits on, and what it lies against. That single fact decides the symptoms, the operation, the recovery, and how many surgeons are needed. Dr Lawrence Okiror, Consultant Thoracic and Robotic Surgeon (GMC 6150382), assesses and removes these tumours at London Bridge Hospital and The Lister Hospital Chelsea, operating jointly with a peripheral nerve surgeon where the brachial plexus is involved and with a spinal neurosurgeon where the tumour extends into the neural foramen. Appointments within 2–3 days. Self-referrals welcome.
Last reviewed: August 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
Schwannoma, neurofibroma and ganglioneuroma are benign in the great majority of cases. They are the commonest tumour group in the paravertebral part of the chest. Benign does not mean it can be ignored, and it does not always mean it should be removed.
The question that changes the operation is whether the tumour extends through the neural foramen towards the spinal canal. Without an MRI, an operative opinion is a guess. With one, the plan is either a single-surgeon keyhole resection or a joint operation.
Under a centimetre and causing nothing, a nerve sheath tumour is left alone — these grow slowly and rarely become symptomatic. Symptomatic at any size, or above a centimetre, opens the surgical conversation. Several lesions is a selection question, not a bar to surgery.
Because the pathology is the least variable part of this diagnosis. Two people can be told they have a schwannoma in the chest and receive advice that appears to contradict itself — one offered a keyhole operation and home in two days, the other told it needs two surgeons and eight hours of theatre. Both can be right. What differs is not the tumour. It is which nerve it grew from, and what it has come to lie against.
A tumour on an intercostal nerve, running along the underside of a rib, causes focal nerve pain and comes out through three small ports. The same tumour on the sympathetic chain high in the chest sits against the nerves that control the eyelid and pupil, and the conversation before the operation is different. On the brachial plexus it needs a peripheral nerve surgeon in the room. Growing through the neural foramen towards the spinal canal, it needs a spinal neurosurgeon.
This page is organised around that fact rather than around the diagnosis, because the diagnosis on its own tells you very little about what happens next. If what you can feel is a lump between the ribs rather than something found inside the chest on a scan, the chest wall lump page is the better starting point.
Most people who reach this diagnosis were not being investigated for it. There are four common routes in, and they lead to very different frames of mind.
A CT coronary angiogram arranged for chest pain that finds no coronary disease but picks up a mass alongside the spine. A CT for a cough that did not settle after antibiotics. A chest X-ray during a chest infection. A scan after a road accident. An annual health check. In each case the scan was looking for something else entirely, and the person is well.
Sharp, shooting or burning pain that has been present for months or years, often attributed to muscle, posture or the spine. Frequently triggered by knocks to the chest. Sometimes an emergency department attendance with severe pain and a normal ECG. The scan, when it is finally done, explains a symptom that had no explanation.
A firm lump between the ribs, sometimes with a pinpoint tender spot along the line of a rib. Where the lesion is superficial enough to be felt, it is a chest wall problem and the assessment is set out on the chest wall lump page — alongside the other causes of a lump, most of which are not tumours at all.
A needle biopsy reporting bland, benign nerve sheath tissue, alongside scans that continue to look aggressive. These patients are frequently routed into a sarcoma pathway and can stay there for months while the question remains open. This is dealt with in full below.
Nerves in the chest are wrapped in a protective sheath. A tumour can arise from that sheath, from the nerve itself, or from the chain of nerve tissue that runs alongside the spine. Four types account for almost all of them, and although they are grouped together as neurogenic tumours, they are not the same disease.
The commonest. It grows from the sheath around the nerve rather than from the nerve fibres themselves, which is why it can often be separated from the nerve and lifted off. Benign, slow-growing, and well defined on imaging. Larger ones frequently contain cystic or degenerate areas, which is where the imaging confusion begins.
Also benign, but it grows through the nerve rather than alongside it, so the nerve fibres run within the tumour. That makes separating tumour from nerve harder, and more often means removing a segment of the nerve with it. Multiple neurofibromas raise the question of neurofibromatosis.
Arises from the sympathetic chain rather than from a nerve sheath. Benign, often large by the time it is found, and typically causing few symptoms for its size. Because the sympathetic chain runs the length of the paravertebral gutter and up towards the thoracic inlet, position matters more here than in any other type.
Uncommon in the chest, and the one that must be actively excluded rather than assumed away. A small proportion secrete hormones, which matters at the point of anaesthesia and surgery rather than in the clinic. A blood test for plasma metanephrines is the check, and it is set out further on the mediastinal surgery page.
A malignant peripheral nerve sheath tumour is uncommon. Two other things can look similar on a scan and behave differently — a solitary fibrous tumour of the pleura, and a soft tissue sarcoma. Both are covered on the rare chest tumours page. This is the reason a scan alone does not close the diagnosis.
It means the tumour will not spread elsewhere in the body, and that is genuinely the most important thing anyone will tell you. It is worth being clear about what it does not mean.
It does not mean painless. A benign tumour sitting on a nerve can produce years of severe, disabling pain, and frequently does. The tumour is not doing anything dangerous; it is doing something intolerable.
It does not mean static. These grow slowly, but slowly over ten years is still growth. Where an old scan exists, it is not unusual to find the lesion already visible on it and smaller. In the paravertebral gutter the direction of travel is towards the spine.
And it does not mean prioritised. This is the part patients find hardest. A benign diagnosis moves you down a waiting list rather than up it, because the systems that manage surgical queues are built around cancer. People with a painful benign nerve tumour can wait a long time for an operation that would resolve it, which is a large part of why this page exists at all.
Because the mechanism is irritation of a nerve, not pressure on a structure. A lesion of one or two centimetres is nowhere near large enough to compress the lung or displace anything. It does not need to be. It sits directly on a nerve, and the intercostal nerves are among the most sensitive in the body.
The practical consequence is that pain is not proportional to size. A small lesion on a report can sit alongside years of severe symptoms, and patients are sometimes told, reasonably enough, that something that small could not be responsible. It can.
Deep pain felt beneath the shoulder blade, in a place that feels underneath rather than on the surface. Burning, throbbing, or a dull stabbing. Pain radiating around the ribs, into the armpit, or down the arm. Pins and needles along the line of a rib. A persistent sense of needing to stretch that stretching never quite reaches. Relief on firm surfaces, so that bad nights are spent on the floor.
Symptoms are often worse bending forwards or twisting, and are frequently set off by a knock to the chest. Many people have worked through the whole neuropathic ladder — amitriptyline, gabapentin, pregabalin, nortriptyline, and on into opioids — with limited benefit, because the drugs are treating the signal rather than its cause.
Not everyone has pain. Ganglioneuromas in particular are often found large and causing very little, and people are sometimes surprised to be told they need an operation when they feel entirely well. Absence of pain does not settle the question either way — it simply means the decision rests on size, growth and position instead. Where chest pain has no clear cause and no lesion has been found, the unexplained chest pain page covers the wider differential.
Most people arrive having read their own report before anyone has explained it. The descriptions used are consistent and, once decoded, mostly reassuring.
The tumour is following the line of a nerve, and the taper is the nerve entering and leaving it. This is one of the more characteristic appearances of a nerve sheath tumour and it is a helpful sign.
The lesion has a clear edge and is displacing surrounding tissue rather than growing into it. Infiltration is one of the features that raises concern; its absence is reassuring, though not conclusive on its own.
Larger schwannomas commonly outgrow their own blood supply in the centre, leaving cystic or dead tissue. It reads alarmingly and is a well-recognised feature of a benign tumour that has been present a long time.
This is the one that changes the plan. Part of the tumour lies in the chest and part has grown back through the opening where the nerve root leaves the spine. One patient described the shape as a snowman lying on its side, and that is exactly right — two connected portions with a narrow waist at the foramen.
An MRI is what makes an operative opinion worth having. A CT will usually find the lesion and describe its position. Only MRI reliably answers whether it extends through the neural foramen towards the spinal canal — and that answer determines whether this is a keyhole operation performed by one surgeon with a stay of a night or two, or a joint operation with a spinal neurosurgeon that takes most of a day.
A surgeon offering an opinion on the operation without that scan is estimating. If you have been offered surgery and no MRI has been done, that is a fair question to ask. The wider role of each scan in chest disease is set out on the chest imaging page.
Two practical points that catch people out. Imaging has a shelf life for surgical planning: a scan more than six months old will usually need repeating before an operation, so a long delay costs a repeat scan as well as time. And where a needle biopsy is being considered, the route the needle takes matters, because it must lie within tissue that would be removed if surgery follows.
This is one of the more difficult situations in chest surgery, and it is more common than the literature suggests. A large nerve sheath tumour shows marked uptake on a PET scan and contains areas of dead tissue. A needle biopsy comes back as bland spindle cells with no aggressive features, consistent with a schwannoma. The two results point in different directions, and the pathway stalls.
Uptake on a PET scan is not, on its own, evidence of cancer. Benign nerve sheath tumours are frequently avid, and the degree of uptake may reflect the size of the lesion rather than how it is behaving. That is worth knowing before the scan rather than after it.
A malignant nerve sheath tumour can arise within a pre-existing benign one, and a needle biopsy of a large tumour samples a small fraction of it. Sampling error is real. Referral into a specialist sarcoma service on the strength of discordant imaging is a defensible decision, and it is what the guidance supports. Anyone who tells you that caution here is simply wrong is overstating the case.
The problem is not the referral. It is that there is no clearly defined route back. When the repeat histology also comes back benign, there is often no criterion that returns the patient to a surgical pathway — so they are biopsied again, reviewed again, and referred on for further specialist opinion, while the thing that would settle the question waits.
That waiting has a particular cost in this disease, because the operation that treats a nerve sheath tumour and the operation that diagnoses it are the same operation. Removing it produces a complete specimen and a definitive answer, and in a benign tumour it is also the treatment. Where a case has been open for months without resolution, a second opinion reviewing the imaging and the pathology together is reasonable, and is often what moves it.
Both are proper answers, and a surgeon who offers only one of them is not giving you the full picture. Three things decide it: size, symptoms, and whether it has grown.
Watched, not removed. Small nerve sheath tumours grow very slowly and are unlikely to become symptomatic, so leaving them alone is a positive decision rather than a deferral. Interval imaging confirms stability. Nothing is being neglected.
Surgery becomes a reasonable conversation. Removal is curative for a benign tumour and it also delivers the definitive diagnosis. The decision remains yours; the point of the consultation is that you make it knowing what each course involves.
The reason for operating on something benign is timing rather than danger. A paravertebral nerve sheath tumour left alone tends to enlarge slowly towards the spine. Removing it while it sits clear of the neural foramen is a keyhole operation performed by one surgeon. Removing it once it has grown into the foramen is a joint operation with a spinal neurosurgeon, considerably longer, with a longer recovery. Nothing about that is urgent, and it is not a reason to rush — but it is the reason that waiting indefinitely is a decision with consequences of its own.
Multiple small nerve sheath tumours along the intercostal nerves are not unusual, and finding six or eight on an MRI is understandably frightening. It is frequently read as a reason not to operate at all, and people are told the lesions cannot be dealt with and referred instead for nerve blocks or pain management.
Having several is a selection question, not a bar to surgery. The lesions that come out are the ones causing symptoms and those above a centimetre; the rest stay under review. Patients have had two or three removed at a single operation. The aim is not to clear the chest of everything visible — it is to remove the ones doing the damage and leave alone the ones that are not.
Where several nerve tumours are present, assessment for an underlying condition such as neurofibromatosis or schwannomatosis is also appropriate, and that is arranged alongside rather than instead of the surgical discussion.
Advice circulates among patients that nobody but a neurosurgeon should operate on a schwannoma. It is worth answering directly, because it is repeated with confidence and it is only partly right. For a tumour within the spine, it holds. For a tumour lying inside the chest, the tumour is reached through the chest, and that access is thoracic surgery. The real question is not which specialty owns the tumour. It is which combination of surgeons the anatomy requires.
The great majority. Removed robotically through three or four small ports, with no rib spreading and no thoracotomy. The tumour is separated from the nerve where that can be done safely; where it cannot, the segment of nerve carrying it is taken with it. A chest drain stays in for a day or two.
At the top of the chest, tumours can involve the nerves running to the arm. These are operated on jointly with a peripheral nerve surgeon, so that the dissection around the plexus is done by someone who does that work routinely. Planned in advance, on the MRI, not decided in theatre.
Where the tumour passes through the neural foramen, the operation is done jointly with a spinal neurosurgeon. The spinal portion is dealt with first and the intrathoracic portion second. It is a longer operation with a longer stay and a longer recovery, and it is a properly planned two-team procedure rather than an escalation.
The robotic platform matters most in exactly the places these tumours sit. The paravertebral gutter and the thoracic inlet are narrow, deep and unforgiving, and wristed instruments with magnified three-dimensional vision allow controlled dissection close to a nerve in a space where rigid instruments cannot work comfortably. The wider case for the platform is set out on the mediastinal surgery page.
Where the diagnosis is uncertain, or where a sarcoma has been raised, the case is discussed at the appropriate multidisciplinary team meeting before any surgical decision — the chest MDT at London Bridge Hospital, and specialist sarcoma services at the Royal Brompton, the Royal National Orthopaedic Hospital, or UCLH where that is the right route.
Most of these operations go well, and the technical part is rarely what determines whether someone feels the operation was a success. That is decided earlier, in what was said beforehand.
A patch of numbness that was predicted and accepted is a side effect. The same numbness in someone who was never warned becomes a complication. The anatomy is identical; the experience is not. Removing a segment of intercostal nerve leaves a strip of altered sensation across part of the chest wall, sometimes with intermittent pins and needles, and most people tolerate it well when they knew it was coming.
The same applies to less obvious consequences. The lower intercostal nerves supply the wall of the upper abdomen as well as the chest, so discomfort felt in the abdomen after an operation on a lower chest tumour has an anatomical explanation. It is far easier to live with a symptom that has a name.
There is no single list. A tumour sitting against the descending aorta carries a different set of considerations from one sitting at the neural foramen, and the consent conversation reflects the individual anatomy rather than a generic form.
Across all of them there are small risks of bleeding, wound infection and air leak, and an expectation of some chest wall numbness. Where the tumour approaches the spine, bleeding into the spinal canal is a recognised risk and a serious one, and it is quantified rather than glossed — well under one percent. Where the tumour sits high on the sympathetic chain, changes to the eyelid and pupil on that side are discussed in advance, because they are a foreseeable consequence of operating there rather than an accident.
You will be shown your own scans at the consultation and taken through what the tumour is sitting against on your images, not on a diagram. That is the part of this that no summary can do for you, and it is the reason the consultation exists.
For a keyhole robotic resection, the usual hospital stay is one to three nights depending on the size of the tumour and what it was lying against. A chest drain is in place for the first day or two; its removal is quick and much less unpleasant than most people expect. Pain is managed with regular medication and is usually settling noticeably by the end of the first week, by which time most people are walking comfortably at home. Desk work is realistic at two to three weeks.
Where a joint operation with a spinal neurosurgeon has been required, the operation is considerably longer and both the stay and the recovery are extended accordingly. That is discussed in specific terms beforehand rather than in general ones.
Some numbness usually persists, and for most people it fades into the background rather than resolving completely. A smaller number have ongoing nerve discomfort in the area for months. This is not unusual, it is explicable in terms of which nerve was involved, and it is something to raise rather than absorb.
Where a benign tumour has been completely removed, follow-up is straightforward: a review to confirm the wounds have healed, the final histology discussed in person, and a clear account of whether anything further is needed. Where multiple lesions remain under observation, interval imaging continues. General recovery guidance after chest surgery is set out on the recovery page.
Questions most commonly asked by patients after a scan report mentions a nerve sheath tumour, a schwannoma, or a mass alongside the spine.
Book a Consultation →Or call Jo Mitchelson:
020 7952 2882
Self-referrals welcome. Private appointments at London Bridge Hospital and The Lister Hospital Chelsea within 2–3 days, with outpatient clinics at Canary Wharf and the City of London. Bring your MRI and any biopsy report. Dr Okiror reviews the imaging with you and sets out whether this is a lesion to watch, a single-surgeon keyhole operation, or a joint procedure.
Jo Mitchelson, PA · 020 7952 2882 · pa@lungsurgeon.co.uk
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