Neurofibrosarcoma of skin and subcutaneous tissues

In this report, we describe 13 cases of primary neurofibrosarcoma of the skin. The tumor presumably arises from small cutaneous nerves, is locally aggressive, and has a potential for metastasis. Characteristic histopathologic features include proliferating atypical spindle cells with slender wavy and pointed nuclei; hypocellular areas with loose, myxoid stroma; and areas of organoid organization such as palisading, whorly, storiform, and tactile body-like formations. The S-100 stain is positive in about 60% of cases. In the current series, most tumors arose in deep dermis and were grade 2 malignant lesions with a moderate degree of cytologic atypia and 2 or fewer mitoses in 10 high-power fields. Three patients died of their malignant lesion. Only two tumors metastasized. Of the 10 patients who had local recurrence, 5 had multiple recurrent lesions. Neurofibrosarcoma should be considered in the differential diagnosis of malignant tumors of the skin. A complete surgical resection of the primary tumor with adequate margins of surrounding normal-appearing tissue is advised.

[Iris nodules, ocular findings and blood grouping in neurofibromatosis]

Through the analyses of 22 cases of neurofibromatosis (NF) patient ranging from 3 months to 63 yrs. old. We found that 4 cases had bilateral hearing loss and 2 of them were excluded from acoustic neuroma. The ocular appearance showed lid neurofibroma in 12 cases, orbital bone abnormalities in 4 cases, iris nodules in 20 cases (90%), congenital glaucoma (4 eyes) in 3 cases which showed abnormal gonioscopy in 3 eyes, lens opacity in 2 cases, mild and moderate myopia in 8 eyes, and high myopia in 7 eyes, occupying 16% of the total. 11 cases belong to 5 pedigrees showing autosomal dominant inheritance. The ABO and MN blood grouping of the NF cases and families in the pedigree showed that NF was more related to ABO than MN blood group. The ocular appearance, especially the shape and number of iris nodules in relation to age and diagnosis is discussed. The significance of 1 case of retinitis pigmentosa, 7 cases of high myopia in relation with NF should be further studied.

Neurofibrosarcoma complicating pregnancy

Sarcomatous degeneration of a neurofibroma during pregnancy is exceedingly rare. Prompt diagnosis followed by surgical resection is recommended.

[Neurofibroma-associated left peroneal nerve palsy in a patient with acute lymphoblastic leukemia]

Peroneal nerve palsy developed in a patient with T cell-type acute lymphoblastic leukemia (ALL) is reported. In the fifth month after starting of chemotherapy against ALL, the patient, a 7-year-old girl, developed drop foot on the left. Three possibilities were considered as its pathogenesis; (1) VCR neuropathy, (2) neurotoxicity of intrathecal MTX, (3) leukemic invasion to the spinal canal. However, there was no evidence of leukemic invasion in any lumbar taps, and no improvement was obtained by cessation of VCR and intrathecal MTX. Examination by CT scan revealed tumors in the intervertebral (L5-S2) region, which was diagnosed to be neurofibromas by biopsy. The tumors compressed the left peroneal nerve and neurotoxicity of antineoplastic agents for ALL could be the cause of her drop foot.

Pulsating orbital plexiform neurofibroma and optic nerve glioma

A 13-year old Nigerian boy presented with a painless swelling which had grown, over ten years, into a pulsatile monstrous deformity of the left side of the face. Histology of the excised tissue showed a plexiform neurofibroma. It manifested with cutaneous, ocular and bony features. There was also a left eye optic nerve glioma. The case is presented and used to highlight the clinicopathological manifestations of orbital plexiform neurofibroma.

Diffuse neurofibroma of the pylorus: a cause of gastric outlet obstruction

We describe a benign diffuse neurofibroma of the pylorus, unassociated with von Recklinghausen's neurofibromatosis, which was a cause of pyloric stenosis; epigastric discomfort, vomiting, and weight loss of 60 lb were the most prominent symptoms. Partial gastrectomy resulted in a cure. The literature on nerve-sheath tumors of the stomach is reviewed.

Juvenile chronic myelogenous leukemia and neurofibromatosis in infancy presenting as ocular hemorrhage

A patient presenting with intraocular hemorrhage at 4 weeks of life was suspected of having sustained a nonaccidental injury. Juvenile chronic myelogenous leukemia (JCML) was diagnosed, and subsequently the patient developed the signs of neurofibromatosis. There is an association between the two conditions, but the poor prognosis from JCML may mean that evolving neurofibromatosis is overlooked, particularly if a family history of the disease is not obtained.

Cotrel-Dubousset instrumentation in adults. A preliminary report

In an attempt to assess the value of the Cotrel-Dubousset (CD) system for adult spinal disorders, the first 50 adult cases performed at Johns Hopkins were reviewed. Treatment of adult scoliosis with the CD system yielded results comparable to standard techniques. Curve correction was directly proportional to the preoperative flexibility with no loss of correction in any case. All patients went on to a solid arthrodesis, with only three patients requiring the use of postoperative orthoses. Operative time was initially prolonged during the phase of acquiring expertise with the system; however, blood loss and hospitalization were comparable. In both the scoliosis and kyphosis groups instrumentation and fusion incorporated the same number of levels as would have been required for conventional instrumentation systems. In the spondylolisthesis, tumor and trauma groups a total of 88 transpedicle screws was used in 18 patients without neurologic complications. Pedicle screws provided a fixation alternative in cases requiring laminectomies. In the 25 cases with tumors, spondylolisthesis, and trauma, CD instrumentation reduced the number of vertebral levels required for fixation. Compared to Harrington or Luque systems, the average number of motion segments spared per patient was 1.3 in the spondylolisthesis group, 2 in the tumor group and 2.1 in the trauma group. This study suggests that the CD system, although initially developed for idiopathic adolescent scoliosis, is versatile and can be safely and effectively applied to a variety of adult spinal conditions. In cases of spinal pathology due to neoplasm, spondylolisthesis, and trauma, CD instrumentation with the option of transpedicle fixation appeared to offer significant advantages over conventional methods, and an average of 1.6 lumbar motion segments could be preserved per case.

Haemorrhagic necrosis of the grey matter of the spinal cord due to accidental injection of iopamidol in a patient with multiple neurofibromas; a clinico-pathological study

Cervical laminectomy was performed in a 34-year-old man with multiple spinal neurofibromas because of a slowly progressive medullary compression. Four weeks later a rapid deterioration necessitated iopamidol myelography by left lateral cervical puncture at C2 level. Despite the establishment of adequate spinal fluid contact, resulting in imaging of the subarachnoid space, part of the contrast medium entered the spinal cord, thus delineating a syrinx from the upper cervical extending to the upper thoracic level. After the puncture the patient developed triplegia, involving the left arm and both legs and a paresis of the right arm. He died from aspiration pneumonia. Autopsy revealed haemorrhagic necrosis of the spinal grey matter. This adverse effect of myelography is argued to have been conditioned by the extreme immobility and displacement of the spinal cord due to the presence of multiple neurofibromas. The deterioration four weeks after the operation was probably caused by a further compression of the spinal cord.

Chemotherapy of bilateral acoustic neuromas

In patients with bilateral acoustic neuromas, it is not unusual for the tumors to be of unequal size. At the time of the first examination, the smaller tumor may have already destroyed the hearing, while the ear with residual hearing may harbor a large acoustic neuroma. The remaining hearing is then at great risk if surgical removal of the tumor is attempted. Chemotherapy of bilateral acoustic neuromas is here presented as a possible alternative to surgery in those patients whose prognosis for conservation of hearing is poor.

Subglottic neurofibroma in a child

Reported here for the first time is a case of subglottic neurofibroma in an infant which was removed by laryngofissure. Neurofibromas are ubiquitous in distribution, but very rare in the larynx and also extremely rare in infancy. Only 9 cases had been reported in children under 9 years of age. In the present case, H.T., a boy aged 2 years and 7 months, complaining of inspiratory stridor since the beginning of December 1985, was admitted to our hospital on Jan. 21, 1986. The tumor was completely removed by laryngofissure and pathological diagnosis showed it to be a neurofibroma. Laryngeal neurofriboma cases are reviewed and discussed.

Intraspinal tumors associated with hydrocephalus

Three cases of intraspinal tumors associated with hydrocephalus were encountered and treated. This review includes 67 cases, including these 3 cases, and discusses the pitfalls associated with intraspinal tumors presenting with hydrocephalus. These tumors are not easily diagnosed, especially in cases where the chief complaint, due to hydrocephalus, is headache or dementia, and does not include back pain. Among the 67 cases reviewed, symptoms suggesting normal pressure hydrocephalus were particularly noticed in patients over 40 years old. In cases presenting with headaches or dementia, back pain corresponding to the tumor location may appear after a shunt operation or external ventricular drainage. This postoperative back pain is important in indicating the presence of an intraspinal tumor.

Paracardiac adenopathy: CT evaluation

To establish the normal CT appearance of lymph nodes in the paracardiac area, we reviewed the CT scans of 50 patients without known malignancy or benign causes of lymphadenopathy. Five patients (10%) showed soft-tissue densities in the paracardiac region. The largest of these measured 3.5 mm. No more than two rounded soft-tissue densities were seen in any of the normal CT studies. Forty-five patients with paracardiac adenopathy were subsequently evaluated. In 27 (60%) of these the masses were due to either carcinoma, sarcoma, or benign disease. In 40%, the cause of paracardiac adenopathy was lymphoma. Features that favor a diagnosis of lymphoma are bilateral disease, multiple nodes, nodes greater than 2 cm in diameter, a lobulated or "matted" appearance, and associated pericardial thickening/effusion. Chest radiographs obtained within 2 weeks of the CT scans in 38 patients revealed only nine cases in which a paracardiac mass could be seen. This study suggests that 1 cm is the upper limit for the diameter of lymph nodes in the paracardiac region, and that paracardiac adenopathy may be caused by a wide variety of nonlymphomatous malignant and benign diseases in addition to lymphoma. Compared with CT, chest radiographs are insensitive for detecting paracardiac lymph node enlargement.

Massive retrogastric bleeding caused by neurofibroma. Case report

A case of massive retrogastric bleeding from a neurofibroma arising from the gastric wall is described. The tumour was removed without opening the gastric mucosa. The possibility of neurofibroma should be borne in mind when there is unexplained bleeding from the digestive tract or the intraperitoneal or retroperitoneal space, particularly in patients with von Recklinghausen's disease.

Neurofibroma of the cervical sympathetic chain presenting with Horner's syndrome

A case of neurofibroma arising from the cervical sympathetic chain and associated with ipsilateral Horner's syndrome in a patient with von Recklinghausen's disease has been presented. The clinical features and the pathology of the lesion have been discussed.

Neurofibroma of the ear

Neurofibromas cause unsightly and crippling deformities. These locally destructive tumors arise along the distribution of peripheral and cranial nerves. The 2 patients presented here had neurofibromas of the external ear. In one patient, the lesion was limited to the auricle. In the other, the tumor extended into the facial nerve and parotid gland. Preoperative computed tomographic scanning, a postauricular approach to the tumor, and careful dissection produced an aesthetic debulking of the auricular neurofibromas with preservation of facial nerve function and improvement in hearing.

Multiple pulmonary neurofibromas with hypoxemia. Occurrence due to pulmonary arteriovenous shunts within the tumors

A 62-year-old woman with multiple neurofibromas of the lung was found to have severe hypoxemia due to right-to-left shunting within the tumors. Pulmonary angiograms demonstrated that the major area of shunting was in a large tumor mass in the right lower lobe. Pathologically the neurofibromas were vascular with hyperplastic small arteries and arterioles and large dilated veins. Multiple pulmonary neurofibromas are rare; and, to our knowledge, never previously reported in association with pulmonary arteriovenous shunting.

Macrodactyly of the foot associated with plexiform neurofibroma of the medial plantar nerve

A case of macrodactyly of the foot associated with plexiform neurofibroma of the digital branches of the medial plantar nerve is reported. The purpose of this article is to investigate the nature of the association of the rare localization of macrodactyly with a pathognomonic feature of von Recklinghausen disease. The case was approached by semiconservative surgical treatment. Two-year follow-up has shown no relapse of the deformity. These facts suggest that this case of macrodactyly was sustained by an underlying disorder, namely, a "forme fruste" of neurofibromatosis, implying the existence of a still unknown pathogenetic mechanism.

Goitre and neurofibroma

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Ocular complications following excision of cerebellopontine angle tumours

The incidence of ocular complications in 91 patients who underwent excision of cerebellopontine angle tumours was reviewed. Facial nerve paralysis occurred postoperatively in 40 of 88 patients (45.5%). Sixty-four percent of these patients recovered; thus the final count was 86% of patients with facial nerve function following tumour removal. Patients who sustained a delayed facial paralysis recovered well. In patients who sustained an immediate paralysis when the nerve was left anatomically intact postoperatively, recovery was again excellent if paralysis was incomplete, and varied if the paralysis was complete. Not surprisingly, postoperative facial paralysis was more common in patients who had had large tumours. Corneal hypoesthesia and a poor Bell's phenomenon were the most important factors in predicting corneal complications as a result of facial nerve paralysis. Eye complications in 45% of the patients who suffered facial nerve paralysis were managed conservatively with ocular lubricants and an eye shield only; the others received some form of eyelid surgery.