Giant intrasacral schwannomas: report of six cases

Ancient Schwannoma Presenting at the Cauda Equina: A Report of a Rare Case

Ancient schwannoma is an uncommon variant of schwannoma. While many reports have presented defining histologic and clinical features of ancient schwannoma, there are only a very few cases in the literature, to our knowledge, of ancient schwannoma presenting at the cauda equina. The current report of ancient schwannoma presenting at the cauda equina adds to the literature and discusses the identification of specific histologic characteristics, the role of conservative medical management, surgical resection, and prognostication in this select subset of patients.

Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management

INTRODUCTION

Women with pelvic pain commonly report pain in their ovaries, vagina, uterus, or bladder. These symptoms may be caused by visceral genitourinary pain syndromes but also may be caused by musculoskeletal disorders of the abdomen and pelvis. Understanding neuroanatomical and musculoskeletal factors that may contribute to genitourinary pain is important for evaluation and management.

OBJECTIVES

This review aims to (i) highlight the importance of clinical knowledge of pelvic neuroanatomy and sensory dermatomal distribution of the lower abdomen, pelvis, and lower extremities, exemplified in a clinical case; (ii) review common neuropathic and musculoskeletal causes of acute and chronic pelvic pain that may be challenging to diagnose and manage; and (iii) discuss female genitourinary pain syndromes with a focus on retroperitoneal causes and treatment options.

METHODS

A comprehensive review of the literature was performed by searching the PubMed, Ovid Embase, MEDLINE, and Scopus databases using the keywords "chronic pelvic pain," "neuropathy," "neuropathic pain," "retroperitoneal schwannoma," "pudendal neuralgia," and "entrapment syndromes."

RESULTS

Retroperitoneal causes of genitourinary pain syndromes have substantial overlap with common conditions treated in a primary care setting. Thus, a comprehensive and systematic history and physical examination, with focused attention to the pelvic neuroanatomy, is key to establishing the correct diagnosis. In the clinical case, such a comprehensive approach led to the unexpected finding of a large retroperitoneal schwannoma. This case highlights the intricacy of pelvic pain syndromes and the complex nature of their possible overlapping causes, which ultimately affects treatment planning.

CONCLUSION

Knowledge of the neuroanatomy and neurodermatomes of the abdomen and pelvis, in addition to understanding pain pathophysiology, is critical when evaluating patients with pelvic pain. Failure to apply proper evaluation and implement proper multidisciplinary management strategies contributes to unnecessary patient distress, decreased quality of life, and increased use of health care services. Khalife T, Hagen AM, Alm JEC. Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management. Sex Med Rev 2022;XX:XXX-XXX.

Surgical management of sacral schwannomas: a 21-year mayo clinic experience and comparative literature analysis

INTRODUCTION

Sacral and presacral schwannomas are rare, accounting for a minority of spinal schwannomas. We present our institution's experience surgically treating spinal schwannomas and compare it to the literature.

METHODS

Data were collected for 27 patients treated surgically for sacral or presacral schwannoma between 1997 and 2018 at all Mayo Clinic locations and 93 patients in the literature. Kaplan-Meier disease-free survival analysis was conducted. Unpaired two-sample t tests and Fisher's exact tests assessed statistical significance between groups.

RESULTS

Our patients and those in the literature experienced a similar age at diagnosis (49.9 y/o. vs 43.4 y/o., respectively). Most of our patients (59.3%) reported full recovery from symptoms, while a minority reported partial recovery (33.3%) and no recovery (11.1%). A smaller percentage in the literature experienced full recovery (31.9%) and partial recovery (29.8%) but also no recovery (1.1%). Our patients experienced fewer complications (14.8% versus 25.5%). Disease-free survival curves for all patients showed no significant variation in progression by extent of resection of schwannoma (log-rank P = 0.26). No lesion progression was associated with full or partial symptom improvement (p = 0.044), and female patients were more likely to undergo resection via a posterior approach (p = 0.042).

CONCLUSION

Outcomes of patients with sacral or presacral schwannomas vary based on patient demographics, tumor characteristics, symptoms, and surgical treatment. Among the range of symptoms experienced by these patients, the most common is pain. Prognosis improves and overall survival is high when the surgical approach towards sacral schwannomas is prepared and executed appropriately.

Surgery of neurogenic tumors of the sacrum

OBJECTIVES

Our objective is to share our experience in neurogenic tumors of the sacral area, an uncommon disease, and assess approaches, intraoperative techniques, complications and clinical course of patients in a case series.

METHODS

We conducted a retrospective analysis of 19 cases of patients with neurogenic tumors in the sacral area who were diagnosed and underwent surgery at our center. Of them, 8 were male and 11 were female. They had a mean age at diagnosis of 51 years (with an age range of 25-78 years). Six patients were asymptomatic and were diagnosed incidentally, while the majority (11 patients) presented with lumbar pain accompanied by other symptoms: pain radiating to the legs, pelvic pain, sensory alterations and loss of strength in the legs. Two patients presented with another primary symptom on diagnosis: pain in the pelvic region and in the left leg. All patients underwent a least one imaging test (MRI/CT scan). Nine patients had tumors limited to the sacrum or with subsequent spread, with surgery via the posterior route. In 6 cases, an exclusively anterior approach was employed owing to the pre-sacral location of the tumor; 4 cases required both an anterior and posterior approach.

RESULTS

The 6 patients who were asymptomatic at diagnosis continued to have no symptoms after surgery. In 8 patients, symptoms resolved after surgery, and at discharge 4 had pain in the lumbar region or legs, which improved in subsequent consultations. One patient had symptoms consistent with motor and sensory deficit in the right leg deriving from impairment of the external popliteal sciatic nerve. The mean follow-up period was 69 months (6-178 months). Histologically, 17 cases were classified as schwannomas, one case was classified as neurofibroma, and one case was classified as neurofibrosarcoma, which received radiotherapy. Three patients with benign histologies had further surgery for local recurrences.

CONCLUSIONS

When selecting the approach, the large size that these tumors can reach, their relationship with structures, and their anterior or posterior spread should be taken in to account. Resecting the tumor mass as much as possible provides greater benefit to the patient, as this decreases the odds of tumor recurrence without increasing intraoperative and postoperative complications when multidisciplinary teams are also used.

Giant sacral schwannoma excised under intraoperative neuromonitoring in an elderly patient: case report

Schwannomas are mainly benign tumors arising from the Schwann cells of the peripheral nerve sheath. These tumors can often be associated with non-specific symptoms, such as abdominal heaviness. In this article, we present a detailed description of the surgical management of a giant sacral schwannoma in an elderly patient, for which intraoperative neuromonitoring made it possible to distinguish easily the nerves of the sacral plexus from which the tumor originated and to remove it without complications. Treatment of these rare and symptomatic giant tumors is still a challenge for surgeons; to treat adequately these tumors; a multidisciplinary approach is required to ensure an optimal therapeutic approach to reduce the risk of recurrence and, on the other hand, is not associated with unnecessary iatrogenic neurological damage.

A Case of Incidental Schwannoma Mimicking Necrotic Metastatic Lymph Node from Bladder Cancer

Background and Objectives: Retroperitoneal schwannoma is a very rare case of schwannoma which commonly occurs in the other part of the body. However, it is difficult to distinguish schwannoma from other tumors before pathological examination because they do not show specific characteristics on imaging study such as ultrasound, computed tomography (CT), and magnetic resonance image (MRI). Case summary: A 60-year-old male showed a retroperitoneal cystic tumor which is found incidentally during evaluation of coexisted bladder tumor. Neurogenic tumor was suspicious for the retroperitoneal tumor through pre-operative imaging study. Finally, a schwannoma was diagnosed by immunohistochemical examination after complete surgical excision laparoscopically. Conclusion: As imaging technology is developed, there may be more chances to differentiate schwannoma from other neoplasm. However, still surgical resection and histopathological examination is feasible for diagnosis of schwannoma.

Surgery of neurogenic tumors of the sacrum

OBJECTIVES

Our objective is to share our experience in neurogenic tumors of the sacral area, an uncommon disease, and assess approaches, intraoperative techniques, complications and clinical course of patients in a case series.

METHODS

We conducted a retrospective analysis of 19 cases of patients with neurogenic tumors in the sacral area who were diagnosed and underwent surgery at our center. Of them, 8 were male and 11 were female. They had a mean age at diagnosis of 51 years (with an age range of 25-78 years). Six patients were asymptomatic and were diagnosed incidentally, while the majority (11 patients) presented with lumbar pain accompanied by other symptoms: pain radiating to the legs, pelvic pain, sensory alterations and loss of strength in the legs. Two patients presented with another primary symptom on diagnosis: pain in the pelvic region and in the left leg. All patients underwent a least one imaging test (MRI/CT scan). Nine patients had tumors limited to the sacrum or with subsequent spread, with surgery via the posterior route. In 6 cases, an exclusively anterior approach was employed owing to the pre-sacral location of the tumor; 4 cases required both an anterior and posterior approach.

RESULTS

The 6 patients who were asymptomatic at diagnosis continued to have no symptoms after surgery. In 8 patients, symptoms resolved after surgery, and at discharge 4 had pain in the lumbar region or legs, which improved in subsequent consultations. One patient had symptoms consistent with motor and sensory deficit in the right leg deriving from impairment of the external popliteal sciatic nerve. The mean follow-up period was 69 months (6-178 months). Histologically, 17 cases were classified as schwannomas, one case was classified as neurofibroma, and one case was classified as neurofibrosarcoma, which received radiotherapy. Three patients with benign histologies had further surgery for local recurrences.

CONCLUSIONS

When selecting the approach, the large size that these tumors can reach, their relationship with structures, and their anterior or posterior spread should be taken in to account. Resecting the tumor mass as much as possible provides greater benefit to the patient, as this decreases the odds of tumor recurrence without increasing intraoperative and postoperative complications when multidisciplinary teams are also used.

Case report of seminal vesical schwannoma treated with conservative strategy

RATIONALE

Schwannoma is a benign peripheral nerve sheath tumor composed of Schwann cells and caused by genetic mutation or deletion. It rarely occurs in seminal vesicles. The optimal therapic strategy for asymptomatic cases is still unclear.

PATIENT CONCERNS

A 42-year-old man presented no clinical symptoms. A mass in his left seminal vesicle was found incidentally in a computed tomography scan and transrectal ultrasound-guided biopsy revealed the mass was schwannoma.

DIAGNOSIS

The patient was diagnosed as schwannoma of the seminal vesicle with no significant extension to the surrounding tissues.

INTERVENTIONS

The patient underwent computed tomography or magnetic resonance imaging scans periodically to estimate the alteration of the lesion and further strategy.

OUTCOMES

After 20-month follow-up, computed tomography scans showed no significant alteration to the lesion and no clinical symptoms were reported by the patient.

LESSONS

Conservative strategy might be an effective treatment option for asymptomatic patients with seminal vesical schwannoma. The period of follow-up depends on the size of the tumor.

Giant Sacral Schwannoma Causing Bilateral Hydronephrosis: Case Report and Review of the Literature

BACKGROUND

Giant sacral schwannomas are very rare, and less than 1%-5% of spinal schwannomas are found in the sacral region. These frequently grow to considerable size because of permissive anatomic location and benign, slow growth of tumor. They can be unnoticed before reaching a huge size.

CASE DESCRIPTION

We report a rare case of a giant sacral schwannoma in a 46-year-old man. The patient presented with difficulty in passing urine, episodic constipation, and swelling of the right lower extremity for 6 months. Magnetic resonance imaging revealed 160 x 110 x 110 mm encapsulated heterogenous solid mass originated from left S1 spinal nerve extending into the pelvis and abdomen. Sigmoid colon and rectum were displaced to the right side, and bladder was displaced anteriorly. Left side of the S1 and S2 vertebral bodies, left S1 and S2 neural foramen were also eroded. It also compressed ureters causing bilateral hydronephrosis. The patient underwent a 2-stage procedure in which complete resection was achieved.

CONCLUSIONS

We report the second case of a completely resected giant sacral schwannoma with bilateral hydronephrosis in the literature. Performing a 2-stage procedure is important in giant sacral schwannomas. Morbidity can be minimized, and extent of resection can be maximized with the help of combined anterior/posterior approach.

Giant Pelvic Schwannoma: Case Report and Review of the Literature

INTRODUCTION

Pelvic schwannomas are rare, mostly benign tumors. They are usually asymptomatic until their massive growth compresses adjacent organs. We describe the case of a 53-year-old man with a pelvic schwannoma who initially complained of constipation and urinary retention.

AREAS COVERED

We analyzed the clinical presentation, histopathology, diagnostic imaging tools, and the treatment options for pelvic schwannomas, compared with the few other cases reported in the literature.

EXPERT COMMENTARY

Pelvic schwannomas are masses that can grow to considerable size, producing symptoms over time. Due to their size and localization, surgery, although difficult, is the only available treatment.

Giant Invasive Sacral Schwannoma with Aortic Bifurcation Compression and Hydronephrosis

BACKGROUND

Sacral schwannomas are rare tumors arising from nerve sheath Schwann cells. They are classified into 3 types: first type schwannoma arising from the sacrum, second type schwannoma eroding the sacrum, and third type schwannoma extending extensively, involving anterior, posterior, and retroperitoneal space. Among these type 2 sacral tumors, according to Klimo's classification, an eroding sacrum extending all over posteriorly, anteriorly, and laterally is still rarer. Only 38 cases have been reported in literature reviews. Only 6 cases of giant tumors of >10 cm in any 1 dimension have been reported.

CASE DESCRIPTION

We present such a giant sacral schwannoma, with invasiveness eroding the sacrum; compressing the ureters, aortic bifurcation, bladder, and bowel; and presenting as lower abdominal pain, hydronephrosis, dysuria, and constipation. This is the first case reported in the literature that has described a large retroperitoneal tumor compressing retroperitoneal structures-aortic bifurcation vascular compression and ureter compression causing hydronephrosis.

CONCLUSIONS

Though complete resection, which caused various severe postoperative complications in the reported cases, is the best option, a less morbid procedure would be appropriate; hence we underwent subtotal excision of the tumor, with complete recovery of our patient's symptoms without neurologic deficit.

The natural history of incidental retroperitoneal schwannomas

The natural history of asymptomatic retroperitoneal schwannomas is poorly understood. This study aimed at investigating the natural history of incidental retroperitoneal schwannomas. The medical charts and imaging studies of 22 asymptomatic patients under observation for at least 12 months for retroperitoneal schwannomas were reviewed. The duration of follow-up ranged between 13 and 176 months (mean 48 months). In the 22 patients managed by the “wait and see” approach, the average tumor size at initial presentation was 51 mm, which increased to 57 mm at final follow-up. During the final follow-up, 2 patients required surgical treatment for tumor enlargement, while the remaining patients remained asymptomatic without surgery. The average growth rate of the tumors was 1.9 mm/year (range: -1.9 to 8.7 mm/year). The majority of asymptomatic retroperitoneal schwannomas demonstrate minimal growth and may be suitable for management with the “wait and see” approach.

[Resection of a giant sacral schwannoma: case report and literature review]

Neurogenic sacral tumors are extremely rare. In most reported cases, this pathology was associated with neurofibromatosis. Sacral tumors manifest themselves at the stage when the neoplasm volume becomes giant, but these manifestations usually go unnoticed for the patient. Surgical approach to the sacral region is extremely challenging; intimate proximity of tumor capsule to vital organs, vessels, and nerves makes radical surgical treatment of these neoplasms rather difficult. A case report of radical resection of a schwannoma that was destroying the sacrum and continued to grow after radiotherapy is presented in this article.

Clinical features and surgical treatment of sacral schwannomas

BACKGROUND

Sacral schwannoma is relatively rare and both the early diagnosis and appropriate treatment of sacral schwannomas are equally very challenging.

METHODS

11 sacral schwannoma cases operated at the Second Affiliated Hospital, School of Medicine, Zhejiang University, from 2012 to 2016, were investigated retrospectively and 10 were followed up. All patients were assessed with X-ray, CT and MRI, and underwent an intralesional excision.

RESULTS

One patient was male, nine were female and the average age was 48 (ranging between 31 and 63). Three patients suffered from back and leg pain, and seven had no obvious symptoms. The average blood loss during surgery was 980ml (ranging between 100 and 2,000ml). Six patients underwent preoperative biopsy. The surgeries were performed via the combination of an anterior and posterior approach in two patients, a posterior approach in seven patients, and an anterior approach in one patient. Residual tumors were not detected in all patients after surgery. Unfortunately, the postoperative complications occurred in three patients, namely bowel and bladder dysfunction (two patients) and cerebrospinal fluid leakage with secondary intracranial infection (one patient). The average follow-up was 22.7 months (8-44 months). All patients were relieved from preoperative symptoms after the last follow-up.

CONCLUSIONS

The typical findings of our cases in MRI were a well-circumscribed lesion with a heterogenous signal intensity on T2-weighted image, which may be helpful for preoperative decision-making. Intralesional excision can be successfully performed using single anterior or single posterior or both, and is an important procedure in the treatment of sacral schwannomas.

Non-Syndromic Spinal Schwannomas: A Novel Classification

Schwannomas are the most frequent primary tumors of the spine with an incidence of 0.3-0.5/100,000 person per year. Current treatment for non-syndromic spinal schwannomas is total resection of the tumor with preservation of neurovascular structures. This study aims to report neurologic and radiologic outcome following treatment of non-syndromic spinal schwannomas along with a novel tumor classification used in our clinic. A retrospective case series was carried out with a patient sample of 82 male and female patients with non-syndromic spinal schwannomas. All patient data were retrospectively collected from the hospital records. As a routine procedure, after admittance and primary evaluation, patients' tumors were classified using CT or MRI in accordance with our proposed classification method, which employs a dual designation method with tree groups (A, B, and C) for tumor volume and four types (I, II, III, and IV) for tumor localization. Subsequent resection surgery was followed by neurological assessments and follow up at 45th, 180th, and 360th postoperative day. Along with Karnofsky performance status scale, pain, sensory deficits, and motor weakness were scored to assess neurologic recovery. Our finding indicates that patients with different tumor types significantly differ in their neurological scores and show consistent but differential neurological recovery at early and late time points postsurgery. Complications during and postsurgery were minimal, occurring only in two patients. Our findings further reinforce the established safety of total resection operations and indicate that our proposed classification is a simple, effective tool that has proven helpful in preoperative planning and avoiding unnecessary surgical approaches.

Ancient Schwannoma of the Cauda Equina: Our Experience and Review of the Literature

Ancient schwannomas (AS) are exceedingly rare variant of common schwannomas (CS). Only two cases involving the cauda equina region have been previously reported in literature. AS are typically associated with a higher histological degree of degenerative changes (Antoni B areas). It is of peculiar importance, according to our opinion, to outline that, because of their extremely slow growth (which explains the increase of the degenerative changes in respect to the CS) and their typical soft consistency in respect to their standard counterparts, AS usually imply an even better prognosis.

Posterior approach for giant S1 neurofibroma in Von Recklinghausen's disease: Is total resection realistic?

Bilateral sacral neurofibromas are uncommonly seen in neurofibromatosis type 1 (NF1) also known as Von Recklinghausen's disease. They often grow to enormous dimensions before detection owing to bone scalloping. Resections of “giant” S1 neurofibromas are difficult due to the limitations of operative window in sacrum and critical functions associated with S1 nerve root. We report a case of bilateral S1 neurofibromas in a patient of NF1 where she had a giant left-sided neurofibroma with extensive bone erosion and a small fusiform neurofibroma on the right side. The tumor was excised completely on the left and near totally on the right side via posterior approach. There were no postoperative neurological deficits and the patient recovered well. Usually, complete excision harbors the chances of postoperative neurological deficits due to the eloquence of the nerve root involved and complete resection without significant morbidity seems unrealistic. However, excision of giant ones may not result in grave deficits always if the patient is neurologically intact before surgery. Also, in selected patients, only posterior approach may suffice for giant neurofibromas with extensive bone scalloping and complete removal can be attempted successfully despite narrow corridors.

Neurological outcome following resection of benign presacral neurogenic tumors using a nerve-sparing technique

BACKGROUND

Benign presacral nerve sheath tumors represent up to 10% of all presacral tumors. Limited data exist regarding the impact of the surgical technique on neurological outcomes following resection.

OBJECTIVE

The aim of this study was to test our hypothesis that a nerve-sparing resection technique results in the improvement of preoperative neurological dysfunction and minimal postoperative neurological morbidity.

DESIGN

This study is a case series of all patients with benign neurogenic presacral tumors operated on by the same 2 surgeons between 2004 and 2010 at our institution.

SETTINGS

This study was performed at a tertiary care center.

PATIENTS

Adult patients with benign presacral neurogenic tumors who underwent a nerve-sparing resection were included.

MAIN OUTCOME MEASURES

Postoperative urogenital, anorectal, and lower-extremity neurological functions were analyzed.

RESULTS

Seventeen patients were identified with a mean age of 40 years; 14 were women. Preoperatively, 13 patients had symptoms from neurological dysfunction or presumed mass effect of the tumor. The mean tumor size was 7.4 cm. The pathology was a schwannoma in 12 patients and neurofibroma in 5 patients. Mortality was nil, and 30-day morbidity was noted in 3 patients (hemorrhage, ileus, acute respiratory distress syndrome, deep vein thrombosis, and transient foot drop). Mean follow-up was 36 months. Of the 13 symptomatic patients, 7 achieved complete resolution of symptoms and 5 had improved, but persistent symptoms. None of the 4 asymptomatic patients developed postoperative neurological dysfunction.

LIMITATIONS

Small sample size was a limitation of this study.

CONCLUSIONS

With the use of a nerve-sparing technique, function-preserving resection can be safely completed with an overall improvement in symptoms.

Laparoscopic management of sacral nerve root schwannoma with intractable vulvococcygodynia: report of three cases and review of literature

Herein we report the feasibility of laparoscopic resection of schwannomas of the sacral nerves roots in 3 women with intractable vulvodynia and coccygodynia. Laparoscopic en bloc resection of the sacral schwannomas was performed, with primary control of the tumor blood supply and with exposure and sparing of the sacral nerve roots. In all 3 patients, laparoscopy was successful, with minimal blood loss and without complications. Histologic examination confirmed the diagnosis of schwannoma without malignant transformation in all 3 women. At mean follow-up of 27.66 months, no patient reported recurrence or worsening of symptoms. All patients are able to walk normally without gait aids. Primary control of the tumor blood supply during laparoscopic surgery to resect deep sacral masses reduces considerably the risk of operative hemorrhage. Compared with classic neurosurgical approaches, laparoscopic exposure of the rectum, ureters, and sacral nerve roots renders the procedure safer and easier, with less risk of postoperative functional morbidity.

The management of sacral schwannoma: report of four cases and review of literature

Sacral schwannoma is a rare retrorectal tumor in adults. Postoperative sacral neurological deficit is difficult to avoid. Currently, there is no established consensus regarding best treatment options. We present the management and outcomes of sacral schwannoma in 4 patients treated with intralesional curettage and postoperative radiation. There were 3 women and one man (average age: 45.5 years) with long duration of lumbosacral pain with or without radiculopathy. Intralesional curettage was performed by posterior approach and adjuvant radiation therapy with dosage of 5000–6600 cGy was given after surgery. The mean follow-up time was 18 months (range 4–23 months). Symptoms of radiculopathy had decreased in all patients. The recent radiographic findings show evidence of sclerosis at the sacrum one year postoperatively, but the size was unchanged. Intralesional curettage and adjuvant radiation therapy can be used in the treatment of sacral schwannoma to relieve symptoms and preserve neurological function.

Low-back pain as the presenting sign in a patient with a giant, sacral cellular schwannoma: 10-year follow-up

Giant sacral tumors present unique challenges to surgeons because there is no established consensus regarding the best treatment options. The authors report on the care of and outcome in a patient presenting with low-back pain only, who underwent preoperative biopsy sampling and subsequent embolization of the feeding vessels of a giant, sacral cellular schwannoma. The main procedure was performed via a combined posterior-anterior approach with complete microsurgical removal of the tumor, without the use of instrumentation, bracing, or adjuvant radio- and chemotherapy. At the 10-year follow-up, no evidence of residual tumor, recurrence, or instability was recognizable. Giant, sacral cellular schwannomas can be aggressively completely removed without any significant morbidity, achieving long-term control of the disease.

Giant sacral schwannoma: a report of six cases

Sacral and presacral schwannomas are often found incidentally, because they present with vague symptoms or symptomless. Schwannoma occurring in this area occasionally presents with enormous dimensions, known as a giant schwannoma. The tumor removal is a surgical challenge due to the difficult approach and abundant vascularity. The aim of this study is to review cases of giant sacral schwannomas focusing the surgical management and outcome. Six patients with sacral and presacral schwannoma were treated surgically. The patients included two males and four females, and the mean age was 47.8 years. All patients experienced pain at the time of presentation. The tumors were classified as intraosseous type in one case, dumb-bell type in four cases, and retroperitoneal type in one case. The tumors were removed with a piecemeal subtotal excision in three patients, a partial excision in two patients, and enucleation in one patient. The surgeries were performed by the combination of an anterior and posterior approach in three patients, a posterior approach in two patients, and an anterior approach in one patient. The mean surgical time was 7.8 hrs, and the mean blood loss was 2572 g. The tumor recurred in one patient after the partial excision and was removed completely in a second surgery. No patient, including the patient who underwent the second surgery, presented with pain and obvious neurological deficit at the final follow-up. The surgical treatment of the giant sacral schwannoma with a piecemeal subtotal excision can achieve a good outcome, avoiding unnecessary neurological deficit.

Schwannoma in the retroperitoneum

Schwannoma (neurilemmoma) is a peripheral nerve sheath tumor and commonly occurs singularly on the head, neck, and trunk. Giant schwannoma is rarely located on the retroperitoneum and pelvic cavity. The majority of symptoms caused by the tumor are due to the effect of its mass. Surgical resection is enough to treat the tumor. Schwannoma is reported usually as benign, and despite incomplete resection of the tumor, the risk of recurrence and metastasis is low. A schwannoma on the retroperitoneum that was preoperatively misdiagnosed as a malignant adnexal mass in a 60-year-old menopausal woman is presented, with a brief review of the literature.

Pediatric presacral masses

Various types of masses may affect the presacral area in children. A presacral mass may be congenital or developmental or may arise from inflammation. The mass may have neural, vascular, lymphatic, or mesenchymal origins and may be primary (as in focal disease) or systemic (as in multifocal disease). Because the clinical manifestations of presacral masses are often nonspecific, imaging plays an important role in the detection and differentiation of these masses. Information obtained from imaging is also critical for management, especially for surgical planning. For these reasons, it is important that radiologists be familiar with the anatomy of the presacral region and with the imaging features of the various lesions that may occur in this region in children. For the accurate interpretation of findings, radiologists also must know the specific advantages and limitations of each of the imaging modalities used to evaluate this category of abnormalities.

Giant nerve sheath tumour: report of six cases

Giant nerve sheath tumour is a rare tumour originating from the nerve sheath. It differs from the conventional nerve sheath tumour only by the size these tumours can reach. There are two main type of tumours that occur in the nerve sheath which include neurofibroma and schwannoma. The current views are that schwannomas arise from the progenitor of the schwann cell. Whereas the neurofibroma series probably arise from a mesenchymal origin closer to a fibroblast. We report on six cases of nerve sheath tumour that occur in the spinal and paraspinal region that presented to us over a 5 year period.

Spinal extradural schwannoma

OBJECT

The authors endeavor to define the clinical and surgery-related profile of spinal nerve sheath tumors located in the extradural space outside both the dural sac and, apparently, the nerve roots' sleeve.

METHODS

A series of 24 extradural schwannomas was retrospectively selected after reviewing the notes of spinal nerve sheath tumors surgically treated at La Sapienza University of Rome. Clinical data, tumor-related characteristics, and outcome were analyzed. Women predominantly harbored these tumors. On admission sensory nerve root dysfunction was infrequently reported, whereas pyramidal tract deficits were often present. The tumor, generally large, was most frequently located in the intermediate thoracic segments and high cervical region; only one was reported in the lumbosacral region. Considerable erosion of vertebral bodies was reported in almost one third of the cases. In four patients eloquent nerve roots, that of C-5 in three and that of S-1 in one, were involved with the tumor. Radical tumor resection, with preservation of the nerve roots, was possible in several cases, whereas in two patients manipulation and resection of the C-5 root produced transient and permanent, respectively, root palsy. At follow-up examination patients for whom walking was impossible before surgery were now able to walk.

CONCLUSIONS

Extradural schwannomas can be distinguished from other nerve sheath tumors growing inside the spinal canal by their clinicoradiological features and unlikely nerve root origin. After surgery, recovery from pyramidal tract deficits, even severe, is noteworthy; in the authors' experience, however, resection of an involved appendicular root is more likely to result in a permanent and significant radicular deficit.

Paleopathological find of a sacral neurilemmoma from ancient Egypt

A large, smooth-walled cavity molded from the pressure of a relatively hard, globular, and lobulated tissue mass was found inside the sacrum of the mature female, Imakhetkherresnet. She was the sister of the lector-priest Iufaa, whose unmolested tomb dates to the late 26th Dynasty (prior to 625 BC). The origin of the lesion could be determined unambiguously by macroscopic, radiographic, and histological analysis. It was caused by a neurilemmoma (schwannoma, neurinoma), a benign tumor originating in a nerve sheath. This is the first description in the paleopathological literature of this kind of tumor occurring in the sacrum.

Presacral cystic schwannoma in a man

Presacral cystic schwannomas are rare, difficult to diagnose, and have only been reported in women. We present the first such case in a male patient. It was incidentally diagnosed during an evaluation for renal colic in a 52-year-old man. The presacral lesion was cystic on computed tomography and measured 10 cm in diameter. The appearance on pelvic magnetic resonance imaging was hyperintense on T(2)-weighted images and of low to intermediate intensity on T(1)-weighted images. Complete excision was achieved without bladder injury. The patient voided without difficulty and was free of local recurrence at 12 months after surgery.

Nerve sheath tumors involving the sacrum. Case report and classification scheme

Nerve sheath tumors that involve the sacrum are rare. Delayed presentation is common because of their slow-growing nature, the permissive surrounding anatomical environment, and nonspecific symptoms. Consequently, these tumors are usually of considerable size at the time of diagnosis. The authors discuss a case of a sacral nerve sheath tumor. They also propose a classification scheme for these tumors based on their location with respect to the sacrum into three types (Types I-III). Type I tumors are confined to the sacrum; Type II originate within the sacrum but then locally metastasize through the anterior and posterior sacral walls into the presacral and subcutaneous spaces, respectively; and Type III are located primarily in the presacral/retroperitoneal area. The overwhelming majority of sacral nerve sheath tumors are schwannomas. Neurofibromas and malignant nerve sheath tumors are exceedingly rare. Regardless of their histological features, the goal of treatment is complete excision. Adjuvant radiotherapy may be used in patients in whom resection was subtotal. Approaches to the sacrum can generally be classified as anterior or posterior. Type I tumors may be resected via a posterior approach alone, Type III may require an anterior approach, and Type II tumors usually require combined anterior-posterior surgery.

Benign sacral tumors

Primary tumors of the sacrum are rare. In adults, the most common sacral tumors are metastases. The most common primary sacral tumor is a chordoma. Chordomas along as well as tumors such as chondrosarcomas, osteosarcomas, myxopapillary ependymomas, myelomas, and Ewing sarcomas are considered malignant. In this article the authors focus on benign sacral tumors.

Surgical pathology of spinal schwannomas: a light and electron microscopic analysis of tumor capsules

OBJECTIVE

Although spinal schwannomas are often encountered, the pathology of the tumor capsule has not been reported. In this study, we describe the ultrastructural pathology of the tumor capsule of spinal schwannomas.

METHODS

In 18 patients who underwent total removal of spinal schwannomas (C2-conus), the tumor capsule was collected and examined by light and electron microscopy.

RESULTS

The thickness of the tumor capsule ranged from 15 to 800 microm (mostly 30-100 microm) and was composed of three layers from the surface to the center: 1) a thinly stretched nerve tissue layer; 2) a fibrous layer of fibrocytes, abundant collagen fibers, and tumor vessels; and 3) a thin transitional layer intermingled with fibrous components and tumor cells. The thickness of each layer varied in different regions of the surface. There was no clear separation between the tumor capsule and the neoplastic tissue, even on the electron microscopic level. A number of nerve fibers ran through the fibrous layer and beneath the capsule as well as in the nerve tissue layer.

CONCLUSION

Compared with vestibular schwannomas, which have been reported to be covered by an extremely thin layer (3-5 microm) of connective tissue, spinal schwannomas were well encapsulated. The capsule was composed of three distinct components; however, the cleavage between thin capsule and tumor cells was indistinct, and the thickness of the axon-containing capsule varied from site to site. Therefore, resection of the nerve of tumor origin, rather than enucleation, would be justified to avoid tumor recurrence. Surgeons should be aware of this pathology when performing the procedure.

Presacral schwannoma with purely cystic form

STUDY DESIGN

Case report.

OBJECTIVE

To point out that presacral schwannoma can display markedly cystic degeneration.

SUMMARY OF BACKGROUND DATA

Benign schwannoma sometimes displays degenerative changes, such as cyst formation, calcification, hemorrhage, and hyalinization. Usually these degenerations are partially seen in the tumors.

METHODS

Medical history, physical findings, imaging features, and histologic findings were reviewed in a case with a large presacral schwannoma.

RESULTS

A 62-year-old woman presented with an 18-month history of right sciatic pain. Magnetic resonance images detected a large cystic, presacral tumor. Initially the tumor was misdiagnosed as a cystic ovarian tumor. Preoperative diagnostic workup led to the diagnosis of cystic schwannoma. Intralesional curettage achieved good pain relief.

CONCLUSIONS

This tumor was unusual in its totally cystic appearance and resemblance to a cystic ovarian tumor or anterior sacral meningocele. Preoperative diagnosis is important to prevent major neurologic deficit at surgery.