Management of giant presacral schwannoma. Clinical series and literature review

Rare retroperitoneal giant sacral schwannoma: A case report

Schwannomas localized in the sacrum are relatively infrequent, accounting for 1-5% of all spinal axis schwannomas; they present with vague symptoms or are symptomless, so often grow to a considerable size before detection. Sacral schwannomas occasionally present with enormous dimensions, and these tumors are termed giant sacral schwannomas. However, their surgical removal is challenging owing to an abundant vascularity. The present study retrospectively analyzed the clinical and follow-up data of a patient with a giant sacral schwannoma. The patient experienced numbness in the left buttock and lower extremity, with radiating pain in the sole of the foot that had persisted for 3 years. A presacral mass was found by computed tomography examination 6 months after the stool had become thin. A tumor resection was performed using the anterior abdominal approach. A schwannoma was diagnosed by postoperative pathology. The postoperative course was uneventful, with the complete resolution of symptoms during the 21-month clinical follow-up. Overall, the present study reports the case of a giant sacral schwannoma with pelvic pain that was resected without complications and also discusses its successful management. Additionally, the study presents a systematic review of the literature. We consider that the surgical treatment of giant sacral schwannomas with piecemeal subtotal excision can achieve good outcomes, avoiding unnecessary neurological deficits.

Presacral tumors: A systematic review of literature

Presacral/Retrorectal tumors (RRT) are rare lesions that comprise a multitude of histological types. Data on surgical management are limited to case reports and small case series. The aim of the study was to provide a comprehensive review of the epidemiology, pathological subtypes, surgical approaches, and clinical outcomes. A PubMed search using terms "retrorectal tumor" and "presacral tumor" was used to identify articles reporting RRT of non-urological, non-gynecologic, and non-metastatic origin. Articles included were between 2015 and 2023. A total of 68 studies were included, comprising 570 patients. About 68.2% of patients were female, and the mean overall age of both sexes was 48.6 years. Based on histopathology, 466 patients (81.8%) had benign lesions, and 104 (18.2%) were malignant. In terms of surgical approach, 191 (33.5%) were treated anteriorly, 240 (42.1%) through a posterior approach, and 66 (11.6%) combined. The mean length of stay was 7.6 days. Patients treated using the posterior approach had a shorter length of stay (5.7 days) compared to the anterior and combined approaches. RRT are rare tumors of congenital nature with prevalence among the female sex. R0 resection is crucial in its management, and minimal access surgery appears to be a safer option in appropriate case selection.

Clinical Characteristics and Surgical Outcomes of 2542 Patients with Spinal Schwannomas: A Systematic Review and Meta-Analysis

OBJECTIVE

This study was conducted to systematically analyze the data on the clinical features, surgical treatment, and outcomes of spinal schwannomas.

METHODS

We conducted a systematic review and meta-analysis under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of bibliographic databases from January 1, 2001, to May 31, 2021, yielded 4489 studies. Twenty-six articles were included in our final qualitative systematic review and quantitative meta-analysis.

RESULTS

Analysis of 2542 adult patients' data from 26 included studies showed that 53.5% were male, and the mean age ranged from 35.8 to 57.1 years. The most common tumor location was the cervical spine (34.2%), followed by the thoracic spine (26.2%) and the lumbar spine (18.5%). Symptom severity was the most common indicator for surgical treatment, with the most common symptoms being segmental back pain, sensory/motor deficits, and urinary dysfunction. Among all patients analyzed, 93.8% were treated with gross total resection, which was associated with better prognosis and less chance of recurrence than subtotal resection. The posterior approach was the most common (87.4% of patients). The average operative time was 4.53 hours (95% confidence interval [CI], 3.18-6.48); the average intraoperative blood loss was 451.88 mL (95% CI, 169.60-1203.95). The pooled follow-up duration was 40.6 months (95% CI, 31.04-53.07). The schwannoma recurrence rate was 5.3%. Complications were particularly low and included cerebrospinal fluid leakage, wound infection, and the sensory-motor deficits. Most of the patients experienced complete recovery or significant improvement of preoperative neurological deficits and pain symptoms.

CONCLUSIONS

Our analysis suggests that segmental back pain, sensory/motor deficits, and urinary dysfunction are the most common symptoms of spinal schwannomas. Surgical resection is the treatment of choice with overall good reported outcomes and particularly low complication rates. gross total resection offers the best prognosis with the slightest chance of tumor recurrence and minimal risk of complications.

Surgical management of sporadic and schwannomatosis-associated pelvic schwannomas

Pelvic schwannomas are rare tumors that may occur either sporadically or in the context of schwannomatosis. We retrospectively reviewed the charts of patients harboring a pelvic schwannoma under conservative management or operated at our reference center between 2016 and 2023. All patients were operated by a multidisciplinary team, combining a vascular surgeon and a neurosurgeon. Twenty-four patients harboring 33 pelvic tumors were included in the cohort, including 12 patients with sporadic lesions, 2 patients with NF2-related schwannomatosis, and 10 patients with NF2-independent schwannomatosis. Multi-nodular tumors were more frequent in schwannomatosis compared to sporadic cases (p = 0.005). The mean age at diagnosis was 41 years old. Schwannomas were located on branches of the sciatic nerve (23/33, 70%), the femoral nerve (6/33, 18%), and the obturator nerve (4/33, 12%). Over the course of the study, 16 patients were operated, including 11 sporadic cases. The indication for surgery was pain (12/16, 75%) or tumor growth (4/16, 25%). Complete resection was achieved in 14 of 16 patients (87%). The mean post-operative follow-up was 37 months (range: 2-168 months). At last-follow-up, complete pain relief was achieved in all 12 patients with pre-operative pain. Post-operative morbidity included 3 long-term localized numbness and one MRC class 4 motor deficit in a multi-nodular tumor in a schwannomatosis patient. Despite its limited size, our series suggests that nerve-sparing resection of pelvic schwannomas offers satisfying rates of functional outcome both in sporadic and schwannomatosis cases, except for multi-nodular tumors.

Minimally Invasive Dorsal Approach for the Treatment of Giant Presacral Schwannomas

BACKGROUND

The treatment of giant presacral schwannomas is currently a grand challenge for neurosurgeons. Although these tumors are benign and do not infiltrate the surrounding tissues, it is difficult to choose the best surgical approach because they are surrounded by the pelvic organs and great vessels. There is no universally accepted approach to the surgical treatment because giant presacral schwannomas are rare in the population. The anterior approach through laparotomy is more often recommended in the literature. A dorsal approach that involves laminotomy and stabilization is also described in the literature. However, these approaches are rather traumatic for the patient and have both intraoperative and postoperative risks.

OBJECTIVE

To report a minimally invasive dorsal approach for the treatment of giant presacral schwannomas.

METHODS

We present a fundamentally new approach to the treatment of these tumors using a minimally invasive dorsal approach, based on the specific anatomy and growth of giant presacral schwannomas. This approach is using the potential of modern neurosurgery.

RESULTS

We describe 2 cases of successful total tumor resection using this novel surgical approach. No complications have been registered after the surgery.

CONCLUSION

A minimally invasive dorsal approach for the treatment of giant presacral schwannomas is sufficient for complete tumor removal, minimizes intraoperative and postoperative risks, is associated with good cosmetic effect, and can be successfully applied in surgical practice.

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.