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Evans DG, Mostaccioli S, Pang D, Fadzil O Connor M, Pittara M, Champollion N, Wolkenstein P, Thomas N, Ferner RE, Kalamarides M, Peyre M, Papi L, Legius E, Becerra JL, King A, Duff C, Stivaros S, Blanco I. ERN GENTURIS clinical practice guidelines for the diagnosis, treatment, management and surveillance of people with schwannomatosis. Eur J Hum Genet 2022; 30:812-817. [PMID: 35361920 PMCID: PMC9259735 DOI: 10.1038/s41431-022-01086-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/04/2022] [Accepted: 03/07/2022] [Indexed: 11/20/2022] Open
Abstract
A Guideline Group (GG) was convened from multiple specialties and patients to develop the first comprehensive schwannomatosis guideline. The GG undertook thorough literature review and wrote recommendations for treatment and surveillance. A modified Delphi process was used to gain approval for recommendations which were further altered for maximal consensus. Schwannomatosis is a tumour predisposition syndrome leading to development of multiple benign nerve-sheath non-intra-cutaneous schwannomas that infrequently affect the vestibulocochlear nerves. Two definitive genes (SMARCB1/LZTR1) have been identified on chromosome 22q centromeric to NF2 that cause schwannoma development by a 3-event, 4-hit mechanism leading to complete inactivation of each gene plus NF2. These genes together account for 70-85% of familial schwannomatosis and 30-40% of isolated cases in which there is considerable overlap with mosaic NF2. Craniospinal MRI is generally recommended from symptomatic diagnosis or from age 12-14 if molecularly confirmed in asymptomatic individuals whose relative has schwannomas. Whole-body MRI may also be deployed and can alternate with craniospinal MRI. Ultrasound scans are useful in limbs where typical pain is not associated with palpable lumps. Malignant-Peripheral-Nerve-Sheath-Tumour-MPNST should be suspected in anyone with rapidly growing tumours and/or functional loss especially with SMARCB1-related schwannomatosis. Pain (often intractable to medication) is the most frequent symptom. Surgical removal, the most effective treatment, must be balanced against potential loss of function of adjacent nerves. Assessment of patients' psychosocial needs should be assessed annually as well as review of pain/pain medication. Genetic diagnosis and counselling should be guided ideally by both blood and tumour molecular testing.
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Affiliation(s)
- D. Gareth Evans
- grid.451052.70000 0004 0581 2008Manchester Centre for Genomic Medicine, Division of Evolution and Genomic Sciences, University of Manchester, MAHSC, St Mary’s Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Stefania Mostaccioli
- grid.419457.a0000 0004 1758 0179IDI-Istituto Dermopatico Immacolata Rome, Rome, Italy ,Italian Association for NF2 and Schwannomatosis Patients NF2 Project Aps, Rome, Italy
| | - David Pang
- grid.420545.20000 0004 0489 3985Pain Department, Guy’s & St Thomas NHS Foundation Trust London, London, UK
| | | | | | | | - Pierre Wolkenstein
- grid.412116.10000 0001 2292 1474Dept of Dermatology, APHP, UPEC, Henri-Mondor Hospital, Créteil, France
| | - Nick Thomas
- grid.46699.340000 0004 0391 9020Department of Neurosurgery, King’s College Hospital London, London, UK
| | - Rosalie E. Ferner
- grid.420545.20000 0004 0489 3985Department of Neurology, Guy’s & St Thomas NHS Foundation Trust London, London, UK
| | - Michel Kalamarides
- grid.462844.80000 0001 2308 1657Department of Neurosurgery, Assistance Publique–Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Matthieu Peyre
- grid.462844.80000 0001 2308 1657Department of Neurosurgery, Assistance Publique–Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Laura Papi
- grid.8404.80000 0004 1757 2304Department of Experimental and Clinical, Medical Genetics Unit, Biomedical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Eric Legius
- grid.5596.f0000 0001 0668 7884Department of Human Genetics, University of Leuven, KULeuven, Belgium ,grid.410569.f0000 0004 0626 3338University Hospital Leuven, Leuven, Belgium
| | - Juan Luis Becerra
- grid.22061.370000 0000 9127 6969Neurology service, Neurosciences Department, Hospital Germans Trias I Pujol, Institut Català de la Salut, Barcelona, Spain
| | - Andrew King
- grid.5379.80000000121662407Geoffrey Jefferson Brain Research Centre, Northern Care Alliance NHS Group, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Chris Duff
- grid.498924.a0000 0004 0430 9101Department of Plastic Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Stavros Stivaros
- grid.5379.80000000121662407Geoffrey Jefferson Brain Research Centre, Northern Care Alliance NHS Group, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Ignacio Blanco
- grid.411438.b0000 0004 1767 6330Clinical Genetics Department, Hospital Germans Trias I Pujol, Barcelona, Spain
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Surgical Management of Sporadic Peripheral Nerve Schwannomas in Adults: Indications and Outcome in a Single Center Cohort. Cancers (Basel) 2021; 13:cancers13051017. [PMID: 33804463 PMCID: PMC7957633 DOI: 10.3390/cancers13051017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/20/2021] [Accepted: 02/24/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Peripheral nerve sheath tumors are associated with significant morbidity. Clinical presentation, tumor location, and therapeutic strategies are variable. We aim to provide high-quality data concerning the results of interdisciplinary operative approaches for surgical resection of schwannomas. Understanding the anatomical and functional challenges of surgical interventions in the peripheral nervous system can help to enhance the outcomes of these therapies. We aim to highlight the need for interdisciplinarity and provide evidence for both excellent functional outcomes, as well as improved quality of life for patients undergoing sporadic schwannoma surgery. Abstract Most sporadic peripheral nerve sheath tumors in adults are schwannomas. These tumors usually present with significant pain but can also cause neurological deficits. Symptomatology is diverse, and successful surgical interventions demand interdisciplinarity. We retrospectively reviewed 414 patients treated between 2006 and 2017 for peripheral nerve sheath tumors. We analyzed clinical signs, symptoms, histology, and neurological function in the cohort of adult patients with schwannomas without a neurocutaneous syndrome. In 144 patients, 147 surgical interventions were performed. Mean follow-up was 3.1 years. The indication for surgery was pain (66.0%), neurological deficits (23.8%), significant tumor growth (8.8%), and suspected malignancy (1.4%). Complete tumor resection was achieved on 136/147 occasions (92.5%). The most common location of the tumors was intraspinal (49.0%), within the cervical neurovascular bundles (19.7%), and lower extremities (10.9%). Pain and neurological deficits improved significantly (p ≤ 0.003) after 131/147 interventions (89.1%). One patient had a persistent decrease in motor function after surgery. Complete resection was possible in 67% of recurrent tumors, compared to 94% of primary tumors. There was a significantly lower chance of complete resection for schwannomas of the cervical neurovascular bundle as compared to other locations. The surgical outcome of sporadic schwannoma surgery within the peripheral nervous system is very favorable in experienced peripheral nerve surgery centers. Surgery is safe and effective and needs a multidisciplinary setting. Early surgical resection in adult patients with peripheral nerve sheath tumors with significant growth, pain, neurological deficit, or suspected malignancy is thus recommended.
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Abstract
Background: Peripheral nerve sheath tumors (PNSTs) are neoplastic soft tissue masses generated from the abnormal proliferation of Schwann cells. Often, these tumors occur in isolation and are known as schwannomas or neurilemmomas. The presence of multiple schwannomas is known as schwannomatosis. The purpose of this article is 2-fold: (1) to review the relevant literature and describe a unique case of this rare condition; and (2) to emphasize salient clinical considerations in the diagnosis and treatment of schwannomatosis. Methods: In this report, we describe the case of a 52-year-old white man who presented with multiple recurrent soft tissue masses of the right hand. On initial presentation, he described pain across his right hand and index finger, which persisted despite numerous prior operations. The index finger had a flexion contracture around the location of the proximal interphalangeal joint, and there were multiple tender masses along the length of the finger and palm. Results: Segmental excision of the affected radial digital nerve was performed. A pulp flap based on contralateral neurovascular bundle resulted in a sensate, pain-free digit. Tissue pathology confirmed the diagnosis of multiple neurilemmomas. Conclusions: We report the success of a radial digital neurectomy in a patient with widespread neurilemmomas, who had previously excluded that painful digit from use. It was through careful consideration of the preoperative differential diagnosis, by valuing the preoperative imaging, and by considering all surgical options with specific attention paid to skin flap design that this good outcome of a fully sensate, pain-free, mobile index finger was achieved.
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Affiliation(s)
| | - Nikhil A. Agrawal
- Baylor College of Medicine, Houston, TX, USA,Nikhil Agrawal, Division of Plastic Surgery, Baylor College of Medicine, Clinical Care Center, 8th Floor, 6701 Fannin Street, Houston, TX 77030, USA.
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Predictive factors of postoperative deficit and functional outcome after surgery for upper limb schwannomas: Retrospective study of 21 patients. HAND SURGERY & REHABILITATION 2020; 39:229-234. [PMID: 32061856 DOI: 10.1016/j.hansur.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 01/15/2023]
Abstract
Schwannomas are the most frequent benign tumors of the peripheral nerves. Tumor enucleation is the traditional surgical treatment. The incidence of neurological complications after surgery varies and predictive factors for these complications are not clearly defined. The aim of this study was to find predictive factors of postoperative neurological deficit after surgical treatment of schwannomas of the upper limb. Twenty-four schwannomas removed from 21 patients were analyzed retrospectively. The patients' mean age was 45.4years and the mean follow-up was 64.4months. Clinical parameters studied were age, gender, nature of preoperative symptoms, duration of symptoms, type of surgery performed, tumor location and size, nerve involved, QuickDASH and DN4 scores. Postoperative neurological deficits occurred in 14 patients (67%), with 11 having a sensory deficit and 7 a motor weakness. Eleven did not exist before surgery (6 sensory, 5 motor). In the postoperative deficit subgroup, 6 schwannomas involved the brachial plexus, 4 the ulnar nerve, and 4 the median nerve. All patients who had a fascicular resection because tumor enucleation was not feasible were in the postoperative deficit subgroup. Ten patients had either unchanged or worse QuickDASH and/or DN4 scores after surgery. Surgical treatment of schwannomas can lead to postoperative complications. Although none of our findings were statistically significant, advanced age, large tumor size, more than 16months between the first symptoms and surgery, and brachial plexus location seem to be more frequently observed in those with a postoperative neurological deficit.
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Zipfel J, Al-Hariri M, Gugel I, Haas-Lude K, Grimm A, Warmann S, Krimmel M, Mautner VF, Tatagiba M, Schuhmann MU. Surgical management of peripheral nerve sheath tumours in children, with special consideration of neurofibromatoses. Childs Nerv Syst 2020; 36:2433-2442. [PMID: 32506255 PMCID: PMC8272701 DOI: 10.1007/s00381-020-04703-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/25/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Peripheral nerve sheath tumours in children are a rare and heterogeneous group, consisting mostly of benign tumours as well as malignant neoplasms. Especially in the paediatric population, diagnostics and indication for therapy pose relevant challenges for neurosurgeons and paediatric neurologists alike. Most paediatric cases that need surgical intervention are associated to neurofibromatosis type 1 (NF1). METHODS We retrospectively reviewed all paediatric cases treated at the Department of Neurosurgery in Tübingen between 2006 and 2017 for peripheral nerve sheath tumours. We analysed clinical signs, symptoms, histology, association to an underlying phacomatosis and sensory/motor function. RESULTS Of the 82 identified patients, the majority had NF1 (76.8%). Nine children bore a sporadic tumour without underlying phacomatosis (11%), 8 had NF2 (9.8%) and 2 schwannomatosis (2.4%), A total of 168 surgical interventions were performed, and 206 tumours were removed. Indication for surgery was in most instances significant tumour growth (45.2%) followed by pain (33.9%). New deficits led to surgery in 12.5% of interventions; malignancy was suspected in 8.3%. Histopathology revealed mostly neurofibromas (82.5%), divided into cutaneous neurofibromas (10.7%), infiltrating plexiform neurofibromas (25.7%) and peripheral nerve-born neurofibromas (46.1%). 12.1% of tumours were schwannomas, 2.9% MPNST, 1.5% ganglioneuroma (n = 3) and 1 hybrid-neurofibroma and perineurinoma each. Leading symptoms, such as pain and motor and sensory deficits, improved after 125/166 interventions (74.4%), remained unchanged following 39 interventions (23.2%) and worsened in 4 occasions (2.4%). CONCLUSION Surgery is safe and effective for (neurofibromatosis associated) peripheral nerve sheath tumours in the paediatric population; however, management needs a multidisciplinary setting. We propose early surgical resection in paediatric patients with peripheral nerve sheath tumours with significant growth, or pain, or motor deficit, or suspected malignancy.
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Affiliation(s)
- Julian Zipfel
- Division of Paediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany. .,Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany. .,Centre for Neurofibromatosis at the Centre of Rare Diseases, University Hospital and University of Tübingen, Tübingen, Germany.
| | - Meizer Al-Hariri
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - Isabel Gugel
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany ,Centre for Neurofibromatosis at the Centre of Rare Diseases, University Hospital and University of Tübingen, Tübingen, Germany
| | - Karin Haas-Lude
- Centre for Neurofibromatosis at the Centre of Rare Diseases, University Hospital and University of Tübingen, Tübingen, Germany ,Department of Paediatric Neurology, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Alexander Grimm
- Department of Neurology, University Hospital Tübingen, Tübingen, Germany
| | - Steven Warmann
- Department of Paediatric Surgery, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Michael Krimmel
- Department of Maxillofacial Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Victor-Felix Mautner
- Neurofibromatosis Centre Hamburg, Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcos Tatagiba
- Division of Paediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany ,Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany ,Centre for Neurofibromatosis at the Centre of Rare Diseases, University Hospital and University of Tübingen, Tübingen, Germany
| | - Martin U. Schuhmann
- Division of Paediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany ,Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany ,Centre for Neurofibromatosis at the Centre of Rare Diseases, University Hospital and University of Tübingen, Tübingen, Germany
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