Surgical Management of Neurofibromatosis

Depression explains the association between pain intensity and pain interference among adults with neurofibromatosis

INTRODUCTION

Neurofibromatoses (NFs; NF1, NF2 and Schwannomatosis) are incurable genetic syndromes characterized by nerve sheath tumors and often accompanied by substantial emotional distress (e.g., depression and anxiety). Pain is also common but understudied in adults with NF and interferes with daily living. In other medical populations, depression and anxiety have a strong association with pain interference. However, research has not explored the relationship of depression and anxiety to pain interference among adults with NF experiencing pain. The aim of this study was to test the hypothesis that depression and anxiety will mediate the association between pain intensity and pain interference among geographically diverse adults with NF who endorse pain.

METHODS

We used baseline data from an RCT of a mind-body intervention aimed at improving quality of life in adults with NF. Participants (N = 214) who endorsed pain completed measures of demographics, clinical characteristics, baseline pain intensity, pain interference, depression, and anxiety. We constructed a multiple mediation model in R using the lavaan package to test our hypothesis.

RESULTS

Preliminary analyses showed differences in pain interference by NF diagnostic subtype (F(2, 206) = 6.82, p = 001). In a model that controlled for NF diagnostic subtype, we found that depression (β = .07, p = .017), but not anxiety (β = -.003, p = .878), partially mediated the association between pain intensity and pain interference.

CONCLUSION

Improving depression has the potential to decrease pain interference among people with NF who experience pain.

TRIAL REGISTRATION

Clinicaltrials.gov Registration #: NCT03406208.

The recurrent plexiform neurofibroma of the scalp in neurofibromatosis type 1: illustrative case

BACKGROUND

Plexiform neurofibroma is a benign tumor of the peripheral nerves. It is an unusual variant of neurofibroma originating from all parts of the nerve. Plexiform neurofibroma is primarily pathognomonic and exhibits an unusual variant from neurofibromatosis type 1 (NF1). The possibility of malignancy and recurrence are the main reasons for long-term, close follow-up.

OBSERVATIONS

The authors report a case of a 14-year-old girl with a recurrent plexiform neurofibroma derived from the peripheral nerves, which also presented with a typical sign of NF1 disease. The aim of the tumor resection is symptomatic relief.

LESSONS

Accomplishing a good outcome can be related to good perioperative planning and a precise operative procedure. The result of anatomical pathology determines the prognosis of the patient. Clinical examination and radiological studies are needed to evaluate the recurrence of complications after surgical procedures.

Long-Term Results for a One-Stage Surgery Technique for Patients With Craniofacial Plexiform Neurofibroma

BACKGROUND

Neurofibromatosis (NF) is an autosomal dominant genetic disorder, and NF type 1 (NF1) is one of the most common forms. Plexiform neurofibroma (PNF) is one of the characteristic expressions of NF1. The proper treatment for patients with craniofacial PNF is surgery. The evaluation methods for the surgical outcome of these patients are still controversial. As a consequence, a one-stage surgical technique and an appropriate evaluation method for patients with craniofacial PNF were discussed in this article.

METHODS

This research is a retrospective study. Nine patients with craniofacial PNF were included in this study. They had undergone a one-stage surgical technique of tumor debulking and nasolabial fold reconstruction. Three methods had been applied to evaluate the surgical outcome.

RESULTS

Significant improvement was observed in 8 patients. Eight patients were assessed by the relatively objective evaluation method. Obvious symmetry improvement was calculated using Mimics software in 7 patients.

CONCLUSION

The surgical technique could achieve good surgical outcomes in both functional and cosmetic terms. Additionally, the relatively objective evaluation technique based on Mimics software could be a more convincing method for evaluating the surgical outcomes of craniofacial patients with PNF.

Bevacizumab for Treatment-Refractory Pain Control in Neurofibromatosis Patients

OBJECTIVE

Chronic pain is a well-known morbidity associated with neurofibromatosis (NF) for which better therapies are needed. Surgery, radiation, and pain medications have been utilized, but often fail to relieve debilitating pain. One patient at our institution was noted to have near complete resolution of pain after treatment with bevacizumab for progressive neurologic deficit associated with NF2, suggesting its potential as an effective pain control method. We aim to better characterize the use of bevacizumab for pain control in this subset of patients.  Patients and Methods: We retrospectively reviewed 38 NF patients treated at our institution.   Results: Of the 38 total NF patients, we found that 63% reported chronic pain, with 18% reporting chronic opiate usage. Nine patients with chronic pain were considered for bevacizumab treatment and five went on to receive infusions. Of these patients, four out of five had previous surgical debulking and two out of five had previous radiation for attempted pain control. One patient had a lesion not amenable to surgery or radiation. Patients received a median of 13 cycles of bevacizumab, and four out of five patients reported a decrease in subjective pain. All patients that had pain relief had a relapse of pain symptoms when the dose was reduced or infusions were paused. Seventy-five percent were able to decrease opiate use. No major complications were noted. All five patients have elected to continue infusions for pain control.  Conclusion: Bevacizumab was, in general, well tolerated and should be considered as a treatment option in NF patients with chronic pain refractory or not amenable to surgical decompression and debulking, radiation, and pain medication.

Comprehensive and Global Approach of Soft-Tissue Deformities in Craniofacial Neurofibromatosis Type 1

BACKGROUND

To present a single-institution experience in the comprehensive and global soft-tissue surgical approach of patients with craniofacial neurofibromatosis type 1 (NF-1).

METHODS

A retrospective analysis of patients with craniofacial NF-1 (n = 20) who underwent craniofacial soft-tissue reconstruction between 1993 and 2014 was conducted. Surgical treatment was individualized according to age, functional and/or aesthetic impairment, neurofibroma types, anatomical location, size, and patient/family and surgical team preferences, regardless of previously published compartmental grading systems. The surgical results were classified based on 2 previously published outcome rating scales (craniofacial symmetry improvement and need for additional surgery).

RESULTS

All patients underwent en bloc translesional surgical excisions, 12 facial suspension, 3 eyebrow suspension, 2 ear suspension, 9 lateral canthopexy, 5 horizontal shortening of the tarsus of lower eyelid, and 1 horizontal shortening of the tarsus of upper eyelid. The degree of craniofacial symmetry improvement was considered "mostly satisfactory" (75%), and the overall rate of surgical results ranked according to the need for additional surgery was 2.4 ± 0.50, with variations according to the spectrum of soft-tissue involvement.

CONCLUSIONS

According to the experience and surgical outcomes presented in this study, the soft-tissue surgical approach of the craniofacial NF-1 should be global, comprehensive, and individualized.

Neurogenic tumors of soft tissue

Neurogenic tumors are an uncommon yet important category of soft tissue tumors in children and adolescents because of their frequent association with various genetic syndromes. The heterogeneous cellular composition of the peripheral nerve and the wide metaplastic capacity of the neural crest and its derivatives generate a variety of neoplasms with neurogenic differentiation. This article reviews the clinicopathologic features and differential diagnosis of neurogenic tumors in the first two decades of life, and highlights use of selected ancillary methods for diagnosis.

Free flap reconstruction of extensive defects following resection of large neurofibromatosis

BACKGROUND

Neurofibromatosis type 1 (NF-1) is a locally invasive tumor that can grow extensively with diffuse infiltration into surrounding tissue. Resecting a large neurofibroma can result in an extensive defect that is difficult to reconstruct and can cause both aesthetic and functional deformities.

METHODS

From 2000 to 2010, 5 patients with NF-1 underwent radical resection and immediate reconstruction with 6 free flaps at our institution. All patients presented with recurrent tumor, and involved head and neck region in 4 and foot in 1 patient. Ages ranged from 18 to 75 years. The follow-up ranged from 1 to 94 months.

RESULTS

Defect sizes ranged from 84 to 252 cm. A single free flap was used in 4 cases and 2 free flaps were used in 1 case. All the flaps survived. Complications included loss of skin graft, necrosis of the distal tip of a flap, and wound dehiscence. All complications were successfully managed with minor surgical procedures.

CONCLUSION

Immediate reconstruction using a free flap after resecting a large neurofibroma is a safe and reliable method that facilitates radical resection of the tumors that are difficult to resect and that may result in an extensive defect.

Peripheral and cranial nerve sheath tumors-a clinical spectrum

To analyze the incidence of nerve sheath tumors in a tertiary care hospital over a period of 5 years and review the literature. Medical case records from last 5 years were retrieved and histopathology and operative details were studied in a retrospective analysis. There is a slight male preponderance when it comes to nerve sheath tumors and acoustic schwannomas accounted for the largest fraction among schwannomas. Nerve sheath tumors include a wide spectrum of schwannomas, neurofibromas and malignant peripheral nerve sheath tumors. Hence combination of clinical, pathological and surgical expertise is needed to diagnose accurately.