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Brown IS, Sokolova A, Rosty C, Graham RP. Cystic lesions of the retrorectal space. Histopathology 2023; 82:232-241. [PMID: 35962741 DOI: 10.1111/his.14769] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/03/2022] [Accepted: 08/09/2022] [Indexed: 12/24/2022]
Abstract
Cysts of the retrorectal space comprise a heterogeneous group of rare lesions. Most develop from embryological remnants and include tailgut cysts, dermoid cysts, rectal duplication cysts, anal canal duplication cysts, sacrococcygeal teratomas and anterior meningocoele. Tailgut cyst is the most common cyst of developmental origin, usually presenting as a multilocular cystic mass with mucoid content and lined by multiple epithelial types. Compared with tailgut cysts, rectal duplication cysts display all layers of the large bowel wall including a well-defined muscularis propria. Retrorectal cysts of non-developmental origin are far less common and represent lesions that either infrequently involve the retrorectal space or undergo extensive cystic change. This review provides an overview of the various histological types of cystic lesions of the retrorectal space, divided into cysts of developmental origin and those of non-developmental origin. A practical pathological and multidisciplinary approach to diagnosing these lesions is presented.
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Affiliation(s)
- Ian S Brown
- Envoi Specialist Pathologists, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Anna Sokolova
- Sullivan Nicolaides Pathology, Brisbane, Queensland, Australia
| | - Christophe Rosty
- Envoi Specialist Pathologists, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
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De La Peña NM, Amrami KK, Spinner RJ. Totally Cystic Schwannoma: A Misnomer. World Neurosurg 2021; 157:21-29. [PMID: 34600160 DOI: 10.1016/j.wneu.2021.09.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although partial cystic degeneration is commonly observed in schwannoma, cases of totally cystic forms have also been reported. A literature review of cases describing totally cystic schwannoma was performed to assess their imaging characteristics. METHODS PubMed was queried with the phrases "totally cystic schwannoma," "purely cystic schwannoma," and "completely cystic schwannoma." A total of 19 papers encompassing 22 cases of reported totally cystic schwannoma were included. Patient characteristics, clinical presentation, and reported imaging characteristics were recorded. Computed tomography and magnetic resonance images from the papers were collected and reviewed by a senior musculoskeletal radiologist. RESULTS The most frequent presenting location of these lesions was in spinal nerve roots. The interpretations of imaging reported in the papers described a homogeneous lesion that was isointense to slightly hyperintense to cerebrospinal fluid (CSF) on T1-weighted images. On contrast administration, the studies described a thin rim of "ring-like" enhancement around the lesion. Our reinterpretation of the imaging revealed heterogeneous lesions that were hyperintense to CSF on T1-weighted images. Post-contrast images typically demonstrated an irregularly thickened enhancing rim. Most images showed evidence of solid components in the lesion, with many containing enhancing soft tissue elements. The observed imaging features were not consistent with simple cystic lesions. CONCLUSIONS Review of the imaging studies of the reported cases of completely cystic schwannoma did not produce any convincing examples of purely cystic lesions. The description of these lesions as "totally cystic" appears to be a misnomer and has diagnostic and therapeutic implications.
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Affiliation(s)
| | | | - Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Pennington Z, Westbroek EM, Ahmed AK, Cottrill E, Lubelski D, Goodwin ML, Sciubba DM. Surgical management of giant presacral schwannoma: systematic review of published cases and meta-analysis. J Neurosurg Spine 2019; 31:711-722. [PMID: 31277062 DOI: 10.3171/2019.4.spine19240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/19/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Giant presacral schwannomas are rare sacral tumors found in less than 1 of every 40,000 hospitalizations. Current management of these tumors is based solely upon case reports and small case series. In this paper the authors report the results of a systematic review of the available English literature on presacral schwannoma, focused on identifying the influence of tumor size, tumor morphology, surgical approach, and extent of resection (EOR) on recurrence-free survival and postoperative complications. METHODS The medical literature (PubMed and EMBASE) was queried for reports of surgically managed sacral schwannoma, either involving 2 or more contiguous vertebral levels or with a diameter ≥ 5 cm. Tumor size and morphology, surgical approach, EOR, intraoperative and postoperative complications, and survival data were recorded. RESULTS Seventy-six articles were included, covering 123 unique patients (mean age 44.1 ± 1.4 years, 50.4% male). The most common presenting symptoms were leg pain (28.7%), lower back pain (21.3%), and constipation (15.7%). Most surgeries used an open anterior-only (40.0%) or posterior-only (30%) approach. Postoperative complications occurred in 25.6% of patients and local recurrence was noted in 5.4%. En bloc resection significantly improved progression-free survival relative to subtotal resection (p = 0.03). No difference existed between en bloc and gross-total resection (GTR; p = 0.25) or among the surgical approaches (p = 0.66). Postoperative complications were more common following anterior versus posterior approaches (p = 0.04). Surgical blood loss was significantly correlated with operative duration and tumor volume on multiple linear regression (both p < 0.001). CONCLUSIONS Presacral schwannoma can reasonably be treated with either en bloc or piecemeal GTR. The approach should be dictated by lesion morphology, and recurrence is infrequent. Anterior approaches may increase the risk of postoperative complications.
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Pizzuti V, di Russo P, Esposito V, Morace R. Computed Tomography-Guided Posterolateral Transsacral Ala Approach to Presacral L5 Schwannoma: Technical Note. World Neurosurg 2019; 128:55-61. [PMID: 31054349 DOI: 10.1016/j.wneu.2019.04.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Presacral schwannomas are rare benign tumors that may reach large size before becoming symptomatic. Total surgical removal has been considered the best treatment option. Tumors arising from the presacral area are commonly managed through anterior approaches, whereas posterior approaches are used for pure intrasacral tumors or large lesions with both intrasacral and presacral extension, alone or in combination with anterior approaches. METHODS We describe a quick and minimally invasive navigation-guided posterolateral approach to a right presacral L5 schwannoma. The lesion was microsurgically removed through high-speed drilling of the upper portion of the right sacral ala, under intraoperative neurophysiologic monitoring. RESULTS The postoperative course was unremarkable, and the patient experienced improvement in his sensory disturbance. Postoperative magnetic resonance imaging and computed tomography scan showed the complete excision of the lesion and the removal of the upper sacral ala with preservation of the right L5-S1 articular complex. The histologic examination confirmed a schwannoma (World Health Organization grade I). CONCLUSIONS The posterolateral transsacral ala approach may represent a minimally invasive option in the surgical management of presacral well-circumscribed benign tumors. Spinal navigation could be properly used to facilitate lesion exposure and to minimize the bone removal. The intraoperative neurophysiologic monitoring is an essential tool for the preservation of the lumbosacral nerve roots.
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Affiliation(s)
- Valentina Pizzuti
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli (IS), Italy; Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Paolo di Russo
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli (IS), Italy.
| | - Vincenzo Esposito
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli (IS), Italy; Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Roberta Morace
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli (IS), Italy
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DI Marco M, Grassi E, Vecchiarelli S, Durante S, Macchini M, Biasco G. Retroperitoneal lymphangioma: A report of 2 cases and a review of the literature regarding the differential diagnoses of retroperitoneal cystic masses. Oncol Lett 2016; 11:3161-3166. [PMID: 27123082 DOI: 10.3892/ol.2016.4367] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 12/17/2015] [Indexed: 12/15/2022] Open
Abstract
Cystic lymphangioma is a type of benign tumor originating from the lymph vessels. The tumor commonly occurs in childhood, in the head or neck regions, and retroperitoneal localization and presentations in adulthood are rare. Determining a pre-operative diagnosis is often challenging, and in the majority of cases, a diagnosis is only possible subsequent to the histological examination of the surgical specimen. A radical resection is the recommended treatment for cystic lymphangioma, and recurrence is usually due to an incomplete excision of the mass. The present study reports 2 cases of cystic lymphangioma, localized in the pancreatic gland and duodenal wall respectively, which were treated with surgical resection. The study also briefly reviews the literature regarding the differential diagnosis of retroperitoneal cystic masses.
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Affiliation(s)
- Mariacristina DI Marco
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Elisa Grassi
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Silvia Vecchiarelli
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Sandra Durante
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Marina Macchini
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Guido Biasco
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, I-40138 Bologna, Italy
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Cho DY, Hur JW, Shim JH, Kim JS. Cystic giant sacral schwannoma mimicking aneurysmal bone cyst : a case report and review of literatures. J Korean Neurosurg Soc 2013; 54:350-4. [PMID: 24294462 PMCID: PMC3841281 DOI: 10.3340/jkns.2013.54.4.350] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/17/2013] [Accepted: 09/30/2013] [Indexed: 12/04/2022] Open
Abstract
To present a rare case of a cystic giant schwannoma of the sacrum mimicking aneurysmal bone cyst (ABC). A 54-year-old man visited our institute complaining left leg weakness and sensory change for several years. Magnetic resonance imaging revealed a large multilocular cystic mass with canal invasion and bone erosion confined to left S1 body. The lesion showed multiple septal enhancement without definite solid component. Initially the tumor was considered as ABC. The patient underwent grossly-total tumor resection with lumbosacral reconstruction via posterior approach. The tumor was proved to be a cystic schwannoma. The postoperative course was uneventful and the patient was relieved from preoperative symptoms. We present a rare case of pure cystic giant schwannoma confined to sacrum mimicking ABC. The surgical treatment is challenging due to the complex anatomy of the sacrum. Schwannoma should be considered in the differential diagnosis of osteolytic sacral cysts.
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Affiliation(s)
- Dong-Young Cho
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
The purpose of this presentation is to allow the radiologist to discuss the diagnosis of retroperitoneal schwannoma, involving mostly a fortuitous discovery and a misleading clinical presentation. We present 4 cases of retroperitoneal schwannoma, two having benefited from a surgery and two others of a therapeutic abstention. The retropritoneal localization and the imaging are good indicator elements of this pathology. The constant improvement of the CT and MR imaging allows a better approach of this entity also by specifying its localization and its anatomical relationships to guide the therapeutic attitude which must be remain mutidisciplinary.
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Possover M, Kostov P. Laparoscopic management of sacral nerve root schwannoma with intractable vulvococcygodynia: report of three cases and review of literature. J Minim Invasive Gynecol 2013; 20:394-7. [PMID: 23522662 DOI: 10.1016/j.jmig.2012.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 12/20/2012] [Accepted: 12/24/2012] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Marc Possover
- Department of Gynecology/Oncology/Neuropelveology, Hirslanden Clinic, Zürich, Switzerland.
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Abstract
STUDY DESIGN Assessment of different surgical approaches and procedures to remove different types of neurogenic tumors (Types I-IV). OBJECTIVE To aid surgeons faced with operating on a sacral neurogenic tumor by providing guidelines for determining the best surgical approach to use based on the way a neurogenic tumor presents. SUMMARY OF BACKGROUND DATA It is often difficult to determine the best surgical approach to use when operating on sacral neurogenic tumors. This retrospective study reports on the outcomes of patients with sacral neurogenic tumors and the surgical approach used in each case in order to better assess the most appropriate surgical approach and procedure to use with each tumor type. METHODS Between July 1998 and July 2006, 48 cases (18 males) with sacral neurogenic tumors were admitted and treated. Average age was 47 years old (range, 17-75). The average period of follow-up was 47 months. There were 41 cases with benign tumors and 7 cases of malignant tumors. Depending on how the tumor presented, 1 of 3 surgical approaches was used, an anterior approach (7 patients), a posterior approach (22 patients), or a combined anterior-posterior approach (19 patients). RESULTS For the cases of Type I and the cases of Type II and III in which tumors grew forward but were lower than S1 level, surgical resection of tumors required a simple posterior approach. The cases of Type II and III in which tumors grew forward and expanded higher than S1 level required a combined anterior-posterior approach. For cases of Type IV, a simple anterior approach for resection of tumors was used. CONCLUSION In surgical resection of sacral neurogenic tumors, surgical approach depends on the location and size of the tumors. Intraspinal tumors should be excised from a posterior approach. For giant neurogenic tumors that arise from the sacrum and involve the spinal canal, surgical resection should be done by a combined anterior-posterior approach. Giant presacral neurogenic tumors located below the S1 level can be removed by a posterior approach. The anterior surgical approach should be used for giant presacral neurogenic tumors that are located above S1 and do not involve the spinal canal.
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Jaiswal A, Shetty AP, Rajasekaran S. Giant cystic intradural schwannoma in the lumbosacral region: a case report. J Orthop Surg (Hong Kong) 2008; 16:102-6. [PMID: 18453671 DOI: 10.1177/230949900801600124] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report a case of a giant cystic intradural schwannoma of the lumbosacral region in a 30- year-old man who presented with a 2-year history of non-specific lower back pain. Lateral radiographs demonstrated scalloping of the posterior wall of L5 and the upper sacrum. Magnetic resonance imaging revealed a 12 x 2.3-cm intradural multi-septated cystic lesion extending from L3 to S2 with predominant hypointense signal on T1-weighted images and a mixed signal on T2-weighted images. There was heterogeneous rim enhancement of the retrosacral portion of lesions following the administration of gadolinium contrast. The tumour was completely excised. Histological investigation confirmed the diagnosis of cystic schwannoma with alternating hypercellular (Antoni A) and hypocellular (Antoni B) areas in a fibrillar background. The patient had complete relief of symptoms and remained asymptomatic after 2 years of follow-up.
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Affiliation(s)
- A Jaiswal
- Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, India
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Borges G, Bonilha L, Proa M, Fernandes YB, Ramina R, Zanardi V, Menezes JR. Imaging features and treatment of an intradural lumbar cystic schwannoma. ARQUIVOS DE NEURO-PSIQUIATRIA 2005; 63:681-4. [PMID: 16172724 DOI: 10.1590/s0004-282x2005000400025] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Spinal schwannomas are frequently observed among patients treated in a reference neurosurgery center. Cystic spinal schwannomas, however, are very scantly found. Due to its indolent behavior and benign course, the diagnosis of schwannomas may pose a challenge to the care giver, and the imaging findings can be misleading. In this article, we illustrate an example of a pauci-symptomatic 55 year-old male patient whose complaint was solely a non specific lumbar pain. Investigation revealed a large cystic lesion comprising the lower lumbar intradural space. He was then treated with microneurosurgical technique involving complete removal of the tumor and reconstruction of the duramater. Histological and immunohystochemical diagnosis were consistent with cystic schwannoma. The patient presented with complete recovery of his symptom. In this article we aim to emphasize the clinical presentation and treatment of lumbar spine schwannomas, and to illustrate the imaging findings within this uncommon case.
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Affiliation(s)
- Guilherme Borges
- Neurology and Neurosurgery Department, State University of Campinas (UNICAMP), Campinas, SP, Brazil.
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Yang DM, Jung DH, Kim H, Kang JH, Kim SH, Kim JH, Hwang HY. Retroperitoneal cystic masses: CT, clinical, and pathologic findings and literature review. Radiographics 2005; 24:1353-65. [PMID: 15371613 DOI: 10.1148/rg.245045017] [Citation(s) in RCA: 229] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cystic lesions of the retroperitoneum can be classified as either neoplastic or nonneoplastic. Neoplastic lesions include cystic lymphangioma, mucinous cystadenoma, cystic teratoma, cystic mesothelioma, müllerian cyst, epidermoid cyst, tailgut cyst, bronchogenic cyst, cystic change in solid neoplasms, pseudomyxoma retroperitonei, and perianal mucinous carcinoma. Nonneoplastic lesions include pancreatic pseudocyst, nonpancreatic pseudocyst, lymphocele, urinoma, and hematoma. Because the clinical implications of and therapeutic strategies for retroperitoneal cystic masses vary depending on the cause, the ability to noninvasively differentiate between masses is important. Although there is substantial overlap of computed tomographic (CT) findings in various retroperitoneal cysts, some CT features, along with clinical characteristics, may suggest a specific diagnosis. CT may provide important information regarding lesion location, size, and shape; the presence and thickness of a wall; the presence of septa, calcifications, or fat; and involvement of adjacent structures. The most important clinical parameters include patient gender, age, symptoms, and clinical history. Familiarity with the CT and clinical features of various retroperitoneal cystic masses facilitates accurate diagnosis and treatment.
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Affiliation(s)
- Dal Mo Yang
- Department of Radiology, Gachon Medical School Gil Medical Center, 1198 Guwol-Dong, Namdong-Gu, Incheon 405-760, South Korea.
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Affiliation(s)
- A Gharbi
- Service Central de Radiologie, CHU Ibn Rochd, Casablanca, Morocco.
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Abstract
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.
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Affiliation(s)
- Sero Andonian
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021-6007, USA
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Klimo P, Rao G, Schmidt RH, Schmidt MH. Nerve sheath tumors involving the sacrum. Case report and classification scheme. Neurosurg Focus 2003; 15:E12. [PMID: 15350043 DOI: 10.3171/foc.2003.15.2.12] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Paul Klimo
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah 84132-2303, USA
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