Plexiform Neurofibroma: A Case Report

Plexiform's perplexities: a tale of two plexiform neurofibromas

Plexiform neurofibroma (PF) is a rare benign variant belonging to a subtype of neurofibromatosis type 1 that forms bulging or deforming masses arising from the peripheral nerve sheath. These masses involve surrounding connective tissue or dermal layers, leading to multiple cutaneous changes and certain characteristic appearances. It is these appearances that aid in the diagnosis of PF. We have encountered two distinct patients diagnosed with this disorder. While one patient was clinically and pathologically confirmed for PF, the other had no characteristic cutaneous changes. The diagnosis was made with postoperative histopathology and confirmed with an immunohistochemical examination. There are various modalities in the management of PFs, with surgery being a mainstay in the treatment of disfiguring large PFs, especially in resource-restrained settings. In view of high recurrence rates, postoperative clinical follow-up is a must. This paper describes these patients' typical and atypical clinical presentation and subsequent management.

Magnetic Resonance Imaging of Central Nervous System Manifestations of Type 1 Neurofibromatosis: Pictorial Review and Retrospective Study of Their Frequency in a Cohort of Patients

Background: type 1 neurofibromatosis (NF1) is the most common neurocutaneous disorder, and it is an inherited condition that causes a tumour predisposition. Central nervous system (CNS) manifestations are a significant cause of morbidity and mortality in NF1. We provide a pictorial review of neuroradiological features of NF1, with emphasis on magnetic resonance imaging (MRI), and we assess the frequency of those features on a cohort of NF1 patients. Methods: we retrospectively evaluated all patients with a diagnosis of NF1 who underwent MRI of the spine and brain in our centre over a period of almost 5 years. A total of 74 patients were enrolled, 28 males and 46 females, with a mean age of 21 ± 12.67 years. The frequency of CNS manifestations encountered in our cohort of NF1 patients was assessed and compared with the data found in other studies published in the literature. Results: many of our findings were in line with the literature, and possible interpretations for those that turned out to be different were suggested in the discussion. Conclusion: imaging plays a central role in the diagnosis and management of NF1, and the knowledge of CNS manifestations could be critical for its early detection and identification, such as for treatment planning and prognostic implications.

Animal metaphors in oral pathology-A review

Oral pathology is a challenging yet intriguing subject. By comparing pathological traits to things we typically encounter, it is possible to reduce the difficulty of memorising these qualities. Hence, the usage of various analogical methods, like the usage of metaphors, conveys likeliness or similarities between two items and can help the students. A lot of pathological features have a resemblance to animals we see on a frequent basis. Students might find comparing, examining and comprehending oral pathology easier when the information is compared with familiar animals. This article is an attempt to compile animal metaphors related to oral pathology.

Use of the subfascial plane in debulking an extensive lower extremity plexiform neurofibroma: A case report

INTRODUCTION

Plexiform neurofibromas (PNs) are characterized by their diffuse masses with tortuous expansion along nerve branches. While surgery is the primary management for PNs, the optimal surgical approach remains unestablished.

CASE PRESENTATION

A 35-year-old lady presented with a large hanging mass covering the medial aspect of the thigh and the leg. It caused discomfort, disfigurement, and occasional pain. The patient was planned for the debulking surgery under spinal anesthesia. Incisions were given on the normal-looking skin adjacent to the mass, through the skin layers, subcutaneous tissue and deep fascia until the muscles were seen. The mass was then approached and elevated in the subfascial plane (relatively avascular). Large, dilated, dense tortuous vessels could be seen in the suprafascial and subcutaneous planes. Maximum area that could be removed was marked and excised. The normal contour of the left lower extremity was restored close to achieving a thigh and a leg lift.

DISCUSSION

PNs pose surgical challenges due to their vascularity and difficult locations. The subfascial debulking approach presented in the case aims to reduce intraoperative hemorrhage by avoiding highly vascular areas and preventing entry into blood sinuses within the neurofibromatous tissue. This technique also minimizes the risk of inadvertent injury to nearby neurovascular structures.

CONCLUSION

The proposed subfascial approach, significantly reduces intraoperative hemorrhage during the debulking of a PN.

Plexiform neurofibromatosis of the lower back: A rare case report

INTRODUCTION

Plexiform neurofibromatosis is a relatively rare manifestation of Type 1 neurofibromatosis (NF-1). This condition leads to gross disfiguration along with functional disability. We are presenting a case of 49 year male with Plexiform neurofibromatosis of lower back. The aim of this rare case report is also to discuss the management difficulties encountered.

PRESENTATION OF CASE

A 49 year male presented to us with gradually increasing swelling over the lower back which was present since his 10 years of age. He had already undergone debulking surgery for the same swelling 10 years back. For the last 2 years the swelling had increased in significant amount. He gave history of similar swellings in his father and grandfather. Proper examination revealed multiple café au lait macules, giant plexiform neurofibroma over lower back and multiple nodular swellings all over the body (neuroma). Biopsy report from previous surgery showed neurofibroma. He underwent debulking surgery. The procedure went for 12 h continuous. Intraoperatively, the mass was highly vascular and excessive bleeding was encountered. About 3 L of blood loss was there and patient received 12 units of blood products.

DISCUSSION

Plexiform neurofibromas are uncommon and may occur in around 30 % patients with NF-1. The genetic defect lies in chromosome 17 that encodes a protein neurofibromin. It causes disfiguration and severe distress to patients. Debulking surgery is one of the treatments to decrease the difficulties occurred from the mass. The aim of this report is to discuss the difficulties occurred in surgical intervention of this rare condition like excessive blood loss.

CONCLUSION

Although timely intervention could limit the disfigurement and morbidity associated with large lesion, due to unpredictable natural course and growth pattern, it is difficult to decide best time to intervene surgically. Registration of such rare case facilitates patient monitoring and development of appropriate treatment protocols.

MULTIPLE NEUROENDOCRINE NEOPLASIA IN A PATIENT WITH TYPE I NEUROFIBROMATOSIS (NF1): REPORT OF A NEW MUTATION (NF1, EXONS 2-30 DELETION) AND LITERATURE REVIEW

BACKGROUND

Plexiform neurofibromas represent a common neoplasia of type 1 neurofibromatosis in which neurofibromas arise from multiple nerves involving connective tissue and skin and rarely affect the colon and rectum. Co-occurrence of plexiform neurofibromas, neuroendocrine tumors with primary involvement of the rectum, and medullary thyroid carcinoma in patients with neurofibromatosis type 1 is a previously undescribed condition. The aim of this manuscript was to present a case of primary plexiform neurofibroma and neuroendocrine tumors of the upper rectum in a patient with neurofibromatosis type 1 whose genetic sequencing found a novel mutation in the neurofibromatosis type 1 gene and to review the literature.

CASE REPORT

A 49-year-old woman with a familial history of neurofibromatosis type 1 complained of abdominal cramps for 6 months. She had previously been submitted for a total thyroidectomy due to medullary thyroid carcinoma. She was submitted to a colonoscopy, which identified a submucosa lesion located in the upper rectum. The patient was referred for a laparoscopic rectosigmoidectomy, and the histopathological study of the surgical specimen identified two different tumors. An immunohistochemical panel was done for histopathological confirmation of the etiology of both lesions. The results of the panel showed intense immunoexpression of S100 protein in the largest and superficial lesion, as well as positivity for chromogranin and synaptophysin in the minor and deep lesion confirming the diagnosis of rectal plexiform neurofibromas concomitant with neuroendocrine tumors. The proliferative activity rate using Ki-67 antibodies showed that both tumors had a low rate of mitotic activity (<1%). Genetic sequence panel identified an undescribed mutation in the neurofibromatosis type 1 gene (deletion, exons 2-30). The patient's postoperative evolution was uneventful, and she remains well, without recurrence, 3 years after surgery.

CONCLUSION

The co-occurrence of medullary thyroid carcinoma, plexiform neurofibromas, and neuroendocrine tumors of the rectum in patients with neurofibromatosis type 1 is an exceptional and undescribed possibility, whose diagnosis can be confirmed by the immunohistochemical staining and genetic panel.

The forgotten lacrimal gland and lacrimal drainage apparatus: pictorial review of CT and MRI findings and differential diagnosis

The lacrimal gland is a bilobed serous gland located in the superolateral aspect of the orbit. Lacrimal system pathologies can be broadly divided into pathologies of the lacrimal gland and those of the nasolacrimal drainage apparatus. These include distinct congenital, infectious, inflammatory, and benign, indeterminate, and malignant neoplastic lesions. Trauma and resultant fractures affecting lacrimal drainage apparatus is not part of this review; only non-traumatic diseases will be discussed. CT is the initial modality of choice because of its ability to delineate lacrimal system anatomy and demonstrate most lacrimal drainage system abnormalities and their extent. It also assesses bony architecture and characterizes any osseous changes. MRI is helpful in further characterizing these lesions and better assessing involvement of the surrounding soft tissue structures. In this pictorial review, we will review the anatomy of the lacrimal system, describe CT/MRI findings of the common and uncommon lacrimal system abnormalities and discuss relevance of imaging with regards to patient management.

A novel HDAC11 inhibitor potentiates the tumoricidal effects of cordycepin against malignant peripheral nerve sheath tumor through the Hippo signaling pathway

Neurofibromatosis type 1 (NF1) is an autosomal dominant neurocutaneous disorder. Clinically, the hallmarks of NF1 include skin pigmentation and cutaneous neurofibroma. Some NF1 patients develop plexiform neurofibroma (PN) since early childhood. Pathologically, PN contains abundant Schwann cells, blood vessels and connective tissues, which may transform into a malignant peripheral nerve sheath tumor (MPNST). MPNST is a highly invasive sarcoma without any effective therapy. Recently, both in vitro and in vivo studies showed that cordycepin can inhibit the growth of MPNST cells. Cordycepin causes cell cycle arrest at G2/M phase and downregulates the protein levels of α-tubulin, p53 and Sp1. Herein, the present study revealed that the HDAC11 inhibitor, FT895, can synergistically enhance the tumoricidal effect of cordycepin against MPNST cells in vitro. Treatment with the combination of cordycepin and FT895 reduced the size of MPNST in the xenograft mouse model. The combined treatment decreased the protein levels of α-tubulin and KIF18A, which may disrupt the microtubule organization leading to the mis-segregation of chromosomes and aneuploidy. Moreover, the expression levels of TEAD1 and its co-activator TAZ, the candidate proteins in hippo signaling pathway, were suppressed after combined treatment. Sequence analysis found a few binding sites for the transcription factor, TEAD1 in the promoter regions of TUBA1B, KIF18A, TEAD1, TAZ, YAP, TP53 and SP1 genes. ChIP-qPCR assay showed that the combined treatment decreases the binding of TEAD1 to the promoters of TUBA1B, KIF18A, TEAD1, TAZ and YAP genes in STS26T cells. The reduced binding to TP53 and SP1 promoters was also found in S462TY cells, which was further confirmed by immunoblotting. The down-regulation of these important transcriptional factors may contribute to the vulnerability of MPNST. In summary, HDAC11 inhibitor, FT895 can potentiate the tumoricidal effect of cordycepin to suppress the MPNST cell growth, which was probably mediated by the dysfunction of hippo-signaling pathway.

Primary Bone Leiomyosarcoma in Neurofibromatosis Type 1: Extremely Rare Concurrency

Neurofibromatosis type 1 (NF1) is a complex autosomal dominant, multisystem genetic disease affecting about 1 in 3500 individuals. Plexiform neurofibromas represent a rare variant (30%) of NF1 in which the spread of tumor cells along nerve fascicles leads to a diffuse mass of thickened nerve fibers. Affected patients with NF1 have a greater chance of developing soft tissue sarcomas than the general population. Leiomyosarcoma is one of the most frequent soft tissue sarcomas, seldom observed in patients with NF1. Herein we report a rare concurrency of bone leiomyosarcoma in a patient with a plexiform neurofibroma, adding to the few reported cases of leiomyosarcomas in patients with NF1. Our case is a 14-year-old male who is a known case of NF1 and presented with a four-month history of pain and swelling on the medial side of the right knee. Imaging and biopsy confirmed the diagnosis of leiomyosarcoma. Based on the authors' knowledge and search, this is the first reported case of plexiform neurofibroma with a primary bone leiomyosarcoma, representing an extremely rare concurrency. Patients with such uncommon tumors should be assessed regularly, and continuous follow-up is essential.

Challenging Management of Plexiform Schwannoma and Plexiform Neurofibroma

ABSTRACT

Plexiform variants of neurofibromas and schwannomas are rare and typically arise in superficial soft tissues in the head and neck region. The treatment of these tumors is challenging and no generally accepted guidelines exist for their optimal management. The purpose of this study was to review the management and long-term prognosis of head and neck plexiform neurofibromas and schwannomas at 2 tertiary care academic hospitals in Finland over a 31-year period. The pathology files were searched for plexiform neurofibromas and schwannomas between the years 1990 and 2020. The case notes were reviewed for full management details. Two plexiform schwannomas and 6 plexiform neurofibromas were identified. Five of the 6 plexiform neurofibromas were managed operatively. All patients with a surgically managed plexiform neurofibroma underwent multiple operations. Sclerotherapy abolished 1 patient's cutaneous plexiform neurofibromas. The management of plexiform neurofibromas and plexiform schwannomas remains challenging. Sclerotherapy may offer a promising management option for cutaneous plexiform neurofibromas.

Pancreatic Neuroendocrine Tumors: Molecular Mechanisms and Therapeutic Targets

Pancreatic neuroendocrine tumors (pNETs) are unique, slow-growing malignancies whose molecular pathogenesis is incompletely understood. With rising incidence of pNETs over the last four decades, larger and more comprehensive 'omic' analyses of patient tumors have led to a clearer picture of the pNET genomic landscape and transcriptional profiles for both primary and metastatic lesions. In pNET patients with advanced disease, those insights have guided the use of targeted therapies that inhibit activated mTOR and receptor tyrosine kinase (RTK) pathways or stimulate somatostatin receptor signaling. Such treatments have significantly benefited patients, but intrinsic or acquired drug resistance in the tumors remains a major problem that leaves few to no effective treatment options for advanced cases. This demands a better understanding of essential molecular and biological events underlying pNET growth, metastasis, and drug resistance. This review examines the known molecular alterations associated with pNET pathogenesis, identifying which changes may be drivers of the disease and, as such, relevant therapeutic targets. We also highlight areas that warrant further investigation at the biological level and discuss available model systems for pNET research. The paucity of pNET models has hampered research efforts over the years, although recently developed cell line, animal, patient-derived xenograft, and patient-derived organoid models have significantly expanded the available platforms for pNET investigations. Advancements in pNET research and understanding are expected to guide improved patient treatments.

Complications of Neurofibromatosis 1 (NF1) in an Adult With Multiple Comorbidities

Neurofibromatosis (NF) is an autosomal genetic disorder with three types, including NF1, NF2, and schwannomatosis. It is characterized by bulging and deforming masses arising from multiple nerves involving skin folds and connective tissues. Prompt diagnosis and provision of care for NF1 patients by clinicians aware of the diverse clinical features of this disorder are needed for optimum patient care and management. A 65-year-old African American female with a past medical history significant for multiple neurofibromas covering more than 95% of her total body surface area (TBSA), presented to a primary care clinic with an enlarged ulcerated neurofibroma of the right elbow. She reported associated pulsating, sharp pain, which was radiating to her entire right upper extremity. For most of her adult life, the lesion has been present and began as the rest of the neurofibromas on her body but gradually enlarged with eventual ulceration three months before the visit. The patient reported a failed surgical resection for the same neurofibroma several years ago. She also reported diffuse tenderness of the lesion, which severely impaired her daily living activities and limited her sleep ability. She acknowledged using multiple over-the-counter analgesics, prescription hydrocodone/acetaminophen 5/325 mg as needed, and gabapentin 300 mg orally twice daily but denied significant symptom alleviation. The patient was started on oral clindamycin hydrochloride 300 mg every six hours for 10 days and a topical mupirocin ointment 2% three times daily for five days. Subsequent visits showed no improvement of the ulcer, which necessitated a referral to wound care. After multiple wound care visits without progress, the patient was referred to a plastic surgeon for evaluation for repeat ulcer resection. NF1 patients develop multiple tumors (neurofibromas); approximately 8%-15% percent of them present with malignant peripheral nerve sheath tumors (MPNST) within the patient's lifetime. Tumor ulceration is a rare but possible complication of NF1. Due to the acute ulcerated fibromas' complications, previous unsuccessful cosmetic management, and ambiguity about NF1 disorder, the patient's quality of life was impaired. The physical and emotional pain the patient experienced impacted her activities of daily living and likely contributed to or exacerbated her diagnoses of substance use disorder and major depressive disorder. NF1 is incurable and can be associated with complications that deteriorate the quality of life, depending on symptom severity. The condition impacts patients' bodies, minds, and spirits, as seen in this patient who had diagnoses of substance use disorder and major depressive disorder, as well as a history of suicidal ideation and suicide attempts. The treatment of conditions related to NF1 is best managed in centers equipped with doctors experienced in treating patients with NF1. A multidisciplinary management approach is ideal. Preferably, for the management of chronic pain and beyond, the osteopathic holistic approach, targeting the body, mind, and spirit, in combination with other innovative non-pharmacotherapies and pharmacotherapy methods, would be beneficial.

Imaging diagnosis of plexiform neurofibroma- unravelling the confounding features: A report of two cases

Peripheral nerve sheath tumors such as neurofibroma, comprise 5% of all benign soft tissue tumors and usually occur due to an underlying neurofibromatosis. A plexiform neurofibroma, which is a tumor occurring exclusively in neurofibromatosis1, is a rare entity and is an uncommon variant of neurofibroma. We report the clinical and imaging features of plexiform neurofibroma in two young male patients, in whom the imaging diagnosis was confirmed after biopsy. The report not only aims to highlight the characteristic imaging features of plexiform neurofibroma but we also emphasize the ultrasound appearances which are significantly characteristic and can effectively lead to the correct diagnosis at the preliminary stage of investigation. The tumors which originate from nerve sheath, are large, lobulated masses and demonstrate typical imaging features of simultaneous involvement of subcutaneous and cutaneous tissues along with infiltrative invasion of deeper structures. The tumors characteristically display fat and fluid contents and a “target sign’ on evaluation by ultrasound, CT and MRI. Imaging plays an important role in confirming the diagnosis, delineating involved structures, excluding simulating conditions and forewarning a possible malignant transformation.

Neural Hypertrophy and Hyperplasia in a Case of Chronic Ovine Pancreatitis

Nerves can be severely reshaped in human pancreatic diseases such as chronic pancreatitis (CP) and pancreatic cancer, in which pancreatic nerves can undergo hypertrophy or hyperplasia. This neural plasticity is associated with neuropathic pain. Although there are several animal models of CP, pancreatic neuropathy is not well-characterized. Thus, the translational value of these in-vivo models cannot be entirely ascertained for the study of neural plasticity. We now describe spontaneous alterations characteristic of pancreatic neural plasticity in a lamb. Microscopic lesions of chronic sclerosing pancreatitis were associated with neuronal hypertrophy and hyperplasia. Although CP and pancreatic tumours are common in many animal species, to the authors' knowledge, spontaneous occurrence of associated pancreatic neural plasticity has not been reported in any non-human species. Sheep might be a suitable animal model for the study of this condition.

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.

Benefits of robotic devices in medical rehabilitation of a case with neurofibromatosis type1

The term neurofibromatosis (NF) describes a group of genetic disorders that primarily affect the cell growth of neural tissues. Three clinically and genetically distinct forms of neurofibromatosis have been described: neurofibromatosis type 1 (NF1), neurofibromatosis type 2 (NF2) and schwannomatosis. The inheritance pattern is autosomal dominant for all three types. We present the case of a 57 years old man, admitted to the Medical Rehabilitation Clinical Hospital Baile Felix, Romania, who was diagnosed with spastic tetraparesis, neurofibromatosis type 1, chronic viral hepatitis B and D, hypercholesterolemia, sarcopenia and osteoporosis. The objectives of the rehabilitation treatment were combating pain; preventing and correcting vicious postures at rest and during activity; maintaining or increasing joint mobility; increasing the mobility of the cervical and lumbar spine; decreasing spasticity; increasing strength of paralyzed muscles; improving motor control of paralyzed limbs; transfers re-education, gait re-education; improving breathing; improving ADLs; maintaining autonomy; gaining daily independence; prevention of recurrent complications and increasing the quality of life. The rehabilitation treatment was complex, performed over a period of 2 weeks and included various physiotherapy approaches, hydrokinetotherapy, massage, occupational therapy, robotic devices and virtual reality. It improved the patient's functional independence and quality of life. Innovations in information technology will refine and increase the efficiency, expertise and competence of medical rehabilitation, in order to ensure comfort for the patient and an appropriate and safe therapeutic approach. Keywords: neurofibromatosis, robotic devices, medical rehabilitation,

Non-Coding RNA and Tumor Development in Neurofibromatosis Type 1: ANRIL Rs2151280 Is Associated with Optic Glioma Development and a Mild Phenotype in Neurofibromatosis Type 1 Patients

Non-coding RNAs (ncRNAs) are known to regulate gene expression at the transcriptional and post-transcriptional levels, chromatin remodeling, and signal transduction. The identification of different species of ncRNAs, microRNAs (miRNAs), circular RNAs (circRNAs), and long ncRNAs (lncRNAs)-and in some cases, their combined regulatory function on specific target genes-may help to elucidate their role in biological processes. NcRNAs' deregulation has an impact on the impairment of physiological programs, driving cells in cancer development. We here carried out a review of literature concerning the implication of ncRNAs on tumor development in neurofibromatosis type 1 (NF1), an inherited tumor predisposition syndrome. A number of miRNAs and a lncRNA has been implicated in NF1-associated tumors, such as malignant peripheral nerve sheath tumors (MPNSTs) and astrocytoma, as well as in the pathognomonic neurofibromas. Some authors reported that the lncRNA ANRIL was deregulated in the blood of NF1 patients with plexiform neurofibromas (PNFs), even if its role should be further elucidated. We here provided original data concerning the association of a specific genotype about ANRIL rs2151280 with the presence of optic gliomas and a mild expression of the NF1 phenotype. We also detected the LOH of ANRIL in different tumors from NF1 patients, supporting the involvement of ANRIL in some NF1-associated tumors. Our results suggest that ANRIL rs2151280 may be a potential diagnostic and prognostic marker, addressing early diagnosis of optic glioma and predicting the phenotype severity in NF1 patients.

Giant Pelvic Neurofibroma in Patient with Plexiform Sciatic Neurofibroma and Neurofibromatosis Type 1

BACKGROUND

Neurofibromatosis is a genetic disease with an autosomal dominant type of inheritance. It is a multisystem disease in which, besides skin manifestations, there is a possibility for the involvement of other organs and systems, and an atypical variant of neurofibromatosis type 1 can also be observed- the so-called plexiform neurofibroma. In patients with this inherited disease, mortality is higher due to the existing risk for malignant transformation and development of malignant peripheral nerve sheath tumours (MPNSTs) or neurofibrosarcoma.

CASE REPORT

We present a 25-year-old woman with neurofibromatosis type 1 and a family history of the disease-father and grandmother with NF-1, with fatal outcome in the grandmother as a result of malignant transformation to neurofibrosarcoma. The patient has clinical data for multiple cafés- au- lait spots on the skin of the trunk, upper and lower limbs, and plexiform tumour formation in the seating area. From the performed imaging diagnostic there are available MRT data for 1) giant pelvic neurofibroma, 2) plexiform giant neurofibroma in the subcutaneous fat on the right thigh and gluteal fat tissue to the right, passing through the midline in the area of the external genitalia, leading to deformation of the front wall of the sacrum with bilateral meningoceles and 3) diffuse involvement of the bladder wall from the process in the area of the trigonum vesicae felleae/the two urethral ostium, as well as 4) the presence of neurofibromas in the course of the iliac vessels on the right. Surgical removal of the oval pelvic formation, identified as neurofibroma was planned, as well as the initiation of systemic therapy with Sirolimus for the plexiform sciatic formation, infiltrating the bladder.

CONCLUSION

Neurofibromatosis type-1 is a problematic disease due to the parallel systemic involvement of different organs and systems, which can be both limited and diffuse. Limited tumour lesions in the form of neurofibromas with diverse localisation (as in the patient we describe) could be surgically removed without difficulty. On the other hand, the diffuse involvement of internal organs within a giant, network-3spreading plexiform neurofibromas (as in the described patient) makes interdisciplinary interventions impossible, and therefore therapeutic alternatives should be considered.

Simultaneous Forehead Lift and Blepharoplasty Techniques in Management of Orbito-Temporal Plexiform Neurofibroma

Plexiform neurofibromas are common complications in neurofibromatosis type 1 patients. Currently, surgery is the treatment of choice. However, complete surgical resection is difficult due to the infiltration to the surrounding tissue and the increased vascularity. Plexiform neurofibromas arising in the orbito-temporal area pose a greater challenge due to its critical function and cosmetic importance of the face. Such plexiform neurofibromas, separately designated as orbito-temporal plexiform neurofibromas, show complex symptoms such as severe ptosis, ectropion, lacrimal gland dysfunction, and even vision loss. We present a case of successful correction of upper eyelid entropion and severe eyebrow ptosis in a 48-year-old orbito-temporal plexiform neurofibromas patient with combined forehead lift and blepharoplasty techniques including double fold formation and mass excision.

Magnetic resonance imaging findings for differential diagnosis of perianal plexiform schwannoma: Case report and review of the literature

Plexiform schwannoma is an extremely rare variant of schwannoma, accounting for approximately 5% of cases. Due to the rarity and lack of typical symptoms, signs and radiological images, a definite diagnosis of plexiform schwannoma may not be made by clinicians prior to biopsy. In the present study, we report the first case (to our knowledge) of perianal plexiform schwannoma arising from the overlapped skin of the ischioanal fossa, and we propose an intratumorally nonenhanced circumferential capsule dividing the tumour into multiple homogeneously enhanced nodules as a magnetic resonance imaging feature to aid in the differential diagnosis of plexiform schwannoma from ancient schwannoma, cavernous haemangioma, liposarcoma and plexiform neurofibroma.

Plexiform Neurofibroma of the Posterior Tibial Nerve Misdiagnosed as Proximal Tarsal Tunnel Syndrome: A Case Report

Plexiform neurofibromas of the foot are rare, benign tumors of the peripheral nerves. Diagnosis can be challenging if they present with symptoms mimicking other peripheral nerve pathologies. Tarsal tunnel syndrome is an entrapment syndrome of the entire tibial nerve behind the medial malleolus and under the flexor retinaculum. The clinical presentation typically includes posteromedial pain, positive Tinel's sign, and neurogenic signs, including both the sensation of numbness and the actual hypoesthesia and clawing of the toes. Here, we report the case of a 59-year-old female patient with plexiform neurofibroma with symptoms similar to those of tarsal tunnel syndrome. The plexiform neurofibroma was surgically excised and the nerve function was partially preserved.

Lady with wings: a case report of giant neurofibromatosis type I

RATIONALE

Neurofibromatosis type I (NF-I) accounts for approximately 90% of neurofibromatosis. NF-I is an autosomal dominant genetic disease which results from the gene mutation of NF-I situated in chromosome 17q11.2.

PATIENT CONCERNS

A 32-year-old lady presented with a giant wing like structure on her back which started growing from her childhood.

DIAGNOSIS

A diagnosis of NF-I was confirmed as she presented with multiple cutaneous nodules, multiple café-au-lait macules of different sizes, scoliosis deformity, and positive family history of neurofibroma.

INTERVENTIONS

Surgical excision of tumor and multiple Z plasty reconstruction of the back was carried out.

OUTCOMES

The excised neurofibroma weighed 6.7 kg containing thickened nerves, nerve roots, and circuitous vessels. The histopathological report confirmed plexiform and diffuse type cutaneous neurofibroma without any malignant transformation. Surgical excision and reconstruction with regular follow-up is an excellent choice of treatment for such a giant neurofibroma as in this case.

LESSONS

NF-I is a genetic disease which could present as a giant cutaneous neurofibroma. One of the treatment options for giant neurofibromas causing deformity and physical disability is by surgical excision and histopathological examination with regular follow-up for NF-I recurrence.

Extensive Peculiar Cutaneous Form of Neurofibromatosis Type I as a New Mutation - a Case Report

Neurofibromatosis-1 (NF1) is one of the most common hereditary multisystemic disorders. The disease manifests a variety of characteristic features that include: hyperpigmentary abnormalities of the skin (café-au-lait macules, freckles in the axillae, and iris Lisch nodules) and growth of benign peripheral nerve sheath tumors (neurofibromas) in the skin. Associated extracutaneous clinical features include: skeletal abnormalities, neurological, cardiovascular, endocrine and other malformations. NF1 is caused by mutation in the neurofibromatosis-1 gene, which codes for the protein neurofibromin. The inheritance of NF1 follows an autosomal dominant trait, although about 50% of patients present with new („de novo“) mutations, and represent the first member of their family. No difference in the severity of the disease can be found in patients with familial mutations versus those with new mutations. We present a 78-year-old female patient with an extreme cutaneous form of neurofibromatosis who reported no affected family member. Apart from skin problems, she had no major health issues in childhood and adolescence, but in recent decades she had frequent headaches, occasional abdominal pain, and vision and hearing impairment. About 10 to 14 days before admission, she developed a severe cough, shortness of breath, and chest and abdominal pain. On examination, the patient of short stature (hight: 152 cm, weight: 49 kg) presented with thousands of soft nodules dispersed over the whole body, except on extensor sides of thighs and lower legs; the nodules varied in color from skin-colored, livid erythematous, to brown-grey; the nodules on the abdomen were moist, partly bleeding from the base, and accompanied by an unpleasant odor. Her feet were also densely covered by dark purple lumps, with dystrophic changes of the toe nails that were thickened, frayed, and yellowish. The skeletal abnormalities included: short stature, severe osteoporosis and osteosclerosis of the head bone structure; degenerative arthropathc-spondylotic changes of the thoracolumbar spine segment with signs of diffuse skeletal hyperostosis; pronounced degenerative changes of the lumbar spine. CT scans of the head, chest and abdomen showed the following abnormalities: flattening of the paraventricular gyri and reduction of brain parenchyma with hypodensity of the white matter in terms of cortical atrophy; periventricular bilateral small post-ischemic microvascular brain lesions of varying chronicity; in the parenchyma of the upper left lung lobe the apical presence of small areas of pleural effusion with consequent subatelectic region; distended stomach and a small inner wall herniation; hypotrophic right kidney; atherosclerotic lesions of the abdominal aorta; low grade infrarenal kinking of the abdominal aorta. Pathohistological analysis of biopsy specimen taken from the nodule corresponded with cutaneous neurofibroma. Consultative examinations of various specialists pointed to the existence of the following comorbidities: obstructive respiratory syndrome and right lobe pneumonia that were treated by antibiotics, aminophylline and dexamethasone infusions; psycho-organic syndrome without focal neurological deficit; Lisch nodules in each eye, and senile cataract. Considering the age and medical presentation of the patient, no other treatment was considered. In conclusion, this is a sporadic case of cutaneous neurofibromatosis 1 in a 78-year-old female patient who presented with extremely severe cutaneous neurofibromas, making this case at least rather peculiar.