Schwannomatosis affecting all three major nerves in the same upper extremity

Giant schwannoma on the lower leg: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Peripheral nerve sheath tumors are common neoplasm with different biological features ranging from benign to malignant. The majority of these tumors are smaller than 5 cm, whereas those larger are termed giant schwannomas. When localized in the lower legs, the maximum length of the schwannoma is less than 10 cm. We report a case of giant schwannoma of the leg and its management.

CASE PRESENTATION

A 11-year-old boy presented with a 13 cm × 5 cm firm, smooth, well-defined margin mass in the posterior-medial aspect of right leg. The tumor was fusiform, well capsulated, multi-lobulated soft tissue with 13 cm × 4 cm × 3 cm in size at the biggest region. On MRI the tumor was low signal, isointense with adjacent tissue on T1S, hyper-intense on T2-FS sequences and surrounded by a thin fat-like intense rim. Biopsy findings were considered most consistent with Schwannoma (Antoni A). Tumor resection was performed. The mass appeared capsulated, white, and glistening with 132 mm × 45 mm × 34 mm in size. Postoperative course was uneventful without neurological deficit.

CLINICAL DISCUSSION AND CONCLUSION

Schwannomas are the most common peripheral nerve sheath tumors that derived almost entirely from Schwann cells. Schwannomas usually affect the head and neck region, localization in the lower extremity is rare. When located in lower extremity, the maximum diameter of 5 cm is described in most studies. Clinical presentation of schwannomas is unclear and unspecific. Diagnosis is based on ultrasound, MRI, and histology. The recommended treatment for schwannoma is surgical enucleation or resection without damaging the involved nerve.

Schwannoma in the extremity: clinical features and microscopic intra-capsular enucleation

Objective: Schwannomas are the most common type of neoplasm of the peripheral nerves. Enucleation is a standard surgical procedure; however, it occasionally results in iatrogenic nerve injury, even with atraumatic procedures. Herein, we present the clinical characteristics of schwannoma arising in the extremities and discuss the clinical outcomes of extra- and intra-capsular enucleation.

Patients and Methods: We reviewed 122 schwannomas treated at our institute. Schwannomas arising from the minor nerve (n=30) or intramuscularly (n=15) were operated using the extra-capsular technique. Of the 77 major nerve schwannomas, 62 schwannomas were treated using the intra-capsular technique and 15 schwannomas using the extra-capsular technique.

Results: Neurological deficits following enucleation were significantly lower using the intra-capsular technique than with the extra-capsular technique. The patient age, duration of symptoms, maximum tumor diameter, and site of occurrence were not associated with subsequent neurological deficits. With both techniques, no tumor recurrence was observed at the final follow-up.

Conclusion: These results support the use of intra-capsular micro-enucleation as a safe and reliable treatment for every type of schwannoma. To minimize the risk of nerve injury, en bloc resection should not be used because the main purpose of schwannoma surgery is the relief of symptoms, not tumor resection.

Cystic schwannoma of the distal forearm. Case presentation

Schwannomas are well-encapsulated, benign tumors arising from Schwann cell constituting the nerve sheaths. We report a case of a cystic conventional schwannoma, measuring 2.5×3 cm, located in the distal forearm of a 33-year-old female patient with no sign of neurofibromatosis type 2 or type 3. The mass was painless, but Tinel’s sign was positive. Ultrasonography showed a soft tissue cystic mass diagnosed as being synovial cyst in the left distal forearm. Surgical resection was performed without any complications. Histopathological examinations oriented the diagnosis to a schwannoma, but immunohistochemical stainings proved the tumor origin in Schwann cells and made the differential diagnosis with other pathologies, like neurofibroma, leiomyoma, epithelial cyst, synovial cyst, or ganglion cyst.

Recurrent Schwannomatosis of the Hand

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.

Schwannomas of the upper extremity: analysis of 34 cases

BACKGROUND

Schwannomas are the most common benign tumours developing in peripheral nerves. They usually present as a slow-growing mass, sometimes associated with pain and paraesthesia. The aim of this study is to define the correct preoperative diagnosis, to review the surgical treatment employed and to evaluate short- and long-term neurological deficits.

METHODS

Thirty-four patients affected by schwannoma in the upper limbs were treated in the period 1995-2011. In 15 patients the tumour was located on the ulnar nerve, in 8 on the median nerve, in 2 on the radial nerve, in 1 on the anterior interosseous nerve, in 1 on the muscle-cutaneous nerve, and in the remaining 7 on the digital nerves. All patients were surgically treated using a microsurgical approach.

RESULTS

The enucleation of the mass was possible without fascicle lesion in 12 cases. In 22 cases resection of the indissociable fascicles was performed. Postoperative paraesthesia was present in 28 out of 34 treated patients; this clinical sign regressed in a mean period of 12 months in 27 patients.

CONCLUSIONS

When approaching a palpable mass in the upper limbs, the possibility of a peripheral nerve tumour should always be considered. It is important to look for typical signs of schwannomas, such as a positive Tinel sign and peripheral paraesthesia. Imaging assessment with magnetic resonance imaging (MRI) and ultrasonography enables the determination of where the tumour takes its origin and from which nerve. Microsurgical techniques and know-how are recommended in approaching the resection in order to respect as many nerve fibres as possible.

A rare case of malignant schwannoma of the brachial plexus

We report a rare case of malignant schwannoma of the brachial plexus treated during a surgical campaign aimed at the poorest communities in the Cuzco region of Peru. A Peruvian 40-year-old-female from a mountain community presented with a mass on the lateral side of her left supraclavicular space. No imaging tools were available during this surgical campaign and so a biopsy of the tumor was carried out. Histopathological examination revealed it to be a low grade malignant schwannoma. A nerve enucleation of the tumor was chosen as neither chemotherapy nor radiotherapy was available. The tumour was a firm mass 4 cm x 3 cm x 2 cm in size. After excision of the lesion the patient presented neurological sequelae (deltoid, bicep, and tricep weakness) but her condition improved over the next 3 years. We report this case of malignant schwannoma of the brachial plexus as its incidence is very rare (the reported incidence is 0.001%) and because of its challenging treatment in poor healthcare conditions.