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Pisapia JM, Adeclat G, Roberts S, Li YR, Ali Z, Heuer GG, Zager EL. Tumors of the brachial plexus region: A 15-year experience with emphasis on motor and pain outcomes and literature review. Surg Neurol Int 2023; 14:162. [PMID: 37292396 PMCID: PMC10246342 DOI: 10.25259/sni_163_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/12/2023] [Indexed: 06/10/2023] Open
Abstract
Background Brachial plexus region tumors are rare. In this study, we reviewed our experience with resection of tumors involving or adjacent to the brachial plexus to identify patterns in presentation and outcome. Methods We report a retrospective case series of brachial plexus tumors operated on by a single surgeon at a single institution over 15 years. Outcome data were recorded from the most recent follow-up office visit. Findings were compared to a prior internal series and comparable series in the literature. Results From 2001 to 2016, 103 consecutive brachial plexus tumors in 98 patients met inclusion criteria. Ninety percent of patients presented with a palpable mass, and 81% had deficits in sensation, motor function, or both. Mean follow-up time was 10 months. Serious complications were infrequent. For patients with a preoperative motor deficit, the rate of postoperative motor decline was 10%. For patients without a preoperative motor deficit, the rate of postoperative motor decline was 35%, which decreased to 27% at 6 months. There were no differences in motor outcome based on extent of resection, tumor pathology, or age. Conclusion We present one of the largest recent series of tumors of the brachial plexus region. Although the rate of worsened postoperative motor function was higher in those without preoperative weakness, the motor deficit improves over time and is no worse than antigravity strength in the majority of cases. Our findings help guide patient counseling in regard to postoperative motor function.
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Affiliation(s)
- Jared M. Pisapia
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Giscard Adeclat
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanford Roberts
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yun R. Li
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Zarina Ali
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory G. Heuer
- Department of Neurosurgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Eric L. Zager
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Shekouhi R, Chim H. Patient demographics, tumor characteristics, and outcomes following surgical treatment of benign and malignant brachial plexus tumors: a systematic review. Int J Surg 2023; 109:972-981. [PMID: 37097618 PMCID: PMC10389507 DOI: 10.1097/js9.0000000000000309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 02/15/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Various treatment options have been introduced for the management of primary tumors of the brachial plexus (BP), ranging from conservative therapy to wide local excision with/without postoperative chemoradiotherapy. However, no consensus exists regarding optimal treatment strategies based on collated and published data. OBJECTIVE The aim of this study was to investigate the clinicopathological characteristics and outcome of patients with primary tumors of the BP who underwent surgical treatment. DATA SOURCES A systematic search of the four main online databases, including Web of Science (WOS), PubMed, Scopus, and Google Scholar, was conducted. STUDY SELECTION All related articles addressing the clinical outcome and role of surgical interventions for management of primary tumors of the BP. INTERVENTION Optimal surgical and radiotherapeutic interventions for benign and malignant lesions based on the pathologic characteristics and location of primary BP tumors. RESULTS A total of 687 patients (693 tumors) with a mean age of 41.7±8.7 years old were evaluated. In total, 629 (90.8%) tumors were benign, and 64 (9.2%) were malignant, with a mean tumor size of 5.4±3.1 cm. The location of the tumor was reported for 639 patients. For these tumors, 444 (69.5%) originated from the supraclavicular region, and 195 (30.5%) were infraclavicular. The trunks were the most common location for tumor involvement, followed by the roots, cords, and terminal branches. Gross total resection was achieved in 432 patients and subtotal resection (STR) was performed in 109 patients. With neurofibromas, STR still resulted in good outcomes. The outcomes following treatment of malignant peripheral nerve sheath tumors were poor regardless of the type of resection. In general, symptoms related to pain and sensory issues resolved rapidly postoperatively. However, the resolution of motor deficits was often incomplete. Local tumor recurrence occurred in 15 (2.2%), patients and distant metastasis was observed in only eight (1.2%) cases. The overall mortality was 21 (3.1%) patients among the study population. LIMITATIONS The main limitation was the lack of level I and II evidence. CONCLUSIONS The ideal management strategy for primary BP tumors is complete surgical resection. However, in some cases, particularly for neurofibromas, STR may be preferable to preserve maximal neurological function. The degree of surgical excision (total or subtotal) mainly depends on the pathological characteristics and primary location of the tumor.
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Affiliation(s)
- Ramin Shekouhi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Florida
| | - Harvey Chim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Florida
- Lilian S. Wells Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
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Chen M, Li X, Feng X. Case report: Brachial plexopathy caused by malignant peripheral nerve sheath tumor and review of the literature. Front Neurol 2023; 14:1056341. [PMID: 36727116 PMCID: PMC9884823 DOI: 10.3389/fneur.2023.1056341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023] Open
Abstract
Brachial plexopathy (BP) is easily misdiagnosed due to its complexity and varying clinical presentation. Malignant peripheral nerve sheath tumors (MPNST) can accumulate in the brachial plexus and share symptoms with BP, which may hinder the differential diagnosis between BP induced by radiation or metastases, and MPNST-derived BP, in patients with a history of breast cancer and radiation exposure. A 34-year-old Chinese female presented with MPNST. The tumor involved the brachial plexus. She had a history of breast cancer and radiotherapy. The first consideration was radiation- or breast cancer metastasis-derived BP. Clinical examination was performed. Finally, a diagnosis of MPNST of the brachial plexus was made, which guided an accurate treatment plan. This report highlights the importance of correctly diagnosing BP etiology for guiding precise treatment. BP caused by MPNST needs to be considered in clinical practice, and biopsy plays a central role in the differential diagnosis. Complete local surgical resection can prolong survival of patients with MPNST and improve treatment prognosis.
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Suárez C, López F, Rodrigo JP, Mendenhall WM, de Bree R, Mäkitie AA, Vander Poorten V, Takes RP, Bondi S, Kowalski LP, Shaha AR, Fernández-Alvarez V, Gutiérrez JC, Zidar N, Chiesa-Estomba C, Strojan P, Sanabria A, Rinaldo A, Ferlito A. Benign Peripheral Non-cranial Nerve Sheath Tumors of the Neck. Adv Ther 2022; 39:3449-3471. [PMID: 35689724 DOI: 10.1007/s12325-022-02191-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022]
Abstract
Benign peripheral non-cranial nerve sheath tumors are rare lesions, including both schwannomas and neurofibromas. These tumors arise from Schwann cells, and may originate from any peripheral, cranial, or autonomic nerve. Most of them are localized and sporadic but multifocal systemic forms can occur. Cervical sympathetic chain, brachial plexus, cervical plexus and spinal roots and nerves are the major nerve systems commonly affected. Dumbbell-shaped intra- and extradural tumors occur most commonly in the cervical spine, as well as purely extradural and paravertebral tumors. The management of these tumors has improved greatly owing to the developments in imaging techniques and surgical innovations such as endoscopically assisted approaches and robotic surgery. Microsurgical intracapsular excision of the tumor helped by the use of intraoperative fluorescent dyes and intraoperative neurophysiological monitoring minimize postoperative neural deficit, since most schwannomas are encapsulated. Most tumors can be removed with a low rate of complications and recurrence. Radiotherapy should be considered for growing lesions that are not amenable to surgery. In asymptomatic patients, observation and serial scans is an option for elderly infirm patients.
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Affiliation(s)
- Carlos Suárez
- Instituto de Investigación Sanitaria del Principado de Asturias, Avenida de Roma s/n, 33011, Oviedo, Spain.
| | - Fernando López
- Instituto de Investigación Sanitaria del Principado de Asturias, Avenida de Roma s/n, 33011, Oviedo, Spain.
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, CIBERONC, Avenida de Roma s/n, 33011, Oviedo, Spain.
| | - Juan P Rodrigo
- Instituto de Investigación Sanitaria del Principado de Asturias, Avenida de Roma s/n, 33011, Oviedo, Spain
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, CIBERONC, Avenida de Roma s/n, 33011, Oviedo, Spain
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Antti A Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Vincent Vander Poorten
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
- Otorhinolaryngology, Head and Neck Surgery, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - Robert P Takes
- Department of Otolaryngology-Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stefano Bondi
- Head and Neck Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, TO, Italy
| | - Luiz P Kowalski
- Head and Neck Surgery and Otorhinolaryngology Department, A C Camargo Cancer Center and University of São Paulo Medical School, São Paulo, Brazil
| | - Ashok R Shaha
- Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Julio C Gutiérrez
- Department of Neurosurgery, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Nina Zidar
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Carlos Chiesa-Estomba
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospital Universitario Donostia, San Sebastián, Spain
| | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia/Hospital Universitario San Vicente Fundación, 050010, Medellín, Colombia
- CEXCA Centro de Excelencia en Enfermedades de Cabeza y Cuello, 050021, Medellín, Colombia
| | | | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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Dubuisson A, Reuter G, Kaschten B, Martin D, Racaru T, Steinmetz M, Gérardy F. Management of benign nerve sheath tumors of the brachial plexus: relevant diagnostic and surgical features. About a series of 17 patients (19 tumors) and review of the literature. Acta Neurol Belg 2021; 121:125-131. [PMID: 33387349 DOI: 10.1007/s13760-020-01560-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
Brachial plexus (BP) tumors are rare, potentially difficult-to-manage lesions. The method is retrospective chart analysis. Among the 17 patients, four had neurofibromatosis and one schwannomatosis (NF +). The latter has bilateral BP tumors that remain stable on MRI at a 6.5 year follow-up. Another NF + patient has bilateral non-operable BP plexiform neurofibromas. The complaints of the 15 operated patients were radiated pain, a mass, local pain, paresthesia, a neurological deficit (n = 15, 12, 7, 10, 7). On MRI, the tumors appeared as nodular or ovoid large masses. Four operated tumors were proximal, reaching the foramen. The FDG-PET scan (n = 4) always showed tumor hypermetabolism. A preoperative percutaneous biopsy was done in three patients before neurosurgical consultation; one of them developed neurogenic pain and a sensory deficit following two percutaneous biopsies for a misinterpreted cervical lymphadenopathy. Surgery was performed using a supra-, infra-, supra- + infra-clavicular or posterior subscapular approach (n = 8, 3, 3, 1). Intraoperative electrophysiology was used in all patients. Complete or gross total resection was achieved in 14 patients. Two patients had fascicle reconstruction with grafts. Pathology revealed 13 schwannomas and two neurofibromas. Neurogenic pain transiently developed or worsened after surgery in five patients. At last follow-up, a mild deficit remained in four patients (preexisting in three). No recurrence had occurred. We conclude that a thorough examination of any patient with a cervical or axillary mass is crucial to avoid misinterpretation as a lymphadenopathy. MRI is the best imaging modality. Most BP benign tumors can be completely and safely resected through the use of microsurgical techniques and intraoperative electrophysiology.
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Affiliation(s)
| | - Gilles Reuter
- Department of Neurosurgery, CHU Liege, Liège, Belgium
| | | | - Didier Martin
- Department of Neurosurgery, CHU Liege, Liège, Belgium
| | - Tudor Racaru
- Department of Neurosurgery, CHU Liege, Liège, Belgium
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Fiani B, El-Farra MH, Dahan A, Endres P, Taka T, Delgado L. Brachial plexus tumors extending into the cervicothoracic spine: a review with operative nuances and outcomes. Clin Transl Oncol 2021; 23:1263-1271. [PMID: 33449268 DOI: 10.1007/s12094-020-02549-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/27/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The rarity and anatomical complexity of brachial plexus tumors (BPTs) impose many challenges onto surgeons performing surgical resections, especially when these tumors invade the cervicothoracic spine. Treatment choices and surgery outcomes heavily depend on anatomical location and tumor type. METHODS The authors performed an extensive review of the published literature (PubMed) focusing on "brachial plexus tumors" that identified invasion of the cervicothoracic spine. RESULTS The search yielded 2774 articles pertaining to "brachial plexus tumors". Articles not in the English language or involving cervicothoracic spinal invasion were excluded. CONCLUSIONS Recent research has shown that the most common method used to resect tumors of the proximal roots is the dorsal subscapular approach. Despite its association with high morbidity rate, this technique offers excellent exposure to the spinal roots and intraforaminal portion of the spinal nerve. The dorsal approach is used to resect recurrent lower trunk tumors and dumbbell-shaped neurofibromas, yet it is also the least common overall approach used in brachial plexus tumor resections. The ventral or anterior technique is commonly used to resect tumors at the cord to division level, and root to trunk level. Motor complications, transient nerve palsy, and bleeding are among the most common complications of the anterior supraclavicular approach. Further controlled studies are needed to fully determine the optimal surgical approach used to obtain the best outcomes and least complications for each type of brachial plexus tumor.
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Affiliation(s)
- B Fiani
- Department of Neurosurgery, Desert Regional Medical Center, 1150 N. Indian Canyon Drive, Palm Springs, CA, 92262, USA.
| | - M H El-Farra
- University of California Riverside School of Medicine, 92521 Ucr Botanic Gardens Rd, Riverside, CA, 92507, USA
| | - A Dahan
- University of California Riverside School of Medicine, 92521 Ucr Botanic Gardens Rd, Riverside, CA, 92507, USA
| | - P Endres
- University of California Riverside School of Medicine, 92521 Ucr Botanic Gardens Rd, Riverside, CA, 92507, USA
| | - T Taka
- University of California Riverside School of Medicine, 92521 Ucr Botanic Gardens Rd, Riverside, CA, 92507, USA
| | - L Delgado
- University of California Riverside School of Medicine, 92521 Ucr Botanic Gardens Rd, Riverside, CA, 92507, USA
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Nelson CN, Dombi E, Rosenblum JS, Miettinen MM, Lehky TJ, Whitcomb PO, Hayes C, Scott G, Benzo S, Widemann BC, Chittiboina P. Safe marginal resection of atypical neurofibromas in neurofibromatosis type 1. J Neurosurg 2020; 133:1516-1526. [PMID: 31653805 PMCID: PMC8320705 DOI: 10.3171/2019.7.jns191353] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/12/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Patients with neurofibromatosis type 1 (NF1) are predisposed to visceral neurofibromas, some of which can progress to premalignant atypical neurofibromas (ANFs) and malignant peripheral nerve sheath tumors (MPNSTs). Though subtotal resection of ANF may prevent malignant transformation and thus deaths with no neural complications, local recurrences require reoperation. The aim of this study was to assess the surgical morbidity associated with marginal resection of targeted ANF nodules identified via preoperative serial volumetric MRI and 18F-FDG-PET imaging. METHODS The authors analyzed clinical outcomes of 16 NF resections of 21 tumors in 11 NF1 patients treated at the NIH Clinical Center between 2008 and 2018. Preoperative volumetric growth rates and 18F-FDG-PET SUVMax (maximum standardized uptake value within the tumor) of the target lesions and any electromyographic or nerve conduction velocity abnormalities of the parent nerves were measured and assessed in tandem with postoperative complications, histopathological classification of the resected tumors, and surgical margins through Dunnett's multiple comparisons test and t-test. The surgical approach for safe marginal resection of ANF was also described. RESULTS Eleven consecutive NF1 patients (4 male, 7 female; median age 18.5 years) underwent 16 surgical procedures for marginal resections of 21 tumors. Preoperatively, 13 of the 14 (93%) sets of serial MRI studies and 10 of the 11 (91%) 18F-FDG-PET scans showed rapid growth (≥ 20% increase in volume per year) and avidity (SUVMax ≥ 3.5) of the identified tumor, respectively (median tumor size 48.7 cm3; median growth rate 92% per year; median SUVMax 6.45). Most surgeries (n = 14, 88%) resulted in no persistent postoperative parent nerve-related complications, and to date, none of the resected tumors have recurred. The median length of postoperative follow-up has been 2.45 years (range 0.00-10.39 years). Histopathological analysis confirmed significantly greater SUVMax among the ANFs (6.51 ± 0.83, p = 0.0042) and low-grade MPNSTs (13.8, p = 0.0001) than in benign neurofibromas (1.9). CONCLUSIONS This report evaluates the utility of serial imaging (MRI and 18F-FDG-PET SUVMax) to successfully detect ANF and demonstrates that safe, fascicle-sparing gross-total, extracapsular resection of ANF is possible with the use of intraoperative nerve stimulation and microdissection of nerve fascicles.
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Affiliation(s)
- Charlie N. Nelson
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Eva Dombi
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jared S. Rosenblum
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Markku M. Miettinen
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Tanya J. Lehky
- Electromyography Section, National Institute of Neurological Disorders and Stroke
| | - Patricia O. Whitcomb
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Christina Hayes
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Gretchen Scott
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Sarah Benzo
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Brigitte C. Widemann
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Disorders and Stroke
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Neurolymphomatosis caused by diffuse large B-cell lymphoma presenting as isolated brachial plexopathy. Chin Med J (Engl) 2019; 132:2762-2764. [PMID: 31765359 PMCID: PMC6940089 DOI: 10.1097/cm9.0000000000000514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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