Peripheral nerve injuries in the pediatric population: a review of the literature. Part III: peripheral nerve tumors in children

INTRODUCTION

Peripheral nerve tumors type, inciedence and treatment in the pediatric population should be analyzed.

METHODS

We have performed an extense literature review of this subject.

RESULTS

incidence and distribution are similar to those observed in adults. The most common peripheral nerve tumors in children are neurofibromas and schwannomas. Malignant peripheral nerve sheath tumors are also observed, specially associated with genetic syndromes, like neurofibromatosis and Carney complex.

CONCLUSION

In this review, peripheral nerve tumors have been divided into three categories to aid with understanding: reactive and hyperplastic lesions, benign tumors, and malignant tumors. The most frequent lesions have been described.

Creating a comprehensive research strategy for cutaneous neurofibromas

Objective

Outside of procedural-based methods, there are currently no established medical treatments for cutaneous neurofibroma (cNF), which afflict up to 99% of patients with NF1. Further, adult patients often report cNF are the greatest burden of living with NF1. The Neurofibromatosis Therapeutic Acceleration Program (NTAP) launched a think tank to address core questions to facilitate development of effective therapeutics for cNF in people with NF1.

Methods

Experts (with and without explicit experience with NF1 or cNF) from multiple scientific and medical disciplines, representing the ranks of academia, industry, and government agencies, were invited to become a member of a team addressing a specific subset of questions pertinent to cNF. Teams met monthly to review published and unpublished materials, and created summaries about the material known and unknown that may influence therapeutic development for cNF. Teams prioritized questions and organized supporting data, which was presented to the entire body of experts by each team at a research summit.

Results

Four themes were identified as being relevant to creating a comprehensive research strategy for cNF: (1) establishing definitions of cNF, (2) determining the biology of cNF with respect to tumor initiation, progression, and maintenance, (3) outlining the factors that guide therapies development, and (4) defining core considerations for clinical trials design and optimization for cNF.

Conclusion

Considerations and key questions for each of the thematic areas were identified and provided basis for a request for applications launched by NTAP focused on cNF and are described in the accompanying articles of this supplement.

A neurogenic tumor containing a low-grade malignant peripheral nerve sheath tumor (MPNST) component with loss of p16 expression and homozygous deletion of CDKN2A/p16: a case report showing progression from a neurofibroma to a high-grade MPNST

Development of malignant peripheral nerve sheath tumors (MPNSTs) is a stepwise process that involves the alteration of many cell cycle regulators and the double inactivation of the NF1 gene. Inactivation of the TP53 gene and deletion of the CDKN2A/p16 gene are known to play an important role in the process. Herein, we present a 19-year-old man with a familial history of neurofibromatosis type 1, in whom the tumor arose from the intercostal nerve and showed 3 components: a neurofibroma, a low-grade MPNST, and a high-grade MPNST. Loss of p16 expression and homozygous deletion of the CDKN2A/p16 gene were observed in both the low-grade and the high-grade MPNST. In contrast to low-grade MPNSTs, high-grade MPNSTs generally tend to lose expression of p16 and harbor homozygous deletion of the CDKN2A/p16 gene. Loss of p16 expression and homozygous deletion of the CDKN2A/p16 gene in low-grade MPNST in our case might be related to its progression to high-grade MPNST. To the best of our knowledge, this is the first study correlating the p16 expression status and CDKN2A/p16 gene alteration in low-grade MPNSTs.

Solitary neurofibroma of the palatine tonsil: a case report

We present a rare case of a benign tumor of the tonsil in a 49-year-old woman. The tumor was excised in its entirety, and the patient's postoperative course was uneventful. No evidence of recurrence was detected during follow-up. Although some sporadic cases of tonsillar schwannoma have been reported, to the best of our knowledge this is only the second case of a solitary neurofibroma of the palatine tonsil to be reported in the English-language literature.

[Diagnosis and treatment of olfactory cleft diseases]

OBJECTIVE

To discuss the diagnosis and treatment of the diseases originated in the olfactory cleft.

METHODS

Eight consecutive patients with the diagnosis of olfactory cleft diseases, encountered between December, 2003 and May, 2006, were included in this retrospective study. On the basis of case reports, the related anatomy, diagnosis and treatment of olfactory cleft diseases were discussed.

RESULTS

For the 8 patients with olfactory cleft diseases, the clinical and pathological diagnosis were as follows: adenocarcinoma, squamous cell carcinoma, inverted papilloma, glioma with cerebrospinal fluid (CSF) rhinorrhea, pyocyst of the superior turbinate, angiofibrosteoma, neurofibroma and hemangioma. All patients were treated by endoscopic surgery. Postoperative radiotherapy was given to two patients with malignant tumour.

CONCLUSIONS

The diseases in the olfactory cleft are not uncommon, which are often overlooked. In order to avoid misdiagnosis, (1) it is important to pay attention to this specific anatomic area; (2) the particularity of olfactory cleft diseases should be emphasized, especially in the cases of huge tumors. In that cases, the primary sites of olfactory cleft tumors can not be correctly judged preoperatively by CT scans, which can only be found during endoscopic surgery. For the treatment of olfactory cleft diseases, surgery under endoscope is the treatment of choice. If the tumor is malignant, postoperative radiotherapy should be added.

Experimental therapeutic approaches to peripheral nerve tumors

✓Discovery that the Schwann cell is the primary cell type responsible for both the neurofibroma as well as the schwannoma has proven to represent a crucial milestone in understanding the pathogenesis of peripheral nerve tumor development. This information and related findings have served as a nidus for research aimed at more fully characterizing this family of conditions. Recent discoveries in the laboratory have clarified an understanding of the molecular mechanisms underlying the pathogenesis of benign peripheral nerve tumors. Similarly, the mechanisms whereby idiopathic and syndromic (NF1- andNF2-associated) nerve sheath tumors progress to malignancy are being elucidated. This detailed understanding of the molecular pathogenesis of peripheral nerve tumors provides the information necessary to create a new generation of therapies tailored specifically to the prevention, cessation, or reversal of pathological conditions at the fundamental level of dysfunction. The authors review the data that have helped to elucidate the molecular pathogenesis of this category of conditions, explore the current progress toward exploitation of these findings, and discuss potential therapeutic avenues for future research.

Perinatal epidermal growth factor receptor blockade prevents peripheral nerve disruption in a mouse model reminiscent of benign world health organization grade I neurofibroma

Benign peripheral nerve tumors called neurofibromas are a major source of morbidity for patients with neurofibromatosis type 1. Some neurofibroma Schwann cells aberrantly express the epidermal growth factor receptor (EGFR). In a mouse model in which the CNPase promoter drives expression of human EGFR in Schwann cells, nerves develop hypertrophy, mast cell accumulation, collagen deposition, disruption of axon-glial interactions, characteristics of neurofibroma and are hypoalgesic. Administration of the EGFR antagonist cetuximab (IMC-C225) for 2 weeks beginning at birth in CNPase-hEGFR mice normalized all pathologies at 3 months of age as evaluated by hotplate testing or histology and by electron microscopy. Mast cell chemoattractants brain-derived neurotrophic factor, monocyte chemoattractant protein-1, and transforming growth factor-beta1, which may account for mast cell accumulation and fibrosis, were reduced by cetuximab. Later treatment was much less effective. A birth to 2-week pulse of cetuximab blocked hEGFR phosphorylation and Schwann cell prolifera-tion in perinatal mutant nerve, so CNPase-hEGFR Schwann cell numbers correlate with the cetuximab effect. A >250-fold enlarged population of EGFR(+)/p75(+) cells was detected in newborn Nf1(+/-) mouse nerves. These results suggest the existence of an EGFR(+) cell enriched in the perinatal period capable of driving complex changes characteristic of neurofibroma formation.

Spinal Cord Metastasis of a Non-neurofibromatosis Type-1 Malignant Peripheral Nerve Sheath Tumor: An Unusual Manifestation of a Rare Tumor

Malignant peripheral nerve sheath tumors are rare spindle-cell sarcomas derived from Schwann cells or pluripotent cells of the neural crest. They arise from the spinal roots, peripheral nerves, brachial and lumbosacral plexi, cranial nerves and terminal nerve fibers within soft tissue, intestine, lung and bone. These tumors recur either locally, or metastasize distally. Most of these tumors occur in association with neurofibromatosis type 1. Spinal cord metastasis from malignant nerve sheath tumors associated with neurofibromatosis type 1 is very rare. We describe a rare case of near-total spinal cord metastasis in a patient with malignant nerve sheath tumor in the absence of neurofibromatosis, and highlight the microscopic findings and natural history of this disease process.

Radiotherapy and Radiosurgery for Benign Neurofibromas

The purpose of this study was to evaluate the efficacy of radiotherapy (RT) and stereotactic radiosurgery (SRS) for neurofibromas. We studied 4 patients treated with RT (3 patients) or SRS (1 patient) and followed from 1.7 to 14.8 years. The tumor remained locally controlled in all patients. No significant complications related to treatment were observed. RT and SRS are likely to locally control neurofibromas in patients who require treatment and are not good candidates for complete resection.

The biology and management of laryngeal neurofibroma

OBJECTIVES

To review the presentation of laryngeal neurofibroma, including its association with neurofibromatosis types 1 and 2, and present guidelines for its management.

DESIGN

Retrospective study.

PATIENTS

Five pediatric patients with laryngeal neurofibroma, 4 girls (80%) and 1 boy (20%), were treated at a tertiary pediatric medical center from 1973 through 2003. Recorded data included age at initial presentation, sex, symptoms, significant medical and family history, preoperative evaluation, location of the tumor, surgical procedure, complications, outcome, and recurrence.

RESULTS

The 5 patients presented with stridor and cafe-au-lait spots at or shortly after birth. All patients were diagnosed as having neurofibromatosis type 1 by the established criteria. Studies evaluating the disease processes included plain radiography, computerized tomography, magnetic resonance imaging, barium swallow, and laryngoscopy and bronchoscopy under anesthesia. Pathologic examination of biopsy specimens from all patients showed neurofibromas with plexiform and/or diffuse features. Treatments included tracheotomy (n = 4), carbon dioxide laser excision (n = 4), modified neck dissection (n = 3), partial pharyngectomy (n = 1), supraglottic laryngectomy (n = 1), and endoscopic hemilaryngectomy (n = 1). Three patients were successfully decannulated. Follow-up ranged from 1 to 15 years. One patient was lost to follow-up. No evidence of malignant degeneration was noted.

CONCLUSIONS

Neurofibroma of the larynx is a rare condition that should be considered in the differential diagnosis of children with a submucosal laryngeal mass. In our series, all patients had associated neurofibromatosis type 1. Complete surgical excision is the treatment of choice in cases of localized small lesions. To prevent debilitating outcomes due to aggressive surgery, minimally invasive procedures (partial excision via endoscopic approach) may be preferable for larger lesions that infiltrate the surrounding vital structures. Long-term follow up of these patients is essential owing to the possibility of malignant transformation.

Neurofibroma and schwannoma

PURPOSE OF REVIEW

Neurofibromas and schwannomas are benign peripheral nerve sheath tumours that occur as isolated sporadic lesions, but have their major clinical impact on the neurocutaneous diseases neurofibromatosis 1 and neurofibromatosis 2. The gene products neurofibromin and merlin (schwannomin), respectively, are thought to act as tumour suppressors. The aim of this review is to document recent advances in our understanding of the clinical characteristics and pathogenesis of neurofibromas and schwannomas in the neurofibromatoses.

RECENT FINDINGS

Animal models have shed light on the pathogenesis of neurofibromas confirming that the Schwann cell initiates neurofibroma formation. New data suggest that individuals with neurofibromatosis 1 have a 10% lifetime risk of developing malignant peripheral nerve sheath tumours. Positron emission tomography with the glucose analogue 18-fluorodeoxyglucose might be helpful in the diagnosis of malignant peripheral nerve sheath tumours. Such tumours associated with neurofibromatosis 1 show a loss of neurofibromatosis 1 expression and high levels of Ras, but malignant transformation requires additional genetic events that inactivate key cell cycle regulators. Neurofibromatosis 2-associated vestibular schwannomas have variable growth rates that tend to decline with age. Early microsurgery for small tumours results in optimal preservation of hearing and facial nerve function. Currently, radiosurgery for these lesions produces similar results. Systematic follow-up of both groups will determine the best treatment method. Merlin's function as a tumour suppressor has not been elucidated. The control of cell cycle progression and abnormal intracellular and extracellular signalling could all play a part.

SUMMARY

Molecular advances will allow a biological approach to targeted therapies for neurofibromas, malignant peripheral nerve sheath tumours and schwannomas. Knowledge of the pathogenesis of these tumours will have implications for our understanding of the neurofibromatoses and of the formation of sporadic tumours.

Intramural neurofibroma of the trachea treated by multiple stents

The case history is presented of a patient in whom an intramural tracheal neurofibroma developed, causing severe airway stenosis. The patient was treated with multiple stents over a period of 5 years because of progression of the disease and associated airflow limitation. Clinicians should be aware of this rare complication of neurofibromatosis.

Diagnosis and management of neurofibromatosis type 1

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder whose major feature is the occurrence of multiple neurofibromas, which are benign tumors of the nerve sheath. It affects an estimated one in 3000 to 4000 individuals. In addition to neurofibromas, there are many other clinical manifestations, including malignant tumors such as gliomas or malignant peripheral nerve sheath tumors, and nontumor effects such as skeletal dysplasia and learning disability. Diagnosis is established on the basis of clinical criteria. Molecular genetic testing is feasible, but the large size of the gene and wide range of pathogenic mutations have so far impeded the development of a clinical diagnostic test. Insights into pathogenesis have followed from identification of the NF1 gene and the development of animal models. The major function of the gene product appears to be regulation of the ras protein. Tumors are believed to arise by the loss of function of the NF1 protein, suggesting that NF1 behaves as a tumor suppressor gene. Heterozygous effects on some cell types are also likely, however. The role of ras in the pathogenesis of tumors in NF1 has suggested an approach to treatment using ras inhibitors, some of which are likely to begin in clinical trials in NF1 patients in the near future.

Neurogenic tumors of the head and neck in children

Soft tissue tumors make up 63% of all tumors in children. Tumors of the sympathetic chain make up 7.4% of tumors arising in children (nine new cases a year for every million children in USA) while neurofibrosarcomas make up 3.4% (2.4 new cases per year for every million children). There is a certain difference between the frequency of benign forms (rather elevated) and that of malignant forms (rather low). Diagnosis is possible by echo-scan, computed tomography, magnetic resonance imaging and fine-needle aspiration biopsy. As regards therapy, surgical resection represents the treatment of choice. In our experience, 35 neurogenic tumors in pediatric patients (8-16 years), arising in head and neck spaces, were observed and treated in the period 1976 and 1995. Twenty-six cases were schwannomas, six were neurofibromas and three were olfactory neuroblastomas. All the patients underwent surgery. Sacrifice of the affected nerve was necessary in 12 cases (all neurofibromas and eight neurinomas). In one case of olfactory aesthesioneuroblastoma a combined approach (extra-intracranial approach) was employed. Two patients are alive and disease-free with 5 and 7 years follow-up. As regards dysfunctional pathology following surgical resection, we report definitive facial nerve palsy in two cases, permanent laryngeal palsy in six cases, tongue dysfunction in one case and cheek hypoaesthesia in one case.

[A rare case of a primary intrabronchial neurofibroma]

HISTORY AND CLINICAL FINDINGS

A 42-year-old woman, a smoker for many years, had suffered from dry cough for some time. She was admitted because of haemoptyses, the first one month previously. Physical examination was unremarkable.

INVESTIGATIONS

Chest radiography in two planes showed no abnormality. Computed tomography revealed a space-occupying lesion adjacent to the right main bronchus, strongly suspicious of a central bronchial carcinoma. Bronchoscopy showed a smoothly circumscribed tumour in the upper lobe bronchus which almost occluded its lumen. Multiple biopsies failed to establish the benignity/malignity of the tumour.

TREATMENT AND COURSE

The tumour was removed by upper lobe resection. There was no macroscopic intraoperative evidence of infiltration. Histology provided the surprising diagnosis of a benign neurofibroma.

CONCLUSION

Thoracotomy should, if at all possible, be performed whenever biopsy of a pulmonary mass fails to establish its benignity. Intrapulmonary neurofibroma is very rare, unless it is part of v. Recklinghausen's disease.

Benign soft-tissue lesions in children

This article is a review of the common benign soft-tissue lesions of the spine and extremities. Reviewed are the pathophysiology, natural history, appropriate work-up, and treatment options. A recommendation is given to consider the diagnosis as possible malignancy and approach such lesions with caution.

[Primary retroperitoneal tumor--an analysis of 303 cases]

Primary retroperitoneal tumor (PRT) is of a heterogeneous group of neoplasms of mesenchymal origin. From April 1964 through April 1992, 303 PRT cases were treated. Of the 288 cases with histological confirmation, 197 suffered from malignant tumors and 91 were benign. Since the PRT patients were usually symptomless, diagnosis was made late in the majority of patients. It resulted in low radical resection rate in both the malignant (36.9%) and the benign (84.6%) PRT owing to invasion to adjacent organs. The tumor recurrence rate was also high, being 74.2% for the malignant and 11.7% for the benign tumors. The overall 2-, 5-, and 10-year survival rates in the patients with malignant tumors were 55.3%, 19.5%, and 9.8%, respectively. The results of treatment were dependent primarily on completeness of tumor resection. Adjuvant radiotherapy could improve the survival rates but adjuvant chemotherapy did not help. In patients with tumor recurrence, operation remained to be the treatment of choice. If complete resection was impossible, the alternative was debulking operation followed by radiotherapy.

Expanded spectrum of viral therapy in the treatment of nervous system tumors

Despite aggressive therapy, many nervous system neoplasms, including malignant gliomas, medulloblastomas, malignant meningiomas, and neurofibrosarcomas, maintain high mortality rates. The authors recently utilized a thymidine kinase-negative herpes simplex-1 mutant virus, dlsptk, with reduced neurovirulence, for the effective treatment of malignant human gliomas in cell culture and in nude mouse in vivo models. The range of human nervous system tumors that might be responsive to viral therapy is now expanded. Three medulloblastoma, four malignant or atypical meningioma, and five neurofibrosarcoma cell lines or early-passage tumors were treated with the dlsptk virus in cell culture. A cell death rate of at least 99% was evident in every tumor tested for at least one multiplicity of infection within 14 days after treatment. Control tumor cell cultures remained viable. To test dlsptk therapy in vivo, the authors treated human medulloblastoma subcutaneous xenografts with two doses of dlsptk. Mean growth ratios were significantly inhibited in the treated group when compared to control tumors, and there was a significant number of tumor regressions in the treated animals. Similar results were seen with human malignant meningioma xenografts in a subrenal capsule study. These results encourage the further investigation of viral therapy in the treatment of a broad spectrum of nervous system tumors refractory to conventional treatment methods.

Sarcomas of the head and neck. Prognostic factors and treatment strategies

The authors reviewed 164 cases of head and neck sarcoma from adult patients seen at the University of California, Los Angeles (UCLA), between 1955 and 1988. The median follow-up was 70 months. Multivariate analysis demonstrated that tumor grade, size, and surgical margin status were the most important independent prognostic factors. Thirty-one percent (27 of 85) of patients with high-grade lesions were free of disease versus 81% (44 of 55) with low-grade lesions at last follow-up. Sixty-seven percent (50 of 76) of patients with lesions smaller than 5 cm were free of disease versus 38% (33 of 88) with lesions larger than 5 cm. In 16 patients, low-grade lesions, measuring less than 5 cm and with negative margins histologically, were controlled with surgery alone. For the 94 patients whose primary tumors were treated at UCLA, local control was achieved in 52% (26 of 50) of patients treated with surgery alone and 90% (20 of 22) with combined therapy (surgery and radiation therapy [RT] with or without chemotherapy). Seventy-five percent (6 of 8) of patients with positive surgical margins treated with postoperative RT achieved local control versus 26% (5 of 19) of patients receiving no additional treatment. In conclusion, surgery alone appears to be adequate treatment for small, low-grade tumors and negative surgical margins. Patients with incomplete resection or high-grade tumors should receive aggressive treatment--surgery and RT.

Huge plexiform neurofibroma of the head and liver--case report

Neurofibromatosis (NF) is a hereditary autosomal dominant disorder. Von Recklinghausen first described NF in 1882, which is now classified as Neurofibromatosis 1 (NF-1). NF-1 is the most commonly encountered NF which affects 1 in 4000 persons. Clinical manifestations of NF-1 include: generalized cutaneous neurofibroma, pigmented skin patches (cafe-au-lait spots), pigmented iris hamartoma (Lisch nodules), skeletal abnormally, CNS tumors, etc. The subject of this case study is a young adult male with a huge plexiform neurofibroma involving both the liver and head regions. The head tumor measured 10 x 8 x 3.5 cm3 in size, weighted approximately 180g with overlying hyperpigmented skin and an underlying congenital skull defect. A CT scan and MRI of the head and neck revealed a well defined lobulated tumor and deformed external ear. A abdominal sonogram, CT scan and MRI showed a huge plexiform neurofibroma with liver invasion. Lisch nodules and multiple cafe-au-lait spots were also found. Surgical removal of the head tumor along with an external ear reconstruction was performed. Satisfactory cosmetic results and improved hearing were achieved.

[Biliary obstruction in von Recklinghausen disease]

The EVR is an uncommon autosomic dominant hereditary pathology that typically presents neurofibromas in the course of the spinal, cranial and neurovegetative nerves. Occasionally, neurofibromas can be found in the gastrointestinal tract. In this setting, the most frequent locations are jejunum, stomach and ileum. Seldom, they are in duodenum where could become ulcerated determining bleeding and severe pain simulating an acute pancreatitis. There are sympathetic and parasympathetic nerves in the minor epiploon arising from the splanchnic and vagus respectively. It results in a thick network around the extrahepatic biliary system that could be the neurofibromas origin; when they become bigger biliary obstruction can results needing chirurgical treatment. Previously, it is important to discard another probable causes of biliary obstruction (lithiasis, sclerosant cholangitis, biliary or pancreatic neoplasms) with all available proceedings (echosonography, CPRE, TAC, etc).

Embolization of paraspinal masses

Arterial embolization is a method of palliative therapy for both primary and metastatic tumors. This treatment is frequently used in the liver and kidney, but has not been previously extended to paraspinal masses. Five patients with recurrent renal cell carcinoma or neurofibrosarcoma underwent palliative embolization for pain or mass effect. All had relief of pain after embolization. Four patients showed change in the mass on follow-up computed tomography scan with one demonstrating tumor shrinkage. Arterial embolization can be an effective method for palliation of pain and mass effect caused by paraspinal masses.

Malignant nerve sheath tumors of the head and neck

Malignant nerve sheath tumors comprise approximately 5% of all soft tissue sarcomas; only 8% to 15% of these tumors arise in the head and neck. Most tumors appear as a rapidly expanding nonpainful mass in the face or lateral neck. Reported association with Von Recklinghausen's disease varies from 26% to 70%. Wide surgical excision is generally the recommended primary treatment. Recently, there has been a trend to include postoperative radiation therapy as a primary modality.

Neoplasms of the vagus nerve

A tumor of the vagus nerve often is discovered unexpectedly at operation. We report 36 of these rare neoplasms in 35 patients. The majority of the tumors presented as a mass in the upper cervical or parapharyngeal region. Usually the mass was asymptomatic. The following types and frequencies of neoplasms of the vagus nerve were noted: paragangliomas, 50%; neurilemmomas, 31%; neurofibromas, 14%; and neurofibrosarcomas, 6%. Surgical resection, with preservation of the vagus nerve when possible, is the treatment of choice. The clinical features, diagnosis, management, and prognosis of the tumors are presented. Special problems that occur with vagal neoplasms include postoperative dysfunction, catecholamine secretion, and intracranial or skull-base extension.

Primary malignant tumours of the trigeminal nerve

We report a case of primary malignant schwannoma of the trigeminal nerve, and review the 5 previously reported cases. Clinical presentation, along with radiological and pathological features are discussed.

Neurofibromatosis and childhood tumors

Although tumors are a known complication of von Recklinghausen's neurofibromatosis (NF), they often develop after the second decade and their characteristics in the pediatric population are unclear. To define the frequency and distribution of tumor types in children with NF, the authors reviewed the experience at Children's Hospital of Pittsburgh between 1953 and 1984. During that time, 121 children younger than 18 years with documented NF were seen. Three patients (2.5%) developed locally extensive, unresectable sarcomas, two of which were clearly neural in origin. Two other children died from complications of highly cellular but not histologically malignant neurofibromas. Seventeen patients (14%) had brain tumors, of which 3 (2.5%) were malignant astrocytomas and 9 were optic gliomas. Two children had acute myelogenous leukemia. Although it has been said that patients with NF are particularly susceptible to the oncogenic effects of radiation, 12 children were treated with a median of 5000 rad to their tumor bed. Follow-up after radiation in that small cohort of patients ranged from 6 months to 12 years (mean, 6 years). Eleven of 12 patients experienced adequate local control. During the follow-up period, none developed a second tumor outside or within the radiation port that could be related to radiation. The authors conclude that clinically significant tumors in children with NF, not all of which are histologically malignant, are not rare. Although more prospective information is needed on response to and sequelae from therapy, the data in this report suggest no contraindication to aggressive therapy.

[Neurofibrosarcoma of the perineum associated with von Recklinghausen's disease: a case report and review of the literature]

A case of perineal neurofibrosarcoma associated with von Recklinghausen's disease is reported. The patient was a 30-year-old man, who complained of a mass between the scrotum and anus. The mass was asymptomatic. On Jan. 13, 1981, simple excision was performed. Histological examination revealed neurofibrosarcoma. After 3 months he had recurrence of the perineal tumor. Combined chemotherapy and radiation therapy were performed. But, his condition became worse due to general metastasis and he died 12 months after operation. A total of 22 cases of perineal neoplasms are reviewed.

Neurofibroma of the tongue: a case report

A tumor of nerve origin is relatively rare in the oral region. We report a neurofibroma of the tongue observed in a 34-year-old woman.

Pathology of jugular foramen neurofibroma

Tumors of jugular foramen may closely resemble glomus jugulare tumors clinically and radiographically. A tissue diagnosis is necessary to make a differentiation of these tumors. This conclusion is supported by the findings in a temporal bone from a patient who was diagnosed clinically as having a glomus jugulare tumor 57 years before her death at the age of 84 years. Compression of the 7th and 8th cranial nerves in the internal auditory canal and the 10th and 11th cranial nerves at the jugular foramen represents the mechanism of neural signs produced by a neurofibroma arising in the jugulare foramen. This case further demonstrates that conservative treatment of benign extradural tumors may be compatible with a long and useful life.

Neurogenic sarcomas of the neck in neurofibromatosis

Based on two observations and a review of the literature, the pathological and clinical findings in sarcomas of the neck in patients with neurofibromatosis are described. Histologically these neurogenic tumours show a manifold picture; in addition to spindle-cell sarcomas pleomorphic structures are to be found, which can be similar to rhabdomyo-, lipo-, chondro-, angio-, or osteogenic sarcomas so that a histological diagnosis of a neurogenic sarcoma cannot always be made without clinical details. Up to the present surgical treatment is preferred; the value of cytostatic therapy and irradiation is controversial. The results of treating these tumours are unsatisfactory. Of 29 cases reported in the literature, only two could be found in which the patient survived without a recurrence for more than five years.

Effect of interferon in therapy of skin and head and neck tumors

The clinical experimental model of HLI application in the therapy of skin and mucosal cancers of the head and neck has opened new prospects in HLI utilization. Based on clinical observations and research it may be concluded that HLI, if applied topically in the area of the tumor, may induce its disappearance or regression. If applied presurgically, it blocks the dispersion of neocytes during surgery. Also, HLI inhibits metastatic dissemination of malignant tumors and therefore might reduce the percentage of patients with recurrence, decreasing the chance of survival of any other primary tumor.

Neurofibrosarcoma

Case histories of 10 patients with neurofibrosarcoma, including 14 (70%) with neurofibromatosis, evaluated over 10 years were reviewed to determine the incidence of local and systemic recurrence and the most effective means of therapy for this rare neoplasm. Initial therapy resulted in complete local disease control in only 11 (55%) patients. Local excision, or local excision plus radiation or chemotherapy resulted in local recurrence in 8 of 12 patients. Radical surgery alone, or radical surgery combined with radiation and chemotherapy resulted in local recurrence in 1 of 6. Even with complete local disease control, 7 of 16 (44%) patients died of metastases. Both A.J.C. Clinical Stage II and III patients had a similar poor prognosis. Associated neurofibromatosis did not worsen prognosis. These data suggest that both moderate and high-grade primary neurofibrosarcoma are highly malignant neoplasms and should be treated by radical resection. Preoperative intraarterial Adriamycin and radiation--found to be successful for other highly malignant sarcomas--may be of benefit. Since distant disease occurs despite local control, postoperative adjuvant chemotherapy trials are warranted.

Solitary neurogenous sarcomas of the head and neck

The clinical histories of three patients with neurogenous sarcomas involving the head and neck are detailed. The most satisfactory treatment suggested for such tumors involves combined therapy with chemotherapy, radiation, and radical surgical excision. By so doing, potential patient cure might be further increased and survival rates further improved.