Neurofibroma: Case Series with Clinical Features and Recommendations

Neurofibroma is an autosomal benign disorder. It can be localized, diffuse or invasive like plexiform neurofibroma that involves the nerves, muscle, tissues, skeleton. It represents itself as a destructive variant of neurofibroma, mostly present as orbital or periorbital neurofibroma or may be associated with autosomal dominant disease. Clinical diagnosis of neurofibromatosis (NF) according to National Institutes of Health (NIH) criteria should have more than two of the seven features including lisch nodules, cafe'- au-lait spots, plexiform neurofibroma, optic glioma, freckling, first degree relative with NF or dysplasia of cortical bones. However, proper early diagnosis is still crucial due to its various presentation such as cheek mass, painless swelling on skin, chalazion, intratracheal tumor, genital swelling or ptosis. It is reported that neurofibroma often represents as ocular or facial swelling. Here we are presenting features of neurofibroma of eight cases of patients from Civil Hospital, Karachi. These cases had main complain of overhanging skin mass mainly on orbital or periorbital region that damage the area and with poor daily activities. Multiple nodules on face and body along with them Cafe'-au-lait spots and lisch nodules were main signs. While, other signs i.e. ptosis, pterygium, telecanthus and muddy discoloration of conjunctiva need further evaluation for correlation with neurofibromatosis. Debulking surgery was planned for most of the cases but the huge disfigurement caused by overhanging skin mass and nodules made it a challenge for plastic surgeons to provide good outcomes with minimum damage. Keywords: neurofibroma; lisch nodules; ptosis; Cafe'-au-lait spot; periorbital; overhanging skin.

Identification of potential common genetic modifiers of neurofibromas: a genome-wide association study in 1333 patients with neurofibromatosis type 1

BACKGROUND

Neurofibromatosis type 1 (NF1) is characterized by the highly variable and unpredictable development of benign peripheral nerve sheath tumours: cutaneous (cNFs), subcutaneous (scNFs) and plexiform (pNFs) neurofibromas.

OBJECTIVES

To identify neurofibroma modifier genes, in order to develop a database of patients with NF1.

METHODS

All patients were phenotypically evaluated by a medical practitioner using a standardized questionnaire and the causal NF1 variant identified. We enrolled 1333 patients with NF1 who were genotyped for > 7 million common variants.

RESULTS

A genome-wide association case-only study identified a significant association with 9q21.33 in the pNF phenotype in the discovery cohort. Twelve, three and four regions suggestive of association at the P ≤ 1 × 10-6 threshold were identified for pNFs, cNFs and scNFs, respectively. Evidence of replication was observed for 4, 2 and 6 loci, including 168 candidate modifier protein-coding genes. Among the candidate modifier genes, some were implicated in the RAS-mitogen-activated protein kinase pathway, cell-cycle control and myelination. Using an original CRISPR/Cas9-based functional assay, we confirmed GAS1 and SPRED2 as pNF and scNF candidate modifiers, as their inactivation specifically affected NF1-mutant Schwann cell growth.

CONCLUSIONS

Our study may shed new light on the pathogenesis of NF1-associated neurofibromas and will, hopefully, contribute to the development of personalized care for patients with this deleterious and life-threatening condition.

Intratemporal facial nerve neurofibroma causing facial paralysis in an infant: Case report and review of the literature

This article describes the first recorded case of intratemporal neurofibroma in an infant. A literature review of all other existing cases of intratemporal neurofibroma is performed, finding that the majority of cases involve multiple segments and can be found in the mastoid segment most often. Most common symptoms described included facial paralysis, otalgia, and conductive hearing loss, respectively.

Distinct Transcriptional Profiles in the Different Phenotypes of Neurofibroma from the Same Subject with Neurofibromatosis 1

Neurofibromatosis 1 is a prevalent hereditary neurocutaneous disorder. Among the clinical phenotypes of neurofibromatosis 1, cutaneous neurofibroma (cNF) and plexiform neurofibroma (pNF) have distinct clinical manifestations, and pNF should be closely monitored owing to its malignant potential. However, the detailed distinct features of neurofibromatosis 1 phenotypes remain unknown. To determine whether the transcriptional features and microenvironment of cNF and pNF differ, single-cell RNA sequencing was performed on isolated cNF and pNF cells from the same patient. Six cNF and five pNF specimens from different subjects were also immunohistochemically analyzed. Our findings revealed that cNF and pNF had distinct transcriptional profiles even within the same subject. pNF is enriched in Schwann cells with characteristics similar to those of their malignant counterpart, fibroblasts, with a cancer-associated fibroblast-like phenotype, angiogenic endothelial cells, and M2-like macrophages, whereas cNF is enriched in CD8 T cells with tissue residency markers. The results of immunohistochemical analyses performed on different subjects agreed with those of single-cell RNA sequencing. This study found that cNF and pNF, the different neurofibromatosis phenotypes in neurofibromatosis 1, from the same subject are transcriptionally distinct in terms of the cell types involved, including T cells.

Rapidly expanding giant neurofibroma of the back with intratumoral hematoma: a case report and literature review

Neurofibromatosis type I is a common genetic disease that can lead to disfigurement, neurological and functional disorders. However, it is rare to meet the case which a huge mass is formed rapidly after neurofibroma ruptures. This case report describes a rare case of a 52-year-old female with a rapidly expanding mass on her back and mild anemia as the main symptoms. Physical examination showed a huge mass on the back and a surface ulceration with the diameter of 6 cm. Imaging examination revealed the abundant blood supply to the lesion. We performed preoperative arterial embolization, and surgical resection on the fifth day after embolization. After operation, proper blood transfusion and vacuum sealing drainage (VSD) were given. Through 9-months follow-up study, the incision of the patient recovered well and there was no sign of tumor recurrence. Therefore, this case report provides clinicians with valuable experience in the treatment for rapidly expanding neurofibroma.

Perinatal folate levels do not influence tumor latency or multiplicity in a model of NF1 associated plexiform-like neurofibromas

OBJECTIVE

In epidemiological and experimental research, high folic acid intake has been demonstrated to accelerate tumor development among populations with genetic and/or molecular susceptibility to cancer. Neurofibromatosis type 1 (NF1) is a common autosomal dominant disorder predisposing affected individuals to tumorigenesis, including benign plexiform neurofibromas; however, understanding of factors associated with tumor risk in NF1 patients is limited. Therefore, we investigated whether pregestational folic acid intake modified plexiform-like peripheral nerve sheath tumor risk in a transgenic NF1 murine model.

RESULTS

We observed no significant differences in overall survival according to folate group. Relative to controls (180 days), median survival did not statistically differ in deficient (174 days, P = 0.56) or supplemented (177 days, P = 0.13) folate groups. Dietary folate intake was positively associated with RBC folate levels at weaning, (P = 0.023, 0.0096, and 0.0006 for deficient vs. control, control vs. supplemented, and deficient vs. supplemented groups, respectively). Dorsal root ganglia (DRG), brachial plexi, and sciatic nerves were assessed according to folate group. Mice in the folate deficient group had significantly more enlarged DRG relative to controls (P = 0.044), but no other groups statistically differed. No significant differences for brachial plexi or sciatic nerve enlargement were observed according to folate status.

Combined CDK4/6 and ERK1/2 Inhibition Enhances Antitumor Activity in NF1-Associated Plexiform Neurofibroma

PURPOSE

Plexiform neurofibromas (PNF) are peripheral nerve sheath tumors that cause significant morbidity in persons with neurofibromatosis type 1 (NF1), yet treatment options remain limited. To identify novel therapeutic targets for PNF, we applied an integrated multi-omic approach to quantitatively profile kinome enrichment in a mouse model that has predicted therapeutic responses in clinical trials for NF1-associated PNF with high fidelity.

EXPERIMENTAL DESIGN

Utilizing RNA sequencing combined with chemical proteomic profiling of the functionally enriched kinome using multiplexed inhibitor beads coupled with mass spectrometry, we identified molecular signatures predictive of response to CDK4/6 and RAS/MAPK pathway inhibition in PNF. Informed by these results, we evaluated the efficacy of the CDK4/6 inhibitor, abemaciclib, and the ERK1/2 inhibitor, LY3214996, alone and in combination in reducing PNF tumor burden in Nf1flox/flox;PostnCre mice.

RESULTS

Converging signatures of CDK4/6 and RAS/MAPK pathway activation were identified within the transcriptome and kinome that were conserved in both murine and human PNF. We observed robust additivity of the CDK4/6 inhibitor, abemaciclib, in combination with the ERK1/2 inhibitor, LY3214996, in murine and human NF1(Nf1) mutant Schwann cells. Consistent with these findings, the combination of abemaciclib (CDK4/6i) and LY3214996 (ERK1/2i) synergized to suppress molecular signatures of MAPK activation and exhibited enhanced antitumor activity in Nf1flox/flox;PostnCre mice in vivo.

CONCLUSIONS

These findings provide rationale for the clinical translation of CDK4/6 inhibitors alone and in combination with therapies targeting the RAS/MAPK pathway for the treatment of PNF and other peripheral nerve sheath tumors in persons with NF1.

Fatal Retroperitoneal Bleeding in Neurofibromatosis Type 1: A Clinically Occult Complication

ABSTRACT

Neurofibromatosis type 1 (NF1) is a common, autosomal dominant neurocutaneous syndrome. The most frequent clinical manifestations include multiple neurofibromas, café-au-lait spots, dystrophic scoliosis, benign and malignant peripheral nerve sheath tumors, and paragangliomas. Neurofibromatosis type 1 vasculopathy is a less well-recognized constellation of vascular pathologies that can cause significant medical complications in patients with NF1. A rare manifestation of this process is neurofibroma infiltration of vasculature with resultant bleeding. The case presented herein illustrates a rare example of a massive fatal hemorrhage due to disruption of a large paraspinal artery in the setting of a diffuse, infiltrative neurofibroma. This case highlights the potential of benign neurofibromas to infiltrate major blood vessels, leading to extensive bleeding and death.

[Neurofibromas in Type I Neurofibromatosis. Description of a clinical case and literature review]

Neurofibromatosis type 1 (NF1) is the most frequent genodermatosis. Its cutaneous findings are key for early diagnosis, as they usually appear at early age. Café-au-lait macules are the most known cutaneous findings. Neurofibromas are the most frequent cutaneous tumors in patients with NF1, showing multiple clinical manifestations. They are classified as superficial and deep lesions, and su perficial neurofibromas are subdivided in cutaneous or subcutaneous. Some neurofibromas may be present since birth; however, most appear during adolescence. Neurofibromas constitute 2 out of 7 of the NIH criteria of Neurofibromatosis type 1. Most of them are benign, do not require treatment and their recognition allows an early diagnosis of the disease.

OBJECTIVE

To describe and classify neu rofibromas associated with NF1 through a clinical case.

CLINICAL CASE

18-year-old male diagnosed since childhood with NF1 presents with multiple oval nodules on his face, occipital area, and wrist, multiple blue-red macules on his back and an asymptomatic pink plaque in his thigh. Ultrasound of the nodules was suggestive of neurofibromas and a skin biopsy of the lesions in the back and thigh were consistent with cutaneous neurofibromas.

CONCLUSION

This case illustrates the varied clinical manifestations of neurofibromas in adolescence. Recognition of neurofibromas by the pediatrician, pediatric neurologist and/or dermatologist is crucial for the early diagnosis of NF1.

RETRACTED: A case report of a 4-year-old girl with neurofibromatosis type 1

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Authors. A diagnostic discordance in the original pathology reports has been noticed and requires further evaluation, therefore the paper will be retracted.

Intranodal Neurofibroma: A Case Report and Literature Review

PURPOSE

To report a case of neurofibroma involving the lymph nodes and to perform a literature review on this topic.

OBSERVATIONS

A 72-year-old woman with a history of neurofibromatosis and biopsy-proven malignant melanoma of the left forearm underwent wide local excision of the malignant lesion along with sentinel axillary lymph node biopsy. Histological examination of axillary nodes revealed diffuse neurofibromatosis within 2 lymph node capsules. A thorough review of the English literature pertaining to intranodal neurofibroma was performed by querying Google Scholar and PubMed. Only 5 cases of intranodal neurofibroma have been described until now.

CONCLUSIONS AND IMPORTANCE

Neurofibroma involving the lymph nodes is rare and this is the first reported case that is shown to diffusely involve the intracapsular space. Furthermore, intranodal neurofibroma can represent a diagnostic pitfall in the evaluation of sentinel lymph nodes for metastatic melanoma.

A case of jejunal neurofibroma in von Recklinghausen's disease with active hemorrhage, detected and located with gastrointestinal bleeding scintigraphy: A case report with literature review

A 69 year old patient was admitted to hospital with massive gastrointestinal hemorrhage. The clinical presentation of the patient, except for bleeding, was dominated by the presence of neurofibromatosis type 1 - Von Recklinghausen disease. The patient was referred to multislice computed tomography (CT) angiography, magnetic resonance imaging (MRI), esophagogastroduodenoscopy and colonoscopy, which were performed without successful detection of the bleeding site. The MRI examination showed the existence of a tumor located in the small pelvis. After that, gastrointestinal bleeding scintigraphy (GIBS) with technetium-99m (^99mTc) pyrophosphate in vivo labeled erythrocytes was done. Gastrointestinal bleeding scintigraphy showed active intraluminal bleeding from the projection of jejunum, which flowed through the small intestine to the descending colon and the sigmoidal and rectal segment of the colon. Surgical resection of the abdomen revealed the existence of tumors in the jejunum with active bleeding and resection and anastomosis was done. Histopathological verification showed intestinal neurofibroma. In this case GIBS showed usefulness in proving the existence of active bleeding in the small intestine and its localization, and it was of a great help in planning the surgical treatment of a patient.

18F-NaF Uptake in Retroperitoneal Neurofibroma and Uterine Leiomyoma Calcifications

A 48-year-old woman with intermittent lower back pain for 9 months and known retroperitoneal neurofibroma underwent F-NaF PET/CT scan to assess possible bony lesions causing the pain. Incidentally, the images showed elevated NaF activity in the retroperitoneal neurofibroma. In addition, uterine leiomyoma with heterogeneous calcifications revealed increased NaF activity.

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.

Intradural extramedullary spinal masses treated at the Wits teaching hospitals between 2014 - 2017

BACKGROUND

Intradural extramedullary (IDEM) spinal masses are common lesions with varying histological diagnoses often associated with significant neurological deficits. This study aimed to describe the epidemiology, management and perioperative outcome of IDEM tumours seen at the teaching hospitals of the University of the Witwatersrand, Johannesburg, between 2014 and 2017.

RESULTS

92 patients were included in the study. The ages ranged from 21 to 87 years, sex ratio was M:F 1:1.4, and duration of symptoms prior to diagnosis ranged between 3 days to 18 months. Local and radicular type pain as well as motor weakness were the commonest symptoms. 67% had severe neurological deficit McCormick Grade III and IV. Schwannoma (26) Neurofibromas (21) and Meningiomas (16) and were the most frequent tumour types. Meningiomas predominantly occurred at the cranio-cervical and thoracic levels. Nerve sheath tumours were mostly found at the cervical and lumbar levels while filum terminale ependymomas occurred at the thoracolumbar area. Laminectomy was the commonest surgical approach employed, and the extent of resection varied, with total excision in half the cases. Neurological function was regained in 3 patients, deteriorated in two and was unchanged in the remainder.

CONCLUSION

IDEM tumours are an important subset of spinal cord compressive lesions Presentation with severe neurological deficit is common and though resection is feasible neurological deficit remains in the vast majority. Earlier detection should improve the results of surgery.

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.

Cutaneous neurofibromas

Objective

To present the current terminology and natural history of neurofibromatosis 1 (NF1) cutaneous neurofibromas (cNF).

Methods

NF1 experts from various research and clinical backgrounds reviewed the terms currently in use for cNF as well as the clinical, histologic, and radiographic features of these tumors using published and unpublished data.

Results

Neurofibromas develop within nerves, soft tissue, and skin. The primary distinction between cNF and other neurofibromas is that cNF are limited to the skin whereas other neurofibromas may involve the skin, but are not limited to the skin. There are important cellular, molecular, histologic, and clinical features of cNF. Each of these factors is discussed in consideration of a clinicopathologic framework for cNF.

Conclusion

The development of effective therapies for cNF requires formulation of diagnostic criteria that encompass the clinical and histologic features of these tumors. However, there are several areas of overlap between cNF and other neurofibromas that make distinctions between cutaneous and other neurofibromas more difficult, requiring careful deliberation with input across the multiple disciplines that encounter these tumors and ultimately, prospective validation. The ultimate goal of this work is to facilitate accurate diagnosis and meaningful therapeutics for cNF.

[Anesthetic Management of a Patient with von Recklinghausen Disease after Surgeries for Thoracic and Spinal Neurofibroma]

Von Recklinghausen disease is an autosomal domi- nant neurocutaneous disorder, characterized by cuta- neous neurofibromas, accompanied by café-au-lait spots. We report a case of a 51-year-old man with von Recklinghausen disease who had been operated on for thoracic and spinal neurofibroma. Exploratory thoracotomy was performed under general anesthesia combined with epidural anesthesia. After tracheal intubation with spiral tube, one lung ventilation was performed using blocker tube. General anesthesia was maintained by inhalation of oxygen, air, and desflurane and the continuous infusion of remifentanil. The opera- tive course was uneventful. The patient emerged from general anesthesia smoothly, and was extubated safely. There was no neurological abnormality after operation. Preoperative evaluation of airway status and neuro- logical findings are essential in the anesthetic management of the patient with von Recklinghausen disease. This case suggests that we must take the complication into account for anesthetic management and select the appropriate anesthetic method by routine preoperative estimation. It is of great importance that anesthesiologists evaluate the airway status and neurological find- ings of patients with von Recklinghausen disease.

[Ultrasound-guided Thoracic Epidural and Spinal Anesthesia for the Management of Patients Undergoing Systemic Neurofibroma Resection]

We report successful anesthetic management of a patient undergoing systemic neurofibroma resection using thoracic epidural and spinal anesthesia. A 40- year-old man (weight 66 kg) with von Recklinghausen's disease and intermittent convulsions was scheduled for large-scale tumor resection on the back and arms. He also had chronic obstructive pulmonary disease and stiff neck We decided not to perform operation under general anesthesia. Before epidural or spinal anesthesia, we confirmed that there were no fibromas -in the subdermal lesion for needle progression by ultraso- nography. Thoracic epidural anesthesia was performed at the T2-3 level with 0.25% ropivacaine 5.0 ml, and spinal anesthesia with 0.5% isobaric bupivacaine 3.0 ml. To calm his anxiety, we continuously adminis- tered dexmedetomidine 0.4-0.8 μg · kg(-1) - hr(-1). The operation was performed uneventfully without se- vere pain. Dexmedetomidine was continued until the next morning. The patient showed no signs of convul- sions or intractable pain postoperatively.

Clinical characteristics and outcomes of intratemporal facial nerve neurofibromas

This study aimed to present clinical features and outcomes of 10 patients with intratemporal facial nerve neurofibromas.

METHODS

The ten patients underwent complete tumor removal, and nerve grafting was performed on 3 cases whose nerve integrity was sacrificed. They were followed up after surgery.

RESULTS

All patients firstly complained of facial palsy, and progressive sensorineural hearing loss was also present in one case. Insidious onset of facial palsy was found in 6 of 10 cases (60.0%). There was multi-segment involvement in 5 of 10 cases (50.0%). During the follow-up of 4.2±1.5 ys (range, 2-6 ys), 1 of 6 cases who successfully maintained nerve integrity recovered to Grade III, and the others remained or recovered to Grade V or even Grade VI. In contrast, all of the 3 cases with nerve grafting recovered from Grade VI to Grade III or Grade IV. No tumor recurrence was noted.

CONCLUSIONS

Facial nerve neurofibromas mainly presented with insidious facial palsy, and tended to affect multiple segments of facial nerve. It seemed that complete tumor removal and nerve grafting had better outcomes of facial nerve compared to complete tumor removal with nerve integrity preserved.

Solitary Neurofibroma with Malignant Transformation: Case Report and Review Of Literature

Solitary neurofibromas are rare tumors associated mainly with neurofibromatosis and widely described in the literature as benign. We report a case of a 55-year-old female with no history of neurofibromatosis who presented with a slow-growing, painless lump on her torso. Pathologic evaluation of the lesion after excisional biopsy revealed high mitotic activity and increased cellularity within the lesion as well as positive S-100 stain. She was diagnosed with solitary subcutaneous neurofibroma with features of malignant peripheral nerve sheath tumor transformation. To our knowledge, no other case of a solitary neurofibroma that transformed into a malignant tumor in this location was described in the literature.

Ocular motility abnormalities in orbitofacial neurofibromatosis type 1

PURPOSE

To evaluate the causes of ocular motility disturbances in a group of patients with orbitofacial neurofibromatosis (OFNF) with neurofibromas on the lid, brow, face, or in the orbit from infancy or early childhood.

METHODS

The medical records of patients with OFNF from one institution were retrospectively reviewed; selected patients were reexamined.

RESULTS

A total of 45 patients with unilateral OFNF and 4 with bilateral OFNF were included. Of these, 14 had no strabismus and relatively good vision, with no ductional abnormalities on either side despite large globes, sphenoid dysplasia, and neurofibromas in the orbit and/or cavernous sinus in many. The 8 patients with comitant strabismus also had no ductional abnormalities with a similar constellation of anatomic abnormalities, but these patients all had poor vision in at least one eye. The 27 patients with incomitant strabismus all had downward displacement of the globe and limited ductions.

CONCLUSIONS

The pathologic anatomic changes associated with OFNF do not always cause ocular motility abnormalities: strabismus generally was not present when ocular motility was full and visual acuity was good. Comitant strabismus occurred in the setting of full ocular motility with reduced vision in at least one eye. Incomitant strabismus was always accompanied by reduced vision and a ductional abnormality in one or both eyes due to anatomic abnormalities of the orbit and skull.

A painless neck swelling and von Recklinghausen

BACKGROUND

Von Recklinghausen's disease, an autosomal dominant genetic disorder, may occasionally present with unusual localizations of neurofibromas.

CLINICAL CASE

A 46-year old woman, known with Von Recklinghausen's disease, reported a swelling and a feeling of pressure and globus sensation. Clinical examination revealed multiple large nodi on the right side of the neck. Laboratory testing including thyroid-stimulating hormone (TSH) was normal. An MRI showed a 1 x 3 x 10 centimeter sausage-like structure compressing the right jugular vein. At surgical exploration a string-like tumour firmly attached to the right vagal and recurrent laryngeal nerve was found. The tumor and both nerves were macroscopically curative resected. Histopathological examination demonstrated a plexiform cervical vagus nerve neurofibroma without malignancy.

CONCLUSION

Patients with Von Recklinghausen's disease presenting with painless neck swellings may harbour cranial nerve neurofibromas.

A rare case of a solitary intraocular neurofibroma

BACKGROUND

Solitary neurofibroma in the absence of neurofibromatosis is of rare occurrence and very few cases have been reported till date.

OBJECTIVE

To report a case of a solitary intra-ocular neurofibroma.

CASE

A 65-year-old man presented to us with a large swelling appearing to arise from right pthisical eye for the past one and a half years. After knowing the extent and origin of mass lesion, right eyeball was enucleated and subjected to histopathological examination which revealed intraocular neurofibroma in the absence of neurofibromatosis which is of very rare occurrence.

CONCLUSION

The isolated neurofibroma of intraocular origin can present as an isolated orbital mass without systemic features.

[Lacosamide as an alternative in the treatment of post-surgery neuropathic pain in an allergic patient]

INTRODUCTION

Neuropathic pain is a condition that is still not well understood, although it affects a significantly high percentage of the population. The main problem lies in the fact that it can become a fairly disabling pathology. The most frequent treatment is based essentially on two drugs: gabapentin and pregabalin. Other pharmaceuticals, such as antidepressants, opioids or N-methyl-D-aspartate receptor antagonists can also be employed in combination with the primary drugs. All the same, treatment remains unsatisfactory. Furthermore, it must be borne in mind that there may be patients who are allergic to the two main drugs.

CASE REPORT

We report the case of a 36-year-old female with neuropathic pain secondary to surgery to correct a neurinoma in the brachial plexus, who could not be treated with gabapentin or pregabalin because of a personal history of allergy to these substances. Treatment with another drug (lacosamide), however, was very effective and displayed a very good response.

CONCLUSIONS

Lacosamide is a third-generation antiepileptic drug that has been proven to be effective, safe and with few side effects. It has been considered a good therapeutic option for the treatment of neuropathic pain in patients who are allergic to pregabalin.

Intrascrotal extratesticular neurofibroma as a possible cause of failed descent in ipsilateral testis

Intrascrotal extratesticular neurofibromas (IEN) often originate from genitofemoral nerve (GFN) and present as a paratesticular mass. Synchronous presence of IEN and undescended testis has not been reported previously. A 12-year-old boy with neurocutaneous syndrome and congenital giant melanocytic nevi along with IEN and ipsilateral undescended testis is presented, to discuss the underlying pathophysiology of failed testicular descent in the presence of IEN.

A case of neurofibroma of the appendix in von Recklinghausen disease

A 67-year-old man with von Recklinghausen disease (VRD) was found to have an ill-defined large mass in the ileocecal area on abdominal computed tomography when he was examined for abdominal pain in the right lower quadrant. Because of high serum C-reactive protein level and leukocytosis appendiceal tumor complicated by appendicitis was diagnosed. Due to the possibility of malignancy, standard cancer surgery was carried out to remove the mass, i.e., ileocecal resection together with dissection of the regional lymph nodes. The cecum was displaced by a remarkably enlarged appendix with a firm and thickened wall. The distal portion of the appendix was cystically dilated, forming an abscess. The pathological diagnosis was neurofibromatosis with mucus hyperplasia and abscess formation in the appendix. Neurofibroma of the appendix is very rare, even in patients with VRD. Although it is benign, prompt resection is recommended because of a high risk of appendicitis and malignant transformation.

Neurofibroma of the sciatic nerve with neurofibromatosis type 1

A 28-year-old man with neurofibromatosis type 1(NF1) presented with a tumor in the sciatic nerve and femoral nerve. The differential diagnosis of malignant peripheral nerve sheath tumor was based on clinical, radiological, and histological evidence. The tumor apparently originated in sciatic nerve at the posterior aspect of the left thigh. The lesion was resected totally without neural damage to the sciatic nerve. The tumor did not recur after 2 years.

Orbital inflammation after use of zoledronic acid for metastasized prostate carcinoma

Report of a case of orbital inflammation after the use of zoledronic acid for metastasized prostate cancer.

Solitary neurofibroma of the palate. A case report

The neurofibroma is a benign tumor of neuronal origin not frequently located in the oral cavity. The possible association of this neoplasia with systemic pathologies, such as Von Recklinghausen's disease and multiple endocrine neoplasia, makes its diagnosis fundamental. The diagnosis is, in most cases, quite complex, because of the neurofibroma's strong similarities with a great number of benign neoformations of the connective tissue, of the epithelium, and of the bone. The histology represents, therefore, the fundamental diagnostic criterion, in particular, through the use of appropriate immunohistochemical analysis. This articles presents the case of a solitary neurofibroma, subtype I (common Schwann cell type), detected on the left-hand side of the posterior region of the palate in a 56-year-old woman, which presented itself as an otherwise non-symptomatic ulcerated mass. After a careful anamnesis, an incisional biopsy was performed in order to establish the histological nature of the neoformation. The immunohistochemical test, which resulted positive for S-100 and negative for the epithelial membrane antigen and keratin, allowed the diagnosis of a presumably benign lesion deriving from a neural differentiation. The surgical excision of the entire mass was accompanied by the extraction of the upper left-hand second molar, which was attached to the mass through its palatal root.

Posterior midline approach for large anterior/anterolateral foramen magnum tumours

The standard surgical approaches described for excision of anterior or anterolaterally placed foramen magnum (FM) tumours are the far lateral approach, the extreme lateral approach and the transoral approach. In general the posterior midline approach is considered not suitable for these lesions. We have operated on 27 patients with benign anterior/anterolaterally placed FM tumours in the last 8 years. Thirteen of these were operated via the posterior midline approach. All these 13 patients had large or giant tumours displacing the cervicomedullary region posteriorly and laterally. This allowed adequate access through this approach with minimal handling of neural tissue. For small lesions, the far lateral approach was used. Most of the patients improved significantly neurologically. We recommend the standard midline posterior approach for large/giant FM tumours as the tumour size itself provides enough working space for the surgeon. For small lesions, the far lateral approach is preferred.

Treatment of orbital schwannomas and neurofibromas

We present an overview of the treatment and clinical outcome of five orbital peripheral nerve tumours, carried out in our centre from 1999 to 2003. The surgical approach was determined by the location and extension of the lesion. Supraorbital orbitotomy was performed in two superiorly located lesions, a transconjunctival approach in one medial, basal, extraconal lesion. A pterional extradural approach was used in two cases with involvement of the apex, superior orbital fissure and cavernous sinus. Three patients were diagnosed as having schwannoma, one as neurofibroma, and one as cystic mixed neurofibroma and schwannoma. One patient suffered from multiple schwannomas [bilateral acoustic schwannomas, cervical schwannomas (NF2)]. One patient showed bilateral orbital neurofibromas, plexiform cutaneous neurofibroma (NF1) and glaucoma due to a coexisting Marfan's syndrome. Local recurrences were not seen after complete resection in all patients. Surgery is the therapeutic goal.

Localized hypertrichosis in a pediatric patient--what is the mechanism for excess hair growth?

Localized hypertrichosis is an uncommon complaint among pediatric dermatology patients. We highlight an instance of localized hypertrichosis due to an underlying diffuse neurofibroma in a patient with known neurofibromatosis 1. The classification and possible underlying pathogenic mechanisms of localized hypertrichosis in pediatric patients is discussed.

Neurofibroma of the pinna

Neurofibromas are relatively common lesions of the nervous system, but only a few cases involving the pinna have been reported. The emphasis in most of these reports was on the cosmetic deformity; functional impairment in the form of hearing loss has been mentioned in only a few reports. We report a case of pinnal neurofibroma in which the primary complaint was otitis externa; hearing loss and cosmetic deformity were also present. Surgical excision resulted in an excellent functional and cosmetic outcome. This case demonstrates that neurofibroma of the pinna in the area of the external meatus can produce functional as well as cosmetic impairment, and surgery can produce a very satisfactory result.

Transoral approach to a huge neurofibroma of the parapharyngeal space: a case report

Neurofibroma of the parapharyngeal space accounts for less than 2% of all parapharyngeal space neoplasms. A 38-year-old man presented with complaints of snoring and left-sided nasal obstruction. Medical history also revealed numerous huge skin neurofibromas and multiple café au lait spots all over the body. Pharyngeal endoscopic examination disclosed a firm, nonpulsatile submucosal mass, pushing the left pharyngeal region approximately 5 cm medially, and extending to the inferior part of the epiglottis. The tumor was removed by transoral excision without any subsequent complications. Histological and immunohistochemical examinations revealed a neurofibroma.

Absence of gene mutations in a case of concomitant presence of carcinoid of the ampulla of vater pheochromocytoma and Von Recklinghausen disease

The rare association between Von Recklin-ghausen's disease (VRD) and tumours other than in central nervous system is well recognized. However, the concomitance of VRD, a carcinoid of the ampulla of Vater, and a pheochromocytoma has been described very rarely in literature. Furthermore, the possible role of the genes usually involved in multiple endocrine neoplasia (MEN) syndromes, in this association, is unclear. We report the case of a patient affected by VRD and extra-adrenal pheochromocytoma, operated on in the past for a carcinoid of the ampulla of Vater. To determine if genes involved in MEN syndromes might play a role in this particular triad, we investigated the presence of somatic or germline mutations in the RET proto-oncogene and menin gene by non isotopic polymerase chain reaction single stranded conformation polymorphism (PCR-SSCP) and heteroduplex gel electro-phoresis. The results demonstrated that no somatic or germline mutations in the MEN-1 and MEN-2 genes were involved in the pathogenesis of these tumours.

A peripheral nerve sheath tumour as a cause of nasal obstruction

Neurogenic tumours form a very small percentage of all neoplastic lesions of the head and neck region. However, the head and neck region is by far the most common location for benign peripheral nerve tumours. Several cases involving the nose have been sporadically documented throughout the medical literature. We present a rare case of a solitary neurofibroma arising from the lateral nasal wall of a 68-year-old woman. En bloc surgical resection of the mass was achieved by the lateral rhinotomy approach. The clinical significance of this case report is due to its rare site. In recent medical literature, there has been only one report concerning a solitary neurofibroma arising from the inferior turbinate. This case also highlights the importance of considering this clinical entity in the differential diagnosis when encountering a unilateral soft tissue mass in the nasal cavity.

Unusual association of adrenal pheochromocytoma and para-aortic neurofibroma in pregnancy

The association of pheochromocytoma (PHEO) and pregnancy is uncommon and life threatening for both the fetus and the mother. Early diagnosis and treatment is essential to decrease maternal and fetal mortality and to differentiate the disease from the more common pre-eclampsia. While medical treatment should be started immediately after diagnosis, the timing of surgical treatment is still debated. We describe the case of a 27-yr-old woman in the 18th week of pregnancy who showed a biochemical pattern typical of PHEO and, by imaging studies, 2 tumors with the same characteristics: the first localized on the right adrenal gland, the second at the right renal hilum. The patient underwent surgery because of suspicion of malignant PHEO with local metastasis, while histology revealed a rare association of a solitary PHEO and para-aortic neurofibroma, both tumors embryologically deriving from a common cell precursor.

Intraarticular Neurofibroma of the Hip

The magnetic resonance imaging findings in 2 cases of pathologically proven hepatocellular carcinoma that mimicked focal nodular hyperplasia are presented. Both cases were found in patients with cirrhosis, a condition in which focal nodular hyperplasia is unlikely to occur. Recognition that hepatocellular carcinoma may mimic focal nodular hyperplasia in patients with cirrhosis may prevent misdiagnosis and allow for earlier intervention.

Palatal Neurofibroma Associated With Localized Periodontitis

BACKGROUND

Neurofibromatosis type 1 (NF1) is the most common form of neurofibromatosis. While typically considered a dermatologic disorder, intraoral signs of neurofibromatosis occur quite commonly. This clinical entity can be confused with periodontitis because of the presence of periodontal pockets. In this report, we present the case of a palatal neurofibroma with radiographic involvement in a patient with NF1.

METHODS

A 40-year-old female patient was referred from her general dentist to evaluate advanced periodontitis in the maxillary left quadrant. The patient's medical history was significant for a soft tissue lesion excised from her back 11 years previously and diagnosed as a neurofibroma. Subsequent medical examination at that time confirmed a systemic diagnosis of NF1. A comprehensive periodontal evaluation was performed, and panoramic and periapical radiographs were taken. Teeth were tested for vitality. An incisional biopsy was completed for histopathologic examination.

RESULTS

The periodontal evaluation revealed the presence of 6 to 9 mm probing depths adjacent to teeth #14 and #15. Panoramic and periapical radiographs showed a circumscribed 0.8x0.9-cm unilocular radiolucency superimposed over the root of tooth #13 and extensive horizontal bone loss on the distal side of #15. Incisional biopsy confirmed the presence of a neurofibroma, and because of the extent of the lesion, the patient was referred to the Oral and Maxillofacial Surgery service for complete excision.

CONCLUSIONS

Neurofibromas can cause extensive destruction of alveolar bone, mimicking periodontitis. Due to the potential systemic and genetic implications, the diagnosis of neurofibroma requires appropriate medical referral.

Melanocytic nevi are associated with neurofibromas in neurofibromatosis, type I, but not sporadic neurofibromas: a study of 226 cases

BACKGROUND

Neurofibromatosis, type 1, is associated with cutaneous melanin pigmentation, but an association with ordinary melanocytic nevi has not been described.

METHODS

This retrospective case-control study was designed to see if neurofibromas in patients with neurofibromatosis, type 1 (NF-1) differ from sporadic neurofibromas (SN) in their incidence of associated melanocytic nevi and other histologic features. Slides from 114 NF-1 were compared with 112 SN and 300 intradermal melanocytic nevi (IDN).

RESULTS

Small lentiginous melanocytic nevi were identified over 13 NF-1 (11%) but no SN (P=0.0002). Compared with other NF-1, NF-1 with nevi were more frequently associated with melanocytic hyperplasia, giant melanosomes and diffuse neurofibroma (P<0.03). Compared with SN, NF-1 were also more frequently associated with melanocytic hyperplasia, lentigo simplex-like changes, diffuse neurofibroma and plexiform neurofibroma (P<0.001). Sebaceous hyperplasia (14%), dermal elastosis (9%), lipomatous change (8%), epithelial cysts (4%) and keratin granulomas or folliculitis (3%) were not significantly different in prevalence between NF-1, SN and the control group of IDN.

CONCLUSIONS

This study suggests that there is a difference in the potential for melanocytic proliferation in NF-1 compared with SN. NF-1, SN and IDN are associated with a similar range of incidental histologic changes. Ball NJ, Kho GT. Melanocytic nevi are associated with neurofibromas in neurofibromatosis, type 1, but not sporadic neurofibromas. A study of 226 cases.