Sacral Schwannoma Research Articles

816 A Benign Diagnosis for Suspected Malignant Differential of a Sacral Lytic Lesion.

Abstract 49-year-old relatively healthy man presented to the ER with abdominal and associated low back pain. Past history was significant for excision of spinal benign tumor excision and 30-year pack history of smoking. Review of systems was significant for recurrent leg swelling and muscle aches. Neurological exam was non focal. CT scan of the abdomen and pelvis revealed a lytic sacral lesion with soft tissue component. The rest of the skeletal survey and system evaluation was unremarkable. Patient was referred to Oncology, suspecting the localized plasmacytoma variant of multiple myeloma with an inconclusive sacral mass biopsy report. Full blood count, comprehensive metabolic panel, Beta-2 microglobulin serum protein electrophoresis (SPEP), and free light chains assays undertaken were all within normal ranges. Further second opinion was sought for the biopsy results to undertake special stains which concluded the biopsy as schwannoma. In view of the persisting recurring pain and swelling, further MRI imaging and IR guided biopsy was suggested. However, the patient was with limited insurance coverage. He opted to defer further evaluation and adopted a “wait and see” approach and has since remained stable. Sacral schwannomas are rare. It is possible that his previous extradural lesion could have been a schwannoma. Schwannomas are slow growing and relatively asymptomatic. As they are typically lytic lesions can easily be mistaken for malignant lesions and have to be considered in the differential of osteolytic lesions as they can grow in close proximity to bony structures.

Giant sacral schwannoma in a neurofibromatosis type 2 patient

BackgroundNeurofibromatosis type 2 is an autosomal dominant disorder, mainly characterized by multiple neurological lesions, such as schwannomas, meningiomas, neurofibromas and intramedullary ependymomas. Schwannomas are usually small circumscribed lesion. Sacral location of a schwannoma with cystic change is a very rare finding. We are presenting one such case with giant cystic schwannoma with fluid–fluid levels in sacral region.Case presentationWe present a case of 13-year-old female patient, presenting with pelvic pain and gradually progressive bilateral lower limb weakness. On MRI, giant cystic schwannoma with internal fluid–fluid levels was noted in sacral region, extending anteriorly into the presacral region, causing mass effects on pelvic organs, which explained the cause of her symptoms. She also showed the presence of bilateral vestibular schwannoma and multiple small cerebral lesions, leading to the diagnosis of neurofibromatosis type 2.ConclusionsOur current case of neurofibromatosis type 2, diagnosed by presence of bilateral vestibular schwannoma, shows atypically large sacral cystic schwannomas and cerebral subcortical lesions, probably representing glial microhamartomas. Sacral schwannomas can be of giant size with cystic changes and fluid–fluid levels, mimicking aneurismal bone cyst, as in current case.

N°351 - Sacral schwannoma removal with IOM

N°351 - Sacral schwannoma removal with IOM

Surgical management of sacral schwannomas: a 21-year mayo clinic experience and comparative literature analysis.

Sacral and presacral schwannomas are rare, accounting for a minority of spinal schwannomas. We present our institution's experience surgically treating spinal schwannomas and compare it to the literature. Data were collected for 27 patients treated surgically for sacral or presacral schwannoma between 1997 and 2018 at all Mayo Clinic locations and 93 patients in the literature. Kaplan-Meier disease-free survival analysis was conducted. Unpaired two-sample t tests and Fisher's exact tests assessed statistical significance between groups. Our patients and those in the literature experienced a similar age at diagnosis (49.9 y/o. vs 43.4 y/o., respectively). Most of our patients (59.3%) reported full recovery from symptoms, while a minority reported partial recovery (33.3%) and no recovery (11.1%). A smaller percentage in the literature experienced full recovery (31.9%) and partial recovery (29.8%) but also no recovery (1.1%). Our patients experienced fewer complications (14.8% versus 25.5%). Disease-free survival curves for all patients showed no significant variation in progression by extent of resection of schwannoma (log-rank P = 0.26). No lesion progression was associated with full or partial symptom improvement (p = 0.044), and female patients were more likely to undergo resection via a posterior approach (p = 0.042). Outcomes of patients with sacral or presacral schwannomas vary based on patient demographics, tumor characteristics, symptoms, and surgical treatment. Among the range of symptoms experienced by these patients, the most common is pain. Prognosis improves and overall survival is high when the surgical approach towards sacral schwannomas is prepared and executed appropriately.

Surgical management of giant presacral schwannoma: systematic review of published cases and meta-analysis.

Giant presacral schwannomas are rare sacral tumors found in less than 1 of every 40,000 hospitalizations. Current management of these tumors is based solely upon case reports and small case series. In this paper the authors report the results of a systematic review of the available English literature on presacral schwannoma, focused on identifying the influence of tumor size, tumor morphology, surgical approach, and extent of resection (EOR) on recurrence-free survival and postoperative complications. The medical literature (PubMed and EMBASE) was queried for reports of surgically managed sacral schwannoma, either involving 2 or more contiguous vertebral levels or with a diameter ≥ 5 cm. Tumor size and morphology, surgical approach, EOR, intraoperative and postoperative complications, and survival data were recorded. Seventy-six articles were included, covering 123 unique patients (mean age 44.1 ± 1.4 years, 50.4% male). The most common presenting symptoms were leg pain (28.7%), lower back pain (21.3%), and constipation (15.7%). Most surgeries used an open anterior-only (40.0%) or posterior-only (30%) approach. Postoperative complications occurred in 25.6% of patients and local recurrence was noted in 5.4%. En bloc resection significantly improved progression-free survival relative to subtotal resection (p = 0.03). No difference existed between en bloc and gross-total resection (GTR; p = 0.25) or among the surgical approaches (p = 0.66). Postoperative complications were more common following anterior versus posterior approaches (p = 0.04). Surgical blood loss was significantly correlated with operative duration and tumor volume on multiple linear regression (both p < 0.001). Presacral schwannoma can reasonably be treated with either en bloc or piecemeal GTR. The approach should be dictated by lesion morphology, and recurrence is infrequent. Anterior approaches may increase the risk of postoperative complications.

Surgical Management of Giant Sacral Schwannoma: A Case Series and Literature Review

Giant sacral schwannomas are rare and difficult to treat. Unexpected neurologic deficits after surgery and tumor recurrence should be considered when surgery is performed. We attempt to remove the tumors via piecemeal total or subtotal excision, leaving parts of the capsule adjacent to nerves to preserve the nerves. This study aimed to present the cases of giant sacral schwannoma at our institutions as well as review the relevant literature and to discuss surgical management. This study included 11 patients (5 male and 6 female, mean age 53 years) with giant sacral schwannoma who were treated surgically. The clinical features, surgical details, and outcomes were investigated retrospectively. The tumors were intraosseous type in 4 cases, dumb-bell type in 3 cases, and retroperitoneal type in 4 cases. The surgeries were performed by a combined anterior and posterior approach in 4 cases, a posterior approach in 4 cases, and an anterior approach in 3 cases. The tumors were removed via piecemeal total or subtotal excision in 7 cases, partial excision in 3 cases, and enucleation in 1 case. After surgery, symptoms improved in all cases. The tumor recurred in 2 patients after partial excision. No patients receiving piecemeal total or subtotal excision showed recurrence. One patient developed motor weakness after piecemeal subtotal excision, but the symptoms resolved. Adopting an appropriate surgical approach based on the location of the tumor is important. Piecemeal total or subtotal excision, with parts of the capsule adjacent to nerves left behind may help achieve a good outcome, avoiding a postoperative neurologic deficit.

Management of presacral schwannomas—a 10-year multi-institutional series

Presacral or sacral schwannomas are relatively rare clinical entities thought to account for only 1 in every 40,000 hospitalizations. These lesions are benign, frequently monofocal, and arise from the exiting sacral nerve roots. Lesions are often asymptomatic, but may present with bulk symptoms (constipation, urinary frequency), sciatica, lower extremity weakness, and para-axial lumbosacral pain. At present, the treatment of choice for these lesions is gross total resection, with an approach dictated by the size of the intrasacral component. Despite numerous isolated case reports, few case series exist. Of those extant series, none are multi-institutional and only a handful describe multiple alternative approaches for the treatment of these tumors. Here we describe a series of seven patients treated at two tertiary care centers for sacral schwannoma with post-operative follow-up as far as 6 years.

Sacral Schwannoma: Which precautions to take to achieve a complete and safe excision

Background: Schwannomas are benign tumors that arise from the Schwann cells of the nerve fibers, they are found incidentally, usually asymptomatic, in some cases patiens can have pelvic heaviness, numbness or lower lumbar pain and extremely odd. Surgery is diagnostic and therapeutic. With this case we want to describe the precausions we carried out to have a safe surgery and a successful outcome.

Quantitative Analysis of the Characteristics of Sacral Giant Cell Tumors Using Contrast-Enhanced Computed Tomography

Background: Although CT morphological characteristics of giant cell tumors (GCTs) of the sacrum have been reported in the literature, the enhanced CT quantitative characteristics of GCTs have not been extensively evaluated. Objectives: The aim of our study was to analyze the enhancement characteristics of giant cell tumors of the sacrum. Patients and Methods: Sixty-one cases were reviewed, including 20 GCTs, 22 sacral chordomas (SCs) and 19 sacral schwannomas (SSs). The CT images of all the three types of tumors were retrospectively analyzed. The enhancement index (EI) of each mass was calculated by the formula: EI(a/v) = [D(a/v) - D(pre)]/D(pre), where D(a/v) was the density of the mass on the enhanced CT (a = arterial phase; v = portal venous phase), and D(pre) was the density of the mass on the pre-enhanced images. The maximum enhancement (Emax) was determined by the following equation: Emax = D(v) - D(pre). The parameters of the different enhancement phases among the 3 groups were compared with One-way ANOVA. Results: On the noncontrast images, the densities of the SCs were lower than those of the GCTs and SSs, but there was no difference between the GCTs and SSs (P > 0.05). In the arterial phase, the EIa of the GCTs was the highest among the three groups (P < 0.05), and that of the SCs was the lowest. In the venous phase, the EIv of the GCTs was higher than that in the arterial phase and was also the highest among the three groups (P < 0.05). A difference was found among the groups, namely, the GCTs, SCs, and SSs (P < 0.05). The EIa and EIv of the SCs were the lowest among the three groups. The Emax of the GCTs was the highest among the three groups (P < 0.05). Conclusion: Quantitative analysis of the characteristics of contrast-enhanced CT is a useful method for diagnosing sacral GCTs and differentiating these tumors from SCs and SSs.

骶椎神经鞘瘤MRI诊断

骶椎神经鞘瘤MRI诊断

Clinical features and surgical treatment of sacral schwannomas.

BackgroundSacral schwannoma is relatively rare and both the early diagnosis and appropriate treatment of sacral schwannomas are equally very challenging.Methods11 sacral schwannoma cases operated at the Second Affiliated Hospital, School of Medicine, Zhejiang University, from 2012 to 2016, were investigated retrospectively and 10 were followed up. All patients were assessed with X-ray, CT and MRI, and underwent an intralesional excision.ResultsOne patient was male, nine were female and the average age was 48 (ranging between 31 and 63). Three patients suffered from back and leg pain, and seven had no obvious symptoms. The average blood loss during surgery was 980ml (ranging between 100 and 2,000ml). Six patients underwent preoperative biopsy. The surgeries were performed via the combination of an anterior and posterior approach in two patients, a posterior approach in seven patients, and an anterior approach in one patient. Residual tumors were not detected in all patients after surgery. Unfortunately, the postoperative complications occurred in three patients, namely bowel and bladder dysfunction (two patients) and cerebrospinal fluid leakage with secondary intracranial infection (one patient). The average follow-up was 22.7 months (8-44 months). All patients were relieved from preoperative symptoms after the last follow-up.ConclusionsThe typical findings of our cases in MRI were a well-circumscribed lesion with a heterogenous signal intensity on T2-weighted image, which may be helpful for preoperative decision-making. Intralesional excision can be successfully performed using single anterior or single posterior or both, and is an important procedure in the treatment of sacral schwannomas.

Two cases report of giant sacral schwannoma with long term MRI follow up

Two cases report of giant sacral schwannoma with long term MRI follow up

Giant balloon-like presacral schwannoma

A 69-year-old female patient visited a gynecologist because of lower abdominal discomfort. Magnetic resonance (MR) imaging was conducted, and the patient was referred to our institute because a presacral abnormal lesion was found. Physical examination revealed absence of neurologic compromise. Plain MR imaging revealed presacral single balloon-like cyst, which was homogenously low intensity on T1-weighted images and high intensity on T2-weighted images (Fig. 1A–C). The succeeding gadolinium-enhanced MR imaging revealed ring enhancement of the lesion (Fig. 1D, E). The initial differential diagnosis of the lesion includes schwannoma, abscess, chordoma, and perineural cyst. We, together with the gynecologists, conducted a laparoscopic excisional biopsy of the lesion. After the aspiration of liquid in the cyst, total extirpation of the lesion was successfully performed. Histologic examination revealed spindle-shaped cells arranged in short bundles with foci of nuclear palisading. Neither nuclear atypia nor mitotic figures were observed. These findings were consistent with benign schwannoma. At the time of the latest follow-up, 2 years after the surgery, the patient was free of symptoms without evidence of regrowth of the lesion (Fig. 2, Left and Right). Sacral schwannomas have a very rare etiology, comprising less than 1% to 5% of all spinal schwannomas, and only around 50 cases have been reported in the literature [1]. Schwannomas can develop degenerative changes with cystic formations; however, purely cystic change is by far a rare finding in the spinal schwannoma, and only few cases of giant sacral schwannoma with significant cystic component have been reported in the literature [2]. Even though the lesion presents significant cystic component, most of the lesions present heterogeneous multilobulated mass. To the best of our knowledge, the single-lobulated giant presacral schwannoma is an extremely rare condition. We advocate that uneven thickness of the cystic wall is one of the factors distinguishing tumors from other simple cystic lesions like perineural cyst.

A Purely Cystic Giant Sacral Schwannoma Mimicking a Bone Cyst: A Case Report

Approximately 1--5% of the spinal schwannomas arise in the sacrum and frequently grow to a considerable size before becoming symptomatic; hence, the term “giant sacral schwannoma” refers to tumors extending into the vertebral body and the extraspinal space (1). Most schwannomas are solid or heterogeneous solid tumors, but they can rarely undergo cystic degeneration, xanthomatous change, or hemorrhage (2). A completely cystic appearance with only thin peripheral wall enhancement is extremely rare. A few cases of solitary cystic schwannomas arising from the spine have been previously reported (3-8). To the best of our knowledge, there is only one previous reported case of a giant solitary cystic schwannoma of the sacrum. Here, we describe a rare case of a totally cystic giant sacral schwannoma presenting as lumbar back pain. Institutional review board approval was obtained.

Differentiation of primary chordoma, giant cell tumor and schwannoma of the sacrum by CT and MRI

ObjectiveTo evaluate criteria to differentiate sacral chordoma (SC), sacral giant cell tumor (SGCT) and giant sacral schwannoma (GSS) with CT and MRI. Materials and methodsCT and MR images of 22 SCs, 19 SGCTs and 8 GSSs were reviewed. The clinical and imaging features of each tumor were analyzed. ResultsThe mean ages of SC, SGCT and GSS were 55.1±10.7, 34.3±10.7 and 42.4±15.7 years old. SCs (77.3%) were predominantly located in the midline of lower sacrum, while most SGCTs (73.7%) and GSSs (87.5%) were eccentrically located in upper sacrum. There were significant differences in age, location, eccentricity, morphology of bone residues, intratumoral bleeding and septations. Multiple small cysts were mainly observed in SGCTs (73.7%) with large central cysts in GSSs (87.5%). SGCTs expanded mainly inside sacrum while SCs and GSSs often extended into pelvic cavity (P=0.0022). Involvement of sacroiliac joints and muscles were also different. Ascending extension within sacral canal was only displayed in SCs. The preservation of intervertebral discs showed difference between large and small tumors (P=0.0002), regardless of tumor type (P=0.095). No significant difference was displayed in gender (P=0.234) or tumor size (P=0.0832) among three groups. ConclusionAge, epicenter of the lesion (midline vs. eccentric and upper vs. lower sacral vertebra), bone residues, cysts, bleeding, septation, expanding pattern, muscles and sacroiliac joint involvement can be criteria for diagnosis. Fluid–fluid level is specific for SGCTs and ascending extension within the sacral canal for SCs. The preservation of intervertebral discs is related to tumor size rather than tumor type.

Giant sacral schwannoma with pelvic and lumbar spine extension

Giant sacral schwannoma with pelvic and lumbar spine extension

Laparoscopic Management of Sacral Nerve Root Schwannoma With Intractable Vulvococcygodynia: Report of Three Cases and Review of Literature

Herein we report the feasibility of laparoscopic resection of schwannomas of the sacral nerves roots in 3 women with intractable vulvodynia and coccygodynia. Laparoscopic en bloc resection of the sacral schwannomas was performed, with primary control of the tumor blood supply and with exposure and sparing of the sacral nerve roots. In all 3 patients, laparoscopy was successful, with minimal blood loss and without complications. Histologic examination confirmed the diagnosis of schwannoma without malignant transformation in all 3 women. At mean follow-up of 27.66 months, no patient reported recurrence or worsening of symptoms. All patients are able to walk normally without gait aids. Primary control of the tumor blood supply during laparoscopic surgery to resect deep sacral masses reduces considerably the risk of operative hemorrhage. Compared with classic neurosurgical approaches, laparoscopic exposure of the rectum, ureters, and sacral nerve roots renders the procedure safer and easier, with less risk of postoperative functional morbidity.

Giant Invasive Sacral Schwannoma Showing Chromosomal Numerical Aberrations [-14,+18,+22

Here, we report on a rare case of a giant invasive sacral schwannoma. The patient was a 58-year-old woman who had a 6-year history of non-specific buttock pain. Histological investigation confirmed the diagnosis of cellular schwannoma. The following numerical aberration was detected using the GTG-banding method for karyotypes: 47,XX,-14,+18,+22. Cytogenetic studies of schwannomas have indicated a complete or partial loss of chromosome 22 as the most common abnormality, but this case is cytogenetically rare because of the recurrence of trisomy 22.

Giant sacral schwannomas

Sacral schwannomas are very rare tumors. There are merely around 50 cases reported in the literature most of which are case presentations. In this study we present a 13-case series, which is one of the most extensive series in the literature. Thirteen giant sacral schwannoma cases operated at Ege University, Faculty of Medicine, Neurosurgery Department between 1995 and 2010 are investigated retrospectively. All patients were assessed with direct radiography, computerized tomography (CT) and magnetic resonance imaging (MRI). The patients were operated, after the diagnosis through biopsy patients with Sridhar Type V classification are included in the study. Five patients were male, eight were female and the average age was 37.1 (ranging between 14 and 55). All the patients were suffering from back and leg pain at the time of consultation. Four patients had sphincter problems and three had weakness in the leg. After the biopsy and histological analysis, intralesionary resections were performed. Five patients went through both anterior and posterior interventions, six patients had only posterior and two had just anterior intervention. One patient had iliac vein injury during the anterior surgery. This patient was reoperated for embolectomy and vein graft because of thrombosis. Average follow-up period was 8.1 years (1-15 years). All patients were assessed with MR annually. A small residual tumor was detected in two patients, however they were not reoperated. Although sacral schwannomas are rare tumors, the diagnosis is not so difficult with CT and MRI. In this study, we suggest biopsy for predetermination of the nature of the tumor as it affects the treatment choice and the method of operation. Surgically, a simple intralesionary excision is an appropriate choice.

Sacral ganglioneuroma

Giant sacral schwannomas are rare and difficult to treat. Unexpected neurologic deficits after surgery and tumor recurrence should be considered when surgery is performed. We attempt to remove the tumors via piecemeal total or subtotal excision, leaving parts of the capsule adjacent to nerves to preserve the nerves. This study aimed to present the cases of giant sacral schwannoma at our institutions as well as review the relevant literature and to discuss surgical management.This study included 11 patients (5 male and 6 female, mean age 53 years) with giant sacral schwannoma who were treated surgically. The clinical features, surgical details, and outcomes were investigated retrospectively.The tumors were intraosseous type in 4 cases, dumb-bell type in 3 cases, and retroperitoneal type in 4 cases. The surgeries were performed by a combined anterior and posterior approach in 4 cases, a posterior approach in 4 cases, and an anterior approach in 3 cases. The tumors were removed via piecemeal total or subtotal excision in 7 cases, partial excision in 3 cases, and enucleation in 1 case. After surgery, symptoms improved in all cases. The tumor recurred in 2 patients after partial excision. No patients receiving piecemeal total or subtotal excision showed recurrence. One patient developed motor weakness after piecemeal subtotal excision, but the symptoms resolved.Adopting an appropriate surgical approach based on the location of the tumor is important. Piecemeal total or subtotal excision, with parts of the capsule adjacent to nerves left behind may help achieve a good outcome, avoiding a postoperative neurologic deficit.