An intraosseous malignant peripheral nerve sheath tumor of the cervical spine: a case report and review of the literature

Malignant Nerve Sheath Tumour - A Case Report

Malignant nerve sheath tumors are rare and aggressive soft tissue sarcomas. They contribute to 5-10% of all soft tissue sarcomas. They can be sporadic, occur in patients with NF1 (neurofibromatosis 1) or can occur after radiation therapy. A high rate of recurrence and hematogenous metastasis is seen in these patients. They are also associated with poor prognosis. A case of malignant nerve sheath tumor seen in a 44-year-old male with pre-existing NF1 is being discussed here due to the unique nature of the disease and its rarity.

Surgical Management of Intraosseous Neurofibroma in Cervical Spine: A Case Report

CASE

A 30-year-old man had cervical radiculomyelopathy and neck pain caused by a massive intraosseous neurofibroma (IONF) originating from the C6 vertebrae. We performed posterior tumor resection with spinal instrumentation and fusion from C3 to T2 and a follow-up resection procedure of the remaining C6 anterior tumor, sacrificing the affected vertebral artery (VA), which accordingly required bypass surgery at 2 months recovery. Reconstruction using a titanium mesh cage was successfully performed. There were no local recurrences at 2 years postoperatively.

CONCLUSIONS

Total tumor resection split into 2 stages with sacrifice of the affected VA is a feasible option for treatment of IONF.

Spinal cord compression from cutaneous malignant peripheral nerve sheath tumor metastasis in a patient with neurofibromatosis Type 1

Background:

Neurofibromatosis Type 1 (NF-1) and previous irradiation are two common risk factors that can result in malignant peripheral nerve sheath tumors (MPNSTs), extremely rare soft-tissue sarcomas. Here, a 63-year-old male with NF-1 presented with diffuse spinal metastases from a subcutaneous MPNST.

Case Description:

A 63-year-old male with NF-1 presented acutely with paraplegia and urinary incontinence. Both CT and MR studies of the thoracic-lumbosacral spine showed multiple metastases from a subcutaneous MPNST. In addition, the patient had a T12 vertebral body pathological fracture.

Conclusion:

Despite its aggressive behavior, some cases of MPNST can be managed with gross total resection and adjuvant radiotherapy. In addition, in the presence of multiple metastases, chemotherapy may play an additional, although questionable role.

The rare primary bone sarcomas: imaging-pathological correlation

Rare primary bone sarcomas are challenging entities both radiologically and pathologically. These include the diagnoses of spindle cell sarcoma (leiomyosarcoma, fibrosarcoma, synovial sarcoma, and malignant peripheral nerve sheath tumor), pleomorphic liposarcoma, and undifferentiated pleomorphic sarcoma. The radiographic and cross-sectional imaging features of each of these tumors are presented, along with current key pathological concepts. Frequently non-specific, the radiological appearances must be correlated with all clinical and pathological information available to enable an accurate diagnosis.

Clinical outcomes of non-osteogenic, non-Ewing soft-tissue sarcoma of bone--experience of the Toronto Sarcoma Program

Non‐osteogenic, non‐Ewing soft‐tissue sarcoma (NONE‐STS) of bone is a rare presentation of primary bone cancers. Optimal treatments and outcomes for this heterogenous group are poorly described. We evaluated the factors associated with long‐term outcomes in patients with this disease. Patients with localized NONE‐STS of bone treated at the Toronto Sarcoma Program from 1987 to 2017 were identified. Clinical characteristics, treatment, and survival information were collected. Kaplan‐Meier (log‐rank) survival estimates from the time of definitive surgery, with uni‐/multivariate analyses (Cox) of sarcoma‐specific survival were performed. A total of 106 patients (60.4% male; median age 46 years) with NONE‐STS of bone were identified. Common histologies included undifferentiated pleomorphic sarcoma [UPS]/malignant fibrous histiocytoma [MFH] (UPS/MFH, 41.5%), leiomyosarcoma (LMS, 20.8%), and fibrosarcoma (FS, 11.3%). Tumors were often high grade (59.4%) and involved the extremities (88.7%), with most receiving chemotherapy (67.9%) with cisplatin/doxorubicin‐based regimens (73.6%). In the full cohort, 10‐year DFS (45.7%, [95%CI: 35.7‐55.8%]), OS (53.4%, [95%CI: 41.7‐62.2%]), and SSS (63.9%, [95%CI: 53.9‐72.5%]) were moderate. Histology specific, 10‐year SSS was 70.7% [95%CI: 56.1‐85.5%] for UPS/MFH, 51.8% [95%CI: 29.8‐73.8%] for LMS, and 72.2% [95%CI: 45.1‐99.2%] for FS. Only UPS/MFH (n = 4) showed sarcoma‐related death >10 years. Multivariate analysis identified axial location (HR = 35.5, [95%CI: 3.4‐369.6]), high grade (HR = 16.9, [95%CI: 1.6‐185.1]), and disease relapse (HR = 485.1, [95%CI: 36.3‐6482.6]) as risk factors for death (p < 0.05). Treatment with chemotherapy (HR = 0.1, [95%CI: 0.01‐0.86]) and necrosis ≥85% (HR = 0.2, [95%CI: 0.04‐0.99]) showed improved survival (p < 0.05). NONE‐STS of bone has favorable long‐term survival similar to osteosarcoma. Patients receiving chemotherapy derive benefit in retrospective analyses. UPS/MFH histologies show sarcoma‐related death beyond 10 years. Further data on histologic subgroups are needed.

Intraosseous Malignant Peripheral Nerve Sheath Tumor of 2 Consecutive Lumbar Vertebrae: A Case Report and Literature Review

BACKGROUND

Malignant peripheral nerve sheath tumor (MPNST), which refers to any malignant tumor that originates from peripheral nerve sheath cells, is rarely found in the spine. Primary intraosseous spinal MPNSTs are extremely uncommon; in fact, such an occurrence has been reported in a very limited number of cases hitherto. We report here one case of low-grade intraosseous MPNST in the lumbar vertebrae and review clinical research related to this rare tumor and modus operandi to its treatment.

CASE DESCRIPTION

A 51-year-old man suffering from lower back pain was initially diagnosed with lumbar tuberculosis. The intraoperative histopathologic examination, however, revealed that the occupying lesion was synovial sarcoma when surgeons intended to perform a debridement surgery of what was thought to be tuberculosis. The operation was therefore suspended. Two months later, the patient was referred to our institution. The pathologic sections were reexamined. Its results refuted the earlier thought of being synovial sarcoma, and a final diagnosis of MPNST was made. In addition, preoperative examination revealed that the tumor had advanced rapidly to the adjacent inferior vena cava and pedicle, which ruled out the possibility of performing a total en bloc spondylectomy. Therefore, a marginal resection for 2-level consecutive lumbar vertebrae was performed successfully via an anterior-posterior combined approach. No serious complications were detected at 18-month follow-up.

CONCLUSIONS

Preoperative biopsy is of great importance for the diagnosis of spinal tumors. Marginal resection of a complicated intraosseous spine MPNST via an anterior-posterior combined approach, despite being technically challenging, resulted in good survival and functional outcomes.

Primary Intraosseous Malignant Peripheral Nerve Sheath Tumor of the Medial Cuneiform: A Case Report and Review of the Literature

Peripheral nerve sheath tumors (benign and malignant) usually arise in the soft tissues and are unusual in bone. Intraosseous peripheral nerve sheath tumors are usually benign and constitute approximately 0.2% of all bone tumors. Intraosseous malignant peripheral nerve sheath tumors (MPNSTs) are uncommon and usually result from secondary invasion. Only a few cases of primary intraosseous MPNSTs have been reported in published studies, and these were localized mostly in the mandible (approximately 50%) or maxilla, spine, and, occasionally, in the appendicular skeleton. To the best of our knowledge, we report the first case of primary intraosseous MPNST involving a midtarsal bone (medial cuneiform). The patient was a 62-year-old female who presented with pain and tenderness but without swelling. Imaging revealed nonspecific findings, and the preoperative computed tomography-guided biopsy findings were consistent with MPNST. The patient was treated with neoadjuvant radiotherapy, followed by wide local excision and allograft reconstruction. At the final follow-up examination (24 months), the graft had been incorporated without evidence of local recurrence or distant disease. The patient with primary intraosseous MPNST of the medial cuneiform described in the present report presented with nonspecific clinical and radiologic findings. Thus, a high index of suspicion and histopathologic examination, including immunohistochemistry, are necessary for an accurate diagnosis.

Modern surgical techniques for management of soft tissue sarcomas involving the spine: outcomes and complications

Several types of soft tissue sarcomas may locally extend to the spine. The best therapeutic strategy for such lesions strongly depends on the histological diagnosis. In this article the authors provide an up-to-date review of current guidelines regarding the management of soft tissue sarcomas involving the spine. Special attention is given to outcomes and complications of modern surgical series in order to highlight current challenges in the management of such lesions.

An intraosseous malignant peripheral nerve sheath tumor of the lumbar spine without neurofibromatosis: Case report and review of the literature

A malignant peripheral nerve sheath tumor (MPNST) is defined as any malignant tumor that develops or differentiates from cells in the peripheral nerve sheath. This tumor is commonly associated with neurofibromatosis type 1 (NF1) and previous radiotherapy treatment. Primary intraosseous MPNSTs are extremely rare and a case of the lumbar spine in a patient without NF1 is reported in the present study, with a review of the intraosseous MPNST literature. A 45-year-old female presented with a 1-month history of severe lower back pain and pain radiating to the left leg. A total en bloc spondylectomy of L4 was performed. The postoperative histopathological diagnosis was MPNST with deletion of NF1, confirmed by dual-color fluorescence in situ hybridization (FISH) analysis. The tumor recurred 1 month following the surgery. Although adjuvant chemotherapy was administered, the patient succumbed due to intramedullary dissemination and carcinomatous meningitis 8 months following the initial consultation. NF1 deletion by FISH analysis may be particularly useful in distinguishing MPNST from other high-grade malignancies with overlapping morphological features.

Malignant peripheral nerve sheath tumor of the distal phalanx of the fifth toe: a case report

Malignant peripheral nerve sheath tumor (MPNST) involving bone is rare. We report a case of MPNST of the fifth toe. The lesion was located in the distal phalanx of the right fifth toe and extended into surrounding subcutaneous tissues. Findings on magnetic resonance imaging and histological features of the case are described and the literature is briefly reviewed.

Spinal cord compression revealing an intraosseous schwannoma

A 68-year-old female presented with inflammatory lumbalgia and cruralgia. Physical examination revealed a lumbar stiffness without neurological deficit. Secondarily, paraplegia and urinary retention appeared. Magnetic resonance imaging showed a vertebral compaction of L3 vertebra with medullar compression. Emergent surgery revealed an epidural tumor involving largely the L3 vertebral body. Histology found schwannoma with positive protein S100 on the immunohistochemical study. Metastasis screening revealed bilateral nodular lesions of the lungs and a trochanter high scintigraphic signal. It was a malignant schwannoma. The patient underwent radiotherapy in addition to the total tumor resection.

Favorable outcome after radical resection and subsequent local irradiation of malignant peripheral nerve sheath tumor in the cervical spine

A 25-year-old man presented with malignant transformation to malignant peripheral nerve sheath tumor (MPNST) in the cervical spine associated with neurofibromatosis type 1. He presented with a 3-week history of rapidly increasing weakness and numbness in all four extremities. Magnetic resonance (MR) imaging of the cervical spine demonstrated a dumbbell-shaped tumor, which compressed the spinal cord at the C2-3 level. The tumor was excised, mainly within the spinal canal to decompress the spinal cord. The histological diagnosis was benign neurofibroma. Three months after surgery, he rapidly developed progressive tetraparesis and MR imaging revealed marked regrowth of an extradural mass into the spinal canal. At reoperation, the regrown mass in the spinal canal was totally excised. The histological diagnosis revealed MPNST. He underwent radiation therapy, with a total dose of 32 Gy, for approximately 3 weeks after the second surgery, but MR imaging showed tumor regrowth within the spinal canal, and his condition deteriorated. The decision was made to remove the tumor radically, including the involved facet and extradural lesion. Posterior fusion using a pedicle screw was performed one month later. He manifested no additional neurological deficits. He has been free of relapse for 46 months. Radical resection remains the most effective treatment for MPNST, although complete removal with a clear tumor margin is often impossible in practice.

A retroperitoneal NF1-independent malignant peripheral nerve sheath tumor with elevated serum CA125: case report and discussion

Malignant peripheral nerve sheath tumors (MPNSTs) are usually located in the trunk, extremities, head, or neck, and most occur with neurofibromatosis type 1 (NF1; von Recklinghausen's disease). No biomarkers have previously been found to be associated with their progression. Retroperitoneal NF1-independent MPNSTs are rare; they are considered to be less aggressive and to have better prognoses compared to NF1-related tumors. Currently, en bloc excision is the only consensus treatment approach. In a 27-year-old male with a giant retroperitoneal MPNST and no stigmata or family history of neurofibromatosis type-1 (NF1), a remarkable elevation of serum CA125 was detected. The high-grade tumor displayed a striking progression: the primary lesion, 25 cm in diameter, recurred in its previous site as a 17-cm MPNST less than 50 days after total excision. Subsequent treatment with microwave ablation and huachansu, a traditional Chinese medication, proved ineffective, and the patient died within 3 months. Our case suggests that retroperitoneal MPNSTs can deteriorate rapidly even if NF1 independent, that aggressive treatment may not benefit large high-grade MPNSTs, and that novel and effective treatment is urgently needed. Our case also suggests the possibility of using serum tumor markers in the early detection and monitoring of MPNSTs.

Malignant peripheral nerve sheath tumours of the spine: clinical manifestations, classification, treatment, and prognostic factors

BACKGROUND AND OBJECTIVES

To summarise our experience treating patients with spinal malignant peripheral nerve sheath tumours (MPNSTs).

METHODS

We retrospectively reviewed the records of patients diagnosed with spinal MPNSTs who received surgical treatment from January 1998 to December 2009.

RESULTS

Postoperative follow-up data were available for 14/16 patients with spinal MPNSTs (7 men, 7 women; median age = 44 years [range: 23-68 years]). Eight of 14 (57.1%) patients had primary and 6/14 (42.9%) recurrent MPNSTs. A total of 12/14 (85.7%) patients underwent total tumour resection, whereas 2/14 (14.3%) patients underwent subtotal tumour resection. Malignancies were graded low in 4 (28.6%) and high in 10 (71.1%) cases. A total of 12/14 (85.7%) patients experienced tumour recurrence and 10/14 (71.4%) patients died during the course of follow-up. The 0.5- 1-, 3-, and 5-year survival rates were 64.3, 48.2, 32.1, and 21.4%, respectively. Overall survival was significantly associated with tumour malignant degree (P = 0.012).

CONCLUSION

Diagnosis of spinal MPNSTs should be made with reference to clinical, radiological, and pathological findings. Surgical resection is the best available option for treating spinal MPNST; however, postoperative prognosis is poor.