Scandinavian Journal of Urology and Nephrology
ISSN: 0036-5599 (Print) 1651-2065 (Online) Journal homepage: http://www.tandfonline.com/loi/isju19
Benign Retroperitoneal Schwannoma Vesa Perhoniemi, Ilmari Anttinen, Fawwaz Kadri & llkka Saario To cite this article: Vesa Perhoniemi, Ilmari Anttinen, Fawwaz Kadri & llkka Saario (1992) Benign Retroperitoneal Schwannoma, Scandinavian Journal of Urology and Nephrology, 26:1, 85-87, DOI: 10.3109/00365599209180403 To link to this article: http://dx.doi.org/10.3109/00365599209180403
Published online: 15 Feb 2010.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isju19 Download by: [Monash University Library]
Date: 03 April 2016, At: 22:22
Scand J Urol Nephrol26: 85-87, 1992
BENIGN RETROPERITONEAL SCHWANNOMA Caw Report
Vesa Perhoniemi. Ilmari Anttinen,’ Fawwaz Kadri’ and Ilkka Saario From the Departments of Surgery and ‘Pathology,Maria City Hospital and ‘Radiology, K i i ~ l aCity Hospital. Helsinki. Finland (Submitted November 16, 1990. Accepted for publication February 14, 1991)
Downloaded by [Monash University Library] at 22:22 03 April 2016
Abstract. A rare case of benign retroperitoneal schwannoma in a 76-year-old man is reported. Ultrasound and computerized tomography disclosed two cystic retroperitoneal tumors sized 12 cm and 7 cm. The larger tumor was located anterior to psoas muscle and the smaller one was within the muscle. The larger tumor was excised via laparotomy. After 3.5 years follow-up the intramuscular tumor has remained unchanged and the patient has no symptoms.
Key u,ord.v: schwannoma. neurinoma, neurilemoma. retroperitoneal tumor. diagnosis. operative treatment.
Primary retroperitoneal neoplasms comprise a rare and diverse group of tumors. A schwannoma is in most cases a benign tumor originating from the Schwann cell of the peripheral nerve sheath. The vast majority arise in cranial nerves, with occasional occurrence in the nerves of the extremities (13). Retroperitoneal schwannomas are very rare except in cases of von Recklinghausen’s disease (4, I I , 13). Only a few reports deal with ultrasound (US) and computerized tomography (CT) diagnoses of retroperitoneal schwannomas (4, 7, 11). The rarity of this tumor with delayed diagnosis prompted us to report the present case.
mass displacing the right kidney superiorly and laterally. At laparotomy a well-encapsulated retroperitoneal mass was found. Blood was aspirated and the cystic haematoma-like mass was drained and a biopsy was done. The histologic diagnosis was haematoma and fibrosis. After the operation the patient did well. During the follow-up a C T scan in September 1987 showed that there were still two separate retroperitoneal tumors. The larger tumor displaced right kidney and ureter. and compressed vena cava inferior (Fig. I). Tumors were inhomogenous. with a density between 10-25 HU. Contrast enhancement was also inhomogenous. and some tiny calcifications and a peripheral rim of adipose tissue were observed. Intramuscular tumor eroded the adjacent vertebral body. The C T image was erroneously interpreted as a retroperitoneal hematoma. In September 1988 the patient underwent a second laparotomy for diagnosis. The encapsulated mass anterior to the right psoas muscle was excised. No tumor was found in the abdominal cavity. The intramuscular tumor was not removed.
CASE REPORT A 76-year-old man was hospitalized in April 1987 with acute emesis, pain and a palpable mass in the lower right quadrant of abdomen. The hemoglobin value decreased during the first few hours from 134 to 109 g/l. US showed a well-defined I5 cm retroperitoneal tumor in front of the right psoas muscle and inferior to the kidney. Another solid 7 cm mass was found within the right psoas muscle. US guided fine needle aspiration biopsy was performed twice but was not diagnostic. An excretory urogram demonstrated a
Fig. I. Two adjacent inhomogenous tumors which dislocate the right ureter and vena cava, the latter is also compressed. The vertebral body is eroded. There is a tiny calcification at the periphery of the larger tumor and a fat rim in the smaller one. Scand J Urol Nephrol26
Downloaded by [Monash University Library] at 22:22 03 April 2016
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V. Perhoniemi et al.
Fig. 2a. Area of Antoni A tissue with palisading of cells, arrow (He x 35).
Fig. 2b. Area of Antoni B tissue, arrow (He ~ 3 5 ) .
The excised mass was multicystic with central areas of haemorrhage and necrosis. Microscopically a thick connective tissue capsule surrounded mixed solid, and loose, haemorrhagic tumor tissue. The solid areas were dominated by monomorphic spindleshaped cells, which in some places formed palisades and whorles. The loose areas contained cystic spaces with vascular connective tissue septa, and a diffuse seeding of lymphocytoid cells, and focal aggregates of foamy macrophages. The haemorrhagic areas were dominated by masses of dissolving erythrocytes and fibrosis. No mitotic figures were observed, This finding corresponds to Antoni A and Antoni B tissue characteristic of benign neurilemoma (Fig. 2 a and b). The patient is well and has no symptoms two years postoperatively. The intramuscular tumor is unchanged compared to the earlier examinations and there is no recurrence of the other tumor (Fig. 3).
logical signs and symptoms were first interpreted as an acute retroperitoneal haematoma (10). Surgical excision is recommended because the tumors grow gradually (4, 8, 1 1 , 12). A follow-up may be justified if there are no symptoms in elderly patients and there are contraindications to surgery. The intramuscular tumor in this case did not grow during an observation period of 3.5 years. Although schwannomas constitute a small percentage of all retroperitoneal tumors, it should be included in the differential diagnosis of retroperitoneal mass that is: ( a ) well defined,
DISCUSSION Primary retroperitoneal tumors represent a variety of lesions, of which less than one third are benign and most commonly schwannomas (6, 7, 9). The tumors are usually associated with von Recklinghausen’s neurofibromatosis ( 1 1). A schwannoma is typically well encapsulated and solid, but large tumors become hemorrhagic and necrotic which give radiologic tumor inhomogeneity ( 1 , 2, 4, 11). Also confluent areas of hypocellularity adjacent to more cellular tumor regions may inhomogeneity ( 2 ) . RetrOPeritonea1 haematoma may be similar radiographically. Also in our case clinical and radio&and J Urol Nephrol26
Fig. 3. Two years after operation. Tumor within psoas muscle has remained unchanged. There is no recurrence of the other tumor.
Benign retroperitoneal schwannoma
( b )located in the region of a known nerve ganglia or pathway, and (c) solid or mixed density (4).Both US and CT can help to characterize the lesion but neither provides enough information to enable a specific preoperative diagnosis (2, 4, 5, 11). Percutaneous aspiration biopsy may be diagnostic (3).
REFERENCES 1. Berlin 0, Stener B, Lindahl S, Irstam L, Lodding
Downloaded by [Monash University Library] at 22:22 03 April 2016
2. 3. 4. 5.
P. Vascularization of peripheral neurilemomas: angiographic, computed tomographic, and histologic studies. Skeletal Radio1 1986; 15: 275-283. Cohen LM, Schwartz AM, Rockoff SD. Benign schwannomas: Pathologic basis for CT inhomogeneities. AJR 1986; 147: 141-143. Dahl 1. Hagmar B. ldvall I . Benign solitary neurilemoma (Schwannoma). Acta Pathol Microbiol lmmunol Scand (A) 1984; 92: 91-101. Donna1 JF. Baker ME, Mahony BS. Leight GS. Benign retroperitoneal schwannoma. Urology 1988; 31: 332-334. Egund N, Ekelund L, Sako M, Persson B. CT of soft-tissue tumors. AJR 1981; 137: 725-729.
81
6. Katenkamp von D. Primare Weichteiltumoren des Retroperitonealraumes. Zentralbl Allg Pathol 1983; 127: 195-205. 7. Lane RH. Stephens DH, Reiman HM. Primary retroperitoneal neoplasms: C T findings in 90 cases with clinical and pathologic correlation. AJR 1989; 152: 83-89. 8. McCarthy S. Duray PH. Giant retroperitoneal neurilemoma: A rare cause of digestive tract symptoms. J Clin Gastroenterol 1983; 5: 343-347. 9. Pinson CW, ReMine SG, Fletcher WS. Braasch JW. Long-term results with primary retroperitoneal tumors. Arch Surg 1989; 124: 1168-1 173. 10. Sagel SS, Siege1 MJ, Stanley RJ. Jost RG. Detection of retroperitoneal hemorrhage by computed tomography. Am J Roentgenol 1977; 129: 403-401. I 1. Steers WD, Hodge GB, Johnson DE, Chaitin BA, Charnsangavej C. Benign retroperitoneal neurilemoma without von Recklinghausen’s disease: a rare occurrence. J Urol 1985; 133: 846-848. 12. Takahera H, Takiuchi H, Namiki M, Takaha M, Ohnishi S, Sonoda T. Retroperitoneal schwannoma. Urology 1986; 28: 529-53 I . 13. Whitaker WG, Droulias C. Benign encapsulated neurilemoma: a report of 76 cases. Am Surg 1976; 42: 675-678.
Scand J Urol Nephrol26
ISSN: 0036-5599 (Print) 1651-2065 (Online) Journal homepage: http://www.tandfonline.com/loi/isju19
Benign Retroperitoneal Schwannoma Vesa Perhoniemi, Ilmari Anttinen, Fawwaz Kadri & llkka Saario To cite this article: Vesa Perhoniemi, Ilmari Anttinen, Fawwaz Kadri & llkka Saario (1992) Benign Retroperitoneal Schwannoma, Scandinavian Journal of Urology and Nephrology, 26:1, 85-87, DOI: 10.3109/00365599209180403 To link to this article: http://dx.doi.org/10.3109/00365599209180403
Published online: 15 Feb 2010.
Submit your article to this journal
Article views: 4
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isju19 Download by: [Monash University Library]
Date: 03 April 2016, At: 22:22
Scand J Urol Nephrol26: 85-87, 1992
BENIGN RETROPERITONEAL SCHWANNOMA Caw Report
Vesa Perhoniemi. Ilmari Anttinen,’ Fawwaz Kadri’ and Ilkka Saario From the Departments of Surgery and ‘Pathology,Maria City Hospital and ‘Radiology, K i i ~ l aCity Hospital. Helsinki. Finland (Submitted November 16, 1990. Accepted for publication February 14, 1991)
Downloaded by [Monash University Library] at 22:22 03 April 2016
Abstract. A rare case of benign retroperitoneal schwannoma in a 76-year-old man is reported. Ultrasound and computerized tomography disclosed two cystic retroperitoneal tumors sized 12 cm and 7 cm. The larger tumor was located anterior to psoas muscle and the smaller one was within the muscle. The larger tumor was excised via laparotomy. After 3.5 years follow-up the intramuscular tumor has remained unchanged and the patient has no symptoms.
Key u,ord.v: schwannoma. neurinoma, neurilemoma. retroperitoneal tumor. diagnosis. operative treatment.
Primary retroperitoneal neoplasms comprise a rare and diverse group of tumors. A schwannoma is in most cases a benign tumor originating from the Schwann cell of the peripheral nerve sheath. The vast majority arise in cranial nerves, with occasional occurrence in the nerves of the extremities (13). Retroperitoneal schwannomas are very rare except in cases of von Recklinghausen’s disease (4, I I , 13). Only a few reports deal with ultrasound (US) and computerized tomography (CT) diagnoses of retroperitoneal schwannomas (4, 7, 11). The rarity of this tumor with delayed diagnosis prompted us to report the present case.
mass displacing the right kidney superiorly and laterally. At laparotomy a well-encapsulated retroperitoneal mass was found. Blood was aspirated and the cystic haematoma-like mass was drained and a biopsy was done. The histologic diagnosis was haematoma and fibrosis. After the operation the patient did well. During the follow-up a C T scan in September 1987 showed that there were still two separate retroperitoneal tumors. The larger tumor displaced right kidney and ureter. and compressed vena cava inferior (Fig. I). Tumors were inhomogenous. with a density between 10-25 HU. Contrast enhancement was also inhomogenous. and some tiny calcifications and a peripheral rim of adipose tissue were observed. Intramuscular tumor eroded the adjacent vertebral body. The C T image was erroneously interpreted as a retroperitoneal hematoma. In September 1988 the patient underwent a second laparotomy for diagnosis. The encapsulated mass anterior to the right psoas muscle was excised. No tumor was found in the abdominal cavity. The intramuscular tumor was not removed.
CASE REPORT A 76-year-old man was hospitalized in April 1987 with acute emesis, pain and a palpable mass in the lower right quadrant of abdomen. The hemoglobin value decreased during the first few hours from 134 to 109 g/l. US showed a well-defined I5 cm retroperitoneal tumor in front of the right psoas muscle and inferior to the kidney. Another solid 7 cm mass was found within the right psoas muscle. US guided fine needle aspiration biopsy was performed twice but was not diagnostic. An excretory urogram demonstrated a
Fig. I. Two adjacent inhomogenous tumors which dislocate the right ureter and vena cava, the latter is also compressed. The vertebral body is eroded. There is a tiny calcification at the periphery of the larger tumor and a fat rim in the smaller one. Scand J Urol Nephrol26
Downloaded by [Monash University Library] at 22:22 03 April 2016
86
V. Perhoniemi et al.
Fig. 2a. Area of Antoni A tissue with palisading of cells, arrow (He x 35).
Fig. 2b. Area of Antoni B tissue, arrow (He ~ 3 5 ) .
The excised mass was multicystic with central areas of haemorrhage and necrosis. Microscopically a thick connective tissue capsule surrounded mixed solid, and loose, haemorrhagic tumor tissue. The solid areas were dominated by monomorphic spindleshaped cells, which in some places formed palisades and whorles. The loose areas contained cystic spaces with vascular connective tissue septa, and a diffuse seeding of lymphocytoid cells, and focal aggregates of foamy macrophages. The haemorrhagic areas were dominated by masses of dissolving erythrocytes and fibrosis. No mitotic figures were observed, This finding corresponds to Antoni A and Antoni B tissue characteristic of benign neurilemoma (Fig. 2 a and b). The patient is well and has no symptoms two years postoperatively. The intramuscular tumor is unchanged compared to the earlier examinations and there is no recurrence of the other tumor (Fig. 3).
logical signs and symptoms were first interpreted as an acute retroperitoneal haematoma (10). Surgical excision is recommended because the tumors grow gradually (4, 8, 1 1 , 12). A follow-up may be justified if there are no symptoms in elderly patients and there are contraindications to surgery. The intramuscular tumor in this case did not grow during an observation period of 3.5 years. Although schwannomas constitute a small percentage of all retroperitoneal tumors, it should be included in the differential diagnosis of retroperitoneal mass that is: ( a ) well defined,
DISCUSSION Primary retroperitoneal tumors represent a variety of lesions, of which less than one third are benign and most commonly schwannomas (6, 7, 9). The tumors are usually associated with von Recklinghausen’s neurofibromatosis ( 1 1). A schwannoma is typically well encapsulated and solid, but large tumors become hemorrhagic and necrotic which give radiologic tumor inhomogeneity ( 1 , 2, 4, 11). Also confluent areas of hypocellularity adjacent to more cellular tumor regions may inhomogeneity ( 2 ) . RetrOPeritonea1 haematoma may be similar radiographically. Also in our case clinical and radio&and J Urol Nephrol26
Fig. 3. Two years after operation. Tumor within psoas muscle has remained unchanged. There is no recurrence of the other tumor.
Benign retroperitoneal schwannoma
( b )located in the region of a known nerve ganglia or pathway, and (c) solid or mixed density (4).Both US and CT can help to characterize the lesion but neither provides enough information to enable a specific preoperative diagnosis (2, 4, 5, 11). Percutaneous aspiration biopsy may be diagnostic (3).
REFERENCES 1. Berlin 0, Stener B, Lindahl S, Irstam L, Lodding
Downloaded by [Monash University Library] at 22:22 03 April 2016
2. 3. 4. 5.
P. Vascularization of peripheral neurilemomas: angiographic, computed tomographic, and histologic studies. Skeletal Radio1 1986; 15: 275-283. Cohen LM, Schwartz AM, Rockoff SD. Benign schwannomas: Pathologic basis for CT inhomogeneities. AJR 1986; 147: 141-143. Dahl 1. Hagmar B. ldvall I . Benign solitary neurilemoma (Schwannoma). Acta Pathol Microbiol lmmunol Scand (A) 1984; 92: 91-101. Donna1 JF. Baker ME, Mahony BS. Leight GS. Benign retroperitoneal schwannoma. Urology 1988; 31: 332-334. Egund N, Ekelund L, Sako M, Persson B. CT of soft-tissue tumors. AJR 1981; 137: 725-729.
81
6. Katenkamp von D. Primare Weichteiltumoren des Retroperitonealraumes. Zentralbl Allg Pathol 1983; 127: 195-205. 7. Lane RH. Stephens DH, Reiman HM. Primary retroperitoneal neoplasms: C T findings in 90 cases with clinical and pathologic correlation. AJR 1989; 152: 83-89. 8. McCarthy S. Duray PH. Giant retroperitoneal neurilemoma: A rare cause of digestive tract symptoms. J Clin Gastroenterol 1983; 5: 343-347. 9. Pinson CW, ReMine SG, Fletcher WS. Braasch JW. Long-term results with primary retroperitoneal tumors. Arch Surg 1989; 124: 1168-1 173. 10. Sagel SS, Siege1 MJ, Stanley RJ. Jost RG. Detection of retroperitoneal hemorrhage by computed tomography. Am J Roentgenol 1977; 129: 403-401. I 1. Steers WD, Hodge GB, Johnson DE, Chaitin BA, Charnsangavej C. Benign retroperitoneal neurilemoma without von Recklinghausen’s disease: a rare occurrence. J Urol 1985; 133: 846-848. 12. Takahera H, Takiuchi H, Namiki M, Takaha M, Ohnishi S, Sonoda T. Retroperitoneal schwannoma. Urology 1986; 28: 529-53 I . 13. Whitaker WG, Droulias C. Benign encapsulated neurilemoma: a report of 76 cases. Am Surg 1976; 42: 675-678.
Scand J Urol Nephrol26
