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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Retroperitoneal schwannomas: Advantages of laparoscopic resection. Review of the literature and case presentation of a large paracaval benign schwannoma (with video) Niccolo Petrucciani, Dario Sirimarco, Paolo Magistri, Laura Antolino, Marcello Gasparrini & Giovanni Ramacciato Department of General Surgery, Surgical Department of Clinical Sciences, Biomedical Technologies and Transitional Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital Rome, Italy
Keywords Laparoscopic; retroperitoneal; schwannoma Correspondence Niccolo Petrucciani, via Tronto 32, 00198, Rome, Italy. Tel: 0039 3297372784 Fax: 0039 0633775322 Email: [email protected] Received 26 May 2014; revised 12 September 2014; accepted 16 September 2014
Abstract Retroperitoneal schwannomas represent 0.5%–3% of all retroperitoneal tumors. Complete surgical removal is the treatment of choice because it permits a correct histological diagnosis and prevents eventual degeneration. Laparoscopic surgery has been reported as safe and effective by several authors. We present a comprehensive review of the literature regarding the role of laparoscopy in surgical resection of retroperitoneal schwannomas, and we present a case showing the technique (with video). Laparoscopic resection in experienced hands is safe and effective, and guarantees excellent postoperative results in terms of patient recovery.
DOI:10.1111/ases.12150
Introduction Retroperitoneal schwannomas, which account for 0.5%–3% of all retroperitoneal tumors (1), are benign in the majority of cases. Clinical symptoms and radiological characteristics of schwannomas are not specific, so preoperative diagnosis is difficult. Surgical resection is recommended to obtain a certain histological diagnosis and to completely remove these tumors to prevent eventual degeneration. The laparoscopic approach offers several advantages over open removal: accurate dissection facilitated by visual magnification, fast postoperative patient recovery, and excellent cosmetic results. Good patient selection and experienced surgical teams are required, especially in cases involving a large tumor close to vital vessels.
Case Presentation A 60-year-old woman was admitted to our hospital for the treatment of a right paracaval retroperitoneal tumor. The lesion was discovered 3 years before in a primary
78
referral hospital. It was located in the right paracaval region, and its size was 2.5 × 2.2 × 2.7 cm. Its density was 28 HU. A percutaneous biopsy was attempted at that time, but the specimen was non-diagnostic. Radiological follow-up was continued every 4 months with ultrasound and CT scan. After 3 years, the patient presented at the Emergency Department with an episode of abdominal pain. A CT scan demonstrated an enlargement of the lesion, measuring 9.5 × 4.4 × 2.5 cm (Figure 1); the mass showed a non-homogeneous contrast enhancement. No other lesions were detected. Past medical history and comorbidities included hypertension and resection of an chondromatous hamartoma of the left lung 6 years before. Physical examination was unremarkable, and laboratory work-up showed no pathological findings. The patient underwent laparoscopic resection of the mass (Video S1). Trocar scars are showed in Figure 2. Under general anesthesia, the patient was placed in left lateral decubitus. Peritoneal insufflation with carbon dioxide was performed with a Veress technique, and five trocars, including one 10-mm optic trocar, one 10-mm operative trocar, and three 5-mm trocars, were inserted.
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Laparoscopy for paracaval schwannoma
N Petrucciani et al.
Figure 1 CT scan showing a large right paracaval retroperitoneal tumor.
Figure 2 Patient’s scars 1 month after surgery.
Abdominal carbon dioxide pressure was maintained between 10 and 12 mmHg. The liver was mobilized and lifted with the left trocar. The right colon was mobilized, and a Kocher maneuver was performed to expose the inferior vena cava. The mass was gently dissected and put in an endobag for extraction to avoid potential tumor cells spillage. The left flank trocar incision was slightly enlarged to extract the intact tumor. A drain was placed and removed on postoperative day 1. The postoperative course was uneventful and the patient was discharged in postoperative day 3. Histologically, the tumor was a schwannoma; the immunohistochemical analysis demonstrated the presence of S100 and the absence of desmin. The patient remains disease-free at 15 months.
Discussion Retroperitoneal tumor is a rare entity, and schwannomas account for 0.5%–3% of all retroperitoneal neoplasms (1–3). Only 0.7% of schwannomas are located in the retroperitoneal space (4,5). Differential diagnosis includes
neurofibromas, paragangliomas, pheochromocytomas, liposarcomas, and malignant fibrous histiocytomas. Schwannomas are tumors that arise from the peripheral nerve sheath and consist of Schwann cells in a collagenous matrix (6). Most schwannomas are benign, well circumscribed, and encapsulated. These tumors are often asymptomatic and slow growing, and diagnosis is incidental. If symptomatic, they may cause pain and obstructive or compressive symptoms, according to their location (7–10). A preoperative characterization is difficult because neither the clinical symptoms nor the radiological characteristics of schwannomas are specific. Characteristic CT features are the “target” and “fascicular” signs, which are rare. Percutaneous fine-needle aspiration was proposed by Ferretti et al. to differentiate benign from malignant schwannomas preoperatively (11). In our case, percutaneous aspiration was attempted for cytology, but its result was non-diagnostic. Complete surgical excision represents the treatment of choice and allows for an accurate histological and immunohistochemical examination. Even if the definitive diagnosis is based on histological analysis, some radiological characteristics may help physicians to differentiate benign tumors from malignant tumors and to orient their approach. At preoperative imaging, most schwannomas are well-circumscribed masses with smooth, regular margins and central cystic degeneration that, as in our case, displace rather than invade local structures. Furthermore, as in our case, nerve sheath tumors are located anterior to the psoas muscle arising from the sympathetic chain. Therefore, preoperative imaging may well orient physicians and suggest a diagnosis of benign tumor or benign schwannoma in a consistent percentage of cases. We believe that if there is a suspicion of malignancy (retroperitoneal sarcoma), an open approach is safer and oncologically more correct. However, if a preoperative diagnosis of a retroperitoneal benign schwannoma is highly probable, a laparoscopic approach should be considered because it offers several advantages. Regardless, even for tumors that appear to be benign, we believe that the surgeon should be always ready to convert to open surgery if there is a risk of tumor rupture and intraabdominal dissemination (12). In this case, we choose a laparoscopic approach because suspicion of a benign schwannoma was very high, but we were ready to convert to open surgery in case of doubt, tumor fragility, risk of rupture, and risk of bleeding. As shown in the video, the tumor was well-circumscribed, had smooth margins, and was easily cleavable from other structures. Vascular pedicles were easy to control, and there was no risk of major bleeding. Thus, a laparoscopic resection respecting oncological principles was possible.
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
79
Laparoscopy for paracaval schwannoma
N Petrucciani et al.
Table 1 Review of the literature including all the retroperitoneal schwannomas resected by the laparoscopic approach Author
Sex
Age
Size (cm)
Associated procedures
Histology
Symptoms
Discharge
Complications
Asakage(2) Pazouki et al.(3) Misra et al.(4) Gorgun et al.(5) Rao et al.(6) Yoshino & Yoneda(13) Kang et al.(7) Pinto et al.(8) Descazeaud et al.(9) Nishio et al. (14) Ohigashi et al.(15) Funamizu et al.(10) Present case
M M M F M M F F F F F M F
34 54 41 33 42 67 59 71 62 41 28 55 60
5.5 × 3.5 12 × 9 8×8 4.2 × 5.2 3 × 3.3 8 × 7.5 × 6 – 2 × 1.6 8×5 5×5 3 × 3 × 3.5 6 × 4.5 × 4 9.5 × 4.4
Appendectomy No no No No No No No No No No No No
Benign mixed-type schwannoma Benign schwannoma Schwannoma Benign schwannoma Schwannoma Benign schwannoma Schwannoma Degenerative schwannoma Benign schwannoma Benign schwannoma Benign schwannoma Schwannoma Benign schwannoma
No Pain Pain Pain No No No Pain No No No Pain Pain
Pod 7 – Pod 3 Pod 5 Pod 6 – – – – Pod 14 – Pod 10 Pod 3
No No No No No No No Left pneumothorax No No No No No
F, female; M, male; Pod, postoperative day.
Tumor injury during surgery should be avoided because it may cause local recurrence. In our opinion, conversion to open surgery is mandatory if there is a risk of tumor rupture during laparoscopic resection. Therefore, it is very important to perform a cautious, prudent, and gentle dissection to progressively free the tumor from it attachments. Giving the small number of cases involving laparoscopically resected schwannomas, no clear data on contraindications of laparoscopy have been reported. In our opinion, there are some contraindications to laparoscopic surgery for schwannomas, including malignant schwannoma, recurrent schwannoma, and high risk of tumor rupture or major bleeding. Size (10–12 cm is the maximum diameter of laparoscopically resected schwannoma in the literature) and past history of open surgery represent relative contraindications. Large tumors along the inferior vena cava may represent a challenge and are probably better suited for an open approach. Other anatomical structures that may represent an obstacle to safe laparoscopic resection are the left renal vein, the hemiazygos vein, the spinal vein, and the aorta. Benign schwannomas have a well-defined capsule and, in most cases, may be dissected from the adjacent vital organs; visual magnification provided by the laparoscopic technique guarantees a safe and precise surgery. After careful dissection, tumor extraction should always be done using a laparoscopic endobag to avoid potential tumor cells spillage in the abdominal cavity. Patients presenting with this disease are often young, and they may maximally benefit from laparoscopic surgery’s advantages of fast recovery and good cosmetic outcome. A search of the PubMed database was performed using the MeSH terms “laparoscopic,” “minimally invasive,” and “schwannoma.” A review of the English language literature identified 12 previous cases of laparoscopically
80
resected retroperitoneal schwannomas (Table 1). The majority of patients were young; the most frequent symptom was abdominal pain. The largest tumor, reported by Pazouki et al., had a diameter of 12 cm (3). In our case, the maximum tumor diameter was 9.5 cm, but the neoplasm was adherent to the inferior vena cava. In a study by Pinto et al., only one tumor was degenerated, and only this patient experienced a postoperative complication, a pneumothorax with spontaneous regression. The majority of patients had a short hospital stay without complications and a fast recovery (8). Table 2 reports the preoperative suspected diagnoses, the intraoperative outcomes, and follow–up information on cases retrieved as part of the literature review. Eight authors reported follow-up, with follow-up ranging from 6 to 45 months. No tumor relapse was observed. Although there was little data on long-term follow-up and plans to examine more extensive longterm oncological results, we believe that laparoscopic resection may be proposed for benign tumors as long as the surgeon is experienced and oncological principles are respected during surgery (3–5,8,10,14,15). In conclusion, our experience and the review of previous cases show that laparoscopic resection is safe and effective for removing benign retroperitoneal schwannomas in selected cases and when performed by experienced surgeons, and it guarantees excellent outcomes in terms of patient recovery and satisfaction. Preliminary oncological results seem to be comparable to those obtained with open surgery.
Acknowledgments The authors have no conflicts of interest to disclose and received no financial support for this article.
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Suspected neurogenic tumor Benign cystic tumor Well-defined complex solid and cystic mass
Round, sharply demarcated retroperitoneal solid tumor Solid and cystic mass Well-defined round cystic mass without calcifications or infiltration; schwannoma, nonfunctioning pheochromocytoma or paraganglioma Well-defined encapsulated mass
Asakage(2) Pazouki et al.(3) Misra et al.(4)
Gorgun et al.(5)
Solid mass; neurogenic tumor at intraoperative biopsy Retroperitoneal neurogenic tumor
Benign tumor of neurogenic origin
Neurogenic tumor
High suspicion of retroperitoneal schwannoma
Descazeaud et al.(9)
Ohigashi et al.(15)
Funamizu et al.(10)
Present case
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
DFS, disease-free survival; IVC, inferior vena cava; NR, not reported.
Nishio et al. (14)
Neural soft tissue tumor
Pinto et al.(8)
Kang et al.(7)
Rao et al.(6) Yoshino & Yoneda(13)
Preoperative diagnosis
Author
Right retroperitoneal space anterior to the psoas Right retroperitoneal space attached to the psoas Retroperitoneal space behind the lesser omental sac Right paracaval region, anterior to the psoas
Between the pancreaticoduodenal unit and the IVC Inferior to the left 12th rib and adjacent to the intercostal muscles Retroperitoneal adjacent to the IVC
Adjacent to the dorsal side of the IVC Posterior to the left kidney Left para-aortic region between the aorta and kidney Between the anterior of the right kidney and the IVC Behind the pancreas Left adrenal region
Location
Table 2. Preoperative suspected diagnosis, intraoperative outcomes, and follow-up in the review of the literature
120 min
NR
180 min
195 min
NR
NR
230 min
210 min NR
120 min
306 min NR 140 min
Operative time
50 mL
NR
25 mL
200 mL
NR
NR
150 mL
100 mL NR
200 mL
100 mL NR 100 mL
Blood loss
DFS at 15 months
DFS at 33 months
DFS at 6 months
DFS at 14 months
NR
DFS at 14 months
NR
NR
DFS, but time of follow-up is not reported
NR DFS at 7 months DFS at 45 months
Follow-up
Five-trocar technique
Five-trocar technique
Four-trocar technique
Four-trocar technique
Standard laparoscopy
Standard laparoscopy
Four-trocar technique
Four-trocar technique Standard laparoscopy
Four-trocar technique
Five-trocar technique Four-trocar technique Standard laparoscopy
Approach
N Petrucciani et al. Laparoscopy for paracaval schwannoma
81
Laparoscopy for paracaval schwannoma
N Petrucciani et al.
References 1. Mastoraki A, Toska F, Tsiverdis I et al. Retroperitoneal schwannomas: Dilemmas in diagnostic approach and therapeutic management. J Gastrointest Cancer 2013; 44: 371–374. 2. Asakage N. Laparoscopic resection of a retroperitoneal schwannoma. Asian J Endosc Surg 2012; 5: 25–30. 3. Pazouki A, Khalaj A, Shapoori P et al. Laparoscopic resection of a retroperitoneal schwannoma. Surg Laparosc Endosc Percutan Tech 2011; 21: e326–e328. 4. Misra MC, Bhattacharjee HK, Hemal AK et al. Laparoscopic management of rare retroperitoneal tumors. Surg Laparosc Endosc Percutan Tech 2010; 20: e117–e122. 5. Gorgun M, Sezer TO, Kirdok O. Laparoscopic resection of retroperitoneal schwannoma near the inferior vena. Ann Vasc Surg 2010; 24: 551.e1–551.e4. 6. Rao W, Wang G, Xiu D. Laparoscopic resection of a retroperitoneal schwannoma adherent to vital vessels. Surg Laparosc Endosc Percutan Tech 2009; 19: e21–e23. 7. Kang CM, Kim DH, Seok JY et al. Laparoscopic resection of retroperitoneal benign schwannoma. J Laparoendosc Adv Surg Tech A 2008; 18: 411–416. 8. Pinto D, Kaidar-Person O, Cho M et al. Laparoscopic resection of a retroperitoneal degenerative schwannoma: A case report and review of the literature. Surg Laparosc Endosc Percutan Tech 2008; 18: 121–123. 9. Descazeaud A, Coggia M, Bourriez A et al. Laparoscopic resection of a retroperitoneal schwannoma. Surg Endosc 2003; 17: 520.
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10. Funamizu N, Sasaki A, Matsumoto T et al. Laparoscopic resection of a retroperitoneal schwannoma behind the lesser omental sac. Surg Laparosc Endosc Percutan Tech 2004; 14: 175–177. 11. Ferretti M, Gusella PM, Mancini AM et al. Progressive approach to the cytologic diagnosis of retroperitoneal spindle cell tumors. Acta Cytol 1997; 41: 450–460. 12. Ramacciato G, Nigri GR, Petrucciani N et al. Minimally invasive adrenalectomy: A multicenter comparison of transperitoneal and retroperitoneal approaches. Am Surg 2011; 77: 409–416. 13. Yoshino T & Yoneda K. Laparoscopic resection of a retroperitoneal ancient schwannoma: A case report and review of the literature. Anticancer Res 2008; 27: 2889–2891. 14. Nishio A, Adachi W, Igarashi J et al. Laparoscopic resection of a retroperitoneal schwannoma. Surg Laparosc Endosc Percutan Tech 1999; 9: 306–309. 15. Ohigashi T, Nonaka S, Nakanoma T et al. Laparoscopic treatment of retroperitoneal benign schwannoma. Int J Urol 1999; 6: 100–103.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Video S1 Video showing the laparoscopic resection of a large paracaval schwannoma.
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Retroperitoneal schwannomas: Advantages of laparoscopic resection. Review of the literature and case presentation of a large paracaval benign schwannoma (with video) Niccolo Petrucciani, Dario Sirimarco, Paolo Magistri, Laura Antolino, Marcello Gasparrini & Giovanni Ramacciato Department of General Surgery, Surgical Department of Clinical Sciences, Biomedical Technologies and Transitional Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital Rome, Italy
Keywords Laparoscopic; retroperitoneal; schwannoma Correspondence Niccolo Petrucciani, via Tronto 32, 00198, Rome, Italy. Tel: 0039 3297372784 Fax: 0039 0633775322 Email: [email protected] Received 26 May 2014; revised 12 September 2014; accepted 16 September 2014
Abstract Retroperitoneal schwannomas represent 0.5%–3% of all retroperitoneal tumors. Complete surgical removal is the treatment of choice because it permits a correct histological diagnosis and prevents eventual degeneration. Laparoscopic surgery has been reported as safe and effective by several authors. We present a comprehensive review of the literature regarding the role of laparoscopy in surgical resection of retroperitoneal schwannomas, and we present a case showing the technique (with video). Laparoscopic resection in experienced hands is safe and effective, and guarantees excellent postoperative results in terms of patient recovery.
DOI:10.1111/ases.12150
Introduction Retroperitoneal schwannomas, which account for 0.5%–3% of all retroperitoneal tumors (1), are benign in the majority of cases. Clinical symptoms and radiological characteristics of schwannomas are not specific, so preoperative diagnosis is difficult. Surgical resection is recommended to obtain a certain histological diagnosis and to completely remove these tumors to prevent eventual degeneration. The laparoscopic approach offers several advantages over open removal: accurate dissection facilitated by visual magnification, fast postoperative patient recovery, and excellent cosmetic results. Good patient selection and experienced surgical teams are required, especially in cases involving a large tumor close to vital vessels.
Case Presentation A 60-year-old woman was admitted to our hospital for the treatment of a right paracaval retroperitoneal tumor. The lesion was discovered 3 years before in a primary
78
referral hospital. It was located in the right paracaval region, and its size was 2.5 × 2.2 × 2.7 cm. Its density was 28 HU. A percutaneous biopsy was attempted at that time, but the specimen was non-diagnostic. Radiological follow-up was continued every 4 months with ultrasound and CT scan. After 3 years, the patient presented at the Emergency Department with an episode of abdominal pain. A CT scan demonstrated an enlargement of the lesion, measuring 9.5 × 4.4 × 2.5 cm (Figure 1); the mass showed a non-homogeneous contrast enhancement. No other lesions were detected. Past medical history and comorbidities included hypertension and resection of an chondromatous hamartoma of the left lung 6 years before. Physical examination was unremarkable, and laboratory work-up showed no pathological findings. The patient underwent laparoscopic resection of the mass (Video S1). Trocar scars are showed in Figure 2. Under general anesthesia, the patient was placed in left lateral decubitus. Peritoneal insufflation with carbon dioxide was performed with a Veress technique, and five trocars, including one 10-mm optic trocar, one 10-mm operative trocar, and three 5-mm trocars, were inserted.
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Laparoscopy for paracaval schwannoma
N Petrucciani et al.
Figure 1 CT scan showing a large right paracaval retroperitoneal tumor.
Figure 2 Patient’s scars 1 month after surgery.
Abdominal carbon dioxide pressure was maintained between 10 and 12 mmHg. The liver was mobilized and lifted with the left trocar. The right colon was mobilized, and a Kocher maneuver was performed to expose the inferior vena cava. The mass was gently dissected and put in an endobag for extraction to avoid potential tumor cells spillage. The left flank trocar incision was slightly enlarged to extract the intact tumor. A drain was placed and removed on postoperative day 1. The postoperative course was uneventful and the patient was discharged in postoperative day 3. Histologically, the tumor was a schwannoma; the immunohistochemical analysis demonstrated the presence of S100 and the absence of desmin. The patient remains disease-free at 15 months.
Discussion Retroperitoneal tumor is a rare entity, and schwannomas account for 0.5%–3% of all retroperitoneal neoplasms (1–3). Only 0.7% of schwannomas are located in the retroperitoneal space (4,5). Differential diagnosis includes
neurofibromas, paragangliomas, pheochromocytomas, liposarcomas, and malignant fibrous histiocytomas. Schwannomas are tumors that arise from the peripheral nerve sheath and consist of Schwann cells in a collagenous matrix (6). Most schwannomas are benign, well circumscribed, and encapsulated. These tumors are often asymptomatic and slow growing, and diagnosis is incidental. If symptomatic, they may cause pain and obstructive or compressive symptoms, according to their location (7–10). A preoperative characterization is difficult because neither the clinical symptoms nor the radiological characteristics of schwannomas are specific. Characteristic CT features are the “target” and “fascicular” signs, which are rare. Percutaneous fine-needle aspiration was proposed by Ferretti et al. to differentiate benign from malignant schwannomas preoperatively (11). In our case, percutaneous aspiration was attempted for cytology, but its result was non-diagnostic. Complete surgical excision represents the treatment of choice and allows for an accurate histological and immunohistochemical examination. Even if the definitive diagnosis is based on histological analysis, some radiological characteristics may help physicians to differentiate benign tumors from malignant tumors and to orient their approach. At preoperative imaging, most schwannomas are well-circumscribed masses with smooth, regular margins and central cystic degeneration that, as in our case, displace rather than invade local structures. Furthermore, as in our case, nerve sheath tumors are located anterior to the psoas muscle arising from the sympathetic chain. Therefore, preoperative imaging may well orient physicians and suggest a diagnosis of benign tumor or benign schwannoma in a consistent percentage of cases. We believe that if there is a suspicion of malignancy (retroperitoneal sarcoma), an open approach is safer and oncologically more correct. However, if a preoperative diagnosis of a retroperitoneal benign schwannoma is highly probable, a laparoscopic approach should be considered because it offers several advantages. Regardless, even for tumors that appear to be benign, we believe that the surgeon should be always ready to convert to open surgery if there is a risk of tumor rupture and intraabdominal dissemination (12). In this case, we choose a laparoscopic approach because suspicion of a benign schwannoma was very high, but we were ready to convert to open surgery in case of doubt, tumor fragility, risk of rupture, and risk of bleeding. As shown in the video, the tumor was well-circumscribed, had smooth margins, and was easily cleavable from other structures. Vascular pedicles were easy to control, and there was no risk of major bleeding. Thus, a laparoscopic resection respecting oncological principles was possible.
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
79
Laparoscopy for paracaval schwannoma
N Petrucciani et al.
Table 1 Review of the literature including all the retroperitoneal schwannomas resected by the laparoscopic approach Author
Sex
Age
Size (cm)
Associated procedures
Histology
Symptoms
Discharge
Complications
Asakage(2) Pazouki et al.(3) Misra et al.(4) Gorgun et al.(5) Rao et al.(6) Yoshino & Yoneda(13) Kang et al.(7) Pinto et al.(8) Descazeaud et al.(9) Nishio et al. (14) Ohigashi et al.(15) Funamizu et al.(10) Present case
M M M F M M F F F F F M F
34 54 41 33 42 67 59 71 62 41 28 55 60
5.5 × 3.5 12 × 9 8×8 4.2 × 5.2 3 × 3.3 8 × 7.5 × 6 – 2 × 1.6 8×5 5×5 3 × 3 × 3.5 6 × 4.5 × 4 9.5 × 4.4
Appendectomy No no No No No No No No No No No No
Benign mixed-type schwannoma Benign schwannoma Schwannoma Benign schwannoma Schwannoma Benign schwannoma Schwannoma Degenerative schwannoma Benign schwannoma Benign schwannoma Benign schwannoma Schwannoma Benign schwannoma
No Pain Pain Pain No No No Pain No No No Pain Pain
Pod 7 – Pod 3 Pod 5 Pod 6 – – – – Pod 14 – Pod 10 Pod 3
No No No No No No No Left pneumothorax No No No No No
F, female; M, male; Pod, postoperative day.
Tumor injury during surgery should be avoided because it may cause local recurrence. In our opinion, conversion to open surgery is mandatory if there is a risk of tumor rupture during laparoscopic resection. Therefore, it is very important to perform a cautious, prudent, and gentle dissection to progressively free the tumor from it attachments. Giving the small number of cases involving laparoscopically resected schwannomas, no clear data on contraindications of laparoscopy have been reported. In our opinion, there are some contraindications to laparoscopic surgery for schwannomas, including malignant schwannoma, recurrent schwannoma, and high risk of tumor rupture or major bleeding. Size (10–12 cm is the maximum diameter of laparoscopically resected schwannoma in the literature) and past history of open surgery represent relative contraindications. Large tumors along the inferior vena cava may represent a challenge and are probably better suited for an open approach. Other anatomical structures that may represent an obstacle to safe laparoscopic resection are the left renal vein, the hemiazygos vein, the spinal vein, and the aorta. Benign schwannomas have a well-defined capsule and, in most cases, may be dissected from the adjacent vital organs; visual magnification provided by the laparoscopic technique guarantees a safe and precise surgery. After careful dissection, tumor extraction should always be done using a laparoscopic endobag to avoid potential tumor cells spillage in the abdominal cavity. Patients presenting with this disease are often young, and they may maximally benefit from laparoscopic surgery’s advantages of fast recovery and good cosmetic outcome. A search of the PubMed database was performed using the MeSH terms “laparoscopic,” “minimally invasive,” and “schwannoma.” A review of the English language literature identified 12 previous cases of laparoscopically
80
resected retroperitoneal schwannomas (Table 1). The majority of patients were young; the most frequent symptom was abdominal pain. The largest tumor, reported by Pazouki et al., had a diameter of 12 cm (3). In our case, the maximum tumor diameter was 9.5 cm, but the neoplasm was adherent to the inferior vena cava. In a study by Pinto et al., only one tumor was degenerated, and only this patient experienced a postoperative complication, a pneumothorax with spontaneous regression. The majority of patients had a short hospital stay without complications and a fast recovery (8). Table 2 reports the preoperative suspected diagnoses, the intraoperative outcomes, and follow–up information on cases retrieved as part of the literature review. Eight authors reported follow-up, with follow-up ranging from 6 to 45 months. No tumor relapse was observed. Although there was little data on long-term follow-up and plans to examine more extensive longterm oncological results, we believe that laparoscopic resection may be proposed for benign tumors as long as the surgeon is experienced and oncological principles are respected during surgery (3–5,8,10,14,15). In conclusion, our experience and the review of previous cases show that laparoscopic resection is safe and effective for removing benign retroperitoneal schwannomas in selected cases and when performed by experienced surgeons, and it guarantees excellent outcomes in terms of patient recovery and satisfaction. Preliminary oncological results seem to be comparable to those obtained with open surgery.
Acknowledgments The authors have no conflicts of interest to disclose and received no financial support for this article.
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Suspected neurogenic tumor Benign cystic tumor Well-defined complex solid and cystic mass
Round, sharply demarcated retroperitoneal solid tumor Solid and cystic mass Well-defined round cystic mass without calcifications or infiltration; schwannoma, nonfunctioning pheochromocytoma or paraganglioma Well-defined encapsulated mass
Asakage(2) Pazouki et al.(3) Misra et al.(4)
Gorgun et al.(5)
Solid mass; neurogenic tumor at intraoperative biopsy Retroperitoneal neurogenic tumor
Benign tumor of neurogenic origin
Neurogenic tumor
High suspicion of retroperitoneal schwannoma
Descazeaud et al.(9)
Ohigashi et al.(15)
Funamizu et al.(10)
Present case
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
DFS, disease-free survival; IVC, inferior vena cava; NR, not reported.
Nishio et al. (14)
Neural soft tissue tumor
Pinto et al.(8)
Kang et al.(7)
Rao et al.(6) Yoshino & Yoneda(13)
Preoperative diagnosis
Author
Right retroperitoneal space anterior to the psoas Right retroperitoneal space attached to the psoas Retroperitoneal space behind the lesser omental sac Right paracaval region, anterior to the psoas
Between the pancreaticoduodenal unit and the IVC Inferior to the left 12th rib and adjacent to the intercostal muscles Retroperitoneal adjacent to the IVC
Adjacent to the dorsal side of the IVC Posterior to the left kidney Left para-aortic region between the aorta and kidney Between the anterior of the right kidney and the IVC Behind the pancreas Left adrenal region
Location
Table 2. Preoperative suspected diagnosis, intraoperative outcomes, and follow-up in the review of the literature
120 min
NR
180 min
195 min
NR
NR
230 min
210 min NR
120 min
306 min NR 140 min
Operative time
50 mL
NR
25 mL
200 mL
NR
NR
150 mL
100 mL NR
200 mL
100 mL NR 100 mL
Blood loss
DFS at 15 months
DFS at 33 months
DFS at 6 months
DFS at 14 months
NR
DFS at 14 months
NR
NR
DFS, but time of follow-up is not reported
NR DFS at 7 months DFS at 45 months
Follow-up
Five-trocar technique
Five-trocar technique
Four-trocar technique
Four-trocar technique
Standard laparoscopy
Standard laparoscopy
Four-trocar technique
Four-trocar technique Standard laparoscopy
Four-trocar technique
Five-trocar technique Four-trocar technique Standard laparoscopy
Approach
N Petrucciani et al. Laparoscopy for paracaval schwannoma
81
Laparoscopy for paracaval schwannoma
N Petrucciani et al.
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Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Video S1 Video showing the laparoscopic resection of a large paracaval schwannoma.
Asian J Endosc Surg 8 (2015) 78–82 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
