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SCHWANNOM İN THE ARM: CASE REPORTDokuz Eylul University Faculty of Medicine, Department of Plastic, Reconstructive andAesthetic Surgery, IzmirİNTRODUCTİONSchwannoma is a hard, well-circumscribed, encapsulated and slow-growing benign tumor ofthe nerve sheaths. It was first described by Verocay in 1908. It can be seen at any age, it ismost common between the ages of 20-50 and the female/male ratio is 2:1. It is mostcommon in the head and neck, but 20% of Schwannomas originate from peripheral nerves.Schwannomas constitute 12-19% of upper extremity tumors. They are mostly seen on theflexor sides of the extremities, especially in the wrist and elbow regions. The ulnar nerve isthe most common location in the upper extremity. These tumors can easily be confused withlipomas, neurofibromas, hemangiomas, and synovial cysts.Since the symptoms of peripheral nerve schwannoma often coincide with nerveentrapments, they can easily be misdiagnosed. Symptoms appear by pressing on the mass orsurrounding tissues, there is no medical treatment for schwannomas, the treatment is thecomplete removal of the mass.CASE REPORTWith no known systemic disease, a 62-year-old male patient was admitted to us aftermultiple external center applications upon noticing progression in the size of the nodularlesion located distal to the right arm for about 3 years.The patient had no known history oftrauma.During the examination performed by us, a painful minimal mobile skin nodularlesion measuring 1* 1 cm was detected by palpation on the radial side of the 1/3 distal partof the right arm.On examination, no motor defects were detected while describing minimalhypoesthesia in the radial nerve tract.Magnetic resonance imaging performed in the radialnerve tract distal to the right arm with a size of 17* 12 mm is compatible with schwannomapossible mass lesion was observed.After obtaining written informed consent from the patient, the operation was performedunder general anesthesia with pneumatic tourniquet control. After a longitudinal 3 cmincision made on the lateral arm, the lateral intermuscular septum was dropped. Aftercrossing the septum, the radial nerve was reached. It was observed that the mass waslocated in the middle of the nerve and expanded the radial nerve anteriorly and posteriorly.It looked moderately hard, yellowish, and encapsulated. The nerve sheath was opened andthe tumor was completely removed without damaging the nerve. The mass was well-circumscribed and easily distinguishable from the surrounding tissues.The mass was separated for pathological examination. No sensory or motor deficits weredetected in the radial nerve tracing of the patient, who did not have any problems at thewound site. The patient was discharged on the first postoperative day with good recovery. Inthe pathology report, compact areas (Antoni A) consisting of fusiform cells with palisadicpattern and tumoral structure formed by loose and hypocellular areas (Antoni B) wereobserved. In Antoni A areas, cells with eosinophilic cytoplasm, unclear borders, andelongated nuclei were observed and the lesion was reported as schwannoma.Immunohistochemical S-100 staining supported the diagnosis. The patient reported that allhis complaints were resolved immediately. At the end of the first week, she was completelyasymptomatic and returned to her daily activities.DİSCUSSİONSchwannoma accounts for 5% of soft tissue tumors in adults. It is also more common in theupper extremity than the lower extremity. It mostly involves the ulnar, median and radialnerves in the upper extremity. While 30-70% of all extremity schwannomas have paincomplaints, 20% have paresthesia complaints. Our patient presented with the complaint ofnumbness in the fingers, and the lesion was palpated in the physical examination of ourpatient. The possibility of peripheral nerve sheath tumor should be considered in thedifferential diagnosis of superficial tissue lesions in the extremities. Although Tinel's testpositivity and paresthesia are seen in most of these tumors, lipoma, neurofibroma, ganglioncyst and xanthoma should also be considered in the differential diagnosis. Ultrasonographymay be our first choice in evaluating such superficial lesions, but the most effective imagingmethod is magnetic resonance imaging. It is not possible to differentiate the lesion frommalignant-benign with imaging. Size over 5 cm, irregular borders, surrounding edema,homogeneous necrotic areas, presence of calcification and inactivity on palpation are criteriathat increase the suspicion of malignancy. Schwannomas rarely show malignanttransformation and are encapsulated and well-circumscribed tumors. They rarely recur aftertotal excision and post-excision chemotherapy and radiotherapy are not recommended.In conclusion, peripheral nerve schwannomas are not very common. Sometimes they cancause entrapment neuropathies. Therefore, a careful neurological and physical examinationwill enable such lesions to be noticed. Careful dissection during surgery will minimize nervedamage.Keywords: Schwannoma, radial nerve, arm |
