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Fırat Tıp Dergisi
2006, Cilt 11, Sayı 1, Sayfa(lar) 068-070
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Tc-99m-Diphosphonate Uptake in a Giant Ancient Schwannoma of the Arm
Ersoy KEKİLLİ1, Kadir ERTEM2, Cengiz YAGMUR1
1İnönü Üniversitesi Tıp Fakültesi Nükleer Tıp Anabilim Dalı, MALATYA
2İnönü Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, MALATYA
Keywords: Nerve tumor, schwannoma, scintigraphy, Tc-99m-medronate, Sinir tümörü, schwannoma, sintigrafi, Tc-99m-medronat
Summary
We present a 77-year woman with a size of 9.5x9x7cm giant ancient schwannoma located in the lower arm. Increased activity accumulation in the tumor was seen on the Tc-99m-methylene diphosphonate bone scintigraphy. After excision of the tumor, Pathologic diagnosis could be illustrated as an ancient schwannoma. Previous studies reported that Schwannoma could be demonstrated with increased Tc-99m-diphosphonates activity accumulation but we speculate that this accumulation may be related to tissue types or atypical types of schwannoma. ©2006, Fırat Üniversitesi, Tıp Fakültesi
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  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Introduction
    Schwannoma, also referred neurilemmoma and neurinoma, is rare benign neurogenic tumor developing from Schwann cells arising from of a nerve. The most common sites of occurrence of peripheral nerve schwannomas are the head and neck region, trunk and extremities, but may appear anywhere. As a rule, they grow slowly over a period of years. Outside the setting of neurofibromatosis-2, most schwannomas are solitary 1-3. Ancient schwannoma is an uncommon variant of neurilemmoma that display pronounced degenerative changes such as cyst formation, calcification, hemorrhage, and hyalinization 4,5.

    Imaging methods are important for characterizing the lesions, and they may suggest the diagnosis. However, definitive diagnosis is obtained by biopsy or pathological analysis of the operative specimen.

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  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Case Presentation
    A 77-year woman was referred to our institution for evaluation and treatment of a mass in her volar surface of right lower arm with a localized pain but no symptoms of any paresthesia, hypesthesia and motor and sensory deficit as long as 10 years.

    On radiologic evaluation, 10x8x7 cm multiloculated cystic mass with small solid areas and septae in the lateral surface of the upper arm was showed on the ultrasonography and magnetic resonance imaging. In addition, a fluid–fluid level indicating hemorrhage was present within a largest cystic area on T2-weighted sequences. T1-weighted images after administration of Gd-DTPA showed marked enhancement at the solid components and septae.

    Technetium-99m methylene diphosphonate bone scan was performed. An increased blood flow around of the large hypoactive areas was seen in the second phase of the bone scan (fig. 1). The delayed image showed significant irregular activity accumulation in the lesion on bone scan (fig. 2).


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    Figure 1: An increased blood flow around of the large hypoactive areas was seen in the second phase of the bone scan.


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    Figure 2: The delayed image showed significant irregular activity accumulation in the lesion on bone scan (fig. 2).

    Surgical exploration disclosed an encapsulated mass arising from a musculocutaneus nerve. Histopathologically the spindle cells are arranged in short bundles or interlacing fascicles. In some areas there was whorling of the cells. Scattered atypical cells were seen. There was neither mitosis nor anaplasia. The schwann cells were expressing invariably strong, diffuse immunreactivity for S-100 protein and vimentin (fig 3 and 4). Staining for alpha smooth muscle actin and desmin was not observed. According to these findings, the case was reported as an ancient schwannoma.


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    Figure 3: An H & E-stained section shows spindle cells arranged in bundles and whorls with alternating loosely textured areas. (hematoxylin-eosin, original magnification ×200) (fig. 3).


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    Figure 4: Immunoperoxidase staining for S-100 protein shows intense diffuse cytoplasmic and nuclear positivity. Note the fascicular arrangement of cells with scattered atypical nuclei. (immunohistochemistry S-100, original magnification ×400) (fig. 4).

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  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Discussion
    The term ancient schwannoma was introduced by Ackerman and Taylor in their description of 10 benign tumors of the thorax demonstrating extensive hyalinization. Aside from nuclear atypia, additional changes associated with the degenerative process include formation of cysts, stromal edema, xanthomatous change, hemorrhage, accumulation of siderophages, calcification and hyalinization 3,4.

    The differential diagnosis of peripheral nerve schwannomas include neurofibroma, malignant peripheral nerve sheath tumor, leiomyoma, lymphadenopathy, vascular anomalies, lipomas, angiomas and dermal nerve sheath myoma 2,6.

    Ultrasonography, magnetic resonance and computed tomography were enabled the correct diagnosis of schwannoma. But differential diagnosis of these tumors by imaging modalities can be difficult 6,7. Nuclear medicine may be help for differential diagnosis and distinguish benign schwannoma from malignancy. Previous authors reported that schwannoma could be demonstrated with increased Tc-99m- (V) DMSA 8, F-18-FDG 9, Tl-201 10, I-131-MIBG 11, Tc-99m-diphosphonates 12 activity accumulation but did not uptake Ga-67 8 and Indium-111 octreotide 7.

    In conclusion, surgeons should have a current knowledge of the diagnostic possibilities and the treatment options about peripheral nerve tumors such as schwannomas. The ancient schwannoma can be demonstrated with the bone scintigraphy.

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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • References

    1) Torossian JM, Augey F, Salle M et al. Giant foot schwannoma. British journal of plastic surgery 2001; 54: 74-76.

    2) Schetthauer BW, Woodruff JM, Erlandson RA. Atlas of tumor pathology. Tumors of peripheral nervous system. 3rd series, fascicle 24, AFIP, Washington DC; 1999: 105-170.

    3) Liebau C, Baltzer AW, Schneppenheim M, et al. Isolated peripheral neurilemoma attached to the tendon of the flexor digitorum longus muscle. Arch Orthop Trauma Surg. 2003; 123: 98-101

    4) Enzinger FM, Weiss SW. Soft tissue tumors. 3rd edition, St. Louis-Mosby; 1996: 829-837.

    5) Dodd LG, Marom EM, Dash RC, et al. Fine-needle aspiration cytology of ancient schwannoma. Diagn Cytopathol, 1999; 20: 307-311.

    6) Rettenbacher T, Sogner P, Springer P, et al. Schwannoma of the brachial plexus: cross-sectional imaging diagnosis using CT, sonography, and MR imaging. Eur Radiol. 2003; 13: 1872-1875.

    7) Maini CL, Cioffi RP, Tofani A, et al. Indium-111 octreotide scintigraphy in neurofibromatosis. Eur J Nucl Med. 1995; 22: 201-206.

    8) Kobayashi H, Kotoura Y, Sakahara H, et al. Schwannoma of the extremities: comparison of MRI and pentavalent technetium- 99m-dimercaptosuccinic acid and gallium-67-citrate scintigraphy. J Nucl Med. 1994; 35: 1174-1178.

    9) Ahmed AR, Watanabe H, Aoki J, Shinozaki T, Takagishi K. Schwannoma of the extremities: the role of PET in preoperative planning. Eur J Nucl Med. 2001; 28: 1541-1551.

    10) Charabi S, Lassen NA, Jacobsen GK, et al. Diagnosis and growth evaluation of vestibular schwannomas by SPECT combined with TL-201 thallium. Ugeskr Laeger. 1999; 161: 2673-2678.

    11) Von Moll L, McEwan AJ, Shapiro B, et al. Iodine-131 MIBG scintigraphy of neuroendocrine tumors other than pheochromocytoma and neuroblastoma. J Nucl Med. 1987; 28: 979-988.

    12) Maini A, Tripathi M, Shekar N C, Malhotra A. Sciatic schwannoma of the thigh detected on bone scan: a case report. Clin Imaging. 2003; 27: 191-193.

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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
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