Brachial Plexus Schwannoma: Report of 4 cases with Intralesional Enucleation
Received Date: Oct 11, 2017 / Accepted Date: Dec 11, 2017 / Published Date: Dec 16, 2017
Brachial plexus tumors are rare. It comprises of only 5% of all tumors of upper limb. The two most common brachial plexus region tumors are schwannomas and neurofibromas. Brachial plexus tumours comprises of only 5% of all tumours of upper limb. Schwannomas are most frequently found in the head and neck region, which comprises 25% of all Schwannomas. There are only about 5% of schwannomas present as brachial plexus tumours. Here we report four cases of brachial plexus schwannoma with surgical removal managed in our centre from 2013 to 2016.
Keywords: Schwannomas; Neurofibromas; Clinical; Brain
Brachial plexus tumours are rare. It comprises of only 5% of all tumours of upper limb . The two most common brachial plexus region tumors are schwannomas and neurofibromas [2-4]. Both are benign and arise from the nerve sheath. Jia et al. published a large case series of 143 patients with primary brachial plexus tumors in 2016. In his series, there are 119 schwannoma and 12 neurofibromas . Schwannomas are most frequently found in the head and neck region, which comprises 25% of all Schwannomas. There are only about 5% of schwannomas present as brachial plexus tumours .
The most common clinical presentation of primary brachial plexus tumor includes palpable mass, pain, numbness or paresthesias, weakness etc. [3,4,6]. Brachial plexus schwannoma can present as neck mass, axillary mass, supraclavicular mass or apical lung mass [7-10]. On CT, most schwannomas are iso-dense relative to brain parenchyma. Calcification or areas of hemorrhage are rare, and the enhancement pattern is typically homogeneous. On MRI, schwannomas are iso-intense to hypo-intense on T1-weighted MRI and enhance with gadolinium [11,12]. Malignant transformation of schwannoma is very rare, but it has been reported in literature . Outcome of surgical removal of brachial plexus schwannoma has been reported to be satisfactory .
There were four cases of brachial plexus schwannoma managed operatively in our centre from 2013 to 2016. Pre-operatively, magnetic resonance imaging(MRI) and fine needle aspiration(FNA)/biopsy were performed. All the four cases had intranuclear enucleation done under general anesthesia. Microscope was used to assist the procedure intra-operatively. Pre-and post excision of the tumor, nerve stimulator was used to confirm intact motor function of the nerve. At the site of enucleation, the nerve was wrapped with commercial anti-adhesive paper made of polylactic acid after removal of tumor. All the excised tumors had histopathological proof of schwannoma. There was no evidence of malignancy in all cases. The clinical information of the four cases was summarized in the Table 1.
|Size in cm||Post-op neurology|
|F/69||Palpable mass at right
|1.9 × 1.4 × 1.1||Temporary numbness at
right C5 for 3 weeks,
|M/41||Left upper limb
|N||N||Left C5 C6
|3.0 × 2.5 × 1.5||No more numbness
Motor recovery to power 4/5
|F/32||Palpable mass at right
|1.5 × 1.0 × 1.5||Nil|
and sentinel LN
biopsy for Ca right
|2.0 × 2.8 × 2.3||Nil|
Table 1: Summary of clinical information of 4 cases.
A 69-year-old lady complained of a painful palpable mass at her right supraclavicular fossa (Figure 1). There was no neurological deficit. Tinsel sign was positive. MRI showed there was a well-defined homogenous T1 hypointense (Figure 2) and T2 hyperintense lesion at right C5 nerve root (Figure 3). Supraclavicular approach was used with a L-shaped incision at the lateral border of sternocleidomastoid muscle and upper border of clavicle (Figure 4). A 1.9 cm × 1.4 cm × 1.1 cm tumor was surgically removed from right C5 nerve root (Figure 5). After the operation, there was temporary numbness at right C5 dermatome for 3 weeks. It completely subsided afterwards.
Patient was a 41-year-old male. He presented with left upper limb numbness and weakness. There was no palpable mass. Upon physical examination, there was decreased sensation at left C5 and C6 dermatome. There was also weakness at left supraspinatous, infraspinatous and biceps muscle with MRC grade 3/5. MRI found that there was a welldefined homogenous T1 hypointense and T2 hyperintense lesion (Figures 6 and 7) at upper trunk of left brachial plexus. Supraclavicular approach was used to remove the lesion (Figure 8). Post-operatively, there was no more upper limb numbness. The power of the involved muscle improved to MRC grade 4/5.
A 32 year-old lady complained of a palpable painless mass at her right supraclavicular fossa. Sensory and motor function was intact. There was positive Tinel sign. Pre-operative MRI scan showed typical feature of schwannoma (Figures 9 and 10). Supraclavicular approach was adopted for enucleation of lesion. There was a 1.5 cm × 1.0 cm × 1.5 cm schwannoma at the upper trunk of right brachial plexus. No neurological deficit was found after the surgery.
A 39-year-old lady had cancer of right breast. There was an incidental finding of an axillary mass during lumpectomy of right breast and sentinel lymph node biopsy surgery. Patient was asymptomatic. She was then referred to our team for further management. MRI and biopsy confirmed the mass was a brachial plexus schwannoma (Figures 11 and 12). Deltopectoral approach was used in this case (Figure 13). There was a 2.0 cm × 2.8 cm × 2.3 cm lesion located at posterior cord of right brachial. Enucleation was performed. There was no neurological deficit after the operation.
We obtained similar clinical characteristics of brachial plexus schwannoma as those reported in literature [3,4,6-10]. Brachial plexus schwannoma could be a painless or painful mass. Neurological deficit was not always present. The lesions were found at supraclavicular or axillary region. MRI was a valuable diagnostic tool . In our cases, the MRI features of the tumors were consistent. It showed a welldefined homogenous lesion, hypointense in T1 weighted film and hyperintense in T2 weighted film.
Since the lesion is benign, the aim of surgery should be maximal debulking of tumor with minimal damage to normal nerve fibres.
The described method of intralesional enucleation provided satisfactory outcome in all 4 cases. There was no irreversible neurological damage after the operation. With the mean follow-up period of 27 months, there was no evidence of recurrence of tumor. Our management pathway for brachial plexus schwannoma was summarized below in Figure 14.
- Donner TR, Voorhies RM, Kline DG (1994) Neural sheath tumours of major nerves. J Neurosurg 81: 362-373.
- Ganju A, Roosen N, Kline DG, Tiel RL (2001) Outcomes in a consecutive series of 111 surgically treated plexal tumors: A review of the experience at the Louisiana State University Health Sciences Center. J Neurosurg 95: 51-60.
- Jia X, Yanga J, Chen L, Yu C, Kondo T (2016) Primary brachial plexus tumors: Clinical experiences of 143 cases. Clin Neurol Neurosurg 148: 91-95.
- Blinder DK, Smith JS, Barbaro NM (2004) Primary brachial plexus tumors: Imaging, surgical, and pathological findings in 25 patients. Neurosurg Focus 16: 1-6.
- Huang JH, Samadani U, Zager EL (2003) Brachial plexus region tumors: a review of their history, classification, surgical management, and outcomes. Neurosurg Q 13: 151-161.
- Lee HJ, Kim JH, Rhee SH, Gong HS, Baek GH (2014) Is surgery for brachial plexus schwannomas safe and effective? Clin Orthop Relat Res 472: 1893-1898.
- Kumar A, Akhtar S (2011) Schwannoma of brachial plexus. Indian J Surg 73: 80-81.
- Rashid M, Salahuddin O, Yousaf S, Qazi U, Yousaf K (2013) Schwannoma of the brachial plexus; Report of two cases involving the C7 root. J Brachial Plexus Peripheral Nerve Injury 8: 12.
- Aslan A, Hengameh H, Mostafa C, Farzad I (2015) Schwannoma of the brachial plexus presented as a neck mass: A case report and review of the literature. Int J Otolaryngology Head Neck Surg 4: 104-107.
- Munireddy MV, Pavan BK, Bhaskaran A (2017) Schwannoma of brachial plexus presenting as supraclavicular mass: A rare presentation, evaluation and its management is a challenge to surgeons. J Med Sci Clinical Res 5: 26114-26117.
- Chung SY, Kim DI, Lee BH, Yoon PH, Jeon P, et al. (1998) Facial nerve schwannomas: CT and MR findings. Yonsei Med J 39: 148-153.
- Bartolome A, Gonzalez-Alenda J, Bartolome MJ (1998) Study of the brachial plexus by magnetic resonance. Rev Neurol 26: 983-988.
- Nayler SJ, Leiman G, Omar T, Cooper K (1996) Malignant transformation in a schwannoma. Histopathology 2: 189-192.
- Prem AK, Biju I, Ramya R, Thippeswamy N (2017) Axillary nerve schwannoma: A rare case report. Asian J Neurosurg 12: 787-789.
Citation: Chan JSY, Josephine WYI (2017) Brachial Plexus Schwannoma: Report of 4 cases with Intralesional Enucleation. J Clin Case Rep 7: 1052. Doi: 10.4172/2165-7920.10001052
Copyright: © 2017 Chan JSY, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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