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Clinical Outcomes Following Resection of Giant Spinal Schwannomas: a Case Series of 32 Patients

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Clinical Outcomes Following Resection of Giant Spinal Schwannomas: a Case Series of 32 Patients CLINICAL ARTICLE J Neurosurg Spine 26:494–500, 2017 Clinical outcomes following resection of giant spinal schwannomas: a case series of 32 patients Madeleine Sowash, BA,1 Ori Barzilai, MD,1 Sweena Kahn, MS,1 Lily McLaughlin, BS,1 Patrick Boland, MD,3 Mark H. Bilsky, MD,1,2 and Ilya Laufer, MD1,2 1Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center; 2Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital; and 3Department of Orthopedic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York OBJECTIVE The objective of this study was to review clinical outcomes following resection of giant spinal schwannomas. METHODS The authors conducted a retrospective review of a case series of patients with giant spinal schwannomas at a tertiary cancer hospital. RESULTS Thirty-two patients with giant spinal schwannomas underwent surgery between September 1998 and May 2013. Tumor size ranged from 2.5 cm to 14.6 cm with a median size of 5.8 cm. There were 9 females (28.1%) and 23 males (71.9%), and the median age was 47 years (range 23–83 years). The median follow-up duration was 36.0 months (range 12.2–132.4 months). Three patients (9.4%) experienced recurrence and required further treatment. All recurrenc- es developed following subtotal resection (STR) of cellular or melanotic schwannoma. There were 3 melanotic (9.4%) and 6 cellular (18.8%) schwannomas included in this study. Among these histological variants, a 33.3% recurrence rate was noted. In 1 case of melanotic schwannoma, malignant transformation occurred. No recurrence occurred following gross-total resection (GTR) or when a fibrous capsule remained due to its adherence to functional nerve roots. CONCLUSIONS Resection is the treatment of choice for symptomatic or growing giant schwannomas, frequently re- quiring anterior or combined approaches, with the goals of symptom relief and prevention of recurrence. In this series, tumors that underwent GTR, or where only capsule remained, did not recur. Only melanotic and cellular schwannomas that underwent STR recurred. https://thejns.org/doi/abs/10.3171/2016.9.SPINE16778 KEY WORDS cellular schwannoma; giant schwannoma; melanotic schwannoma; nerve sheath tumor; spinal tumor; oncology CHWANNOMAS are tumors derived from Schwann cells least 2.5 cm. Giant schwannomas most commonly present of the neural sheath. Approximately 95% of schwan- in the lumbar or sacral regions but are also found in the nomas are benign, encapsulated, and slow grow- cervical and thoracic regions.1,10,11,13,21,24 The most common Sing. Within the spine, they can be extradural, intradural symptoms are back pain, radiculopathy, muscle weakness, extramedullary, or rarely intramedullary, and can cause sensory deficit, difficulty with ambulation, and bladder/ spinal cord and nerve root compression. Schwannomas bowel dysfunction, which are the result of spinal cord or occur sporadically or as part of a hereditary disorder, in nerve root compression. particular neurofibromatosis Type 2 or schwannomatosis. Giant schwannomas without associated symptoms Sporadic schwannomas most commonly occur in the 2nd or radiographic growth can be observed. Surgery is the through 5th decade of life, but can occur at any age with treatment of choice for symptomatic or growing schwan- an equal prevalence in men and women.14 nomas, and the surgical approach to giant schwannomas Giant schwannomas of the spine are classified as an in- of the spine is focused on prevention of recurrence and traspinal tumor of at least 2 vertebral bodies in length or symptom relief. Gross-total resection (GTR) is often cura- with an extraspinal extension of at least 2.5 cm.17 Here, tive and can be achieved safely in the majority of cases. we have also included giant paraspinal schwannomas of at However, GTR may be hindered by intimate involvement ABBREVIATIONS EMG = electromyography; GTR = gross-total resection; MPNST = malignant peripheral nerve sheath tumors; SRS = stereotactic radiosurgery; STR = subtotal resection. SUBMITTED July 1, 2016. ACCEPTED September 20, 2016. INCLUDE WHEN CITING Published online January 13, 2017; DOI: 10.3171/2016.9.SPINE16778. 494 J Neurosurg Spine Volume 26 • April 2017 ©AANS, 2017 Unauthenticated | Downloaded 09/26/21 07:43 PM UTC Outcomes of giant spinal schwannomas of functional nerve roots or the spinal cord. In these cases, residual foraminal tumor was left behind and observed in fibrous capsule or tumor may be left to preserve neurologi- asymptomatic cases. Posterior instrumented stabilization cal function. The role of residual fibrous capsule in recur- was used when facetectomy was undertaken to access the rence is uncertain and may not indicate subtotal resection paraspinal tumor component. (STR) of the actual tumor, but rather residual fibrous tis- In cases in which anterior approaches were employed, sue without neoplastic potential. Subtotal resection may the operations were performed in conjunction with sur- predispose the tumor to recurrence, but due to the slow geons who specialize in the region-specific approaches, growth of these tumors, it can be sufficient to provide such as head and neck, thoracic, and abdominal surgeons. long-term relief of symptoms. The current study examines Upper or lower neck dissections provided exposure of the outcomes of surgical treatment of giant paraspinal anterior cervical tumors. Intrathoracic tumors were ap- schwannomas, examines factors associated with recur- proached using thoracotomy or thoracoscopy. Paraspinal rence, and delineates technical considerations for the sur- lumbar tumors were approached using the retroperitoneal gical approach and excision of these tumors. approach. Open laparotomy or laparoscopy was used to approach presacral tumors. Recent operations used the Methods less invasive techniques such as thoracoscopy and lapa- roscopy. Excision of one of the thoracic schwannomas was Between September 1998 and May 2013, 32 patients performed with robotic assistance (da Vinci Surgical Sys- with giant schwannomas of the spine, defined as extending tem, Intuitive Surgical), as previously reported.4 at least 2 vertebral levels intraspinally or 2.5 cm extraspi- nally, were identified. Patients with giant spinal and para- Surgical Technique spinal schwannomas with at least 12 months of follow-up were included. Patients with schwannomas smaller than Neurophysiological monitoring was used in all cases. Surgery for tumors located in the cervical or thoracic 2 vertebral bodies intraspinal or 2.5 cm extraspinal were spinal canal was conducted using spinal cord monitor- excluded, as were 4 cases of schwannomas in the brachial ing with somatosensory and motor evoked potentials. plexus with no spinal canal involvement and 14 cases with Free-running electromyography (EMG) was used during less than 12 months of follow-up. A retrospective chart and lumbar surgery. A nerve stimulator was used to delineate image review was performed. This study was approved by motor nerve roots. the institutional review board of Memorial Sloan Ketter- In tumors located in the spinal canal, a laminectomy ing Cancer Center. spanning the length of the tumor with additional half-lev- Tumor size was measured from the most immediate el exposure above and below the tumor was carried out. preoperative MR or CT imaging available. All but 1 tumor Intraoperative ultrasonography was used to confirm the measurement was confirmed through image review. All location of the tumor prior to dural incision. A straight patients were diagnosed and followed postoperatively with midline dural incision was used to expose the tumor and MRI, with the exception of 1 patient who was diagnosed the spinal cord. In tumors with significant foraminal and preoperatively with CT and 3 patients who were followed paraspinal extension, a horizontal incision along the root postoperatively with CT. sleeve was also performed with its starting point at the vertical incision. Approach Considerations Once the tumor was exposed, blunt dissection around In each case, the surgical approach was dictated by the the capsule was performed to free the tumor of adherent location and size of the tumor. Tumors located entirely or surrounding structures. In cases in which nerve roots were partially within the spinal canal were accessed through suspected to be adherent to the capsule, a nerve stimulator the midline posterior approach. Preference was always was used to determine whether the adherent structure was given to removing the portion of the tumor located within a functional motor nerve root. Once stimulation helped de- the spinal canal because the intraspinal tumor component lineate a safe entry zone on the tumor surface, the area was was the most likely to be or become symptomatic in the coagulated using bipolar forceps and sharply incised. An future. When the posterior approach was used, every ef- ultrasonic aspirator was used to internally decompress the fort was made to maximize the excision of the paraspinal tumor. Piecemeal tumor resection was carried out. Once tumor through the same posterior approach. In cases in portions of the capsule were entirely free of surrounding which a very significant portion of the tumor could not structures, these free segments of the capsule were sharply be removed using the posterior approach, an additional sectioned from the remaining tumor. The steps of inter- anterior approach was used to complete the tumor exci- nal debulking and capsule sectioning were repeated until sion. Tumors without
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