Difference between revisions of "Schwannoma"

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Schwannoma (view source)

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#redirect [[Peripheral nerve sheath tumours#Schwannoma]]
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = Schwannoma - Antoni A and B - very high mag.jpg
| Width      =
| Caption    = Schwannoma showing Antoni A and Antoni B areas. [[HPS stain]].
| Micro      = Antoni A areas (cellular, fibrillary, polar, elongated), Antoni B area (pauci-cellular, loose microcystic tissue), Verocay bodies (paucinuclear area surrounded by nuclei), hyaline thickened [[blood vessel]]s, thick capsule.
+/-peripheral lymphoid cuff (esp. GI tract)
| Subtypes  = conventional schwannoma, cellular schwannoma, plexiform schwannoma, melanotic schwannoma
| LMDDx      = [[meningioma]], [[leiomyoma]], [[GIST]], [[intranodal palisaded myofibroblastoma]], [[MPNST]], [[neurofibroma]], [[biphenotypic sinonasal sarcoma]]
| Stains    =
| IHC        = S-100 +ve, EMA -ve, CD34 +ve
| EM        =
| Molecular  =
| IF        =
| Gross      =
| Grossing  =
| Site      = [[soft tissue lesions|soft tissue]] - [[peripheral nerve sheath tumours]]
| Assdx      =
| Syndromes  = [[neurofibromatosis type 2]], [[Carney complex]] (psammomatous melanotic schwannoma)
| Clinicalhx =
| Signs      =
| Symptoms  =
| Prevalence = common
| Bloodwork  =
| Rads      =
| Endoscopy  =
| Prognosis  = good
| Other      =
| ClinDDx    = [[meningioma]] - esp. at [[cerebellopontine angle]]
}}
'''Schwannoma''' is a relatively common [[peripheral nerve sheath tumour]].


At the [[cerebellopontine angle|cerebellopontine (CP) angle]], they may be referred to as ''acoustic neuroma'' or ''vestibular schwannoma''.
==General==
*A common [[neuropathology]] [[CNS tumours|tumour]] that occasionally shows-up elsewhere.
*often encapsulated tumour of tissue surrounding a nerve.
**Axons adjacent to the tumour are normal... but may be compressed.
*May be a part of [[neurofibromatosis type 2]].
*Occurs at all ages.
==Macro==
*Usu. encapsulated.
*Cystic.
*Yellow patches on white surface.
**Variable lipidization.
==Microscopic==
Features:<ref name=pmid17893219>{{cite journal |author=Wippold FJ, Lubner M, Perrin RJ, Lämmle M, Perry A |title=Neuropathology for the neuroradiologist: Antoni A and Antoni B tissue patterns |journal=AJNR Am J Neuroradiol |volume=28 |issue=9 |pages=1633–8 |year=2007 |month=October |pmid=17893219 |doi=10.3174/ajnr.A0682 |url=http://www.ajnr.org/cgi/reprint/28/9/1633}}</ref>
*Antoni A:
**Cellular.
**'Fibrillary, polar, elongated'.
*Antoni B:
**Pauci-cellular.
**Loose microcystic tissue.
*Verocay bodies - paucinuclear area surrounded by clusters of nuclei - '''diagnostic feature'''.
*Hyaline thickened [[blood vessel]]s.
*Thick capsule.
*In the GI tract: classically have a ''peripheral lymphoid cuff''.<ref name=pmid15728600>{{cite journal |author=Levy AD, Quiles AM, Miettinen M, Sobin LH |title=Gastrointestinal schwannomas: CT features with clinicopathologic correlation |journal=AJR Am J Roentgenol |volume=184 |issue=3 |pages=797–802 |year=2005 |month=March |pmid=15728600 |doi= |url=http://www.ajronline.org/cgi/content/full/184/3/797}}</ref>
*+/-Hemosiderin deposition within tumour.
*Reticulin stain +ve (around individual cells).
Notes:
*Tumour does ''not'' smear well.<ref>MUN. 24 November 2010.</ref>
*Antoni A: may look somewhat like scattered matchsticks.
*Hybrid Schwannoma / [[Neurofibroma]] are overrepresented in hereditary conditions.<ref>{{Cite journal  | last1 = Harder | first1 = A. | last2 = Wesemann | first2 = M. | last3 = Hagel | first3 = C. | last4 = Schittenhelm | first4 = J. | last5 = Fischer | first5 = S. | last6 = Tatagiba | first6 = M. | last7 = Nagel | first7 = C. | last8 = Jeibmann | first8 = A. | last9 = Bohring | first9 = A. | title = Hybrid neurofibroma/schwannoma is overrepresented among schwannomatosis and neurofibromatosis patients. | journal = Am J Surg Pathol | volume = 36 | issue = 5 | pages = 702-9 | month = May | year = 2012 | doi = 10.1097/PAS.0b013e31824d3155 | PMID = 22446939 }}</ref>
DDx:
*[[Meningioma]].
*[[Intranodal palisaded myofibroblastoma]] - if surrounded by a rim of lymphoid tissue, i.e. [[Lymph node pathology|intranodal]].
*[[Leiomyoma]].
*[[Gastrointestinal stromal tumour]].
*[[MPNST]] - schwannoma with ancient change has no significant mitotic activity.<ref name=pmid17244372>{{Cite journal  | last1 = Chan | first1 = PT. | last2 = Tripathi | first2 = S. | last3 = Low | first3 = SE. | last4 = Robinson | first4 = LQ. | title = Case report--ancient schwannoma of the scrotum. | journal = BMC Urol | volume = 7 | issue =  | pages = 1 | month =  | year = 2007 | doi = 10.1186/1471-2490-7-1 | PMID = 17244372 }}</ref>
*[[Neurofibroma]].
*[[Biphenotypic sinonasal sarcoma]] - head and neck.
===Images===
<gallery>
Image:Schwannoma_-_Antoni_A_and_B_-_intermed_mag.jpg | Schwannoma - Antoni A & B - intermed. mag. (WC)
Image:Schwannoma_-_Antoni_A_and_B_-_very_high_mag.jpg | Schwannoma - Antoni A & B - very high mag. (WC)
File:Antoni a fibers schwannoma.jpg | Antoni-A pattern in cerebelloponine angle schwannoma. (WC/jensflorian)
File:Schwannoma 0023.jpg | Antoni-A pattern in cerebelloponine angle schwannoma.(WC/jensflorian)
Image:Nerve_root_schwannoma_-_intermed_mag.jpg | Nerve root schwannoma - intermed. mag. (WC)
File:Schwannoma, S-100 Immunostain (5203888371).jpg | S-100 immunostain in schwannoma. (WC/Ed Uthman)
</gallery>
www:
*[http://www.pathguy.com/~lulo/lulo0003.htm Antoni A (pathguy.com)].
*[http://www.ajnr.org/cgi/content/full/28/9/1633/F8 Antoni A & Antoni B side-by-side (ajnr.org)].
*[http://path.upmc.edu/cases/case639.html Cystic schwannoma - several images (upmc.edu)].
===Schwannoma subtypes===
There are four:<ref name=pmid12792904>{{cite journal |author=Kurtkaya-Yapicier O, Scheithauer B, Woodruff JM |title=The pathobiologic spectrum of Schwannomas |journal=Histol. Histopathol. |volume=18 |issue=3 |pages=925–34 |year=2003 |month=July |pmid=12792904 |doi= |url=}}</ref>
#Conventional schwannoma.
#Cellular schwannoma.
#Plexiform schwannoma.
#Melanotic schwannoma.
====Conventional schwannoma====
*Most common.
====Cellular schwannoma====
*May mimic [[MPNST]].
*Usu. <4 mitoses in 10 HPF (see [[HPFitis]]).
*Absence of Verocay bodies.
*Usu paravertebral location.
Images:
*[http://path.upmc.edu/cases/case518.html Cellular schwannoma (upmc.edu)].
====Plexiform schwannoma====
*May mimic [[MPNST]] if cellular - esp. in childhood.
Images:
<gallery>
Image:Plexiform_Schwannoma_2.jpg | Plexiform schwannoma - low mag. (WC)
Image:Plexiform_Schwannoma_1.jpg | Plexiform schwannoma - high mag. (WC)
</gallery>
====Melanotic schwannoma====
*May be confused with [[melanoma]].
*Psammomatous form (''psammomatous melanotic schwannoma'') associated with a heritable disorder ([[Carney complex]]).
Note:
*[[Carney complex]]:<ref name=pmid12792904/>
**Cutaneous lentigines.
**Myxomas (skin (subcutaneous), subcutanous, [[Atrial myxoma|heart]]).
**Endocrine neoplasms.
Images:
*[http://path.upmc.edu/cases/case387.html Psammomatous melanotic schwannoma - several images (upmc.edu)].
<gallery>
Image:Psammomatous_melanotic_schwannoma_-_high_mag.jpg | Psammomatous melanotic schwannoma - high mag. (WC)
</gallery>
==IHC==
Features:<ref name=pmid12692193>{{cite journal |author=Hirose T, Tani T, Shimada T, Ishizawa K, Shimada S, Sano T |title=Immunohistochemical demonstration of EMA/Glut1-positive perineurial cells and CD34-positive fibroblastic cells in peripheral nerve sheath tumors |journal=Mod. Pathol. |volume=16 |issue=4 |pages=293–8 |year=2003 |month=April |pmid=12692193 |doi=10.1097/01.MP.0000062654.83617.B7 |url=http://www.nature.com/modpathol/journal/v16/n4/full/3880761a.html }}</ref>
*S-100 +ve.
*Glut1 +ve.
*CD34 +ve.
*Cytokeratins ~70% +ve.<ref>{{Cite journal  | last1 = Fanburg-Smith | first1 = JC. | last2 = Majidi | first2 = M. | last3 = Miettinen | first3 = M. | title = Keratin expression in schwannoma; a study of 115 retroperitoneal and 22 peripheral schwannomas. | journal = Mod Pathol | volume = 19 | issue = 1 | pages = 115-21 | month = Jan | year = 2006 | doi = 10.1038/modpathol.3800489 | PMID = 16357842 }}</ref>
*SOX10 +ve.<ref name=pmid18636017>{{cite journal |author=Nonaka D, Chiriboga L, Rubin BP |title=Sox10: a pan-schwannian and melanocytic marker |journal=Am. J. Surg. Pathol. |volume=32 |issue=9 |pages=1291–8 |year=2008 |month=September |pmid=18636017 |doi=10.1097/PAS.0b013e3181658c14 |url=}}</ref>
**-ve in [[synovial sarcoma]], [[rhabdomyosarcoma]], [[chondrosarcoma]].
*EMA -ve. (???)
**Usually +ve (~75% of the time) in meningiomas.<ref>{{Cite journal  | last1 = Rushing | first1 = EJ. | last2 = Bouffard | first2 = JP. | last3 = McCall | first3 = S. | last4 = Olsen | first4 = C. | last5 = Mena | first5 = H. | last6 = Sandberg | first6 = GD. | last7 = Thompson | first7 = LD. | title = Primary extracranial meningiomas: an analysis of 146 cases. | journal = Head Neck Pathol | volume = 3 | issue = 2 | pages = 116-30 | month = Jun | year = 2009 | doi = 10.1007/s12105-009-0118-1 | PMID = 19644540 }}
</ref>
Others:
*Beta-catenin +ve<ref name=pmid11813884>{{Cite journal  | last1 = Hasegawa | first1 = M. | last2 = Muramatsu | first2 = N. | last3 = Tohma | first3 = Y. | last4 = Fukaya | first4 = K. | last5 = Fujisawa | first5 = H. | last6 = Hayashi | first6 = Y. | last7 = Tachibana | first7 = O. | last8 = Kida | first8 = S. | last9 = Yamashita | first9 = J. | title = Expression of E-cadherin-catenin complex in human benign schwannomas. | journal = Histol Histopathol | volume = 17 | issue = 1 | pages = 39-44 | month = Jan | year = 2002 | doi =  | PMID = 11813884 }}</ref> -- not nuclear.<ref name=pmid17711447>{{Cite journal  | last1 = Carlson | first1 = JW. | last2 = Fletcher | first2 = CD. | title = Immunohistochemistry for beta-catenin in the differential diagnosis of spindle cell lesions: analysis of a series and review of the literature. | journal = Histopathology | volume = 51 | issue = 4 | pages = 509-14 | month = Oct | year = 2007 | doi = 10.1111/j.1365-2559.2007.02794.x | PMID = 17711447 }}</ref>
==Molecular==
Overview: <ref>{{Cite journal  | last1 = Agnihotri | first1 = S. | last2 = Jalali | first2 = S. | last3 = Wilson | first3 = MR. | last4 = Danesh | first4 = A. | last5 = Li | first5 = M. | last6 = Klironomos | first6 = G. | last7 = Krieger | first7 = JR. | last8 = Mansouri | first8 = A. | last9 = Khan | first9 = O. | title = The genomic landscape of schwannoma. | journal = Nat Genet | volume = 48 | issue = 11 | pages = 1339-1348 | month = 11 | year = 2016 | doi = 10.1038/ng.3688 | PMID = 27723760 }}</ref>
* Most common: NF2.
* less common: ARID1A, ARID1B, DDR, TSC1, TSC2.
* SH3PXD2A-HTRA1 fusions (10%).
*INI1 mosaic pattern in familiar schwannomatosis.<ref>{{Cite journal  | last1 = Caltabiano | first1 = R. | last2 = Magro | first2 = G. | last3 = Polizzi | first3 = A. | last4 = Praticò | first4 = AD. | last5 = Ortensi | first5 = A. | last6 = D'Orazi | first6 = V. | last7 = Panunzi | first7 = A. | last8 = Milone | first8 = P. | last9 = Maiolino | first9 = L. | title = A mosaic pattern of INI1/SMARCB1 protein expression distinguishes Schwannomatosis and NF2-associated peripheral schwannomas from solitary peripheral schwannomas and NF2-associated vestibular schwannomas. | journal = Childs Nerv Syst | volume = 33 | issue = 6 | pages = 933-940 | month = Jun | year = 2017 | doi = 10.1007/s00381-017-3340-2 | PMID = 28365909 }}</ref>
* LZTR1-associated vestibular schwannomas.<ref>{{Cite journal  | last1 = Evans | first1 = DG. | last2 = Bowers | first2 = NL. | last3 = Tobi | first3 = S. | last4 = Hartley | first4 = C. | last5 = Wallace | first5 = AJ. | last6 = King | first6 = AT. | last7 = Lloyd | first7 = SKW. | last8 = Rutherford | first8 = SA. | last9 = Hammerbeck-Ward | first9 = C. | title = Schwannomatosis: a genetic and epidemiological study. | journal = J Neurol Neurosurg Psychiatry | volume =  | issue =  | pages =  | month = Jun | year = 2018 | doi = 10.1136/jnnp-2018-318538 | PMID = 29909380 }}</ref>
Molecular subgroups:<ref>{{Cite journal  | last1 = Agnihotri | first1 = S. | last2 = Jalali | first2 = S. | last3 = Wilson | first3 = MR. | last4 = Danesh | first4 = A. | last5 = Li | first5 = M. | last6 = Klironomos | first6 = G. | last7 = Krieger | first7 = JR. | last8 = Mansouri | first8 = A. | last9 = Khan | first9 = O. | title = The genomic landscape of schwannoma. | journal = Nat Genet | volume = 48 | issue = 11 | pages = 1339-1348 | month = 11 | year = 2016 | doi = 10.1038/ng.3688 | PMID = 27723760 }}</ref>
*Group 1: vestibular (has significant higher rate of 22q loss).
*Group 2: spinal.
==Sign out==
<pre>
Lesion, Right Ulnar Nerve, Excision:
    - Schwannoma.
</pre>
===Block letters===
<pre>
LESION, LEFT ANTERIOR TIBIA, EXCISION:
- SCHWANNOMA.
- NEGATIVE FOR MALIGNANCY.
</pre>
===Micro===
The sections show a soft tissue spindle cell lesion, with cellular fibrillary areas (Antoni A) and pauci-cellular microcystic areas (Antoni B). There are also pauci-nuclear areas surrounded by clusters of nuclei (Verocay bodies).  Thick hyaline blood vessels are present within the lesion. There is no apparent nuclear atypia.  Mitotic activity is not readily apparent.  No nerve is seen adjacent to the lesion. The lesion is partially encapsulated by fibrous tissue. Focally, ink is seen on the lesional cells.
==See also==
*[[Peripheral nerve sheath tumours]].
==References==
{{Reflist|2}}
[[Category:Peripheral nerve sheath tumours]]
[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Neuropathology tumours]]
Jensflorian
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