- Email: [email protected]
Intrapelvic neurilemoma of the lumbosacral plexus in a pregnant woman
904
Communications
November Am. J. Obst.
in brief
obliterate the involved umbilical vein, so that we can infer its formation. The umbilical cord hemorrhage was within the outer layers of the umbilical vein wall, extending along its peripheral fibers into adjacent cleftlike spaces. The lesion is, therefore, the morphologic picture of a dissecting aneurysm of the umbilical vein. The umbilical vein is arterial in function, although it is venous in relation to the fetal and placental circulation. The connective tissue fibers loosely arranged in Wharton’s jelly actually compose an adventitia for the cord vessels when they are distended with blood in viva.? This explains the more peripheral location of the hematoma in our case when compared to that expected in an arterial dissecting aneurysm. The cause-and-effect role of umbilical cord hematomas and premature delivery or fetal death is not clear. The frequent absence of inflammatory response, liquefaction, or hemolysis indicates these are very acute or rapidly forming lesions. The protective envelop that Wharton’s jelly affords the umbilical vessels makes it unlikely that these lesions are induced by trauma at delivery unless the vessel wall had an antecedent abnormality.
REFERENCES
1. Dippel, 1940. 2. Chacko, Contrib.
A.
L.:
Surg.
A. W., Embryol.
Gynec.
and 35:
&
Reynolds, 135, 1954.
Obst. S.
70: R.
51, M.:
lntrapelvic neurilemoma of the lumbosacral plexus in a pregnant woman FREDRIC
L.
LIEUTENANT (MC)
COMMANDER
USN
HERBERT
G.
LIEUTENANT (MC) WALTER (MC)
EDELMAN,
HOPWOOD,
JR.,
COMMANDER
USN M.
LONERGAN,
CAPTAIN
USN
Defiartments of Neurological Surgery and Obstetrics and Gynecology, Unit8d States Naval Hos#ital, National Naval &fudical Center, Bethesda, Maryland not
The opinions expressed are those of the represent the official views of the United
authors States
and do Navy.
NE
u RILE
rare
lesion
MONA
Of
the
SWd
pkXLlS
15, 1968 & Gynec.
iS
ii
in pregnancy.l
The patient, a 21-year-old primigravida, was admitted to the Obstetrical Service, United States Naval Hosoital. Bethesda. Marvland. at 18 weeks gestation for exploration of a hght dbturator mass which had doubled in size to 8 x 8 cm. within a 4 week period. The mass was smooth and adherent to the right obturator fossa. Pressure on the mass caused right sciatic paresthesias radiating down the posterior thigh to the lateral aspect of the right leg and into the right large toe. Neurological examination was normal and there were no dermatologic manifestations or family history of von Recklinghausen’s syndrome. The uterus was 16 weeks’ size and fetal heart tones were present. After preoperative progesterone treatment operation was performed. The retroperitoneaf space was approached by incising the right round ligament. The mass was easily visualized lying underneath and elevating the lumbosacral plexus. This was incised in the direction of its fibers, and the encapsulated tumor delivered intact. The lumbosacral plexus was left unsutured, the round iigament was suture reapproximated. The patient’s postoperative, antepartum, and puerperal course was uncomplicated. There was no neural deficit. She had a spontaneous vaginal delivery at term. No abnormalities were noted at her 6 week postpartum pelvic examination. Gross examination of the tumor revealed a yellow-gray conical, rubbery mass 4.5 x 3 x 25. cm. Microscopically diffuse interlacing fine bundles of spindle-shaped cells with many bizarre hyperchromatic nuclei were noted. Large dilated vascular channels coursed throughout. Focal areas within the tumor were loose and edematous. Pathologic diagnosis was neurilemoma (Figs. 1 and 2). I
I
Nerve sheath tumors have been classified into three types: ( 1) benign escapsulated neurilemoma (neurilemoma); (2) benign plexiform neurilemoma (neurofibroma) ; and (3 ) maligant neurilemoma (malignant schwannoma) . All are thought to arise from the Schwann cell. Neurofibroma and malignant schwannoma are most frequently associated with von Recklinghausen’s disease, while neurilemoma is frequently a solitary phenomenon, not necessarily associated with von Recklinghausen’s disease. Malignancy has never been found in a neurilemoma, but pregnancy may result in rapid growth of neurilemomas and may precipitate malignant change in neutibromas. Vieta and Pack4 poirit out that a nerve has the ability to accommodate itself to considerable displacement by a benign nenrilemoma without loss of ftmction. This is in contrast to a malignant schwannoma which invades and destroys nerve fibers,
Volume
102
Number
6
Communications
in brief
905
Fig. 1.
benign escapsulated neurilemoma could be enucleated from its bed without resultant neural deficit is consistent with the experience of others.2 REFERENCES
1. Ackerman, L. V.: Tumors of the Retroperitoneum, Mesentery and Peritoneum, in Atlas of Tumor Pathology, Washington, D. C., 1954, Armed Forces Institute of Pathology, Section VI, Fascicles 23 and 24. 2. Rovinsky, J. J., and Guttmacher, A. F.: Medical, Surgical and Gynecologic Complication of Pregnancy, ed. 2, Baltimore, 1965, The Williams & Wilkins Company, p. 446. 3. Stout, A. P.: Tumors of the Peripheral Nervous System, in Atlas of Tumor Pathology, Washington, D. C., 1949, Armed Forces Institute of Pathology, Section II, Fascicle 6. 4. Vieta, J. O., and- Pack, G. T.: Treatment of Tumors of the Perioheral Nerves in Treatment of Cancer and Allied Diseases, in Pack, G. T., and ‘Ariel, I. M., editors: Tumors of the Nervous System, ed. 2, New York, 1959, Paul B. Hoeber, Inc., vol. II, Chap. 18.
Fig. 2. and which, early in its growth, will result in loss of nerve function. In our case rapid growth of the tumor made exploration mandatory. We presume that the abundance of large, bizarre, hyperchromatic, nuclei represented the microscopic equivalent of rapid growth clinically. The fact that this large
Technique to simplify of the Lippes loop ROBERT
A. HATCHER,
insertion
M.D..
The National Communicable Disease Center, Bureau oj Disease Prevention Environmental Control, Public Health Atlanta, Georgia
and Service,
Communications
November Am. J. Obst.
in brief
obliterate the involved umbilical vein, so that we can infer its formation. The umbilical cord hemorrhage was within the outer layers of the umbilical vein wall, extending along its peripheral fibers into adjacent cleftlike spaces. The lesion is, therefore, the morphologic picture of a dissecting aneurysm of the umbilical vein. The umbilical vein is arterial in function, although it is venous in relation to the fetal and placental circulation. The connective tissue fibers loosely arranged in Wharton’s jelly actually compose an adventitia for the cord vessels when they are distended with blood in viva.? This explains the more peripheral location of the hematoma in our case when compared to that expected in an arterial dissecting aneurysm. The cause-and-effect role of umbilical cord hematomas and premature delivery or fetal death is not clear. The frequent absence of inflammatory response, liquefaction, or hemolysis indicates these are very acute or rapidly forming lesions. The protective envelop that Wharton’s jelly affords the umbilical vessels makes it unlikely that these lesions are induced by trauma at delivery unless the vessel wall had an antecedent abnormality.
REFERENCES
1. Dippel, 1940. 2. Chacko, Contrib.
A.
L.:
Surg.
A. W., Embryol.
Gynec.
and 35:
&
Reynolds, 135, 1954.
Obst. S.
70: R.
51, M.:
lntrapelvic neurilemoma of the lumbosacral plexus in a pregnant woman FREDRIC
L.
LIEUTENANT (MC)
COMMANDER
USN
HERBERT
G.
LIEUTENANT (MC) WALTER (MC)
EDELMAN,
HOPWOOD,
JR.,
COMMANDER
USN M.
LONERGAN,
CAPTAIN
USN
Defiartments of Neurological Surgery and Obstetrics and Gynecology, Unit8d States Naval Hos#ital, National Naval &fudical Center, Bethesda, Maryland not
The opinions expressed are those of the represent the official views of the United
authors States
and do Navy.
NE
u RILE
rare
lesion
MONA
Of
the
SWd
pkXLlS
15, 1968 & Gynec.
iS
ii
in pregnancy.l
The patient, a 21-year-old primigravida, was admitted to the Obstetrical Service, United States Naval Hosoital. Bethesda. Marvland. at 18 weeks gestation for exploration of a hght dbturator mass which had doubled in size to 8 x 8 cm. within a 4 week period. The mass was smooth and adherent to the right obturator fossa. Pressure on the mass caused right sciatic paresthesias radiating down the posterior thigh to the lateral aspect of the right leg and into the right large toe. Neurological examination was normal and there were no dermatologic manifestations or family history of von Recklinghausen’s syndrome. The uterus was 16 weeks’ size and fetal heart tones were present. After preoperative progesterone treatment operation was performed. The retroperitoneaf space was approached by incising the right round ligament. The mass was easily visualized lying underneath and elevating the lumbosacral plexus. This was incised in the direction of its fibers, and the encapsulated tumor delivered intact. The lumbosacral plexus was left unsutured, the round iigament was suture reapproximated. The patient’s postoperative, antepartum, and puerperal course was uncomplicated. There was no neural deficit. She had a spontaneous vaginal delivery at term. No abnormalities were noted at her 6 week postpartum pelvic examination. Gross examination of the tumor revealed a yellow-gray conical, rubbery mass 4.5 x 3 x 25. cm. Microscopically diffuse interlacing fine bundles of spindle-shaped cells with many bizarre hyperchromatic nuclei were noted. Large dilated vascular channels coursed throughout. Focal areas within the tumor were loose and edematous. Pathologic diagnosis was neurilemoma (Figs. 1 and 2). I
I
Nerve sheath tumors have been classified into three types: ( 1) benign escapsulated neurilemoma (neurilemoma); (2) benign plexiform neurilemoma (neurofibroma) ; and (3 ) maligant neurilemoma (malignant schwannoma) . All are thought to arise from the Schwann cell. Neurofibroma and malignant schwannoma are most frequently associated with von Recklinghausen’s disease, while neurilemoma is frequently a solitary phenomenon, not necessarily associated with von Recklinghausen’s disease. Malignancy has never been found in a neurilemoma, but pregnancy may result in rapid growth of neurilemomas and may precipitate malignant change in neutibromas. Vieta and Pack4 poirit out that a nerve has the ability to accommodate itself to considerable displacement by a benign nenrilemoma without loss of ftmction. This is in contrast to a malignant schwannoma which invades and destroys nerve fibers,
Volume
102
Number
6
Communications
in brief
905
Fig. 1.
benign escapsulated neurilemoma could be enucleated from its bed without resultant neural deficit is consistent with the experience of others.2 REFERENCES
1. Ackerman, L. V.: Tumors of the Retroperitoneum, Mesentery and Peritoneum, in Atlas of Tumor Pathology, Washington, D. C., 1954, Armed Forces Institute of Pathology, Section VI, Fascicles 23 and 24. 2. Rovinsky, J. J., and Guttmacher, A. F.: Medical, Surgical and Gynecologic Complication of Pregnancy, ed. 2, Baltimore, 1965, The Williams & Wilkins Company, p. 446. 3. Stout, A. P.: Tumors of the Peripheral Nervous System, in Atlas of Tumor Pathology, Washington, D. C., 1949, Armed Forces Institute of Pathology, Section II, Fascicle 6. 4. Vieta, J. O., and- Pack, G. T.: Treatment of Tumors of the Perioheral Nerves in Treatment of Cancer and Allied Diseases, in Pack, G. T., and ‘Ariel, I. M., editors: Tumors of the Nervous System, ed. 2, New York, 1959, Paul B. Hoeber, Inc., vol. II, Chap. 18.
Fig. 2. and which, early in its growth, will result in loss of nerve function. In our case rapid growth of the tumor made exploration mandatory. We presume that the abundance of large, bizarre, hyperchromatic, nuclei represented the microscopic equivalent of rapid growth clinically. The fact that this large
Technique to simplify of the Lippes loop ROBERT
A. HATCHER,
insertion
M.D..
The National Communicable Disease Center, Bureau oj Disease Prevention Environmental Control, Public Health Atlanta, Georgia
and Service,