| OBJECTIVESchwannomas are neoplasms that originate from the schwann cells of the peripheral nerve sheath, most of which are benign, but few may develop into malignant, and transfer to distant tissues through the blood and lymphatic system. Most schwannomas occur in the head, neck or the extremities; rarely are they found in the digestive tract and retroperitoneal space.In recent years, with the development of surgical technology and deep understanding of the pathology, retroperitoneal schwannomas have been reported much more in our country. Statistics showed that0.3%to3.2%of the total schwannomas occurred at the retroperitoneal cavity, which may account for0.5%to12%of all the retroperitoneal masses. Partially due to the complicated retroperitoneal dissection, and partially due to the lack of characteristic imaging findings, its preoperative diagnosis is difficult. What’s more, because of the tumor heterogeneity and secondary hemorrhage, necrosis etc, adrenal schwannomas are difficult to differentiate from mesenchymal adrenal lesions such as adrenal cyst, lipoma and pheochromocytoma. All these factors make the preoperative diagnosis difficult, and the definitive diagnosis relies on postoperative pathology examination. Because most of the schwannomas has completed capsule, this makes it easy to surgery. Complete resection of the adrenal schwannomas, is the ideal treatment for benign schwannomas. According to the specific location, size, and the relationship with the adrenal and kidney, diverse surgeries like radical resection, total resection and subtotal resection may be applied. After radical resection, especially in early cases, patients may expect good prognosis. An extremely low incidence of the schwannomas is malignant, but intraoperative frozen section biopsy is helpful to the qualitative diagnosis of schwannomas, which is of great significance for the choice of operation. For malignant schwannomas, radiation and chemotherapy have a poor effect; if not early diagnosed, patients may have poor prognosis.Clinical data of24cases with adrenal schwannomas in the Provincial Hospital Affiliated to Shandong University will be analyzed retrospectively to evaluate the diagnosis and surgical treatment for adrenal schwannomas.METHODSBased on the pathological diagnosis and imageological examinations,24patients from Provincial Hospital Affiliated to Shandong University are enrolled. Ranging from January2000to March2013, all of the patients were pathologically diagnosed of adrenal schwannomas. All the24patients underwent surgical resection of the tumor, including14cases of open surgery and10cases of laparoscopic surgery (hand-assisted laparoscopic surgery in1case).RESULTSOf all the24patients,14cases are male and10female. Age of onset is25-68years with an average of48.83+12.33years.11cases occurred on the left side, and13cases on the right side. The maximum tumor diameter is at1.0～15.0cm, with an average value of6.23±2.10cm.11cases visited the doctor with back pain, fever or other related symptoms, and13cases were diagnosed because of physical examination. The durations last form7days to2months. All the patients were given preoperative routine examination, biochemical examinations, like liver and kidney function, and test of hormone levels, etc. Together with B ultrasound, CT or MR imaging,5cases were diagnosed of retroperitoneal schwannoma preoperatively, with diagnosis of retroperitoneal neurogenic tumors in11cases, adrenal pheochromocytoma in1case, adrenal cyst in2case and unknown retroperitoneal mass in5cases. All together, the preoperative imaging bears a diagnostic accuracy of20.8%(5/24).24cases were performed surgical treatment, including14cases of open surgery,10cases of laparoscopic surgery (hand-assisted laparoscopic surgery in1case). Of24cases,12carried out intraoperative frozen pathology examination.11cases were diagnosed of benign schwannoma, and one case diagnosed of mesenchymal tumor. Postoperative pathology with immunohistochemical examination confirmed11cases of benign retroperitoneal schwannoma and malignant in1case. On the whole, the intraoperative frozen pathological diagnosis possessed an accuracy rate of91.7%(11/12).Of the open surgery group, a total of14cases, the average operation time was119.64±22.76min; The average bleeding351.43±259.65ml; Intraoperative blood transfusion in5cases; Total hospital stays was18.93±3.79days; Postoperative hospital stays, on average,10.64±2.85days; Postoperative exhausting time was2.00days;2cases showed complications of incision disunion due to infection and fat liquefaction, No other serious complications appeared.10cases enrolled the laparoscopic surgery group, and the average surgery time is133.10±23.60min; The average bleeding106.50±112.72ml; Blood transfusion in1case for200ml; However blood pressure fluctuations showed in2cases, with the blood pressure rose to179/116mmHg, giving back to normal after antihypertensive treatment; Total hospital stays was15.10±1.37days; Postoperative hospital stays, on average,7.80±1.14days; Postoperative exhaust time,1.30days; No case showed up serious complications. Of the24cases, postoperative follow-up was carried out for6～72months, back pain symptoms in7cases disappear,2cases with varying degrees of alleviation;23patients pathologically showed benign, and during the following up of6years, no recurrence or metastasis ensued;1case of postoperative pathology showed malignant, and the patient suffered recurrence6months later, when a second surgery was performed after diagnosis. However,13months later, the cancer came back again, which was improper to perform surgery.23months after the first surgery, the patient died because of multiple organ disfunction due to widely tumor metastasis.CONCLUSION1. The schwannomas at the adrenal area grow slowly, often shown as asymptomatic mass lesions and mostly found in physical examinations. A few patients see the doctor because of back or abdominal pain.2. Due to the complicated retroperitoneal dissection and the lack of characteristic imaging findings, the preoperative diagnosis is difficult for adrenal schwannoma; it is difficult to differentiate from mesenchymal adrenal lesions such as adrenal cyst, lipoma and pheochromocytoma. Confirmed diagnosis calls for the postoperative pathology examination.3. Laparoscopic treatment of the adrenal schwannomas merits shorter operation time, less blood loss and small wound; the patients may expect an early recovery, with favorable curative effect.4. Complete resection of the retroperitoneal schwannomas is the ideal treatment for benign schwannomas. Because most of the schwannomas has completed capsule, this makes it easy to surgery on. After radical resection, especially in early cases, patient prognosis is usually good. The intraoperative frozen section biopsy is helpful to diagnose the schwannomas. For malignant schwannomas, radiation and chemotherapy effect is poor; if not early diagnosed, patients may have poor prognosis. |
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