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08-JULY-2017 MUHAMED ALI AL-TURK 54 YEARS THIRD
RECURRENCE OF SCHWANNOMA LOWER THIRD LEFT POSTERIOR LEG, ABOVE THE KNEE.
The patient has very rare transformation
of the tumor behavior. The first three operation confirmed
presence of benign schwannoma by different histopathologists
and now showing a malignant tumor.
This is the 125th case using the MultiGen. The
purpose is to identify the neural structures and avoiding
It became a usual part of the spine and peripheral nerves
surgery. Click here for
The recurrence was due to huge dimensions
of the tumor and involvement of most of the sciatic nerve
and its divisions. If you notice there is a small schwannoma
at the contra-lateral side.
The patient was operated by me 29-July-1997 for
schwannoma posterior aspect of the left knee.
The patient then was operated for recurrence by
me 30-June-2002, then for second recurrence
03-March-2011. The patient then came
01-July-2017 telling that the mass started to
appear 1 year ago and continued to enlarge.
On examination, the patient is neurologically
free, except for the mass in the lower third of
the leg above the knee. The incision showing
abnormal veins at the medial lower part of the
The patient was sent for investigations and an
extended MRI of the area with contrast and TWIST
were performed. The mass is huge and
multilobulated pushing the tibial nerve anterior
and engulfing the peroneal nerve. There are
feeders to the mass in its lower compartments
which is involving the skin directly.
The old incision was
refreshed and the sciatic nerve was identified
above the lesion and the tibial and peroneal
nerve were also identified at the lower area of
the dissection. The tumor was reaching the skin.
The tumor was multi compartmental and it was
necessary to remove it several parts. Both
tibial and peroneal nerves were inside the tumor
and sharp dissection was carried on. The tibial
nerve was lateral and the peroneal to the medial
side. Dissection of the tibial nerve was
relatively easy, but the peroneal nerve was
severely adherent to the tumor, that dissection
caused slight injury to one fascicle of the
nerve, which later was repaired by 6 zero nylon.
The pushed upward nerves to the biceps and
surrounding muscles were also preserved. The
tibial nerve before dissection was responding
will to 0.6 V and the peroneal nerve to 0.9 V.
After total resection the tibial nerve showed
response to 0.6 V and the peroneal nerve to
0.7V. The patient was sent to control MRI of the
area with contrast and only hematoma was seen in
the bed with the running 2 nerves. Routine closure of the
wound with removal of the previous sinus, which
was noticed after the previous surgery. Redivac
drain with negative pressure. The tumor was sent
for histological verification to rule out signs
Smooth postoperative recovery.
The power of the dorsi and planterflexion of the
left foot was 5/5. He was sent to the ward.
The final histological result was myxoid
liposarcoma transforming to round cell
liposarcoma with areas of ischemic infarctions.
(Dr. Salah Al-Jitawi FRCPath, FIAC). After
telephone communications the final histologic
result was neural sheath sarcoma.
The patient then came 20-July-2017 with healed
wound, but about 70 ml of blood evacuated from
under the skin. There is hypalgesia left L5
territory with no motor deficit.
The patient then came 16-September-2017 with
clean wound and no collection. Advised to
perform MRI to the involved area with contrast,
which was done 17-September-2017 showing
collection of fluid.
The patient then came 11-December-2018 with MRI
done to the area showing three rounded masses
with reactive changes of the skin. He was seen
at Cancer Center and they suggested to him,
total amputation of the left leg, but I advised
him to undergo radiation and to be reevaluated
after one year. He is neurologically free.