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|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 2 | Page : 256-257
Schwannoma of medial cord of the brachial plexus: An uncommon localisation
Ozturk Sait1, Akgun Bekir1, Erol Fatih Serhat1, Okcesiz Izzet2, Yildirim Hanefi2
1 Department of Neurosurgery, Firat University, School of Medicine, Elazig, Turkey
2 Department of Radiology, Firat University, School of Medicine, Elazig, Turkey
|Date of Web Publication||5-May-2015|
Department of Neurosurgery, Firat University, School of Medicine, Elazig
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sait O, Bekir A, Serhat EF, Izzet O, Hanefi Y. Schwannoma of medial cord of the brachial plexus: An uncommon localisation. Neurol India 2015;63:256-7
Schwannomas are rare, slow growing, encapsulated, benign tumours with regular margins that originate from the schwann cells of the nerve sheath.  They are the commonest tumours of peripheral nerves, but less than 5% of all schwannomas arise from the brachial plexus.  Due of their rarity and complex anatomical location, they may pose a formidable challenge to surgeons.
A 38-year old female patient presented with a painful swelling in her right axilla of 4 months duration. She also complained of numbness on the medial aspect of the right forearm and hand. On examination, she had an oval and firm swelling in the right axilla. In addition, muscle weakness with a constant hypoesthesia was observed in the right index and ring fingers. She had a positive Tinel's sign. Her breast examination and mammography were normal. A magnetic resonance image (MRI) revealed a 3 × 3 cm solitary mass in the right axilla, in continuity with the inferior trunk of the brachial plexus, posterior to the pectoralis major muscle and medial to the lateral cord. The lesion showed a homogeneous enhancement [Figure 1]. A right axillary approach was adopted to excise the lesion. A 3 × 3 cm, firm, encapsulated, gray-white mass arising from the medial cord was found [Figure 2]. The tumour was enucleated microsurgically avoiding any damage to the parent nerve. No nerve grafting was required. In the early post-operative period, the patient complained of an increased loss of sensations over the ring and little finger. The pathological diagnosis of the excised axillary lesion was a schwannoma. At her last follow-up appointment 10 weeks after her surgery, she was free of pain and had an advancing Tinel's sign. The muscle weakness in her fingers had shown a steady improvement.
|Figure 1: MRI of the patient. T1-weighted, (a) axial, (b) coronal images show 3x3 cm oval shaped, homogenous contrast enhancement in lesion|
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|Figure 2: Per-operative photograph of the tumor and the cords of the brachial plexus. Medial cord (white star), lateral cord (black star)|
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Brachial plexus tumours are rare and comprise of only 5% of all tumours of the upper limb.  Even though schwannomas may be located in any part of the body, cutaneous nerves of the head and neck region and the flexor parts of the extremities are the most commonly involved. 
Most of the reports in the literature reveal that the upper limb schwannomas are usually located at the origin of main nerves such as the median, radial and ulnar nerves. ,, Schwannomas may be seen after a biopsy procedure or after an iatrogenic injury.  The first reported case of a medial cord schwannoma in the literature is that of a 17-year old male patient where the schwannoma occurred after a lymph node biopsy from the same axilla.  In our case, however, there was no prior history of a biopsy being undertaken.
An axillary schwannoma may often mimic the commonly occurring lymphadenopathy occurrring in that location. Lymphadenopathy as a result of breast cancer should be ruled out in female patients particularly in the age group of 20-55 years. On magnetic resonance imaging (MRI) schwannomas are iso-intense to hypo-intense on T1-weighted images and homogeneously enhance with gadolinium. The imaging characteristics of an axillary lymphadenopathy and a schwannoma often mimic each other and many require an additional imaging techniques to differentiate them. 
As these lesions are slowly growing, they are usually diagnosed when they attain a large size. In a large study focusing on upper extremity schwannomas, the timing between the onset of symptoms and surgical excision was 32 months.  In our case, the time between the onset of symptoms and surgery was only 4 months. The lesion was detected early when its diameter was only 3 cm. In the closed confines of the axillary region, the close proximity of the lesion to the nerves in this area caused early manifestations even when the lesion was small in size. This considerably helped in its early detection. A schwannoma arising from the cords of the brachial plexus or those located at the apex of axillary region may cause early manifestations leading to its earlier detection when compared with a schwannoma occurrring in a more distal upper limb location.
| » Acknowledgement|| |
All authors thank Mr. Ramazan Cakmak for his technical support in the preparation of figures.
| » References|| |
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[Figure 1], [Figure 2]