Peripheral Nerve Sheath Tumor

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Peripheral Nerve Sheath Tumor

Authors, Editors, Case Information Author: Jack Kilgore, MD Affiliation: Vanderbilt University Medical Center, Department of PM&R Co Author(s): Stephen Schaaf, MD Senior Editor: Adam Lewno, DO Clinical Vignette: 77-year-old cyclist presented with acute right lower leg and ankle pain with an associated soft tissue mass just proximal to the lateral malleolus. The symptoms began gradually, without trauma, a few weeks prior to presentation. Exam of the right ankle was notable for pain with direct palpation over the area with radiating pain and numbness into the lateral ankle and foot. There was no weakness or skin changes. A right ankle x-ray demonstrated no osseous abnormalities. Type of Probe Used: 13-5 MHz Linear Array Transducer #1 - Video View Video Transverse axis: Scanning from proximal to distal, the hyperechoic bony structure on the left is the fibula while the hyperechoic bony structure on the right is the tibia. The muscle belly to the left of the fibula is the peroneus longus and the muscle belly to the right of the fibula underneath the peripheral nerve sheath tumor is the extensor digitorum longus. #2 - Video View Video Longitudinal axis: scanning from medial to lateral, the extensor digitorum longus muscle is underneath the peripheral nerve sheath tumor and then the tibia is the hyperechoic bony structure deep to the muscle. Longitudinal view (labeled) Longitudinal axis view of the superficial fibular nerve sheath tumor Longitudinal view (unlabeled) Longitudinal view of the lesion. Transverse view (labeled) Transverse axis view of the superficial fibular nerve sheath tumor. Note the hypoechoic, ovoid mass which appears to be continuous with the nerve Transverse view (unlabeled) Transverse axis view of the lesion Interpretation Image Interpretation: There was a hypoechoic echogenic ovoid mass measuring around 1.1 cm in width by 0.5 cm in thickness by 2.4 cm in length that appeared to be arising and continuous with the distal portion of the superficial fibular nerve. The mass was non compressible, had no significant vascular flow on color Doppler, and had posterior acoustic enhancement. There was tenderness on sonopalpation. Teaching Pearl: Ultrasound is an ideal first-line imaging modality to differentiate soft tissue masses given its high-spatial-resolution, easy access, low cost, ability to assess vascularity, and provides real-time correlation of physical examination findings and patient history during the imaging examination. The differential diagnosis for a soft tissue mass with nerve related symptoms is broad but the most common causes are a peripheral nerve sheath tumor or a neural ganglion cyst. A peripheral nerve sheath tumor is characterized as a round or ovoid hypoechoic mass continuous with the peripheral nerve in question. Sonopalation tenderness is often found over the area recreating the patient's nerve related symptoms. Peripheral nerve sheath tumors in comparison to neural ganglion cysts will be more hypoechoic rather than anechoic in appearance and may have some color flow on doppler. Once established that the mass is a peripheral nerve sheath tumor, the differential should then be narrowed further to a schwannoma, neurofibroma, or malignant peripheral nerve sheath tumor. Due to difficulty in distinguishing these from each other on ultrasound, routine monitoring with repeat imaging or biopsy may be indicated for definitive diagnosis.
NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.

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Authors, Editors, Case Information

#1 - Video

#2 - Video

Longitudinal view (labeled)

Longitudinal view (unlabeled)

Transverse view (labeled)

Transverse view (unlabeled)

Interpretation

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