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1 %HQLJQ5HWURSHULWRQHDO6FKZDQQRPD1DGLUELU<DQ$ UÕVÕ6HEHEL 'U 2 X]KDQ 6DUÕ\ FH 1, Dr. Özcan Özsan 1 'U %DKDU 0 H]]LQR OX 2, Dr. Semih Özkan 1, 'U 7D\IXQ * USÕQDU 1 'U (QJLQ $\GÕQ 2 6RO \DQ D UÕVÕ \DNÕQPDVÕ LOH NOLQL LPL]H EDúYXUDQ QDGLU ELU EHQLJQ UHWURSHULWRQHDO VFKZDQQRPD YDNDVÕ WDNGLP HGLOPHNWHGLU %X odoõúpdgd UHWURSHULWRQGD QDGLU J U OHQ EHQLJQ VFKZDQQRPD WDQÕ KLVWRSDWRORML YH WHGDYL \ Q QGHQ WDUWÕúÕOPÕúWÕU >7XUJXW g]do 7ÕS 0HUNH]L Anahtar Kelimeler: Schwann hücreleri, retroperitoneal neoplasmlar, retroperiton Benign retroperitoneal schwannoma : a rare cause of flank pain A rare case of retroperitoneal benign schwannoma presenting with left flank pain is reported. The diagnosis and histopathology of tumor, therapeutic approach are discussed in this study. [Journal of Turgut Özal Medical Center 1998;5(1):73-77] Key Words: Schwann cells, retroperitoneal neoplasm, retroperitoneal space Retroperitonun primer tümörleri nadir olup, bu W P UOHULQ NDGDUÕQÕ VFKZDQQRPDODU ROXúWXUXU 5HWURSHULWRQHDO W P UOHU RUDQÕQGD N W KX\OX ROPDODUÕQD NDUúÕQ VFKZDQQRPDODUÕQ E \ N ELU NÕVPÕ L\L KX\OXGXU. W KX\OX YDNDODU JHQHOOLNOH 9RQ 5HFNOLQJKDXVHQ KDVWDOÕ Õ LOH ELUOLNWH UDSRU HGLOPLúWLU 6FKZDQQRPD VLQLU NÕOÕIÕ RODQ E W Q \HUOHUGHQ JHOLúHELOGL L JLEL VÕNOÕNOD 9RQ 5HFNOLQJKDXVHQ KDVWDOÕ Õ LOH ELUOLNWHGLU %X KDVWDOÕN LOH ELUOLNWH ROPDGDQ UHWURSHULWRQGD JHOLúHQ VFKZDQQRPDODU RGXNoD QDGLU RODUDN EXOXQPDNWDGÕU %X odoõúpdgd 9RQ 5HFNOLQJKDXVHQ KDVWDOÕ Õ LOH ELUOLNWH ROPD\DQ UHWURSHULWRQHDO \HUOHúLPOL L\L KX\OX VFKZDQQRPD YDNDVÕ WDNGLP HGLOHFHNWLU 9$.$ 7$.'ø0ø \DúÕQGD ELU ED\DQ KDVWD VRO \DQ D UÕVÕ NDUÕQGD úlúoln KLVVL úlnd\hwl LOH P UDFDDW HWWL g]jhoplúlqgh YH DLOH KLND\HVLQGH PDOLJQ KDVWDOÕN YH 9RQ 5HFNOLQJKDXVHQ KDVWDOÕ ÕQD DLW RODELOHFHN ELU ]HOOLN \RNWX øgudu WHWNLNL WDP NDQ VD\ÕPÕ YH UXWLQ EL\RNLP\D LQFHOHPHVL QRUPDO VÕQÕUODUGD\GÕ )L]LN PXD\HQHGH ELU NLWOH SDOSH HGLOPHGL $QFDN VRO NRVWD YHUWHEUDO DoÕ KDVVDVL\HWL YDUGÕ YH VRO E EUHN ORMX GHULQ PXD\HQH LOH hassasiyet gösteriyordu. 86* XOWUDVRQRJUDIL GH VROGD E EUHNWHQ D\UÕ heterojen ekoda 47x50x57 mm lik kitle görüntüsü mevcuttu. CT (computerize tomografi) ve MRI (magnetik rezonans imaging) inceleme sol böbrek alt NXWEXQX ODWHUDOH YH DQWHULRUD GR UX LWHQ SVRDV NDVÕ EDúODQJÕFÕQGDQ NDXGDOH X]DQDQ SDUD YHUWHEUDO E OJHGH NDVÕQ SRVWHULRUXQGD NDODQ [[ FP HEDGÕQGD lobüle ve düzenli kontürlü, içinde hipodens nekrotik DODQODU EXOXQDQ KHWHURMHQ \DSÕGD VROLWHU NLWOHQLQ YDUOÕ ÕQÕ J VWHUGL ùhnlo 6RO VXENRVWDO IODQN LQVL]\RQ LOH UHWURSHULWRQHDO HNVSORUDV\RQ \DSÕOGÕ ÕQGD NLWOHQLQ SVRDV NDVÕ LoLQH GR UX ELU PLNWDU J P OP ú G ]J Q NRQW UO YH NDSV OO ROGX X J U OG dhyuh dokulara invazyona ait bir belirti yoktu. Kapsül çevre GRNXGDQ NROD\FD VÕ\UÕOGÕ.LWOHQLQ REWXUDWRU VLQLU 1 2 øq Q hqlyhuvlwhvl 7ÕS )DN OWHVL hurorml $QDELOLP 'DOÕ 0DODW\D øq Q hqlyhuvlwhvl 7ÕS )DN OWHVL 3DWRORML $QDELOLP 'DOÕ 0DODW\D Journal of Turgut Özal Medical Center 5(1):

2 %HQLJQ UHWURSHULWRQHDO VFKZDQQRPD QDGLU ELU \DQ D UÕVÕ VHEHEL 2 6DUÕ\ FH YH DUN NÕOÕIÕQÕQ ODWHUDOLQGHQ N NHQ DOGÕ Õ J ]OHQGL YH VLQLULQ GHYDPOÕOÕ Õ ER]XOPDGDQ NLWOH NROD\OÕNOD HNVL]H HGLOGL 0DNURVNRSLN LQFHOHPHGH NLWOHQLQ NHVLW \ ]H\L DODFDOÕ JULVDUÕ NDKYHUHQJL UHQNWH\GL YH NLVWLN DODQODU içermekteydi. Mikroskopik incelemede kitlenin fibröz ELU NDSV OOH ohyulol ROGX X YH NDSV O DOWÕQGD JHQLú KHPRUDML DODQODUÕ HQIODPDWXDU K FUH LQILOWUDV\RQX KL\DOLQL]DV\RQ NLVWLN IRUPDV\RQODUÕQ EXOXQGX X J U OG ùhnlo 'LNNDW ohnlfl VD\ÕGD KLVWL\RVLWOHU YH EHOLUJLQ NVDQWRPDW ] GH LúLNOLNOHU YDUGÕ %LU NDo DODQGD NÕVD GHPHWOHU úhnolqgh RUJDQL]H ROPXú VLWRSOD]PD VÕQÕUODUÕ EHOLUJLQ ROPD\DQ YH GHIRUPH QXNOHXVOX L K FUHOHU J oo NOH L]OHQHELOGL ùhnlo 1 NOHHU DWLSL PLWR] YH QHNUR] DODQODUÕQD UDVWODQPDGÕ Lezyon histopatolojik olarak eski schwannoma olarak WDQÕPODQGÕ Post operatif dönemi sorunsuz geçiren hasta, 28 D\OÕN WDNLEL ER\XQFD IL]LN PXD\HQH XOWUDVRQRJUDILOHU ve komputerize tomografi ile izlendi ve nüks belirtisi J ]OHQPHGL ùhnlo 2EWXUDWRU VLQLU IRQNVL\RQODUÕQGD KHUKDQJL ELU ND\ÕS JHOLúPHGL birlikte nöral orijinli tümörler de akla gelmelidir (7). Ultrasonografi ve komputerize tomografide tümörün HQNDSV OH ROXúX PLNV GDQVLWH SDUDVSLQDO \D GD ELOLQHQ VLQLU \ROODUÕQGD \HUOHúLPOL ROPDVÕ Q UDO W P U ùhnlo. Kitlenin preoperatif CT görüntüsü 7$57,ù0$ Schwannoma genellikle Von Recklinghausen KDVWDOÕ ÕQÕQ ELU NRPSRQHQWL RODUDN EHOLULU 9RQ 5HFNOLQJKDXVHQ LOH ELUOLNWH ROPDVÕ GÕúÕQGD JHQHOOLNOH EHQLJQGLU 6LQLU NÕOÕIÕQGD VFKZDQ K FUHOHULQGHQ ND\QDNODQGÕ ÕQGDQ Y FXGXQ KHUKDQJL ELU \HULQGH görülebilir. Soliter benign schwannomalar % EDú ER\XQXQ NXWDQ ] VLQLUOHULQL WXWDU 6DQWUDO \HUOHúLPO RODQODU GDKD ]L\DGH RSWLN YH DNXVWLN VLQLUL tercih ederler (3). Malign schwannomalara benign RODQODUD J UH UHWURSHULWRQGD GDKD VÕN UDVWODQÕU $ UÕ YH Q URORMLN VHPSWRPODU W P U E \ N ER\XWODUD XODúÕQFD\D NDGDU RUWD\D oõnpd] 'HULQ \HUOHúLPOL RODQODU NRPúX RUJDQ LOLúNLOHULQGHQ GROD\Õ VHPSWRPDWLN RODELOLU 5HWURSHULWRQGD JHOLúHQ VFKZDQQRPDODU E EUH H GÕúWDQ EDVÕ UHWHUH GÕúWDQ EDVÕ KLGURQHIUR] YV VHEHEL\OH RUWD\D oõndq VHPSWRPODU P SKHP D UÕODU YH EXOJXODUOD EDúYXUDELOLUOHU.LOR ND\EÕ KHPDW UL DQHPL DWHú JLEL ED]Õ QRQVSHVLILN \DNÕQPDODU PDOLJQ ROJXODUGD J U OHELOLU 7 P U VÕNOÕNOD LOHUL \DúODUGD GHNDWODU DUVÕQGD RUWD\D oõndu YH KHU LNL FLQVWH HúLW RUDQGD UDVWODQDELOLU %LOGLULOHQ MXNVWDDGUHQDO W P UGH ROGX X JLEL DGUHQDO W P UOHUL taklit edebilirler (5). Genellikle belirgin olmayan \DNÕQPDODUD \RO DoDQ YH LQVLGHQWDO RODUDN WHúKLV HGLOHQ UHWURSHULWRQHDO \XPXúDN GRNX W P UOHULQLQ D\ÕUÕFÕ WDQÕVÕQGD EHQLJQ W P UOHU JUXEXQGD QDGLU ROPDNOD ùhnlo. Kitlenin preoperatif MR görüntüsü ùhnlo. Kitlenin preoperatif MR görüntüsü 74 7XUJXWg]DO7ÕS0HUNH]L'HUJLVL

3 6DUÕ\ FH 2 et al. Benign retroperitoneal schwannoma: a rare cause of flank pain ùhnlo. %HOLUJLQ ILEU ] NDSV O Q DOWÕQGD JHQLú ILEURVLV DODQODUÕ NLVW formasyonu ve enflamatuar hücre infiltrasyonu (H&E x20) ùhnlo. Lezyonun içinde hiyalinizasyon ve kist formasyonu (H&E x50) ùhnlo. 6FKZDQQ K FUHOHUL NÕVD GHPHWOHU YH VSLUDO EHQ]HUL \DSÕODU ROXúWXUX\RU + ( [ YH VFKZDQQRPD LKWLPDOLQL DUWÕUDQ ]HOOLNOHUGLU 5HWURSHULWRQGD YH PHGLDVWHQGH \HUOHúLPOL RODQODU GL HU \HUOHUGH UDVWODQÕODQ W P UH RUDQOD GDKD E \ N ROGXNODUÕQGDQ >JHQHOOLNOH SHULIHUGHNL 6FKZDQQRPODU FP odsõqõ VHNRQGHU GHMHQHUDWLI GH LúLNOLNOHU NLVWLN DODQODU YH NDOVLILNDV\RQ J VWHULUOHU %HONL EX EXOJX KDVWDOÕ ÕQ L\L KX\OX ROGX XQXQ YH WHúKLVLQ JHo NRQGX XQXQ ELU LúDUHWL RODELOLU 7 P U Q E \ NO LOH PDOLJQ GHMHQHUDV\RQ DUDVÕQGD bir korelasyon yoktur (6). +LVWRORMLN RODUDN LNL NRPSRQHQWL YDUGÕU < NVHN GHUHFHOL VHOO OHU NRPSRQHQWL RODQ $QWRQL $ YH JHYúHN PLNVRLG NRPSRQHQWL RODQ $QWRQL % DODQODUÕ 'HMHQHUH ROPXú YDNDODUGD EX D\ÕUÕP QHW \DSÕODPÕ\DELOLU g]hoolnoh VDQWUDO YH SHULIHULN VLQLU K FUHOHULQLQ YDUOÕ ÕQÕ GHVWHNOH\HQ 6 SURWHLQLQ LPP QKLVWRNLP\DVDO WHNQLNOHUOH YDUOÕ ÕQÕQ J VWHULOPHVL VFKZDQQRPD\Õ GHVWHNOHU %D]Õ ROJXODUGD \D\JÕQ QHNUR] SOHRPRUIL]P YDUOÕ ÕQGD YH WLSLN $QWRQL $ YH\D % ]HOOLNOHULQLQ \RNOX XQGD SDWRORMLVW KDVWDOÕN WDQÕVÕQD \DQOÕú ELoLPGH \ QHOHELOLU (3). 6FKZDQQRPDQÕQ JHUoHN LQVLGDQVÕ ELOLQPHPHNOH beraber retroperitoneal schwannoma çok nadirdir. WH \D\ÕPODQDQ ELU VHULGH UHWURSHULWRQHDO tümörün sadece biri benign schwannoma idi (7) GD \D\ÕPODQDQ ELU GL HU ELOGLULGH UHWURSHULWRQHDO tümörün sadece 2 si schwannoma idi (11) lerden günümüze literatürdeki bildirilen benign VFKZDQQRP GHQ D]GÕU 6FDQODQ SULPHU retroperitoneal tümörler içinde sadece % 1 VFKZRQQRP YDNDVÕ ELOGLUPLúWLU 3UHRSHUDWLI RODUDN VFKZDQQRQD WDQÕVÕ NR\PDN P SKHP úlnd\hwohu LOH P UDFDDW YH J U QW OHPH \ QWHPOHULQGH D\ÕUW HGLFL ]HOOL L ROPDGÕ ÕQGDQ GROD\Õ güçtür USG de heterojen ekoda kitle mevcuttur. CT YH 05, LQFHOHPHGH NLWOH LPDMÕ PHYFXWWXU %D]Õ YDNDODUGD NLVWLN GH LúLNOLNOHULQ YH NDOVLILNDV\RQODUÕQ J U OPHVL EHQLJQ ROGX XQX GHVWHNOHPHVLQH NDUúÕQ D\ÕUÕFÕ WDQÕ\D \DUGÕPFÕ ROPD] $VSLUDV\RQ ELRSVLVL WHúKLVH \DUGÕPFÕ ROPDNWDQ X]DNWÕU *X] YH DUNDGDúODUÕ /LDP +XUOH\ YH DUNDGDúODUÕ EX WLS ELU JLULúLPLQ EDúDUÕVÕ]OÕ ÕQÕ ELOGLUPLúOHUGLU %X WLS biopsi incelemesinde S-100 protein immunhistokimya odoõúpdvõ EDúDUÕVÕ]GÕU %DVLW HQ NOHDV\RQ LOH UHN UUHQ E \ PH D UÕ úlo ] DVLWOHU YH JHULGH NDODQ W P U Q SRWDQVL\HO PDOLJQ WUDQVIRUPDV\RQODUÕ UDSRU HGLOPLúWLU 7 P U Q FHUUDKL RODUDN JHQLú UH]HNVL\RQ LOH oõnduõopdvõ HQ L\L VHoHQHNWLU *HQHOOLNOH ]D\ÕI YDVN ODUL]HGLUOHU.DSV OO ROGXNODUÕQGDQ NROD\FD GLVVHNH HGLOLUOHU. NHQ DOGÕNODUÕ VLQLU ]HULQGHQ GLVVHNVL\RQODUÕ NROD\GÕU $QFDN OLWHUDW UGH KLSHUYDVN OHU YDNDODU ELOGLULOPLúWLU %L]LP Journal of Turgut Özal Medical Center 5(1):

4 %HQLJQ UHWURSHULWRQHDO VFKZDQQRPD QDGLU ELU \DQ D UÕVÕ VHEHEL 2 6DUÕ\ FH YH DUN REFERANSLAR ùhnlo. postoperatif 9. ayda CT görüntüsü YDNDPÕ]GD VLQLU ]HULQGHQ GLVVHNVL\RQ NROD\ ROPXúWXU.DWKDULQH $% YH DUNQÕQ ELOGLUGLNOHUL YDNDGD REWXUDWRU VLQLU ]HULQGHNL GLVVHNVL\RQ J oo QGHQ NLWOH\L EX \ ]GHQ \HULQGH EÕUDNWÕNODUÕQÕ ELOGLUPLúOHUGLU (5). Bu gibi benign ya da malign tümörlerin UH]HNVL\RQODUÕQÕ WDNLEHQ JHOLúHQ Q URORMLN GHILVLWOHU GH UDSRU HGLOPLúWLU +DVWDPÕ]GD SRVWRSHUDWLI dönemde herhangi bir nörolojik semptom ve bulgu VDSWDQPDPÕúWÕU <HWHUOL GRNX YDUOÕ ÕQGD KLVWRSDWRORMLN WDQÕ\Õ NR\PDN NROD\GÕU %X YDNDGD OH]\RQXQ PRUIRORMLVL YH KLVWRSDWRORMLVL 86* &7 YH 05, EXOJXODUÕ LPPXQKLVWRNLP\D odoõúpdvõqõ JHUHNWLUPH\HFHN Oo GH WDQÕ NR\GXUXFX RODUDN GH HUOHQGLULOPLúWLU +DVWDQÕQ SRVWRSHUDWLI D\OÕN WDNLSWH UHN UUHQV J VWHUPHPHVL WDQÕ\Õ GHVWHNOHPLúWLU 5HWURSHULWRQHDO EHQLJQ VFKZDQQRPDQÕQ SURJQR]X P NHPPHOGLU 7 P U Q PDOLJQ GH RODELOHFH L ]HOOLNOH 9RQ 5HFNOLQJKDXVHQ KDVWDOÕ Õ YDUOÕ ÕQGD XQXWXOPDPDOÕGÕU /H]\RQXQ VLQLU E W QO Q bozmadan total eksizyonu benign olgularda yeterli WHGDYL\L VD ODPDNWDGÕU 6FKZDQQRPD UHWURSHULWRQHDO NLWOHOHULQ D\ÕUÕFÕ WDQÕVÕQGD QDGLU GH ROVD DNÕOGD WXWXOPDVÕ JHUHNHQ ELU OH]\RQGXU drn EHOLUJLQ ROPD\DQ \DNÕQPDODU DUVÕQGD URORML SROLNOLQLNOHULQGH HQ VÕN UDVWODQDQ \DNÕQPD RODQ \DQ D UÕVÕ GD EXOXQDELOLU * U QW OHPH WHWNLNOHUL YH SUHRSHUDWLI L QH ELRSVLOHULQLQ \HWHUOL WDQÕ GHVWH L YHUHPHGLNOHUL EX W P UOHULQ WDQÕ YH WHGDYLVLQGH cerrahi eksplorasyon ve mümkünse sinir koruyucu WHNQLNOHUOH X\JXODQDQ JHQLú FHUUDKL UH]HNVL\RQODU tercih edilmelidir. 1. Jow W, Sathidanand S, Spinazze E, Lillie D. Malignant juxtaadrenal schwannoma. Urology 1991;38: Braash JW, Mon AB. Primary retroperironeal tumors.surg Clin North AM 1967;47: Hurley L, Smith lll JJ, Larsen CR, Silwerman ML. Multible retroperitoneal schwannomas: case report and rewiev of the literature J Urol 1994;151: Steers WD, Hodge GB, Johnson DE, et al. Manign retroperitoneal neurilomma without Von Recklinghausen s disease: a rare occurrence. J Urol 1985;28: Katherine AB, McCarron JP, Vaughan ED, Javidian P. Benign schwannoma of the retroperitoneal space: case report. J Urol 1993;150: Felix EL, Woods DK, Das Gupta TK. Tumors of theretroperitoneum. Curr Probl Cancer 1981;6: Pack GT, Tabah ET, Colective review: Primary retroperitoneals tumors: study of 120 cases. Surg Gynec Obst 1954;99: Donnal JF, Baker ME, Mahony BS, Leight GS. Benign retroperitoneal schwannoma. Urology 1988;31: Russel DS, Rubinstein LJ. Pathology of tumors of the nervous system. 5 th ed. Baltimore: Williams & Wilkins, 1989: Weiss SW, Langlass JM, Enzinger FM,The role of S- 100 protein in the diagnosisof soft tissue tumors with particular reference to benign and malignant schwann cell tumor. Lab Invest 1983;49: Whitaker WG, Droulias C. Benign encapsulated nurilemoma: a report of 76 cases. Am Surg 1976;42: Heaton ND, Page AC, Howard ER. Malignant retroperitoneal schwannoma. J Roy Soc Med 1991; 84: Scanian DB. Primary retroperitoneal schwannoma. J Urol 1959;81: Ghiatas AA, Faleski EJ. Benign solitary schwannoma of the retroperitoneum CT features. South Med J 1989; 82: LP 6+ &KRÕ %, +DQ 0&.LP <, 5HWURSHULWRQHDO neurilemoma: CT and MR findings. AJR 1992; 159: Guz BV, Wood DPjr, Montie JE. Retroperitoneal neural sheet tumors: Clevaland clinics experience. J Urol 1989;142: Liam H, Smith JJ, Larsen CR, Silverman ML. Mutible retroperitoneal schwannomas: case report and review of the literature J Urol 1994;151: Ghosh BC, Ghosh L, Huvas AG, Fortner JG. Malignant schwannoma: a clinicopathologic study. Cancer 1973;31: Bair ED, Woodside JR, Williams WL, Borden TA. Perineal malignant schwannoma presenting as renal cell carcinoma. Urology 1978;11: Krag LV, Soule EH, Masson JK. Benign and malignant neurilemomas of the head and neck. Surg Gynec Obstet 1960; 111: Miller PL, Tessler A, Alexander S, Pinck BD. Retroperitoneal neurilemoma. Urology 1978;11: XUJXWg]DO7ÕS0HUNH]L'HUJLVL

5 6DUÕ\ FH 2 et al. Benign retroperitoneal schwannoma: a rare cause of flank pain 22. Claes H, Oyen R, Stessens R, Vereecken R. Solitary benign schwannoma in the psoas muscle. J Urol 1987;137: <D]ÕúPD DGUHVL 'U 2 X]KDQ 6$5,<h&( øq Q hqlyhuvlwhvl 7ÕS )DN OWHVL Üroloji ABD MALATYA Journal of Turgut Özal Medical Center 5(1):