PMC4508740_01
A: MRI study with sagittal T2-weighted sequence disclosing a hypointense heterogeneous intradural C4-C5 mass, disrupting the medulla. B: axial T2 proton density (PD)-weighted sequence showing a slightly hyperintense. C: Axial FLAIR isointense extramedullary neoplasm extension for the left C5 root without bone destruction, presenting an hourglass shape directed toward the paravertebral area. FLAIR: fluid attenuated inversion recovery, MRI: magnetic resonance imaging.
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F1
T1 and isointense with T2-weighted sequences, invading the left C5 neural foramen (Fig. 1). The patient underwent C3-C5 laminectomy with total resection of a black encapsulated tumor measuring 37 x 30 x 16 mm (Fig. 2).
Surgical view of C3-C5 laminectomy followed by durotomy, revealing (A) intradural extramedullary mass, with (B) black multilobulated appearance that extended to C5 foramen, as confirmed after (C) the total removal of tumor.
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F2
T1 and isointense with T2-weighted sequences, invading the left C5 neural foramen (Fig. 1). The patient underwent C3-C5 laminectomy with total resection of a black encapsulated tumor measuring 37 x 30 x 16 mm (Fig. 2).
Microscopic view of melanotic schwannoma (MS) showing A: a neoplasm with markedly pleomorphic and variable dark brown pigmented Schwann cells with hyperchromatic nuclei surrounding a small nerve root [H&E; x200], B: a detail of spindle-shaped neoplastic epithelioid cells and activated macrophages with melanin granules [H&E; x1000], C: a immunostain for Ki-67 displaying the tumor proliferative status (LI = 15%) [H&E; x200], D: a strong positivity for melanoma-associated antigen HMB-45 [H&E; x200]. H&E: Harry's hematoxylin, LI: labelling index.
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F3
S-100, Human Melanoma Black-45 (HMB-45) and vimentin were positive, with Ki-67 labelling index (LI) of 15%, compatible with MS (Fig. 3).
Computed tomography (CT) scan of the chest showing multiple pulmonary nodules scattered throughout both lungs with thin post contrast enhancing, measuring from a few millimeters to 2 cm. No adenopathy is seen in either the hilar region or the rest of the mediastinum. A: lung filter, B: osseous filter.
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F4
Six months later, she presents worsening of cervical pain and dyspnoea, with evidence of local recurrence and multiple pulmonary nodules (Fig. 4). She was started on multiagent chemotherapy (dicarbazine, cisplatin, and interferon) and submitted to cervical stereotactic radiosurgery (800 cGy).