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Analisis clinico, patologico e inmunohistoquimico de schwannoma en cavidad oral: reporte de caso.

CLINICAL, PATHOLOGICAL, AND IMMUNOHISTOCHEMICAL ANALYSIS OF SCHWANNOMA IN ORAL CAVITY: A CASE REPORT

INTRODUCCION

El schwannoma, tambien conocido como neurilemmoma, neurinoma o fibroblastoma perineural, es una neoplasia benigna de crecimiento lento de los nervios perifericos, generalmente ubicados en tejidos blandos; (1) esta compuesto por celulas de Schwann, que es un tipo de celula glial que envuelve el axon de las neuronas formando la vaina de mielina y cuyo rol principal es guiar correctamente el crecimiento del axon. (2) El schwannoma fue descrito por primera vez en 1910. (3) En la mayoria de los casos, el tumor inicia entre los 20 y 60 anos de edad; (4) la tasa de incidencia mundial es de 1 a 20 casos por 1.000.000 de habitantes por ano. (4) Cerca del 25 al 48% de los casos afecta la region de la cabeza y cuello; en la cavidad oral se observa principalmente en lengua, mucosa bucal y labio. (5)

Su anatomia patologica se caracteriza por lesiones solidas, subcutaneas y asintomaticas; (6) histologicamente esta compuesto por prototipos de organizacion celular denominados Antoni A y Antoni B. (2) La region Antoni A es una zona hipercelular cuyas celulas son fusiformes con nucleos que se disponen en empalizada formando filas paralelas y dando origen a los cuerpos de Verocay. (7) La region Antoni B es una zona hipocelular que se caracteriza por predominio de un estroma mixoide laxo con cambios degenerativos, como formacion de quistes, calcificaciones, hemorragias, hialinizacion e infiltrado inflamatorio. (8) Estos cambios degenerativos con poca frecuencia se malignizan en sarcomas, (9) los cuales son invasivos y con potencial metastasico; (9) en caso de presentarse, pueden ser asociados a una reseccion incompleta de la lesion. (2)

Una vez realizada la escision quirurgica de la lesion, el diagnostico tiene lugar en el momento en que se lleve a cabo el estudio histopatologico. (4) De igual forma, una tomografia computarizada o una imagen de resonancia magnetica pueden mostrar la extension de la lesion. (10) Las pruebas inmunohistoquimicas muestran que las celulas del schwannoma son positivas para la proteina S-100. (3) Otros marcadores celulares asociados a tumores neuronales son: E.N.E., vimentina, glicoproteina, SMA, desmina y dimentina (leu-7). (11,12) Ademas, la proteina ki-67, como marcador, permite determinar la proliferacion celular. (13)

Generalmente, el pronostico de esta lesion es bueno; su transformacion maligna se ha reportado en pocas ocasiones. (10) El tratamiento consiste en la reseccion completa de la lesion preservando la funcion del nervio involucrado. (14) En caso de confirmarse malignidad (que es muy poco frecuente), (9) se recomienda la reseccion extendida y la quimioterapia. (14)

El presente reporte identifica un caso clinico de schwannoma localizado en el fondo del vestibulo de la mucosa bucal derecha, cuyo diagnostico clinico fue confirmado histopatologicamente, en una paciente que asistia a consulta odontologica de rutina en la clinica de UNICOC, sede Cali.

PRESENTACION DEL CASO

Paciente de genero femenino de 55 anos de edad, caucasica, que asiste a cita odontologica rutinaria en la clinica de UNICOC. Durante la evaluacion clinica se detecto en la zona de mucosa bucal derecha una masa nodular, sesil, que invade la submucosa, circunscrita, recubierta por mucosa normal, movible y asintomatica a la palpacion, que media aproximadamente 2 cm de diametro (Figura 1A, 1B y 1C). La paciente relata la presencia de la lesion hace aproximadamente 1 ano, con crecimiento lento e indoloro. No hay evidencia de alteracion en la permeabilidad del tejido ni de parestesia. El diagnostico presuntivo, de acuerdo a las caracteristicas clinicas, fue un fibroma.

Al extraerla, la masa permitio planos de clivaje para su diseccion total; se fijo en formol al 10% y posteriormente se realizo estudio histopatologico e inmunohistoquimico.

Examen macroscopico

Al estudio macroscopico se observo un tejido de consistencia firme, elastico, de aspecto interno fibroso, que procede de la zona submucosa del vestibulo derecho detras del carrillo. El especimen es de forma nodular y mide 1,8 centimetros en su mayor dimension. Para efectos del proceso, se divide en dos mitades y se envian al laboratorio (Figura 1C).

Examen microscopico

Los cortes obtenidos del especimen muestran una neoplasia bien capsulada por una banda fibrosa (Figura 1D) que cubre en su totalidad el componente hiperplasico, el cual se deriva de las celulas de Schwann de nervios perifericos. La expresion histologica del tumor corresponde a un nodulo firme hecho a expensas de celulas fusiformes con nucleos picnoticos dispuestos en bandas que edifican fibrillas longitudinales, y las que se cortan en forma transversal se ven dispuestas en empalizada con un centro fibrilar hialinizado caracterizando cuerpos de Verocay. (Figura 1E). Al interior del tumor se identifican vasos dilatados y congestivos; en otros sitios se observan cavidades seudoquisticas con lagunas de contenido amorfo (Figura 1F). Los bordes de reseccion del tumor aparecen rodeados en su totalidad por la banda fibrosa que le genera encapsulamiento. No hay evidencia de malignidad.

Pruebas inmunohistoquimicas

Para confirmar que la neoplasia deriva de las celulas de Schwann, se evaluaron los siguientes marcadores: neurofilamento

(Tabla 1 y Figura 2A), proteina acida fibrilar glial (Tabla 1 y Figura 2B), sinaptofisina (Tabla 1 y Figura 2C), Leu-7 (Tabla 1 y Figura 2D), proteina S-100 (Tabla 1 y Figura 2E), dimentina (Tabla 1 y Figura 2F).

DISCUSION

Los schwannomas son lesiones neoplasicas benignas poco frecuentes. (15) En el ano 2006, en 44.000 especimenes enviados a la unidad de patologia de la Facultad de Odontologia de Sheffield (Reino Unido), se realizo un estudio para determinar el rango de lesiones histopatologicas diagnosticadas en pacientes mayores de 17 anos durante un periodo de 30 anos (1973-2002), y se encontro que de los 2.452 casos de tumores benignos, 43 pertenecen a schwannomas, es decir, solo el 1,8% de prevalencia. (16)

En Brasil, en el 2011 se realizo un estudio para describir los perfiles clinicos, histopatologicos e inmunohistoquimicos de los schwannomas y neurofibromas en 9.000 casos de lesiones orales durante un periodo de 38 anos (1970 a 2008), y se reportaron 4 schwannomas que equivalian al 0,17% de prevalencia. Ademas, se reporto predileccion por el genero masculino (3: 1), un promedio de edad de 34,7 anos y un tamano promedio de 2,8 cm. (3) En el presente reporte la lesion tumoral midio 1,8 cm en una mujer de 55 anos de edad.

Generalmente, la prevalencia de schwannomas es del 25-50% en la region de cara y cuello; dentro de la localizacion intraoral (1-12%),7 se pueden ver en lengua y piso de boca, zonas de mayor frecuencia, (17) seguidas por la zona de mucosa bucal y labio. (7) Los schwannomas en labio son catalogados como poco frecuentes. (18) Este caso de schwannoma intraoral fue ubicado en la mucosa bucal, que corresponde tambien a una ubicacion con baja frecuencia. (14)

La determinacion exacta del nervio originario puede ser imposible de establecer, y se identifica solo en un 50% de los casos con relacion al nervio de origen. (17) En nuestro caso, no se identifico la localizacion exacta, pero se presume que el sitio de origen pueden ser las ramas perifericas del nervio facial. En un estudio retrospectivo realizado en nueve casos de schwannoma de cavidad oral tratados en el servicio de Cirugia Oral y Maxilofacial

(Espana), se reporto la localizacion submaxilar y yugulodigastrica, donde la tumoracion dependia del nervio lingual y del nervio espinal, respectivamente. (18)

El schwannoma de nuestro caso se detecto en zona de submucosa bucal derecha, como una lesion nodular, sesil, circunscrita, recubierta por mucosa normal, movible, sin evidencia de alteracion en la permeabilidad del tejido y asintomatica a la palpacion, que media aproximadamente 2 cm de diametro.

Los hallazgos histologicos de este estudio concuerdan con los reportes de la literatura con respecto a la presencia de formaciones Antoni A y Antoni B. (15, 16, 19) Generalmente, el diagnostico clinico presuntivo puede referirse a lesiones tumorales benignas tipo fibroma, lipoma o tumor de glandulas salivares. (10)

Las pruebas inmunohistoquimicas muestran que las celulas del schwannoma son positivas para la proteina S-100 (Figura 2E) y para vimentina (Figura 2F), lo que se asocia con el tumor benigno de nervio periferico. (3, 20) La proteina S-100 se presenta de forma normal en celulas derivadas de la cresta neural (celulas de Schwann, melanocitos y celulas gliales). (21) Varios miembros de la familia de la proteina S-100 son utiles como marcadores para ciertos tumores y para la diferenciacion epidermica. Se pueden encontrar en los melanomas, (22) en el 50% de los tumores malignos de la vaina de nervios perifericos, en schwannomas, asi como en celulas del estroma paraganglioma, histiocitoma y sarcomas de celulas claras. Ademas, las proteinas S-100 son marcadores para las enfermedades inflamatorias y pueden mediar la inflamacion y actuar como agentes antimicrobianos. (23)

Otro marcador utilizado que resulto positivo fue la vimentina (Figura 2F). Este marcador se utiliza a menudo para identificar celulas mesenquimales. Tambien es comun encontrarla en las progresiones matastasicas. (24) Se ha reportado que cuando la vimentina es negativa, se pueden excluir los angioleiomiomas. (12, 25)

Para Leu-7 se presento una expresion positiva (Figura 2D). Esta proteina es un marcador antigenico de los linfocitos, especifico para celulas asesinas naturales, que se expresa dentro de los tumores de vaina nerviosa benignos y malignos, asi como en tumores neuroendocrinos. (26, 27) Se ha reportado la expresion de Leu-7 de forma diferencial para schwannoma (25) (Tabla 1).

La proteina fibrilar acida de la glia fue negativa en el caso reportado (Figura 2B). Esta proteina recibe el nombre de filamentos gliales o proteina gliofibrilar acida (GFAP). Es una de las proteinas fibrosas que forman los filamentos intermedios del citoesqueleto intracelular, en particular de celulas gliales como los astrocitos. (28) El marcador de neurofilamento (Figura 2A), que es utilizado para diferenciar otro tipo de tumores de estirpe neural, como el neuroma, tambien resulto negativo. (29)

Por ultimo, se utilizo la sinaptofisina (Figura 2C). Esta es una proteina que se encuentra en las vesiculas presinapticas de las neuronas y celulas neuroendocrinas, por lo que es un marcador util para la identificacion de neoplasias neuronales y neuroendocrinas y para tumores carcinoides. (30) Este marcador no mostro expresion, lo que indica que no hay problemas en la neurotransmision de los tejidos en cuestion.

La presencia de formaciones quisticas, calcificaciones, hialinizacion y hemorragias es signo de cambios degenerativos que no son determinantes de malignidad. (17) Al interior del tumor se identificaron vasos dilatados y congestivos. En otros sitios se observaron cavidades seudoquisticas con lagunas de contenido amorfo (Figura 1D).

El pronostico del schwannoma es en general favorable, siempre y cuando se retire por completo la lesion y se mantenga un enfoque conservador; (18) no obstante, ocasionalmente puede presentar agresividad local y hasta un 2% de malignidad, evidenciada por la presencia de metastasis a distancia. (13) Los controles realizados a la paciente no revelaron ningun deficit neurologico, dolor ni alteracion en la permeabilidad de la mucosa. Otros reportes, en los que el compromiso neurologico es evidente, utilizaron una intervencion quirurgica particular. Por ejemplo, en Finlandia se realizo una revision de casos de neurilemomas de medula espinal en 20 pacientes en quienes la escision quirurgica del tumor fue parcial, para evitar danar el nervio de origen; en este caso, durante el posquirurgico se evidencio dolor local (46%), seguido de dolor irradiado (43%) y paraparesia (31%). (31)

CONCLUSIONES

El schwannoma es un tumor benigno de crecimiento lento, cuyo diagnostico requiere un estudio histopatologico. Es importante considerar la evaluacion clinica de los tejidos blandos en cavidad oral durante la visita odontologica rutinaria, con el fin de identificar este tipo de lesiones nodulares asintomaticas.

RECOMENDACION

En la practica habitual de la odontologia, el estudio de lesiones en la cavidad oral debe acompanarse de estudios anatomopatologicos, que pueden ser complementados con marcadores inmunohistoquimicos, los cuales permiten ampliar el diagnostico y fortalecen la formacion del profesional odontologico.

CONFLICTO DE INTERESES

Los autores declaran no tener ningun conflicto de interes.

CORRESPONDENCIA

Paola Bueno

Institucion Universitaria Colegios de Colombia (UNICOC), sede Santiago de Cali

(+57) 301 788 1203

dra.paolabueno@gmail.com

Cali, Colombia

INTRODUCTION

The schwannoma, also known as neurilemmoma, neurinoma, or perineural fibroblastoma, is a slow-growing benign neoplasm of the peripheral nerves usually located in soft tissues; (1) it is composed of Schwann cells, which is a type of glial cell surrounding the axon of the neurons and forming the myelin sheath, mainly in charge of correctly guide the axon growth. (2) The schwannoma was first described in 1910. (3) In most cases, the tumor starts between the ages of 20 and 60 years; (4) the global incidence rate is 1 to 20 cases per 1,000,000 inhabitants per year. (4) About 25 to 48% of all cases affect the region of the head and neck; in the oral cavity, it is mainly seen in the tongue, the buccal mucosa, and the lips. (5)

Its pathology is characterized by solid, subcutaneous, asymptomatic lesions; (6) histologically it is composed of prototypes of cell organization called Antoni A and Antoni B. (2) The Antoni A region is a hypercellular zone whose cells are fusiform with nuclei arranged in palisade forming parallel rows and producing the Verocay bodies. The Antoni B region is a hypocellular zone characterized by predominance of a loose myxoid stroma with degenerative changes, such as formation of cysts, calcifications, hemorrhages, hyalinization, and inflammatory infiltrate. (8) It is not frequent for these degenerative changes to become malignant sarcomas, (9) which are invasive and have metastatic potential; (9) if they occur, may be associated with incomplete resection of the lesion. (2)

Once the surgical excision of the lesion has been completed, the diagnosis takes place when the histopathological study is carried out. (4) Similarly, a CT scan or a magnetic resonance image can show the extent of the lesion. (10) The immunohistochemical tests show that the schwannoma cells are positive for protein S-100.3 Other cellular markers associated with neuronal tumors are: E.N.E., vimentin, glycoprotein, SMA, desmin, and dimentin (leu-7). (11-12) In addition, the ki-67 protein as a marker allows determining cell proliferation. (13)

Generally, the prognosis of this lesion is good; its malignant transformation has been reported in very few occasions. (10) Treatment consists of complete resection of the lesion while preserving the function of the involved nerve. (14) If malignancy is confirmed (which is very rare), (9) extended resection and chemotherapy is recommended. (14)

This report presents a clinical case of schwannoma located on the bottom of the right vestibular area of the oral mucosa, with diagnosis histopathologically confirmed, in a patient seen for routine dental consultation at Institucion Universitaria Colegios de Colombia (UNICOC) clinic at Cali.

CASE PRESENTATION

A 55-year-old Caucasian female patient attending a routine dental appointment at the UNICOC clinic. During the clinical evaluation, the right oral mucosa area showed a sessile, nodular, circumscribed mass invading the submucosa, covered by a normal movable mucosa; the mass was asymptomatic to palpation, measuring approximately 2 cm in diameter (Figure 1A, 1B and 1C). The patient referred presence of the lesion about 1 year ago, with slow and painless growth. There is no evidence of alteration in tissue permeability nor paresthesia. Based on the clinical characteristics, the presumptive diagnosis was a fibroma.

The extracted mass allowed cleavage planes for its total dissection; it was fixed in 10% formalin; the histopathologic and immunohistochemical study was later performed.

Macroscopic examination

The macroscopic examination showed a firm, elastic tissue of internal fibrous appearance, from the right vestibular submucosa area behind the cheek. The sample was nodular-shaped, measuring 1.8 cm in its widest point. For procedural purposes, it was cut into two halves and sent to the laboratory (Figure 1C).

Microscopic examination

The sections of the specimen showed a neoplasm tightly encapsulated by a fibrous band (Figure 1D) fully covering the hyperplastic component, which is derived from the Schwann cells of peripheral nerves. The histological expression of the tumor corresponds to a firm nodule of spindle-shaped cells with pyknotic nuclei arranged in bands that build longitudinal fibrils; the ones that are transversally cut are arranged in palisade with a fibrillar hyalinized core forming Verocay bodies (Figure IE). The inner part of the tumor shows dilated and congestive vessels; other sites show pseudocyst cavities with pools of amorphous content (Figure IF). The edges of tumor resection are entirely surrounded by the fibrous band that encapsulates it. There is no evidence of malignancy.

Immunohistochemical tests

To confirm that the neoplasm derives from Schwann cells, the following markers were evaluated: neurofilament (table 1 and figure 2A), glial fibrillary acidic protein (table 1 and figure 2B), synaptophysin (table 1 and figure 2C), Leu-7 (table 1 and figure 2D), protein S-100 (table 1 and figure 2E), dimentin (table 1 and figure 2F).

DISCUSSION

Schwannomas are rare benign neoplastic lesions. (15) In 2006, in 44,000 samples sent to the Pathology Unit of the University of Sheffield School of Dentistry (United Kingdom), a study was conducted to determine the range of histopathological lesions diagnosed in patients over 17 years of age for a period of 30 years (1973-2002), finding out that of the 2.452 cases of benign tumors, 43 were schwannomas, i.e. only 1.8% of prevalence. (16)

In Brazil, a study was conducted in 2011 to describe the clinical, histopathological, and immunohistochemical profiles of schwannomas and neurofibromas in 9,000 cases of oral lesions during a period of 38 years (1970 to 2008); only 4 schwannomas were found, accounting for 0.17% prevalence. In addition, there was predilection for males (3:1), an average age of 34.7 years, and a size of 2.8 cm in average. (3) In the present report, the tumor lesion measured 1.8 cm in a 55-year-old woman.

Generally, the prevalence of schwannomas is 2550% in the area of the face and neck; in terms of the intraoral location (1-12%),7 they are mostly seen in the tongue and the floor of the mouth, (17) followed by the area of the buccal mucosa and the lips. (7) The schwannomas in lips are considered uncommon. (18) The present case of an intraoral schwannoma was located on the buccal mucosa, which is also an uncommon location. (14)

The exact location of the nerve originating the lesion may be impossible to establish, and is identified in only 50% of cases. (17) In our case, the exact location was not identified, but the presumed source can be the peripheral branches of the facial nerve. A retrospective study conducted in nine cases of schwannoma of the oral cavity treated in the Oral and Maxillofacial Surgery Service (Spain), reported the submandibular and jugular-digastric location, where the tumor was dependent on the lingual nerve and the spinal nerve, respectively. (18)

The schwannoma in our case was detected in the right oral submucous area, as a nodular sessile, circumscribed lesion covered by normal movable mucosa, with no evidence of alteration in tissue permeability; the lesion was asymptomatic on palpation, measuring approximately 2 cm in diameter.

The histological findings of this study are consistent with reports in the literature regarding the presence of Antoni A and Antoni B formations. (15, 16, 19) Generally, the presumptive clinical diagnosis can refer to benign tumor lesions like fibroma, lipoma, or tumor of salivary glands. (10)

The immunohistochemical tests show that the schwannoma cells are positive for S-100 protein (Figure 2E) and vimentin (Figure 2F), which is associated with the benign tumor of peripheral nerve. (3, 20) The S-100 protein normally appears in cells derived from the neural crest (Schwann cells, melanocytes, and glial cells). (21) Several members of the S-100 protein family are useful as markers for certain tumors and for epidermal differentiation. They can be found in melanomas, (22) in 50% of malignant tumors of peripheral nerves in schwannomas, as well as in cells of stromal paraganglioma, histiocytoma, and clear cell sarcomas. In addition, the S-100 proteins are markers for inflammatory diseases and can mediate inflammation and act as antimicrobial agents. (23)

Another used marker that was positive is vimentin (Figure 2F). This marker is often used to identify mesenchymal cells. It is also commonly found in metastatic progressions. (24) It is reported that when vimentin is negative, angioleiomyomas can be discarded. (12, 25)

As to Leu-7, it showed a positive expression (Figure 2D). This protein is an antigenic marker of lymphocytes, specific for natural killer cells, which is expressed in benign and malignant nerve sheath tumors, as well as in neuroendocrine tumors. (26, 27) The expression of Leu-7 has been reported in a differential manner for schwannoma (25) (table 1).

The glial fibrillary acidic protein (GFAP) was negative in the reported case (figure 2B). This is one of the fibrous proteins that form the intermediate filaments of the intracellular cytoskeleton, particularly glial cells such as the astrocytes. (28) The neurofilament marker (figure 2A), which is used to differentiate other types of neural tumors of neural, like the neuroma, was also negative. (29)

Finally, synaptophysin was also used (Figure 2C). This protein is found in the presynaptic vesicles of neurons and in neuroendocrine cells, and therefore is a useful marker to identify neural and neuroendocrine neoplasms and carcinoid tumors. (30) This marker was not expressed, suggesting that there are no problems in neurotransmission from the involved tissues.

The presence of cystic formations, calcifications, hyalinization, and hemorrhage is a sign of degenerative changes that are not determinants of malignancy. (17) Congestive and dilated vessels were identified inside the tumor. Pseudocyst cavities with pools of amorphous content were observed in other sites (Figure 1D).

The prognosis of schwannomas is generally favorable, provided that the lesion is completely removed, maintaining a conservative approach; (18) however, occasionally there may be local aggressiveness and up to 2% of malignancy, identified by the presence of distant metastasis. (13) The patient in this study went through several clinical exams, which did not show neurological deficit, pain or alterations in mucosa permeability. Other reports, in which neurologic compromise is obvious, used a particular surgical intervention. For example, in Finland, a case review was conducted to evaluate spinal cord neurilemomas in 20 patients who had partial surgical excision of the tumor to avoid damages in the nerve; in that case, there was local post-operative pain (46%), as well as radiated pain (43%), and paraparesis (31%). (31)

CONCLUSIONS

The schwannoma is a slow-growing benign tumor, whose diagnosis requires a histopathological study. It is important to consider the clinical evaluation of soft tissues in the oral cavity during routine dental visits, in order to identify this type of asymptomatic nodular lesions.

RECOMMENDATION

In the habitual practice of dentistry, the study of lesions in the oral cavity should be accompanied by anatomopathological studies, which can be supplemented by immunohistochemical markers, improving diagnostics and strengthening the preparation of dental professionals.

CONFLICT OF INTEREST

The authors declare not having conflicts of interest.

CORRESPONDING AUTHOR

Paola Bueno

Institucion Universitaria Colegios de Colombia

(UNICOC), sede Santiago de Cali

(+57) 301 788 1203

dra.paolabueno@gmail.com

Cali, Colombia

PAOLA BUENO MERCADO [1], JULIO CESAR OSORIO [2], CARLOS EMIRO TASAMA [3], PAULA C. BERMUDEZ JARAMILLO [4]

http://dx.doi.org/ 10.17533/udea.rfo.v28n2a12

[1] DDM. Specialist in Periodontics. Specialist in Hospital Management. Former professor of Clinical Practicum in Periodontics. Institucion Universitaria Colegios de Colombia (UNICOC) at Santiago de Cali. Email: dra.paolabueno@gmail.com

[2] Biologist. MSc in Biology. Research Professor. Institucion Universitaria Colegios de Colombia (UNICOC) at Santiago de Cali. Email: jcosorio@ unicoc.edu.co

[3] DMD. Specialist in Pathology. Master's degree in Higher Education. Professor of General and Oral Pathology. Institucion Universitaria Colegios de Colombia (UNICOC) at Santiago de Cali. Email: ctasama@ unicoc.edu.co

[4] DMD. Master's degree in Health Administration MBA. Professor and researcher at Pontificia Universidad Javeriana at Cali. Email: paula. bermudez@javerianacali.edu.co

Caption: Figure 1. A) image of the tumor lesion in the submucosal area of the right vestibular area behind the cheek, extirpated through surgical dissection. The encapsulated mass protrudes during surgery. B) image of the surgical niche of the lesion. C) image of the encapsulating mass in mm. D) microscopic view of the schwannoma tissue at 4x, showing the fibers of the encapsulation band. E) microscopic view of the schwannoma tissue at 10x under hematoxylin and eosin staining; the Verocay bodies can be seen. F) microscopic view of the schwannoma tissue at 10x under hematoxylin and eosin staining; the bleeding process within the mass of the tumor can be seen.

Caption: Figure 2. Microscopic view of the schwannoma tissue at 40x A) Negative immunohistochemical staining for the neurofitament. B) Negative immunohistochemical staining for the glialfibrillary acidic protein. C) Negative immunohistochemical staining for synaptophysin. D) Negative immunohistochemical staining for Leu-7. E) Positive immunohistochemical staining for S-100 protein. F) Positive immunohistochemical staining vimentin.
Table 1. Guidelines for the diagnostic differentiation of
schwannoma (modified from Buric et at (12))

Markers                                    Result

Encapsulation                                +
Pathological formation        Antoni A and Antoni B areas with
                                       Verocay bodies
Cell differentiation                        High
Source of internal bleeding                  +
Tumor necrosis                               -
Protein S-100                                +
Leu-7                                        +
Glial fibrillary acidic                      -
  protein (GFAP)
Synaptophysin                                -
Neurofilament                                -
Vimentin                                     +


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PAOLA BUENO MERCADO [1], JULIO CESAR OSORIO [2], CARLOS EMIRO TASAMA [3], PAULA C. BERMUDEZ JARAMILLO [4]

[1] qodontologa. Especialista en Periodoncia. Especialista en Gerencia Hospitalaria. Exprofesora de la practica clinica en periodoncia. Institucion Universitaria Colegios de Colombia (UNICOC), sede Santiago de Cali. Correo electronico: dra.paolabueno@gmail.com

[2] Biologo. Master en Ciencias-Biologia. Profesor de Investigacion. Institucion Universitaria Colegios de Colombia (UNICOC), sede Santiago de Cali. Correo electronico: jcosorio@unicoc.edu.co

[3] Odontologo. Especialista en Patologia. Magister en Educacion Superior. Profesor de Patologia Oral y General. Institucion Universitaria Colegios de Colombia (UNICOC), sede Santiago de Cali. Correo electronico: ctasama@unicoc.edu.co

[4] Odontologa. Magister en Administracion de la Salud MBA. Profesora, investigadora de la Pontificia Universidad Javeriana Cali. Correo electronico: paula.bermudez@javerianacali.edu.co

RECIBIDO: FEBRERO 18/2013--ACEPTADO: AGOSTO 16/2016

SUBMITTED: FEBRUARY 18/2013--ACCEPTED: AUGUST 16/2016

Leyenda: Figura 1. A) Imagen donde se presenta la lesion tumoral en zona submucosa del vestibulo derecho detras del carrillo, avulsionada mediante el proceso de diseccion quirurgica. La masa encapsulada se protruye durante la cirugia. B) Imagen donde se presenta el nicho quirurgico de la lesion. C) Imagen de la masa encapsulante globulante que es presentada en mm. D) Vista microscopica a 4X perteneciente al tejido del schwannoma, donde se pueden ver las fibras de la banda de encapsulamiento. E) Vista microscopica a 10X perteneciente al tejido del schwannoma bajo tincion con hematoxilina y eosina, en donde se pueden observar los cuerpos de Verocay. F) Vista microscopica a 10Xperteneciente al tejido del schwannoma bajo tincion con hematoxilina y eosina, en el cual el proceso de sangrado puede ser observado dentro de la masa del tumor.

Leyenda: Figura 2. Vista microscopica a 40Xperteneciente al tejido del schwannoma A) Tincion inmunohistoquimica negativa para el neurofuamento. B) Tincion inmunohistoquimica negativa para la proteina acida fibriiar glial. C) Tincion inmunohistoquimica negativa para sinaptofisina. D) Tincion inmunohistoquimica negativa para Leu-7. E) Tincion inmunohistoquimica positiva para la proteina S-100. F) Tincion inmunohistoquimica positiva para la vimentina.
Tabla 1. Guia para la diferenciacion diagnostica de
schwannoma (modificado desde Buric et al (12))

Marcadores                           Resultado

Encapsulacion                            +
Formacion patologica       Areas Antoni A y Antoni B con
                                cuerpos de Verocay
Diferenciacion celular                 Alta
Foco de sangrado interno                 +
Necrosis tumoral                         -
Proteina S-100                           +
Leu-7                                    +
Proteina Acida Fibrilar                  -
  Glial (GFAP)
Sinaptofisina                            -
Neurofilamento                           -
Vimentina                                +
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Author:Bueno Mercado, Paola; Osorio, Julio Cesar; Emiro Tasama, Carlos; Bermudez Jaramillo, Paula C.
Publication:Revista Facultad de Odontologia
Article Type:Ensayo
Date:Jul 1, 2017
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