NEUROPATHOLOGY REVIEW SERIES

Diagnostic Pathology of Tumors of Peripheral Nerve

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Neoplasms of the peripheral nervous system represent a heterogenous group with a
wide spectrum of morphological features and biological potential. They range from
benign and curable by complete excision (schwannoma and soft tissue perineurioma)
to benign but potentially aggressive at the local level (plexiform neurofibroma) to the
highly malignant (malignant peripheral nerve sheath tumors [MPNST]). In this review,
we discuss the diagnostic and pathologic features of common peripheral nerve sheath
tumors, particularly those that may be encountered in the intracranial compartment
or in the spine and paraspinal region. The discussion will cover schwannoma, neurofi-
broma, atypical neurofibromatous neoplasms of uncertain biological potential, intra-
neural and soft tissue perineurioma, hybrid nerve sheath tumors, MPNST, and the recently
renamed enigmatic tumor, malignant melanotic nerve sheath tumor, formerly referred to
as melanotic schwannoma. We also discuss the diagnostic relevance of these neoplasms
Sarra M. Belakhoua, MD∗ ‡ to specific genetic and familial syndromes of nerve, including neurofibromatosis 1, neurofi-
Fausto J. Rodriguez, MD ∗§¶ bromatosis 2, and schwannomatosis. In addition, we discuss updates in our understanding
of the molecular alterations that represent key drivers of these neoplasms, including
∗
Department of Pathology, Johns neurofibromatosis type 1 and type 2, SMARCB1, LZTR1, and PRKAR1A loss, as well as the acqui-
Hopkins University School of Medicine,
Baltimore, Maryland, USA; ‡ School of
sition of CDKN2A/B mutations and alterations in the polycomb repressor complex members
Medicine, University of Tunis El Manar, (SUZ12 and EED) in the malignant progression to MPNST. In summary, this review covers
Tunis, Tunisia; § Department of Ophthal- practical aspects of pathologic diagnosis with updates relevant to neurosurgical practice.
mology, Johns Hopkins University School
of Medicine, Baltimore, Maryland, USA; KEY WORDS: Neurofibroma, Schwannoma, MPNST, Neurofibromatosis, Schwannomatosis, Schwann cell, NF1,
¶
Sydney Kimmel Cancer Center, Johns NF2, SMARCB1, LZTR1, PRKAR1A
Hopkins University School of Medicine,
Baltimore, Maryland, USA Neurosurgery 88:443–456, 2021 DOI:10.1093/neuros/nyab021 www.neurosurgery-online.com

Correspondence:
Fausto J. Rodriguez, MD,

T
Johns Hopkins University School of
he peripheral nervous system is composed peripheral nervous system is reflected in the
Medicine, of peripheral nerves and ganglia, which morphological and biological heterogeneity of
Sheikh Zayed Tower, Room M2101, arise from the brain stem or the spinal the tumors that arise or differentiate toward its
1800 Orleans St, cord and course throughout the body to reach its various cell components. Tumors of peripheral
Baltimore, MD 21231, USA.
Email: frodrig4@jhmi.edu various targets. Its function is to provide somatic nerve range from benign to highly malignant.
and autonomic innervation. The peripheral Comprehensive molecular genetic profiling
Received, May 15, 2021. nerves are formed by bundles of axons and are using high resolution platforms is currently
Accepted, September 9, 2021. defined at the microscopic level by myelination transforming the approach to pathologic
Published Online, February 16, 2021.
mediated by Schwann cells. Peripheral nerves are diagnosis of disease and cancer, including
C Congress of Neurological Surgeons
composed of organized specialized tissue forming peripheral nerve sheath tumors (PNSTs).
2021. All rights reserved. 3 layers: the endoneurium, the perineurium, Well-defined morphological criteria still allow
For permissions, please e-mail: and the epineurium (Figure 1). The anatomical for classification in most cases, but global
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distribution and histological complexity of the methylation profiling1 in tumor and next-
generation sequencing platforms in tumor and
blood2,3 may provide additional diagnostic
ABBREVIATIONS: ANNUBP, atypical neurofibro- and prognostic information. Although PNSTs
matous neoplasms of uncertain biological potential;
usually develop sporadically in patients lacking
EBV, epstein barr virus; EMA, epithelial membrane
antigen; GTP, guanosine triphosphate; HPFs, high a familial history or genetic predisposition, they
power fields; MMNST, malignant melanotic nerve are important components of a variety of genetic
sheath tumor; NFP, neurofilament protein; PRC, syndromes and pathologic characterization
polycomb repressive complex constitute important diagnostic criteria with
CNS Spotlight available at cns.org/spotlight.
consequences for clinical follow-up and genetic
counseling. These syndromes mainly include

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FIGURE 1. Microanatomy of peripheral nerve. The peripheral nerve is composed of epineurium surrounding
individual units (fascicles, in light green). The various nerve sheath tumors share phenotypic properties
with the non-neoplastic cell components illustrated, predominantly with Schwann cells. Perineurial cells
form the perineurium surrounding individual fascicles and have phenotypic overlap with the neoplastic cells
of perineurioma. A variety of mesenchymal cells populate the epineurium, and although rare, there is a
wide morphological and biological variation in the group of soft tissue neoplasms that may also involve the
peripheral nerve as a primary site. Note that the phenotypic overlap of neoplasms with non-neoplastic cell
counterparts does not imply that the latter are the cell of origin for the related neoplasms. In experimental
models, cells of origin tend to be stem cell/progenitor cell precursors.

neurofibromatosis type 1 (NF1), neurofibromatosis type 2 (NF2), nuclei. These zones are studded with clumps of cellular aggre-
schwannomatosis, and Carney complex4 (Figure 2). gates, where palisading patterns called Verocay bodies may be
In this review, we focus on the major categories of PNST that encountered, which are almost diagnostic at the histologic level
are likely to be encountered in neurosurgical practice. We focus (Figure 3). Paradoxically, Verocay bodies are frequently absent
on those that develop predominantly intracranially and in spinal in vestibular schwannomas. The Antoni B zones are disorga-
nerve roots (Table). Key histologic and molecular genetic features nized arrangements that are hypocellular and feature a variable
that are useful for diagnosis are particularly emphasized. macrophage infiltrate. The surrounding capsule is formed by
multiple layers of collagen fibers. Other common histologic
SCHWANNOMA findings in schwannomas include hyalinized vessels with perivas-
cular hemosiderin deposition, cystic spaces, and degenerative
Schwannomas are benign nerve sheath tumors composed of atypia (“ancient change”). Malignant transformation in schwan-
neoplastic Schwann cells. They develop at multiple body sites nomas is exquisitely rare but usually takes the form of epithelioid
but intracranially they favor the vestibular branch of the VIII malignant peripheral nerve sheath tumor (MPNST), a round cell
cranial nerve. On imaging, they present as masses of the cerebel- malignancy or angiosarcoma.7,8
lopontine angle (Figure 3). As discussed below, bilateral vestibular On immunohistochemistry, schwannomas are diffusely
schwannomas are diagnostic of NF2.5 Schwannomas may also positive for mature Schwann cell markers, including S100 and
involve other cranial nerves and in rare occasions be entirely intra- SOX10 protein (Figure 3). Collagen IV and reticulin special
parenchymal within the brain.6 Grossly, they are usually solitary, stains are positive around individual cells. Epithelial membrane
and the cut surfaces display a light-tan appearance surrounded antigen (EMA) outlines perineurial cells peripherally but is
by a fibrous capsule. A yellow color is frequent because of lipid negative in neoplastic cells. Neurofilament protein (NFP)
content or lipid-laden macrophages. Variably sized cysts and highlights rare entrapped axons, but these are usually encoun-
hemorrhagic changes may be present. Histologically, in their tered in the periphery. Neoplastic cells in schwannoma also
classic form, schwannomas contain compact patterns (Antoni express vascular endothelial growth factor and antiangiogenic
A), alternating with loose patterns (Antoni B). The Antoni therapy with bevacizumab is often used for progressive vestibular
A zones are characterized by increased cellularity and spindle schwannomas in NF2 patients.9

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FIGURE 2. Summary of molecular genetic pathogenesis of nerve sheath tumors. Tumor syndromes of nerve usually develop secondary to
germline mutations in several key tumor suppressor genes: NF1, NF2, SMARCB1, or LZTR1 (schwannomatosis) and PRKAR1A (MMNST,
in Carney complex). In the context of NF1, mutations associated with tumor progression include CDKN2A (p16) in atypical neurofi-
broma/ANNUBP and alterations in members of the PRC 2 (SUZ12 or EED).

variant particularly prone to be mistaken for malignancy.10

TABLE. Peripheral Nerve Tumors Relevant to Intracranial and Important typical features that help in avoiding this pitfall
Paraspinal Locations
include the presence of a continuous peritumoral capsule, a rich
Schwannoma macrophagic infiltrate, and the diffuse expression of Schwann cell
Neurofibroma markers (S100 and SOX10)11 and, in contrast to most MPNST,
Perineurioma retain H3K27 trimethylation (or H3K27me3).12 A diffuse
Hybrid nerve sheath tumor lymphocytic cuff under the capsule may be present, occasionally
Schwannoma/perineurioma containing even well-formed lymphoid follicles. It must be
Neurofibroma/schwannoma
highlighted that malignant transformation of schwannoma into
Neurofibroma/perineurioma
ANNUBP MPNST is exquisitely rare and takes the form of a morpho-
MMNST logical change (eg, epithelioid, small cell, and angiosarcoma).
MPNST Therefore, once the neoplasm is identified as a schwannoma,
Miscellaneous a simple increase in cellularity and/or mitotic activity, in the
Lipoma of VIII cranial nerve context of the features listed above, should not suggest malignant
Glomus tumor of nerve change. Cellular schwannomas may be encountered in a variety
Sarcomas
Primary central nervous system tumors presenting in nerve
of body sites, including paravertebral areas. Involvement of
root (myxopapillary ependymoma, hemangioblastoma) the intracranial compartment is rare, but we have recently
Lymphoma reported our experience with cellular schwannomas in this
Metastatic carcinoma anatomic location.13 The intracranial cellular schwannomas
mostly developed in association with cranial nerve VIII or V. Local
recurrences developed in a subset of patients, but no metastases
Cellular Schwannoma or deaths were documented.
This type of schwannoma is composed almost entirely of
Antoni A patterns lacking Verocay bodies (Figure 3). Although Plexiform Schwannoma
benign, it often displays local aggressiveness (eg, bone erosion). This schwannoma variant has a predilection for superficial
Dense cellularity and mitotic activity make this schwannoma sites, growing mostly in cutaneous or subcutaneous tissues, but

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FIGURE 3. Schwannoma. A, The vestibular branch of cranial nerve VIII is the main intracranial site of origin of schwannoma. B, Antoni A areas are compact
and may contain characteristic palisades known as Verocay bodies. C, Antoni B patterns are composed of loose tissue with variable histiocytic infiltrates. Cellular
schwannoma is a specific variant that is particularly prone to be mistaken for malignancy. D, Mitotic figures may be encountered (arrow). E, Plexiform neurofibromas
are composed of multinodular aggregates of predominantly Antoni A tissue. F, Epithelioid schwannomas are rare, composed of plump cells with prominent nuclei and
nucleoli. Strong expression of mature Schwann cell markers is typical of all schwannomas, including S100 G and SOX10 H. I, Patchy loss or a “mosaic” pattern of
INI1/SMARCB1 immunostaining is typical of syndrome-associated (NF2 and schwannomatosis) schwannomas.

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may also develop in major peripheral nerves and plexi.14 Their Schwannomas developing in the context of SMARCB1-
distinctive feature is a plexiform or nodular growth pattern associated schwannomatosis represent an illustrative model on
(Figure 3). A capsule is usually absent. Plexiform schwannomas the cooperation of tumor suppressor loss in human neoplasia. In
may be associated with local recurrences, but malignant transfor- this context, the sequence involves a “four-hit” event in which

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mation is exceedingly rare. Most occur sporadically, but a small sequential inactivation of both copies of SMARCB1 and NF2
subset (∼5%) develops in genetic syndromes (NF2 or schwanno- occur in the individual tumors.24 This event is probably facili-
matosis). Other rare schwannoma variants include epithelioid,15 tated by the localization of both genes in the chromosome 22q
neuroblastoma-like,16 and reticular.17 arm.

NEUROFIBROMA
Molecular Genetics Neurofibroma is another benign tumor composed of neoplastic
One important aspect of the diagnostic pathology of schwan- Schwann cells, but unlike schwannoma, it also contains additional
nomas is that when multiple, they are an important component non-neoplastic components, including fibroblasts, mast cells,
of NF2 and schwannomatosis, and they represent important perineurial-like cells, and residual axons. Sporadic cutaneous
diagnostic criteria for these syndromes.5,18 The hallmark of NF2 neurofibroma is the most common subtype. However, multiple
is the presence of bilateral vestibular schwannomas. Additionally, neurofibromas are a key feature of NF1, in which there may
these patients develop other tumor types, particularly menin- be involvement of multiple cutaneous sites, peripheral nerves,
giomas and ependymomas. Approximately half of NF2 patients and spinal roots (Figure 4). Gross examination of neurofibromas
have a familial history. Schwannomatosis is sporadic in most involving peripheral nerves demonstrate fusiform enlargement of
instances (75%-85%), with approximately 15% to 25% being the parent nerve fascicle. Cut surfaces are variably yellow and
inherited. These patients almost exclusively develop schwan- translucent depending on the extent of myxoid stroma. The histo-
nomas, but in rare instances, they also develop meningiomas.19,20 logic features of neurofibroma are similar independent of specific
Although schwannomas developing in genetic syndromes and subtype, and include a predominance of Schwann cells with thin
sporadically are indistinguishable in most instances, features wavy nuclei embedded in a myxoid matrix with variable amounts
overrepresented in syndrome-associated cases, include whorling of collagen arranged in a haphazard fashion (Figure 4). Other cell
patterns, myxoid change, nerve edema/infiltration, and a mosaic components that are present in variable amounts include mast
pattern of SMARCB1/INI1 loss by immunohistochemistry.21 cells, lymphocytes, fibroblasts, and EMA-positive perineurial
The exception is NF2-associated vestibular schwannomas, where cells that all contribute to the tumor microenvironment. When
SMARCB1/INI1 positivity remains intact.22 involving nerve roots in the spine, neurofibromas may entrap
A loss of function mutation in the NF2 gene is the most ganglion cells through infiltration of sensory ganglia. In contrast
common genetic feature of schwannomas in sporadic and familial to schwannoma, entrapped axons are frequent in the substance of
forms. The NF2 gene is located at the 22q12.2 chromosomal the neoplasm because it is more infiltrative and, therefore, more
locus and encodes Merlin. Merlin is known to interact with challenging to resect without affecting the parent fascicle. The
cell junctional complexes and plays a role in contact-dependent immunophenotype is characterized by uniform S100 and SOX10
inhibition. It has multiple additional cellular functions, including expression in the neoplastic Schwann cells, whereas EMA labels
activation of oncogenic signaling pathways. Recent genetic perineurial cells and CD34 stromal cells. NFP typically outlines
profiling studies of schwannomas have also found recurrent numerous entrapped axons.
mutations in ARID1A, ARID1B, and DDR1 as well as a
novel SH3PXD2A-HTRA1 fusion in subsets of schwannoma.23 Diffuse Neurofibroma
Germline NF2 mutations are diagnostic of NF2 syndrome. Diffuse neurofibromas typically form plaque-like enlargements
The germline alterations responsible for schwannomatosis are of the skin and underlying subcutis. Approximately 10% of
unknown in most instances, but SMARCB1 (Chr 22q11.23 cases develop in NF1 patients. They lack a capsule and are
locus)24 or LZTR1 (Chr 22q11.21 locus)25 germline mutations poorly demarcated. These tumors may entrap adnexal and under-
occur in subsets. SMARCB1 is a component of the switch/sucrose lying soft tissue structures and frequently contain pseudomeiss-
nonfermentable (SWI/SNF) chromatin remodeling multiunit nerian corpuscles (spherical arrangements of S100-positive cell
complexes that are Adenosine triphosphate dependent and processes) (Figure 4). Transformation into MPNST in diffuse
mediate changes in chromatin architecture and gene expression. neurofibromas is rare, compared to plexiform and intraneural
LZTR1 encodes the leucine zipper-like transcription regulator 1, neurofibromas, but well documented.27
a member of the BTB-kelch superfamily. LZTR1 is a Golgi
complex protein and interacts with the CUL3-based ubiquitin Plexiform Neurofibroma
ligase complex. In addition to schwannomatosis, this gene has also Plexiform neurofibroma is a neurofibroma variant defined
been found to be altered in Noonan syndrome and glioblastoma, at the architectural level as involving multiple peripheral nerve
and may participate in the regulation of RAS/MAPK signaling.26 fascicles, and therefore, it is frequently associated with larger

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FIGURE 4. A, Neurofibroma. Multiple neurofibromas involving cervical nerve roots in a patient with NF1. Neurofibromas are composed of wavy nuclei, somewhat
smaller than those of schwannoma, with associated delicate collagen B and variable myxoid stroma C. D, Plexiform neurofibromas are typical NF1-associated tumors
and form multiple tortuous nodules, reflecting multifasicular involvement best appreciated at low power. E, Diffuse neurofibromas may be infiltrating, frequently
entrapping adnexal structures (arrow) and containing characteristic pseudomeissnerian corpuscles (asterisks). Massive soft tissue neurofibromas are typically enormous
neoplasms, developing exclusively in NF1 patients. F, A cellular, but benign, round cell component is frequent (arrows). G, Neurofibromas frequently involve the dorsal
roots in NF1 patients. Infiltration of dorsal root ganglia should not be mistaken for ganglion cell differentiation. The designation ANNUBP is usually reserved for
the identification of some worrisome histologic features in small biopsies from NF1 patients but not meeting criteria for malignancy. H, This example demonstrates
hypercellularity and nuclear enlargement. I, NFP immunostain is useful in highlighting underlying axons in the substance of neurofibromas (arrow).

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nerves and plexi. This subtype frequently affects (20%-50%) ATYPICAL NEUROFIBROMATOUS NEOPLASM
patients with NF1,28 representing important clinical criteria for OF UNCERTAIN BIOLOGICAL POTENTIAL
the diagnosis, and in these patients, it is an important precursor
for MPNST.29 In fact, plexiform neurofibromas involving large An atypical neurofibroma category has been controversial given

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nerves and body regions are almost limited to patients satis- the nosologic confusion that it creates and applied in various ways
fying clinical criteria for NF1. The rare cases lacking other to denote a range of changes ranging from totally benign and clini-
clinical criteria for NF1 are usually classified as localized or cally inconsequential (eg, degenerative atypia or “ancient change”)
“segmental” NF1. Malignant degeneration of plexiform neurofi- to low-grade malignant change. Clear-cut diagnostic criteria for
bromas occurs in approximately 5% of cases. In plexiform these important changes in the management of neurofibromas,
neurofibroma, the proliferation of Schwann cells involves particularly in the context of NF1, are lacking. A recent published
multiple fascicles, englobing long nerve segments (Figure 4). consensus42 proposed the designation of atypical neurofibromatous
Their distinctive feature is a multinodular enlargement, giving neoplasms of uncertain biological potential (ANNUBP) for a group
them the appearance of “bag of worms” or “string of onions.” of tumors with some worrisome histologic features, but not clearly
The histologic features are similar to neurofibromas occurring deserving a diagnosis of malignancy (Figure 4). Criteria for the
at other sites; therefore, the imaging, gross appearance, and low designation of ANNUBP include neurofibromas with at least 2
power histologic features are essential for diagnosis. Plexiform and of the following 4 features: histologic atypia, loss of the typical
diffuse components can co-exist in individual tumors. neurofibroma architecture, hypercellularity, and increased mitotic
activity (>1/50 but <3 mitotic figures per 10 High power fields
(HPFs) or <1.5 mitoses/mm2 ). This diagnosis should prompt
additional evaluation (eg, tissue sampling) and close clinical
Massive Soft Tissue Neurofibroma follow-up. The sequence of molecular alterations responsible for
This rare neurofibroma variant occurs exclusively in NF1 malignant change in NF1-associated tumors is also beginning
patients. These tumors are remarkable for their often-colossal to be characterized, with premalignant change in neurofibroma
size (which may span an entire limb) and the exquisite infil- demonstrating NF1 inactivation, a low mutation burden, and
tration of local soft tissues, including skeletal muscle and even CDKN2A/B loss.43
bone. They are characterized by slow progression, often beginning
in childhood. They arise in subcutaneous tissue and may be
covered by hyperpigmented skin.30 Histologically, the tumors PERINEURIOMA
are characterized by extensive infiltration of underlying soft
tissues, including skeletal muscle. Pseudomeisnerian corpuscles Perineuriomas are benign tumors composed of neoplastic
and cellular areas are frequently present (Figure 4). perineurial cells. Two types of perineuriomas can be distin-
guished: intraneural and soft tissue perineuriomas, depending
on their association to a major nerve or lack thereof, respec-
tively. Historically, most cases of intraneural perineurioma were
Molecular Genetics interpreted as localized hypertrophic neuropathy, which suggested
The defining genetic event for all neurofibroma subtypes is a reactive process involving nerve and overlapping with a
inactivation of the NF1 gene (chromosome locus 17q11.2), variety of reactive neuropathies. Immunohistochemical, ultra-
encoding neurofibromin, a GTPase-activating protein that is structural, and molecular genetic studies have clarified intra-
expressed in many cell types in the central and peripheral nervous neural perineurioma to be a neoplastic proliferation of perineurial
system. It regulates RAS signaling by mediating the conversion cells rather than a reactive process. Macroscopically, intraneural
of Guanosine triphosphate (GTP)-bound RAS (active) to perineuromas appear as segmental enlargements of nerve. Histo-
its Guanosine diphosphate (GDP)-bound state (inactive).31-33 logic examination demonstrates multiple concentric cytoplasmic
GTP-bound RAS results in activation of MAPK, extracellular layers forming whorls of variable size surrounding central axons
signal-regulated kinase 1 and 2 (ERK1 and ERK2), and increased (“pseudoonion bulbs”)44 (Figure 5). Despite the increased cellu-
PI3K-mTOR signaling. The end result is increased transcription larity, mitotic activity is low to absent. Immunohistochemical
of target genes, cell growth, survival, and proliferation.34-39 NF1 features include membranous staining with EMA, GLUT-1,
inactivation also results in altered cAMP levels through regulation and Claudin-1 positivity, whereas S100 is negative, which
of adenylate cyclase, which affects non-neoplastic (eg, cognitive) differentiates neoplastic cells from underlying resident Schwann
as well as neoplastic manifestations of the disease. NF1 gene cells. Residual non-neoplastic Schwann cells and central axons
inactivation is the sole recurring abnormality in neurofibromas,40 in the pseudo-onion bulbs are identifiable with S100 and
with additional alterations acquired as part of atypical and NFP immunoreactivity, respectively. At the molecular genetic
malignant progression. Of therapeutic relevance, MEK inhibitors level, most intraneural perineuriomas have TRAF7 alterations,
(eg, selumetinib) are currently feasible and may provide thera- and a minority has NF2/chromosome 22 alterations.45 Soft
peutic benefit for some patients with plexiform neurofibroma.41 tissue perineuriomas share the same immunophenotype with

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FIGURE 5. Perineurioma. A, Intraneural perineurioma is a benign nerve sheath tumor characterized by the formation of
pseudo-onion bulbs composed of neoplastic perineurial cells best appreciated on cross sections. B, Longitudinal sections may
appear hypercellular, but the neoplasms are uniformly benign. Soft tissue perineuriomas form solid masses typically unassociated
with major nerves. C, A storiform pattern is typical. EMA expression is typical of all perineurioma subtypes D, although it may
be weak or focal.

intraneural perineuriomas, but they form well-circumscribed schwannoma/perineurioma, which more commonly occurs in
masses unassociated with major nerves.46 Molecular genetic alter- the extremities in the form of subcutaneous/dermal masses.
ations reported include deletions involving the NF1 or NF2 locus The neoplastic cells show a schwannian morphology, but the
in a mutually exclusive fashion.47 A few cases of intracranial overall architecture resembles that of soft tissue perineuriomas.
perineuriomas have been reported, related to dura48 or inside the On immunohistochemistry, all tumors are positive for S100 and
ventricles.49 EMA.50
Another hybrid combination is neurofibroma/schwannoma,
which may involve larger peripheral nerves, and appears to be
HYBRID NERVE SHEATH TUMORS overrepresented in patients with genetic syndromes (schwanno-
It has been increasingly recognized that a subset of benign matosis, NF1, and NF2).51 Monosomy 22 is frequent in these
nerve sheath tumors remains difficult to classify and place in tumors.52 Recently, recurrent ERBB2 mutations were identified
one category because they have features of more than one in a subset of hybrid neurofibroma/schwannomas developing in
recognized subtype (Figure 6). The most frequent variety is the context of schwannomatosis.53

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FIGURE 6. Hybrid nerve sheath tumors. It is increasingly recognized that a subset of benign nerve sheath tumors may contain components of more than 1 tumor type.
A, Hybrid schwannoma-perineurioma is the most frequent hybrid nerve sheath tumor. B, Schwannoma-neurofibroma usually takes the form of schwannian nodules
(asterisk) in a plexiform neurofibroma background. Hybrid neurofibroma-perineurioma with neurofibroma C and perineurioma D components highlighted by S100
E and EMA immunostains F, respectively.

The least common variation is neurofibroma/perineurioma, On immunohistochemistry, MMNSTs are positive for both
the recognition of which is often done through immuno- Schwann cell and melanocytic markers, including S100, SOX10,
histochemistry, which highlights EMA-positive areas within a melan-A, and HMB45. Collagen IV tends to outline tumor
plexiform neurofibroma.54 lobules. Molecular genetic studies of these tumors (sporadic and
syndrome associated) have demonstrated frequent loss of function
MALIGNANT MELANOTIC NERVE SHEATH mutations in PRKAR1A57 located on the chromosome locus
17p22-24. There is an additional, less-well-characterized locus
TUMOR on 2p16 that is responsible for a minority of Carney complex
Malignant melanotic nerve sheath tumors (MMNSTs) are cases. Loss of the protein product of PRKAR1A can be detected
PNSTs composed of neoplastic Schwann cells with melanocytic through immunohistochemistry, which has diagnostic value. The
differentiation. They present as solitary outgrowths bulging mutations take the form of single base pair substitutions, deletions
from spinal nerve roots and autonomic ganglia, and a and insertions, or rearrangements.58 PRKAR1A is one of the main
subset is associated with Carney complex. On gross exami- regulatory subunits that form the Protein kinase A holoenzyme,
nation, MMNSTs form well-circumscribed, heavily pigmented and loss results in an increase in cAMP signaling.
tumors, with central necrosis and hemorrhage variably present. The clinical course of MMNSTs historically has been hard
Histopathology shows a mix of spindled and epithelioid to predict, and the tumors were formerly designated melanotic
neoplastic cells arranged in fascicular patterns (Figure 7). Each schwannoma, given the usual well-developed mature Schwann
neoplastic cell contains multiple intracytoplasmic brown inclu- cell phenotype. However, Torres-Mora et al56 reported high recur-
sions corresponding to melanosomes. The nuclei are round rence and metastatic rates in these tumors, justifying their reinter-
and uniform with small nucleoli. A subset contains psammoma pretation as malignant neoplasms.
bodies, half of which have been associated with Carney
complex in historic series,55 but contemporary series have MALIGNANT PERIPHERAL NERVE SHEATH
not found clinical differences between psammomatous and TUMORS
nonpsammomatous subtypes.56 This syndrome is also charac-
terized by endocrine hyperactivity, patchy skin hyperpigmen- MPNST are usually high-grade malignant spindle cell
tation, and a variety of tumor types, including cardiac myxomas. neoplasms arising in association with nerves, in pre-existing

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FIGURE 7. MMNSTs. A, MMNSTs are distinctive nerve sheath neoplasms with conspicuous pigmentation that frequently involve nerve roots, ganglia (arrows
indicating entrapped ganglion cells) and autonomic nerves. The tumors may be composed of epithelioid cells with macronucloli forming nests B or spindle cells C. D,
Areas of decreased pigmentation may be encountered. E, NFP helps in outlining the axons in the presumed parent nerve. F, Collagen IV may be useful in outlining
basal lamina deposition, a feature of Schwann cells.

Schwann cell neoplasms (most frequently a plexiform neurofi- As mentioned above, most MPNST are high grade and easily
broma) and/or demonstrating a variable Schwann cell phenotype recognized as malignant at the histologic level. The diagnosis
(Figure 8). They are aggressive tumors characterized by a tendency of low grade MPNST is usually made in the context of
to invade surrounding soft tissue and potential for hematogenous NF1-associated neurofibromas with areas of ANNUBP transi-
metastatic spread. MPNST can develop in association with NF1, tioning to low grade MPNST. Although difficult to define,
after radiation exposure, or arise sporadically. Macroscopically, proposed criteria include the presence of changes typical
MPNST present as adherent, exophytic masses. They have a large of ANNUBP but, in addition, greater increases in mitotic
variability in terms of size and consistency, ranging from micro- activity (1.5-4.5 mitoses/mm2 ) or 3 to 9 mitotic figures
scopic change in a pre-existing neoplasm to massive tumors. Areas per 10 HPFs and no necrosis.60 High-grade MPNST are
of necrosis and hemorrhage are common. Microscopically, they characterized by increased mitotic activity, and necrosis is
are usually cellular neoplasms composed of spindle-shaped cells frequent.
with tapered nuclei. They frequently have alternating hyper- and MPNST typically develop in association with larger nerves and
hypocellular areas, which impart a marbled appearance at low plexiform neurofibromas. Rarely they may develop in association
power. Brisk mitotic activity and necrosis are frequent. Perivas- with cranial nerves and/or in the intracranial compartment.61 In
cular aggregates with herniation inside the vascular lumen are a a series of 17 cases, the vestibular nerves were most commonly
characteristic feature. A small subset of MPNST is considered involved, and the tumors were aggressive as those occurring in
low grade, a designation usually applicable to areas of malignant other sites. Careful consideration must be given to exclusion of
change within plexiform neurofibromas in NF1. desmoplastic/spindle cell melanoma, a more common diagnosis
Immunohistochemical stains demonstrate variable S100 in head and neck sites.
and/or SOX10 expression, which is decreased in comparison The morphological spectrum of MPNST is remarkable.
with schwannomas, and maybe altogether negative.11 MPNST Heterologous differentiation may present with a variety
also demonstrate loss of neurofibromin expression and H3K27 of morphologies, including cartilage, bone, skeletal, and
trimethylation. The latter is a key epigenetic marker that is lost smooth muscle. Glandular differentiation is a rare but
in MPNST and has relatively high specificity for the diagnosis.12 well documented phenomenon. Other MPNST variants
However, close mimickers such as melanoma may also demon- include epithelioid MPNST and MPNST with perineurial
strate loss.59 differentiation.

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FIGURE 8. MPNSTs. MPNST are usually high-grade neoplasms that may arise in a neurofibroma precursor (asterisks) A and are characterized by hypercellu-
larity/nuclear atypia B and frequent necrosis C. D, Epithelioid MPNST is a distinctive subset characterized by neoplastic cells with large nuclei with macronucleoli.
MPNST developing in a pre-existing neurofibroma (asterisks) E and displaying low-grade histology, including lesser cell density and rare mitotic figures (arrow) F.
MPNSTs typically have decreased expression of mature Schwann cell markers, including S100 G and SOX10 H, and in fact may be completely negative. Loss of
H3K27 trimethylation (H3K27me3) is a relatively specific feature. I, Retained positivity in underlying endothelial cells is a useful internal positive control (arrows).

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BELAKHOUA AND RODRIGUEZ

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FIGURE 9. Miscellaneous tumors of peripheral nerve. A variety of soft tissue neoplasms may develop in association with a major nerve or nerve root. A, Lipoma of
cranial nerve VIII with associated entrapped ganglion cells (arrow). Synovial sarcoma is a malignant difficult mimic of nerve sheath tumors when arising primarily in
nerve. B, The distinction may require molecular testing. C, Smooth muscle tumors may also involve peripheral nerve occasionally. D, This example developed in an
immunosuppressed patient and was EBV associated (in Situ hybridization study for EBV encoded ribonucleic acid). Diffuse large B-cell lymphoma may present as a
peripheral nerve infiltrate overriding axons E, and is typically outlined by CD20 immunostain F.

Molecular Genetics Myxopapillary ependymoma, hemangioblastoma, and

In MPNST germline or acquired NF1, inactivation is paraganglioma are usually considered tumors of the central
considered an important initiating event, which is followed by nervous system, but they can present as purely involving the spinal
a cascade of other mutations that contribute to the malignant nerve roots. A variety of sarcomas may involve the paraspinal
phenotype. region, nerve roots, and major nerves and are important tumors
CDKN2A inactivation and somatic mutations in members of in the differential diagnosis of MPNST. Leiomyosarcoma may
the polycomb repressive complex (PRC) SUZ12 and/or EED are have morphological overlap with MPNST and may also express
additional important events.62,63 The mutations in PRC compo- S100. However, immunohistochemical markers of smooth
nents lead to loss of H3K27 trimethylation, which is more typical muscle are consistently present, such as smooth muscle actin and
of high-grade tumors. desmin. A group of smooth muscle tumors that may also involve
the intracranial compartment and spinal nerve roots in immuno-
suppressed patients are the Epstein Barr Virus (EBV)-related
MISCELLANEOUS smooth muscle tumors (Figure 9). Monophasic synovial sarcoma
is a more troublesome mimic of MPNST and may present as a
A variety of benign and malignant neoplasms may involve
purely intraneural mass64 (Figure 9). Cytokeratin and EMA are
peripheral nerves, both intracranially and at spinal/perispinal
typically positive, but they may also express S100 and SOX10.
sites. They vary from rare (lipoma) to relatively more frequent
Neurofibromin and H3K27 trimethylation immunoreactivity
(metastatic carcinoma/melanoma).
are usually retained.12,65-68 The identification of SSX1/SSX2
Lipoma of the 8th cranial nerve is a unique benign lesion
gene fusions are diagnostic.69
that differs from lipomas arising at other anatomic locations.
Melanoma, particularly the desmoplastic variant, may be
Magnetic resonance imaging studies are excellent at preoperative
difficult to distinguish from nerve sheath tumors, and it may
diagnosis given the fatty content, which results in hypersensi-
be a mimic of both neurofibroma and MPNST. Prominent
tivity on postcontrast T1-weighted images, disappearing on fat
neural infiltration (“neurotropic melanoma”) is a well-described
suppression. These lesions are composed predominantly of fat
phenomenon, and may in fact be more frequent in head and
(Figure 9), but other mesenchymal components may be encoun-
neck sites than MPNST. Lymphoma, usually the diffuse large
tered such as smooth or skeletal muscle.

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 PERIPHERAL NERVE TUMORS

B-cell type, can present with prominent peripheral nerve or nerve 10. Woodruff JM, Godwin TA, Erlandson RA, Susin M, Martini N. Cellular
root infiltration (Figure 9). Carcinoma from a primary site may schwannoma: a variety of schwannoma sometimes mistaken for a malignant tumor.
Am J Surg Pathol. 1981;5(8):733-744.
also involve cranial or spinal nerves by direct spread from head 11. Pekmezci M, Reuss DE, Hirbe AC, et al. Morphologic and immunohistochemical
and neck sites (eg, squamous cell carcinoma and adenoid cystic features of malignant peripheral nerve sheath tumors and cellular schwannomas.

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carcinoma) or pelvis (eg, prostatic adenocarcinoma) all the way Mod Pathol. 2015;28(2):187-200.
12. Schaefer IM, Fletcher CD, Hornick JL. Loss of H3K27 trimethylation distin-
up to their point of origin, in addition to involving nerve as guishes malignant peripheral nerve sheath tumors from histologic mimics. Mod
metastatic deposits. Pathol. 2016;29(1):4-13.
13. D’Almeida Costa F, Dias TM, Lombardo KA, et al. Intracranial cellular schwan-
nomas: a clinicopathological study of 20 cases. Histopathology. 2020;76(2):275-
CONCLUSION 282.
14. Hebert-Blouin MN, Amrami KK, Scheithauer BW, Spinner RJ. Multin-
The spectrum of neoplasms that may involve the peripheral odular/plexiform (multifascicular) schwannomas of major peripheral nerves:
nervous system is wide, but most primary tumors have a Schwann an underrecognized part of the spectrum of schwannomas. J Neurosurg.
2010;112(2):372-382.
cell phenotype, at least in part. They range from the most benign 15. Hart J, Gardner JM, Edgar M, Weiss SW. Epithelioid schwannomas: an analysis
to the most malignant tumors encountered in surgical pathology. of 58 cases including atypical variants. Am J Surg Pathol. 2016;40(5):704-
They also illustrate the value of diagnostic precision in their 713.
pathologic evaluation, even when benign, given their solid place 16. Goldblum JR, Beals TF, Weiss SW. Neuroblastoma-like neurilemoma. Am J Surg
Pathol. 1994;18(3):266-273.
in the diagnostic criteria of importance to the management of 17. Liegl B, Bennett MW, Fletcher CD. Microcystic/reticular schwannoma: a distinct
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Funding 18. Evans DG, King AT, Bowers NL, et al. Identifying the deficiencies of current
diagnostic criteria for neurofibromatosis 2 using databases of 2777 individuals with
This work was supported in part by NIH grant P30 CA006973 to the Sidney molecular testing. Genet Med. 2019;21(7):1525-1533.
Kimmel Comprehensive Cancer Center (PI: W. Nelson). 19. Melean G, Velasco A, Hernandez-Imaz E, et al. RNA-based analysis of two
SMARCB1 mutations associated with familial schwannomatosis with menin-
Disclosures giomas. Neurogenetics. 2012;13(3):267-274.
20. Bacci C, Sestini R, Provenzano A, et al. Schwannomatosis associated with
The authors have no personal, financial, or institutional interest in any of the
multiple meningiomas due to a familial SMARCB1 mutation. Neurogenetics.
drugs, materials, or devices described in this article. 2010;11(1):73-80.
21. Patil S, Perry A, Maccollin M, et al. Immunohistochemical analysis supports a
role for INI1/SMARCB1 in hereditary forms of schwannomas, but not in solitary,
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