Retroperitoneal plexiform neurofibromas: CT findings

CT findings in retroperitoneal plexiform neurofibromas have been described previously only in a few case reports. This study was performed to characterize the CT features in a larger group of patients with this benign neoplasm and to delineate those findings that suggest the presence of concurrent malignant tumors of the nerve sheath.

From a review of CT scans showing retroperitoneal masses in 25 patients with neurofibromatosis type 1, we identified 16 patients whose clinical and CT features suggested the diagnosis of plexiform neurofibromas. The diagnosis was confirmed by biopsy of the mass in three patients. In the remaining 13 patients, the diagnosis was supported by long-term follow-up in eight and by biopsy confirmation of either a neurofibroma or a plexiform neurofibroma elsewhere in the body in the other five patients. Concurrent retroperitoneal malignant tumors of the nerve sheath were confirmed by biopsy in five patients.

CT showed bilateral, remarkably symmetric masses extending along the medial and posterior aspects of the psoas muscles in 15 of the 16 patients. Parapsoas masses tended to be long and cylindrical. In addition to parapsoas masses, eight patients had bilateral, symmetric masses extending along the anterior aspect of the sacrum in a sheetlike fashion. Masses were identified in the region of the celiac axis and the origin of the superior mesenteric artery in four patients. Only one patient had an isolated celiac/superior mesenteric artery mass without associated parapsoas or presacral masses. Retroperitoneal masses were of homogeneous, low attenuation when compared with adjacent muscle on CT images of 14 patients. Two patients had an unusual swirling and serpiginous pattern of increased attenuation superimposed on a low-attenuation background. Asymmetry in size and attenuation was due to malignant nerve sheath tumors in five patients.

Retroperitoneal plexiform neurofibromas have a characteristic appearance on CT scans. They are typically bilateral, symmetric, low-attenuation masses in a parapsoas or presacral location. Asymmetry in size and attenuation of a larger mass suggests the possibility of a malignant tumor of the nerve sheath. Recognition of the CT features of a retroperitoneal plexiform neurofibroma can obviate the expense, pain, and risk of an unnecessary biopsy. Conversely, detection of findings suggestive of malignant tumor can lead to appropriate recommendation of biopsy.