Correspondence

free the patient of the risk of further plexiform change or malignant degeneration of the proximal nerve or nerve roots. O n the other hand, if left it may remain stationary for years, though it does carry some risk of malignancy.

In the presence of neurofibromatosis a discrete tumour of deep nerve may occasionally be a neurilemoma but is more commonly a neurofibroma and quite likely to be a sarcoma. Before radical treatment can be undertaken histological evidence must be at hand. There may be clinical evidence favouring the possibility of malignancy: recent pain or increasing size, referred pain (though this is almost equally common in the benign tumour of recognizable nerve) and especially motor weakness or impaired sensation (which is rarely seen in benign tumours unless confined as by bone). Where the features are strongly suggestive of sarcoma it is wise to perform a superficial biopsy, disturbing the tumour as little as possible. Radical treatment follows confirmation of diagnosis. When the biopsy is inconclusive, and in those cases in whom in the first instance there is no especial evidence of malignancy, the tumour is exposed and its relationship to the nerve defined. The malignant tumour tends to infiltrate along the nerve and later to penetrate the sheaths and extend into the surroundings. Biopsy of discrete neurofibroma of the deep nerves is unreliable since only one part of the tumour may have undergone malignant change.

The great value of a preliminary segmental biopsy lies in identifying those cases of encapsulated neurilemoma which are not typical in their gross appearance and in whom a conservative approach would be justified when affecting an important nerve.

In frank sarcoma of deep nerves the prognosis is extremely grave. (The less common superficial sarcomas appear to be less malignant.) However it is much more likely that a tumour of a deep nerve will be a neurilemoma. a benign tumour, and it IS desirable that surgeons who will only encounter the problem very occasionally should be aware of this and avoid the tragedy of producing major nerve damage needlessly.

G. Heard

University Hospitni of Wales Heuth Park Cardiff’CF4 4 X W U K

I , Heard G. Nerve sheath tumours and van Recklinghausen’s disease of the nervous system. Ann R Co/l Sirry Engl 1963: 31: 229--48.

Kinney JM. Protein-energy malnutrition in surgical patients. In: Hill GL, ed. Nutrition and the Surgicd Patient. Edinburgh: Churchill Livingstone, 1981: 13. Bennegard K, Eden E, Ekman L, Schersten T, Lundholm K. Metabolic response of the whole body and peripheral tissues to enteral nutrition in weight-losing cancer and noncancer patients. Gastroenterology 1983: 85: 92-9. Mullen JL, Buzby GP. Matthews DC, Smale BF, Rosato EF. Reduction of operative morbidity and mortality by combined preoperative and postoperative nutritional support. Arm Surg 1980; 192: 60413. Jeppsson B, Halliday AW, Blumgart LH, Bengmark S. Pre- and postoperative nutrition in liver surgery. In: Bengmark S, Blumgart L, eds. h e r Surgery. Edinburgh: Churchill Livingstone, 1986: 166.

Nerve tumours of the brachial plexus

Sir The recent paper of Sell and Semple (Br J Surg 1987; 74: 73-4) fulfils an important task in reminding surgeons of the problems of tumours recognized to be arising from nerves. Correctly they point out that neurilemomas are not thought to undergo malignant transformation. However, some reference does need to be made to malignant tumours of recognizable nerves with which neurilemoma and neurofibroma may be confused. When, in the absence of von Recklinghausen’s disease, a solitary tumour is found at operation to be arising from nerve, then it is most probably a neurilemoma, and if so can usually beshelled out of the nerve provided the right plane is entered. When there is no ready plane of cleavage, but on the contrary where the nerve is diffusely involved, then the tumour may be malignant, or it may be a diffuse neurofibroma’ ,

A grossly plexiform involvement of deep nerve is usually associated with von Recklinghausen’s neurofibromatosis. In the absence ofclinical or operative findings suspicious of malignancy it is often best left alone. Removal would usually be incomplete and produce palsy; it would not

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