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Wednesday 27 October 2004

nerve sheath myxoma. Ent.1969

PO eMedicine

Digital cases

- JRC:10739 : Cutaneous neurothekeoma.
- JRC:14664 : Soft tissue, wrist: Neurothekeoma/ Nerve sheath myxoma.
- Neurothekeoma by Ed Euthman.


- neurothekeoma

- neurothekeoma: predominantly myxoid with areas showing a more cellular component and fibrotic stroma

- cellular neurothekeoma


- more often affects females and the head and neck region
- multilobulated or micronodular tumor
- spindled cells / fusiform cells and epithelioid cells
- Nonspecific immunophenotype (ie, uncertain histogenesis): positive for CD63, NSE (89%) and sometimes at least focally for SMA (34 - 60%)
- Negative for S100 and GFAP
- Consistently positive for CD10 (Mod Pathol 2014;27:701)


Neurothekeomas are generally seen to arise in the first 3 decades of life, with a female preponderance. In their study of 178 tumors, Fetsch and coworkers reported patient ages ranging from 20 months to 85 years, with a mean age of 21 years.

The male-to-female ratio was approximately 1:2.

In a study of 133 cases of cellular neurothekeoma, Hornick and Fletcher reported patient ages ranging from 1 to 65 years, with a mean age of 25 years. The male-to-female ratio was 1:1.8.


Neurothekeomas most commonly occur on the head and neck. Specifically, the nose and scalp are the most frequent sites of involvement. These regions are followed by the orbital region, cheeks, and chin.

The upper and lower extremities and the trunk are other commonly reported sites of involvement. Cases of neurothekeomas occurring in the oral mucosa, paranasal sinuses, and eyelids have also been reported.

History - Nosology

Neurothekeoma is a benign, predominantly cutaneous neoplasm that was initially described by Harkin and Reed in 1969 by the name nerve sheath myxoma.In 1980, Gallager and Helwig termed the lesion neurothekeoma (Greek: theke, sheath) to connote both the histologic nested appearance and the purported nerve sheath differentiation.

To date, there remains inconsistency in the literature regarding whether "nerve sheath myxoma" should be included in the morphologic spectrum of "neurothekeoma".

Clinical synopsis

On cutaneous examination, neurothekeomas appear as asymptomatic to mildly tender, flesh-colored solitary nodules. An associated component of overlying erythema may be present. The nodules are most commonly less than 2 cm in diameter.

Neurothekeomas may be mistaken clinically for epidermal inclusion cysts, intradermal nevi, lipomas, pilomatrixomas, or dermatofibromas.


Based on the amount of myxoid matrix, neurothekeoma is histologically divided into myxoid, intermediate, and cellular types.

- myxoid neurothekeoma
- intermediate neurothekeoma
- cellular neurothekeoma

- myxoid neurothekeoma

  • The myxoid neurothekeoma displays a lobulated, nonencapsulated but well-circumscribed proliferation of spindled and epithelioid cells embedded within a myxoid stroma.
  • The myxoid subtype of neurothekeoma is characterized by a lobulated, nonencapsulated but well-circumscribed proliferation of spindled and epithelioid cells in varying proportions.
  • The cells are embedded within a myxoid stroma. Nests are separated by varying amounts of collagen.
  • Due to the large amount of myxoid stroma separating the cells, the tumor cells are said to display a random growth pattern.
  • The histologic features of myxoid neurothekeoma are distinguishing enough that its diagnosis is usually not problematic.
  • The myxoid neurothekeoma displays a lobulated, nonencapsulated but well-circumscribed proliferation of spindled and epithelioid cells embedded within a myxoid stroma.

- Cellular subtype

  • image:
  • The cellular subtype is a poorly circumscribed tumor involving the superficial dermis with possible extension into the superficial subcutis.
  • Infiltration into fat and entrapment of skeletal muscle can be seen.
  • The tumor consists of nests and fascicles of epithelioid cells with vesicular nuclei containing scant myxoid stroma.
  • Due to the fact that the myxoid element determines the size of tumor nodules, the nodules of cellular neurothekeoma are smaller than those of the myxoid subtype.
  • Although the myxoid variant of neurothekeoma is hypocellular, the cellular subtype is hypercellular.
  • Sclerotic collagen is seen more markedly in cellular than myxoid tumors.
  • Osteoclastic giant cells are seen in a minority of cases.
  • Perineural and vascular invasion may rarely be seen in cellular neurothekeoma.
  • Cellular neurothekeoma can be histologically mistaken for melanoma and is, therefore, important to recognize.
  • Also included in the histologic differential diagnosis are Spitz nevi, smooth muscle tumors, fibrohistiocytic tumors, and carcinomas.

- Desmoplastic and atypical variants of cellular neurothekeoma

  • In a study of 133 cellular neurothekeomas, 74 cases (56%) demonstrated at least one atypical feature.
  • Mitotic activity may be present but is usually low, with a mean of 3 per 10 high power fields (HPF) reported in one study.

- Intermediate neurothekeoma

  • Tumors with features of both cellular and myxoid variants are termed intermediate type.
  • In contrast to the random growth pattern seen in myxoid neurothekeoma, cellular and intermediate variants demonstrate a whorled growth pattern. See the images below.
  • The intermediate-type neurothekeoma demonstrates features of both cellular and myxoid variants.


It is generally agreed that the myxoid variant of neurothekeoma is of neural origin. The cellular variant, however, is of questionable origin, as it lacks both consistent neural immunoreactivity and ultrastructural evidence of neural differentiation.

Limited ultrastructural studies have revealed few specific features in neurothekeoma. The myxoid variant is assumed to be schwannian based on ultrastructural and immunohistochemical studies.

Debate remains as to the etiology of cellular neurothekeoma. Some authors argue the fact that cellular neurothekeomas show myxoid areas similar to classic myxoid neurothekeoma means they must have similar neural differentiation.

Other authors have theorized that cellular neurothekeoma may have myofibroblastic or smooth muscle differentiation. It has also been proposed that cellular neurothekeoma represents an epithelioid variant of dermatofibroma.


- S100

  • The myxoid neurothekeoma subtype demonstrates consistent diffuse S100 protein and glial fibrillary acidic protein (GFAP) immunoreactivity, supporting its schwannian differentiation.
  • The cellular subtype has been shown to demonstrate focal positivity for S100 protein in a minority cases.
  • S100 A6 is a member of the S100 protein family that has been demonstrated to have very high sensitivity for cellular neurothekeoma.However, this marker has a low specificity, as it also expressed in melanoma, nevi, neuroblastoma, carcinoma, and fibrohistiocytic tumors.
  • Plaza and coworkers reported 100% sensitivity for S100A6 in their study of 31 cellular neurothekeomas and suggested that immunolabeling of S100A6 in the absence of S100 protein and cytokeratin provides a useful panel in diagnosing cellular neurothekeoma.

- NK1/C3, an antibody that stains neuroectodermal tissue, has been shown to stain cellular neurothekeoma.
- PGP9.5, a broad marker for neuroectodermally derived tumors also demonstrates positivity in cellular neurothekeoma.

  • However, these 2 markers are not specific for cellular neurothekeoma and stain other lesions which enter into its histopathologic differential.
  • For this reason NK1/C3 and PGP9.5 are not helpful when making a close distinction.



  • cellular neurothekeomas are usually diffusely positive for neuron-specific enolase (NSE).

Differential diagnosis

- focal mucinosis
- myxoid malignant fibrous histiocytoma
- myxoid neurofibroma

Prognosis and management

Although neurothekeoma is considered a benign neoplasm, due to the possibility of recurrence and local invasion, it is recommended that wide local excision with frozen-section–margin control be employed for treatment.

In a follow-up study of 85 neurothekeomas, 13 patients demonstrated lesion regrowth. It should be noted, however, that definitive surgical treatment of the studied lesions was not known.

Patients with tumor regrowth were more likely to be younger, female, have facial lesions, and a myxoid pattern on pathology.

In a different follow-up study of 69 cases of cellular neurothekeoma, 10 tumors recurred locally.

No tumor recurred more than once, and all recurring cases had been marginally excised or had involved excision margins. The only features that correlated with recurrence were positive excision margins and head and neck location.No metastases were reported.

Follow-up studies of atypical cellular neurothekeomas have not shown that the presence of increased number of mitoses or cellular atypia correlates with any clinically significant endpoints.

Large tumor size, atypical histologic features (high mitotic rate, pleomorphism, infiltration of adipose) have been shown to have no clinical significance.

Therefore, it is regarded that cellular neurothekeomas behave in a benign fashion and only occasionally recur, generally in the setting of incompletely excised lesions on the face.

See also

- benign tumors of peripheral nerves
- soft tissue tumors


- Neurothekeoma and Plexiform Fibrohistiocytic Tumor: Mere Histologic Resemblance or Histogenetic Relationship? Jaffer S, Ambrosini-Spaltro A, Mancini AM, Eusebi V, Rosai J. Am J Surg Pathol. 2009 Apr 1. PMID: 19342943

- Fetsch JF, Laskin WB, Hallman JR, Lupton GP, Miettinen M. Neurothekeoma: an analysis of 178 tumors with detailed immunohistochemical data and long-term patient follow-up information. Am J Surg Pathol. 2007 Jul;31(7):1103-14. PMID: 17592278

- Hornick JL, Fletcher CD. Cellular neurothekeoma: detailed characterization in a series of 133 cases. Am J Surg Pathol. 2007 Mar;31(3):329-40. PMID: 17325474

- Barnhill RL, Mihm MC Jr. Cellular neurothekeoma. A distinctive variant of neurothekeoma mimicking nevomelanocytic tumors. Am J Surg Pathol. 1990 Feb;14(2):113-20. PMID: 2154139