NEUROFIBROMATOSIS

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Neurofibromatosis (NF) stands as a multifaceted genetic condition that affects the nervous system, leading to the formation of tumors on nerve tissue.

Neurofibromatosis (NF) is a genetic disorder affecting the nervous system, leading to the formation of tumors on nerve tissues.

Types of Neurofibromatosis

There are three types:

• Neurofibromatosis type 1 (NF1): NF1, also known as Recklinghausen disease or von Recklinghausen’s neurofibromatosis, manifests with multiple café au lait spots (light brown skin patches) and soft, fleshy growths called neurofibromas on or under the skin. It can also cause bone abnormalities and scoliosis, with occasional tumors developing in the brain, on cranial nerves, or the spinal cord. Learning disabilities are present in 50% to 75% of NF1 cases.
• Neurofibromatosis type 2 (NF2): NF2, alternatively termed bilateral acoustic neurofibromatosis or vestibular schwannoma neurofibromatosis, presents with multiple tumors on cranial and spinal nerves. The first signs typically involve tumors affecting both auditory nerves, leading to hearing loss starting in the teenage years or early 20s.
• Schwannomatosis: This is a recently identified third type of Neurofibromatosis

NF1 is more prevalent, while NF2 is less common.

Causes

Neurofibromatosis is primarily a genetic disorder of the nervous system, impacting the growth and development of nerve cell tissue. While it’s often inherited from family members through genetic transmission, approximately half of newly diagnosed cases occur without any familial history. This is because neurofibromatosis can also result from spontaneous mutations in genes.

The mutations associated with each type of neurofibromatosis are as follows:

1. Neurofibromatosis 1 (NF1):
   • Mutation in the NF1 gene located on chromosome 17.
   • The NF1 gene normally produces a protein called neurofibromin, which regulates cell growth.
   • Mutations in NF1 result in the loss of neurofibromin, leading to uncontrolled cell growth and tumor formation.
2. Neurofibromatosis 2 (NF2):
   • Mutation in the NF2 gene located on chromosome 22.
   • The NF2 gene encodes for a protein called merlin or schwannomin, which acts as a tumor suppressor.
   • Changes to the NF2 gene lead to the loss of merlin protein, allowing for uncontrolled cell growth and tumor formation.
3. Schwannomatosis:
   • Associated with mutations in two known genes: SMARCB1 and LZTR1.
   • Both genes normally function as tumor suppressors.
   • Mutations in these genes are linked to the development of schwannomas, the characteristic tumors seen in schwannomatosis.

These genetic mutations disrupt normal cellular processes, leading to the growth of tumors characteristic of each type of neurofibromatosis. While neurofibromatosis is primarily a genetic condition, the exact mechanisms underlying the development of tumors and other associated symptoms are still being studied.

Prevalence

NF is relatively rare, with an estimated occurrence of 1 in every 3,000 births worldwide. However, it’s crucial to note that NF1 is more common than NF2, with NF1 affecting approximately 1 in 3,000 individuals and NF2 affecting about 1 in 25,000 individuals.

Symptoms

Neurofibromatosis (NF) manifests with distinct symptoms depending on the type. Here’s an overview of the symptoms associated with each type:

Neurofibromatosis 1 (NF1) Symptoms:

1. Café au lait spots: These are light brown skin patches and are usually present in multiples.
2. Freckles in the armpit or groin area: Known as axillary or inguinal freckling.
3. Lisch nodules: Tiny growths in the colored part of the eye (iris), typically not affecting eyesight.
4. Neurofibromas: Benign tumors that develop on or under the skin, sometimes deeper within the body.
5. Bone deformities: This may include scoliosis (twisted spine) or bowed legs.
6. Optic nerve tumors: Tumors along the optic nerve that can cause vision problems.
7. Nerve-related pain: Pain associated with nerve tissue.
8. High blood pressure
9. Osteoporosis
10. Learning disabilities
11. Large head size
12. Short stature

Neurofibromatosis 2 (NF2) Symptoms:

1. Hearing loss: Often the first symptom, affecting both ears.
2. Facial muscle weakness
3. Dizziness
4. Poor balance
5. Uncoordinated walking
6. Early onset cataracts
7. Headaches

Schwannomatosis Symptoms:

1. Pain: Often the primary symptom, resulting from enlarging tumors.
2. Numbness and tingling: Sensory changes in the fingers or toes.
3. Weakness: Particularly in the fingers and toes.
4. Chronic pain
5. Loss of muscle mass

These symptoms may vary in severity among individuals, and some symptoms may overlap between different types of neurofibromatosis. Regular monitoring and management by healthcare professionals are essential for individuals with neurofibromatosis to address symptoms and optimize quality of life.

Risk Factors

The primary risk factor for neurofibromatosis is having a family history of the condition. In some cases, NF can also arise due to spontaneous genetic mutations.

Diagnosis

Diagnosing neurofibromatosis involves a comprehensive evaluation utilizing various tests and criteria. Here’s an overview of the diagnostic process for each type:

Neurofibromatosis 1 (NF1) Diagnosis:

• Physical examination and medical history, including family history.
• Assessment of symptoms, such as café au lait spots, neurofibromas, freckling in specific areas, optic glioma, Lisch nodules, and bony lesions.
• Criteria for diagnosis include the presence of two or more of the following features:
  1. Café au lait spots meeting specific size criteria.
  2. Two or more neurofibromas or one plexiform neurofibroma.
  3. Freckling in specific areas.
  4. Optic glioma.
  5. Lisch nodules.
  6. Distinctive bony lesions.
  7. Family history of NF1.

Neurofibromatosis 2 (NF2) Diagnosis:

• Evaluation based on medical history, family history, and symptoms.
• Diagnostic criteria include:
  1. Bilateral vestibular schwannomas or family history of NF2 with unilateral or bilateral vestibular schwannomas, plus additional associated health conditions.
  2. Specific symptoms like multiple meningiomas, glioma, neurofibromas, schwannoma, juvenile cataracts, hearing loss, ringing in the ears, balance problems, and headaches.

Schwannomatosis Diagnosis:

• Diagnostic criteria for schwannomatosis include:
  1. Absence of vestibular tumors on MRI in individuals over 30, absence of known NF2 gene mutation, and presence of two or more schwannomas.
  2. Confirmation of schwannoma through biopsy.
  3. Family history of schwannomatosis in first-degree relatives.
  4. Segmental schwannomatosis, where tumors are limited to specific body areas.

These diagnostic criteria help healthcare professionals accurately identify and classify neurofibromatosis types, enabling appropriate management and treatment plans for affected individuals.

Treatments

Neurofibromatosis (NF) treatment primarily focuses on managing symptoms since there’s currently no cure. Treatment approaches can vary widely based on the specific symptoms and complications experienced by each individual. Here’s an overview of treatment options and potential complications associated with neurofibromatosis:

Treatment Options:

1. Surgery: Surgical removal of problematic growths or tumors is often considered, especially when they cause significant discomfort or impair function.
2. Chemotherapy or Radiation: If tumors become malignant (cancerous), chemotherapy or radiation therapy may be recommended to target cancer cells.
3. Bone Surgery: Surgical intervention may be necessary to address skeletal problems like scoliosis or fractures.
4. Therapy: This may include physical therapy to improve mobility, counseling to cope with emotional distress, or participation in support groups.
5. Cataract Removal: Surgery to remove cataracts may be performed to improve vision.
6. Pain Management: Aggressive management of pain associated with the condition may involve medications or other interventions.
7. Stereotactic Radiosurgery: This technique may be used to target tumors precisely with radiation.
8. Auditory Interventions: Auditory brainstem and cochlear implants may be considered to address hearing loss.

Home Care Tips

For individuals living with NF,

• Maintaining regular medical check-ups is essential for monitoring the progression of the condition.
• Practicing good skincare
• Protecting the skin from injuries can help prevent the development of neurofibromas.

Possible Complications

1. Neurological Problems: Difficulty learning or cognitive impairment may occur, particularly in NF1.
2. Psychological Distress: Anxiety or distress related to changes in appearance, such as numerous café au lait spots, may impact mental well-being.
3. Skeletal Issues: Bowing of legs, scoliosis, fractures, or low bone density increasing the risk of osteoporosis may arise.
4. Vision Problems: Tumors pressing against the optic nerve can lead to vision impairment.
5. Cardiovascular Complications: High blood pressure and breathing difficulties may occur.
6. Cancer Risk: Increased susceptibility to certain cancers, including breast cancer, leukemia, brain tumors, and soft tissue cancers, is observed in NF1.
7. Benign Adrenal Gland Tumor: This may cause high blood pressure.
8. Hearing Loss: Common in NF2 due to vestibular schwannomas.
9. Nerve Damage: Facial nerve damage and weakness or numbness in extremities may occur in NF2.
10. Skin Tumors: Benign skin tumors or schwannomas may develop in NF2.
11. Severe Pain: Schwannomatosis may lead to severe pain requiring specialized medical treatment or surgery.

Prevention

Since neurofibromatosis is a genetic condition, it cannot be prevented. However, genetic counseling may be beneficial for individuals with a family history of NF to understand their risk and make informed decisions about family planning.

When to See a Doctor

It’s important to consult a healthcare professional if you or your child exhibit any signs or symptoms of neurofibromatosis, such as the presence of multiple neurofibromas, café-au-lait spots, or unexplained vision or hearing problems.

Outlook/Prognosis

The outlook for individuals with neurofibromatosis varies depending on the type and severity of symptoms. While some individuals may experience mild symptoms and lead productive lives, others may face significant disability or life-threatening complications, particularly in NF2. Regular monitoring and management by healthcare professionals are essential to optimize outcomes and quality of life for individuals with neurofibromatosis.

Sources

1. National Institutes of Health (NIH) – Genetics Home Reference
2. Mayo Clinic – Neurofibromatosis
3. National Organization for Rare Disorders (NORD) – Neurofibromatosis
4. MedlinePlus – Neurofibromatosis
5. National Institute of Neurological Disorders and Stroke.
6. American Association of Neurological Surgeons: “Neurofibromatosis.”
7. Children’s Tumor Foundation: “Schwannomatosis.”
8. Neurofibromatosis Type 2 — Information and Services.
9. Genetics Home Reference: “Neurofibromatosis type 1.”