Malignant Peripheral Nerve Sheath Tumor of the Head and Neck in The Pericarotid Plexiform: A Case Report of a Rare Disease Entity

Malignant Peripheral Nerve Sheath Tumor of the Head and Neck in The Pericarotid Plexiform: A Case Report of a Rare Disease Entity | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Malignant Peripheral Nerve Sheath Tumor of the Head and Neck in The Pericarotid Plexiform: A Case Report of a Rare Disease Entity Farhan Alanazi, Hisham Almousa, Shahd Alsaqoub, Saeed AlQahtani, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7551879/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Malignant peripheral nerve sheath tumors (MPNST) are rare high-grade sarcomas that arise from cells of the peripheral nerve sheaths. They are considered as one of the most aggressive malignant lesions in the head and neck region, with a notably high rate of local recurrence. In the current case report, we described A 28-year-old female known to have neurofibromatosis type 1 (NF1) with a rare case of MPNST in the right sided neck and reviewed the relevant literature. Computed tomography (CT) scan of the head and neck with contrast was initially obtained and showed right sided soft tissue neck mass that was predominantly cystic. Head and neck magnetic resonance imaging (MRI) with contrast demonstrated a large right pericarotid plexiform heterogeneously enhancing tumor. Subsequently surgical excision of the mass under general anesthesia was done. Histopathology of the mass was reported to be malignant peripheral nerve sheath tumor (low grade). The patient was kept on regular follow-up in the head and neck combined clinic, and the surgical site healed well in six weeks, with no sign of local recurrence or metastasis. Malignant peripheral nerve sheath tumor pericarotid plexiform neurofibromatosis head and neck neoplasm Figures Figure 1 Figure 2 Figure 3 Introduction Malignant peripheral nerve sheath tumors (MPNST) are rare high-grade sarcomas that originate from cells of the peripheral nerve sheaths [ 1 ]. They constitute approximately 5–10% of all soft tissue sarcomas [ 2 ]. The extremities and trunk are the most commonly affected sites, while involvement of the head and neck is rare [ 3 ]. Approximately half of MPNST cases are associated with neurofibromatosis type 1 (NF1), whereas the remaining cases occur sporadically or following radiation therapy [ 4 ]. MPNST is associated with a high mortality rate, with a 5-year overall survival estimated at approximately 52% [ 3 ]. These tumors most commonly occur in individuals aged between 20 and 60 years [ 5 ]. MPNST that are high-grade, larger in size, and located in the trunk or head and neck are more likely to have a poor prognosis [ 5 ]. Despite the absence of standard management, surgical resection is the mainstay of treatment, with radiation therapy or chemotherapy considered as adjuncts when indicated [ 6 ]. Multiple studies have demonstrated that the extent of surgical resection is associated with improved survival, whereas the addition of radiation therapy or chemotherapy does not appear to significantly enhance survival outcomes [ 7 ]][ 8 ][ 9 ]. This case report described a rare case of NF1 patient who developed MPNST in the right sided neck region. Additionally, a review of the literature on similar cases of MPNST was also performed and discussed. Case Report A 28-year-old female, known to have neurofibromatosis type 1 presented complaining of right-sided neck swelling that was increasing gradually in size over the past 3 years. It was associated with difficulty in swallowing, shortness of breath on exertion, mild pain, and choking with liquids. She denied any history of trauma, apnea, or previous exposure to chemoradiation. She had a history of C3, C4 and C5 laminoplasty with excision of a spinal lesion, which was diagnosed as neurofibroma. Also, there was a history of left sided neck swelling that was excised almost 13 years ago in another center where the histopathology was reported as neurofibroma. There was no family history of head and neck malignancies. Examination revealed a right sided neck mass expanding over levels 2 to 5 approximately measuring 5*6 cm with no skin changes, tenderness, or fluctuation. Nasopharyngoscopy showed bilateral mobile vocal folds with mass effect on the right vocal fold. The rest of the physical examination was unremarkable. Computed tomography (CT) scan of the head and neck with contrast showed a right sided soft tissue neck mass that was predominantly cystic, measuring 9.4*4.2cm, and was showing multiple faintly small solid areas within (Fig. 1 A, 1 B). Magnetic resonance imaging (MRI) of the head and neck with contrast demonstrated a large right pericarotid plexiform heterogeneously enhancing tumor on T1 and T2 weighted images (Fig. 1 C, 1 D). CT angiogram showed patent anterior and posterior circulation. After discussing the modalities for treating such masses in the tumor board and the benefits of the surgery, the patient agreed to undergo a surgical excision of the mass (Fig. 2, 3 ). On the first postoperative day, she was doing well apart from hoarseness and mild choking. Swallowing assessment was done on the second day, which was unremarkable, and the patient discharged home. Histopathology of the mass was reported to be malignant peripheral nerve sheath tumor (low grade). The patient was kept on regular follow-up for up to six months in the head and neck combined clinic, and the surgical site healed well in six weeks, with no sign of local recurrence or metastasis. However, she was found to have right vocal fold immobility with 2mm glottic gap. She planned to continue follow up in combined oncology and otorhinolaryngology clinic with consideration for possible chemoradiotherapy in case the patient showed any clinical sign or symptoms of recurrence during the follow-up period. Figure 1 A: CT coronal showed right sided neck predominantly cystic soft tissue mass lesion measuring 9.4*4.2cm which shows multiple faintly small solid areas within. Figure 1 B: CT sagittal showed right sided neck predominantly cystic soft tissue mass lesion measuring 9.4*4.2cm which shows multiple faintly small solid areas with Figure 1 C: MRI T1 coronal showed large right plexiform heterogeneously enhancing tumor. Figure 2: Intraoperative right sided neck soft tissue mass Discussion Malignant peripheral nerve sheath tumors (MPNSTs) are a rare subtype of soft tissue sarcoma, with an estimated incidence of 0.001% [ 5 ]. Approximately half of MPNSTs cases are associated with neurofibromatosis type 1 (NF1), with a lifetime risk of 8–13% [ 10 ]. These tumors most commonly diagnosed between 20 and 40 years of age in patients with NF1, and between 30 and 60 years when they occur sporadically, with no gender predilection [ 11 ][ 2 ]. MPNSTs most commonly arise in the proximal extremities and trunks, and rarely in the head and neck (12–19%) [ 2 ], [ 3 ], [ 5 ]. Clinically, MPNSTs typically present as an enlarging, painless mass. Patients may also report pain, paresthesia, or other neurological deficits. A cohort study of head and neck MPNSTs demonstrated that these tumors most commonly arise from peripheral and autonomic nerves, followed by connective and soft tissues [ 12 ]. Imaging is essential for the diagnosis of MPNST, and certain findings should raise suspicion for malignancy, including large tumor size (> 5 cm), heterogeneous appearance, ill-defined margins, invasion of surrounding fat planes, and surrounding edema [ 13 ]. The majority of MPNSTs are classified as high-grade sarcomas arising from mesenchymal tissues. Histopathology typically demonstrates malignant tissue composed of spindle cells arranged in cellular fascicles, along with a mixture of poorly defined cellular and cystic components [ 14 ][ 15 ]. The mainstay treatment of MPNSTs is complete surgical resection with negative margins. Neoadjuvant radiotherapy is recommended if the tumor is more than 5 cm. A study demonstrated that patients who had primary radiotherapy had slightly improved survival outcomes than did patients who underwent surgery alone, or surgery and post operative radiotherapy, however the difference wasn’t statistically significant [ 12 ]. The survival and local recurrence of MPNSTs are poor. Worse prognosis is seen with NF 1 mutation, large size, deep to fascia, high grade, metastases, and location (trunk and head and neck) [ 16 ]. MPNST carries high potential for recurrence and metastasis. About 40% of patients have a local recurrence within 1 year of surgery, and about 40–60% of patients develop metastases within 1 year of surgery[ 17 ][ 4 ]. MPNSTs can affect multiple organs and the management differ in the literature as in 1986 Ducatman et al suggest radical resection of the tumor with a wide margin of normal tissue, and in scenarios where radical tumor excision is not feasible, amputation may be considered as a potential therapeutic intervention, while chemotherapy only effective in case of disseminated disease rather than localized [ 5 ]. Furthermore, Ferner et al suggest that postoperative radiotherapy is necessary for all patients with MPNSTs [ 14 ]. Moreover, Kar et al suggest radical surgical resection followed by adjuvant radiotherapy improve the overall survival rate for MPNSTs patients [ 18 ]. Zhu et al present a case of spinal MPNSTs and found that spinal cases should be treated with surgical excision and postoperative intensity-modulated radiotherapy increased the overall survival and decrease the risk of recurrence [ 19 ]. Furthermore, Gousias et al present a case of intracranial MPNSTs and found that the best treatment choice for those patients is complete surgical resection followed by radiotherapy and chemotherapy is preserved only for relapsed or metastasized cases [ 20 ]. Lastly Lambrou et al present a case of vulva MPNSTs in female patient and recommended complete surgical resection followed by radiotherapy while chemotherapy only in selected cases [ 21 ]. In literature there are a few studies about MPNSTs in the head and neck region (Table 1 ). In the present study the age of the patient is 28 years and the tumor size is 9.4*4.2cm. Borovika et al present a case of 62 years old female with MPNSTs of carotid sheath measuring 2.3*2.5*4.3 cm and was managed using surgical excision followed by radiation therapy with no local recurrence or metastases after 1 year of follow up [ 22 ]. Furthermore, Verma et al report a case of 35 years old female with MPNSTs of right parapharyngeal space measuring 7*8*11 cm that was managed by wide excision of the mass followed by adjuvant radiotherapy with no local recurrence after 1 month follow up [ 23 ]. Lastly Mullins et al report a case of 34 years old male known to have NF1 with MPNSTs in the left parapharyngeal space measuring 5.2*3.3*4.9 cm that was treated by surgical excision followed by adjuvant radiation therapy with no local recurrence or metastasis after 3 months of regular follow up [ 24 ]. However, Minovi et al conducted a retrospective study involving 10 patients who underwent surgical treatment of MPNST in the head and neck region over a 20-year period [ 25 ]. Of these, 8 cases were located in the lateral skull base and 2 in the paranasal sinuses. Their long-term follow-up revealed a disease-specific survival rate of 50% at two years and only 20% at five years. Table 1 MPNSTs in the head and neck region Author name/year Age/gender Size of the tumor NF1 status investigation management Recurrence Borovika et al (2023) 62/F 2.3*2.5*4.3 cm Not known to have NF1 Ultrasound followed by MRI surgical excision followed by radiation therapy No Recurrence Verma et al (2019) 35/F 7*8*11 cm Not known to have NF1 CT scan followed by MRI surgical excision followed by radiation therapy No Recurrence Mullins et al (2014) 34/M 5.2*3.3*4.9 cm known to have NF1 MRI surgical excision followed by radiation therapy No Recurrence Present case 28/F 9.4*4.2cm known to have NF1 CT scan followed by MRI and CT angiography surgical excision with possible chemo radiotherapy in case of of recurrence No Recurrence Conclusion Due to their rarity and the difficulties in early detection and treatment, MPNST acts as one of the most aggressive malignant lesions in the head and neck region, with a notably high rate of local recurrence. The prognosis has historically been poor, and the current mainstay of treatment appears to be surgical resection with negative margins followed by radiation therapy if needed. Nevertheless, NF1 patients must be carefully followed up on and require prompt diagnosis and treatment. More research is needed to develop better and more affordable treatments for MPNSTs. Declarations Consent for Publication: Informed consent was taken from the patient for his anonymized information to be published. The authors declare that there is no conflict of interest. Ethics approval and consent to participate: No ethical approval required for reporting individual cases or case series. Informed consent was taken from the patient for his anonymized information to be published. Statement of Human and Animal Rights: This article does not contain any studies with human or animal subjects. Funding: Authors state no funding involved. Author Contribution FA: Research idea, Manuscript writing, Literature reviewHA: Manuscript writing, Literature reviewSA: Manuscript writing, Literature reviewSA: Manuscript writing, Literature reviewAA: Supervision, reviewing the manuscriptFA: Supervision, reviewing the manuscript Acknowledgement The authors would like to thank Editage (www.editage.com) for English language editing. Data availability: The datasets used during the current study are available from the corresponding author on reasonable request. References Sbaraglia M, Bellan E, Dei Tos AP (2021) The 2020 WHO Classification of Soft Tissue Tumours: news and perspectives, Pathologica , vol. 113, no. 2, pp. 70–84, Apr. 10.32074/1591-951X-213 Huang JH, Zhang J, Zager EL (Jul. 2005) Diagnosis and treatment options for nerve sheath tumors. Expert Rev Neurother 5(4):515–523. 10.1586/14737175.5.4.515 Mowery A, Clayburgh D (Nov. 2019) Malignant peripheral nerve sheath tumors: Analysis of the national cancer database. 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World J Surg Oncol 4. 10.1186/1477-7819-4-55 Zhu B et al (May 2012) Malignant peripheral nerve sheath tumours of the spine: clinical manifestations, classification, treatment, and prognostic factors. Eur Spine J 21(5):897. 10.1007/S00586-011-2093-Y Gousias K, Boström J, Kovacs A, Niehusmann P, Wagner I, Kristof R (2010) Factors of influence upon overall survival in the treatment of intracranial MPNSTs. Review of the literature and report of a case, Radiat Oncol , vol. 5, no. 1, p. 114, Nov. 10.1186/1748-717X-5-114 Lambrou NC, Mirhashemi R, Wolfson A, Thesiger P, Penalver M (May 2002) Malignant peripheral nerve sheath tumor of the vulva: A multimodal treatment approach. Gynecol Oncol 85(2):365–371. 10.1006/gyno.2002.6600 Borovika A, Deksnis R, Zariņš J, Isajevs S (Mar. 2023) Rare malignant peripheral nerve sheath tumor of vagus nerve: A case report. Int J Surg Case Rep 104. 10.1016/J.IJSCR.2023.107940 Verma R, Gautam V, Bahl A, Bal A (2020) Malignant peripheral nerve sheath tumor of the parapharyngeal space arising from cervical sympathetic chain: A rare entity, J Cancer Res Ther , vol. 16, no. 3, pp. 630–633, Apr. 10.4103/JCRT.JCRT_1005_17 Mullins BT, Hackman T (2014) Malignant Peripheral Nerve Sheath Tumors of the Head and Neck: A Case Series and Literature Review, Case Rep Otolaryngol , vol. pp. 1–6, 2014. 10.1155/2014/368920 Minovi A, Basten O, Hunter B, Draf W, Bockmühl U (May 2007) Malignant peripheral nerve sheath tumors of the head and neck: Management of 10 cases and literature review. Head Neck 29(5):439–445. 10.1002/HED.20537 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 06 Nov, 2025 Reviews received at journal 04 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviewers invited by journal 04 Nov, 2025 Submission checks completed at journal 03 Nov, 2025 First submitted to journal 31 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7551879","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":540943218,"identity":"b5f86850-c351-4b98-9fac-bf4a492e5495","order_by":0,"name":"Farhan Alanazi","email":"","orcid":"","institution":"Prince Mohammed Medical City","correspondingAuthor":false,"prefix":"","firstName":"Farhan","middleName":"","lastName":"Alanazi","suffix":""},{"id":540943219,"identity":"b9046238-cc8f-4e64-afca-424da062e7ff","order_by":1,"name":"Hisham 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1","display":"","copyAsset":false,"role":"figure","size":845905,"visible":true,"origin":"","legend":"\u003cp\u003e1A: CT coronal showed right sided neck predominantly cystic soft tissue mass lesion measuring 9.4*4.2cm which shows multiple faintly small solid areas within.\u003c/p\u003e\n\u003cp\u003eFigure 1B: CT sagittal showed right sided neck predominantly cystic soft tissue mass lesion measuring 9.4*4.2cm which shows multiple faintly small solid areas with\u003c/p\u003e\n\u003cp\u003eFigure 1C: MRI T1 coronal showed large right plexiform heterogeneously enhancing tumor.\u003c/p\u003e\n\u003cp\u003eFigure 1D: MRI T2 Axial showed large right pericarotid plexiform heterogeneously enhancing tumor.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7551879/v1/d9c863d1e57b1ef191b79b89.jpeg"},{"id":96244679,"identity":"a7d1ad3f-ad59-4b2c-9538-7383c5979f1d","added_by":"auto","created_at":"2025-11-19 07:19:04","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1176572,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative right sided neck soft tissue mass\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7551879/v1/de488828eec440b671da71ad.jpeg"},{"id":96246858,"identity":"f5164e1e-405b-4bca-ae3b-53b955227695","added_by":"auto","created_at":"2025-11-19 07:26:47","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":209973,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative excised mass measuring 9*4 cm.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7551879/v1/5afd23ff2b686ce0b052fa45.jpeg"},{"id":96255959,"identity":"59487078-66e5-4aa4-8fe9-f1eb0e278326","added_by":"auto","created_at":"2025-11-19 07:49:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2686150,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7551879/v1/e7ade882-1dce-4f8b-a4e2-96163bd237c2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Malignant Peripheral Nerve Sheath Tumor of the Head and Neck in The Pericarotid Plexiform: A Case Report of a Rare Disease Entity","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMalignant peripheral nerve sheath tumors (MPNST) are rare high-grade sarcomas that originate from cells of the peripheral nerve sheaths [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. They constitute approximately 5\u0026ndash;10% of all soft tissue sarcomas [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The extremities and trunk are the most commonly affected sites, while involvement of the head and neck is rare [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Approximately half of MPNST cases are associated with neurofibromatosis type 1 (NF1), whereas the remaining cases occur sporadically or following radiation therapy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. MPNST is associated with a high mortality rate, with a 5-year overall survival estimated at approximately 52% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These tumors most commonly occur in individuals aged between 20 and 60 years [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. MPNST that are high-grade, larger in size, and located in the trunk or head and neck are more likely to have a poor prognosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Despite the absence of standard management, surgical resection is the mainstay of treatment, with radiation therapy or chemotherapy considered as adjuncts when indicated [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Multiple studies have demonstrated that the extent of surgical resection is associated with improved survival, whereas the addition of radiation therapy or chemotherapy does not appear to significantly enhance survival outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This case report described a rare case of NF1 patient who developed MPNST in the right sided neck region. Additionally, a review of the literature on similar cases of MPNST was also performed and discussed.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 28-year-old female, known to have neurofibromatosis type 1 presented complaining of right-sided neck swelling that was increasing gradually in size over the past 3 years. It was associated with difficulty in swallowing, shortness of breath on exertion, mild pain, and choking with liquids. She denied any history of trauma, apnea, or previous exposure to chemoradiation. She had a history of C3, C4 and C5 laminoplasty with excision of a spinal lesion, which was diagnosed as neurofibroma. Also, there was a history of left sided neck swelling that was excised almost 13 years ago in another center where the histopathology was reported as neurofibroma. There was no family history of head and neck malignancies. Examination revealed a right sided neck mass expanding over levels 2 to 5 approximately measuring 5*6 cm with no skin changes, tenderness, or fluctuation. Nasopharyngoscopy showed bilateral mobile vocal folds with mass effect on the right vocal fold. The rest of the physical examination was unremarkable. Computed tomography (CT) scan of the head and neck with contrast showed a right sided soft tissue neck mass that was predominantly cystic, measuring 9.4*4.2cm, and was showing multiple faintly small solid areas within (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA,\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Magnetic resonance imaging (MRI) of the head and neck with contrast demonstrated a large right pericarotid plexiform heterogeneously enhancing tumor on T1 and T2 weighted images (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC,\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). CT angiogram showed patent anterior and posterior circulation. After discussing the modalities for treating such masses in the tumor board and the benefits of the surgery, the patient agreed to undergo a surgical excision of the mass (Fig.\u0026nbsp;2,\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). On the first postoperative day, she was doing well apart from hoarseness and mild choking. Swallowing assessment was done on the second day, which was unremarkable, and the patient discharged home. Histopathology of the mass was reported to be malignant peripheral nerve sheath tumor (low grade). The patient was kept on regular follow-up for up to six months in the head and neck combined clinic, and the surgical site healed well in six weeks, with no sign of local recurrence or metastasis. However, she was found to have right vocal fold immobility with 2mm glottic gap. She planned to continue follow up in combined oncology and otorhinolaryngology clinic with consideration for possible chemoradiotherapy in case the patient showed any clinical sign or symptoms of recurrence during the follow-up period.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA: CT coronal showed right sided neck predominantly cystic soft tissue mass lesion measuring 9.4*4.2cm which shows multiple faintly small solid areas within.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB: CT sagittal showed right sided neck predominantly cystic soft tissue mass lesion measuring 9.4*4.2cm which shows multiple faintly small solid areas with\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC: MRI T1 coronal showed large right plexiform heterogeneously enhancing tumor.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure 2: Intraoperative right sided neck soft tissue mass\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMalignant peripheral nerve sheath tumors (MPNSTs) are a rare subtype of soft tissue sarcoma, with an estimated incidence of 0.001% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Approximately half of MPNSTs cases are associated with neurofibromatosis type 1 (NF1), with a lifetime risk of 8\u0026ndash;13% [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These tumors most commonly diagnosed between 20 and 40 years of age in patients with NF1, and between 30 and 60 years when they occur sporadically, with no gender predilection [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMPNSTs most commonly arise in the proximal extremities and trunks, and rarely in the head and neck (12\u0026ndash;19%) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Clinically, MPNSTs typically present as an enlarging, painless mass. Patients may also report pain, paresthesia, or other neurological deficits. A cohort study of head and neck MPNSTs demonstrated that these tumors most commonly arise from peripheral and autonomic nerves, followed by connective and soft tissues [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Imaging is essential for the diagnosis of MPNST, and certain findings should raise suspicion for malignancy, including large tumor size (\u0026gt;\u0026thinsp;5 cm), heterogeneous appearance, ill-defined margins, invasion of surrounding fat planes, and surrounding edema [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe majority of MPNSTs are classified as high-grade sarcomas arising from mesenchymal tissues. Histopathology typically demonstrates malignant tissue composed of spindle cells arranged in cellular fascicles, along with a mixture of poorly defined cellular and cystic components [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e][\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe mainstay treatment of MPNSTs is complete surgical resection with negative margins. Neoadjuvant radiotherapy is recommended if the tumor is more than 5 cm. A study demonstrated that patients who had primary radiotherapy had slightly improved survival outcomes than did patients who underwent surgery alone, or surgery and post operative radiotherapy, however the difference wasn\u0026rsquo;t statistically significant [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe survival and local recurrence of MPNSTs are poor. Worse prognosis is seen with NF 1 mutation, large size, deep to fascia, high grade, metastases, and location (trunk and head and neck) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMPNST carries high potential for recurrence and metastasis. About 40% of patients have a local recurrence within 1 year of surgery, and about 40\u0026ndash;60% of patients develop metastases within 1 year of surgery[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMPNSTs can affect multiple organs and the management differ in the literature as in 1986 Ducatman et al suggest radical resection of the tumor with a wide margin of normal tissue, and in scenarios where radical tumor excision is not feasible, amputation may be considered as a potential therapeutic intervention, while chemotherapy only effective in case of disseminated disease rather than localized [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Furthermore, Ferner et al suggest that postoperative radiotherapy is necessary for all patients with MPNSTs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Moreover, Kar et al suggest radical surgical resection followed by adjuvant radiotherapy improve the overall survival rate for MPNSTs patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Zhu et al present a case of spinal MPNSTs and found that spinal cases should be treated with surgical excision and postoperative intensity-modulated radiotherapy increased the overall survival and decrease the risk of recurrence [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Furthermore, Gousias et al present a case of intracranial MPNSTs and found that the best treatment choice for those patients is complete surgical resection followed by radiotherapy and chemotherapy is preserved only for relapsed or metastasized cases [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Lastly Lambrou et al present a case of vulva MPNSTs in female patient and recommended complete surgical resection followed by radiotherapy while chemotherapy only in selected cases [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn literature there are a few studies about MPNSTs in the head and neck region (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the present study the age of the patient is 28 years and the tumor size is 9.4*4.2cm. Borovika et al present a case of 62 years old female with MPNSTs of carotid sheath measuring 2.3*2.5*4.3 cm and was managed using surgical excision followed by radiation therapy with no local recurrence or metastases after 1 year of follow up [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Furthermore, Verma et al report a case of 35 years old female with MPNSTs of right parapharyngeal space measuring 7*8*11 cm that was managed by wide excision of the mass followed by adjuvant radiotherapy with no local recurrence after 1 month follow up [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Lastly Mullins et al report a case of 34 years old male known to have NF1 with MPNSTs in the left parapharyngeal space measuring 5.2*3.3*4.9 cm that was treated by surgical excision followed by adjuvant radiation therapy with no local recurrence or metastasis after 3 months of regular follow up [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, Minovi et al conducted a retrospective study involving 10 patients who underwent surgical treatment of MPNST in the head and neck region over a 20-year period [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Of these, 8 cases were located in the lateral skull base and 2 in the paranasal sinuses. Their long-term follow-up revealed a disease-specific survival rate of 50% at two years and only 20% at five years.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMPNSTs in the head and neck region\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor name/year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge/gender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSize of the tumor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNF1 status\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003einvestigation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003emanagement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eRecurrence\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBorovika et al (2023)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62/F\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.3*2.5*4.3 cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNot known to have NF1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUltrasound followed by MRI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003esurgical excision followed by radiation therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo Recurrence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVerma et al (2019)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35/F\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7*8*11 cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNot known to have NF1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCT scan followed by MRI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003esurgical excision followed by radiation therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo Recurrence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMullins et al (2014)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.2*3.3*4.9 cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eknown to have NF1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMRI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003esurgical excision followed by radiation therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo Recurrence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresent case\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28/F\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.4*4.2cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eknown to have NF1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCT scan followed by MRI and CT angiography\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003esurgical excision with possible chemo radiotherapy in case of of recurrence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo Recurrence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDue to their rarity and the difficulties in early detection and treatment, MPNST acts as one of the most aggressive malignant lesions in the head and neck region, with a notably high rate of local recurrence. The prognosis has historically been poor, and the current mainstay of treatment appears to be surgical resection with negative margins followed by radiation therapy if needed. Nevertheless, NF1 patients must be carefully followed up on and require prompt diagnosis and treatment. More research is needed to develop better and more affordable treatments for MPNSTs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConsent for Publication:\u003c/h2\u003e\u003cp\u003eInformed consent was taken from the patient for his anonymized information to be published.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eThe authors declare that there is no conflict of interest.\u003c/p\u003e\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\u003cp\u003eNo ethical approval required for reporting individual cases or case series. Informed consent was taken from the patient for his anonymized information to be published.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eStatement of Human and Animal Rights:\u003c/h2\u003e\u003cp\u003eThis article does not contain any studies with human or animal subjects.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eAuthors state no funding involved.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFA: Research idea, Manuscript writing, Literature reviewHA: Manuscript writing, Literature reviewSA: Manuscript writing, Literature reviewSA: Manuscript writing, Literature reviewAA: Supervision, reviewing the manuscriptFA: Supervision, reviewing the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank Editage (www.editage.com) for English language editing.\u003c/p\u003e\u003ch2\u003eData availability:\u003c/h2\u003e\u003cp\u003eThe datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSbaraglia M, Bellan E, Dei Tos AP (2021) The 2020 WHO Classification of Soft Tissue Tumours: news and perspectives, \u003cem\u003ePathologica\u003c/em\u003e, vol. 113, no. 2, pp. 70\u0026ndash;84, Apr. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.32074/1591-951X-213\u003c/span\u003e\u003cspan address=\"10.32074/1591-951X-213\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang JH, Zhang J, Zager EL (Jul. 2005) Diagnosis and treatment options for nerve sheath tumors. 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Head Neck 29(5):439\u0026ndash;445. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/HED.20537\u003c/span\u003e\u003cspan address=\"10.1002/HED.20537\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Malignant peripheral nerve sheath tumor, pericarotid plexiform, neurofibromatosis, head and neck neoplasm","lastPublishedDoi":"10.21203/rs.3.rs-7551879/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7551879/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMalignant peripheral nerve sheath tumors (MPNST) are rare high-grade sarcomas that arise from cells of the peripheral nerve sheaths. They are considered as one of the most aggressive malignant lesions in the head and neck region, with a notably high rate of local recurrence. In the current case report, we described A 28-year-old female known to have neurofibromatosis type 1 (NF1) with a rare case of MPNST in the right sided neck and reviewed the relevant literature. Computed tomography (CT) scan of the head and neck with contrast was initially obtained and showed right sided soft tissue neck mass that was predominantly cystic. Head and neck magnetic resonance imaging (MRI) with contrast demonstrated a large right pericarotid plexiform heterogeneously enhancing tumor. Subsequently surgical excision of the mass under general anesthesia was done. Histopathology of the mass was reported to be malignant peripheral nerve sheath tumor (low grade). The patient was kept on regular follow-up in the head and neck combined clinic, and the surgical site healed well in six weeks, with no sign of local recurrence or metastasis.\u003c/p\u003e","manuscriptTitle":"Malignant Peripheral Nerve Sheath Tumor of the Head and Neck in The Pericarotid Plexiform: A Case Report of a Rare Disease Entity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-16 16:29:18","doi":"10.21203/rs.3.rs-7551879/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"39624285792568112754053808832108974656","date":"2025-11-06T09:45:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-04T17:47:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192537608380020477896472152935416602432","date":"2025-11-04T06:30:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-04T05:57:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-04T04:55:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Otolaryngology","date":"2025-11-01T00:38:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e2099f8b-3f54-437a-84ce-8148dbd76be0","owner":[],"postedDate":"November 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-16T16:29:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-16 16:29:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7551879","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7551879","identity":"rs-7551879","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}