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Wu KY, Murthy NK, Howe BM, Dyck PJB, Spinner RJ. Diagnostic value of proximal cutaneous nerve biopsy in brachial and lumbosacral plexus pathologies. Acta Neurochir (Wien) 2023; 165:1189-1194. [PMID: 37009932 DOI: 10.1007/s00701-023-05565-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/16/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Brachial and lumbosacral plexopathies can result from numerous non-traumatic etiologies, including those of inflammatory, autoimmune, or neoplastic origin, that often require nerve biopsy for diagnosis. The purpose of this study was to evaluate the diagnostic efficacy of medial antebrachial cutaneous nerve (MABC) and posterior femoral cutaneous nerve (PFCN) nerve biopsies in proximal brachial and lumbosacral plexus pathology. METHOD Patients undergoing MABC or PFCN nerve biopsies at a single institution were reviewed. Patient demographics, clinical diagnosis, symptom duration, intraoperative findings, post-operative complications, and pathology results were recorded. Biopsy results were classified as diagnostic, inconclusive, or negative based on the final pathology. RESULTS Thirty patients undergoing MABC biopsies in the proximal arm or axilla and five patients with PFCN biopsies in the thigh or buttock were included. MABC biopsies were diagnostic in 70% of cases overall and 85% diagnostic in cases where pre-operative MRI also demonstrated abnormalities in the MABC. PFCN biopsies were diagnostic in 60% of cases overall and in 100% of patients with abnormal pre-operative MRIs. There were no biopsy-related post-operative complications in either group. CONCLUSIONS In diagnosing non-traumatic etiologies of brachial and lumbosacral plexopathies, proximal biopsies of the MABC and PFCN provide high diagnostic value with low donor morbidity.
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Affiliation(s)
- Kitty Y Wu
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Gonda 8-214, Rochester, MN, 55905, USA
| | - Nikhil K Murthy
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Gonda 8-214, Rochester, MN, 55905, USA
| | | | - P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Gonda 8-214, Rochester, MN, 55905, USA.
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Jack MM, Smith BW, Capek S, Marek T, Carter JM, Broski SM, Amrami KK, Spinner RJ. The spectrum of brachial plexopathy from perineural spread of breast cancer. J Neurosurg 2022; 137:1368-1377. [PMID: 35213832 DOI: 10.3171/2021.12.jns211882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Perineural spread of breast cancer to the brachial plexus can lead to pain, sensory alterations, and upper-extremity weakness. Although rare, perineural spread is an often-misdiagnosed long-term complication following breast cancer diagnosis. The objective of this study was to critically review the clinical, radiological, and pathological findings of biopsy-proven perineural spread of breast cancer to the brachial plexus. METHODS This is a retrospective study from a single institution in which a total of 19 patients with brachial plexus involvement from perineural spread of breast cancer who underwent fascicular biopsy between 1999 and 2021 were identified. Clinical, radiographic, and pathological data were retrospectively collected. Descriptive statistics were calculated for the cohort. RESULTS The mean age of patients at the time of diagnosis of breast cancer perineural spread was 60.6 ± 11.5 years. The diagnosis of brachial plexopathy due to perineural spread was on average 12 years after the primary diagnosis of breast cancer. There was also a delay in diagnosis due to the rarity of this disease, with a mean time from initial symptom onset to diagnosis of perineural spread of 25 ± 30 months. All patients at the time of presentation had upper-extremity weakness and pain. Nearly all patients demonstrated T2 signal change and nodular so-called sugar-coating contrast enhancement on brachial plexus MRI. Similarly, all patients who underwent PET/MRI or PET/CT had increased FDG uptake in the involved brachial plexus. Breast cancer perineural spread has an overall poor prognosis, with 16 of 19 patients dying within 5.9 ± 3.0 years after diagnosis of perineural spread. CONCLUSIONS Perineural spread should be considered in patients with a history of breast cancer, even 10 years after primary diagnosis, especially in patients who present with arm pain, weakness, and/or sensory changes. Further diagnostic workup with electrodiagnostic studies; brachial plexus MRI, PET/CT, or PET/MRI; and possibly nerve biopsy is warranted to ensure accurate diagnosis.
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Affiliation(s)
- Megan M Jack
- 1Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brandon W Smith
- 1Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Stepan Capek
- 2Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Tomas Marek
- 3Department of General Surgery, Nassau University Medical Center, East Meadow, New York
| | - Jodi M Carter
- 4Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota; and
| | | | | | - Robert J Spinner
- 1Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
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3
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Spinner RJ. A novel mechanism for the formation and propagation of neural tumors and lesions through neural highways. Clin Anat 2021; 34:1165-1172. [PMID: 34309059 DOI: 10.1002/ca.23768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 12/25/2022]
Abstract
By recognizing anatomic and radiologic patterns of rare and often misdiagnosed peripheral nerve tumors/lesions, we have defined mechanisms for the propagation of neural diseases. The novel concept of the nervous system serving as a complex system of "highways" driving the neural and perineural spread of these lesions is described in three examples: Intraneural dissection of joint fluid in intraneural ganglion cysts, perineural spread of cancer cells, and dissemination of unknown concentrations of neurotrophic/inhibitory factors for growth in hamartomas/choristomas of nerve. Further mapping of these pathways to identify the natural history of diseases, the spectrum of disease evolution, the role of genetic mutations, and how these neural pathways interface with the lymphatic, vascular, and cerebrospinal systems may lead to advances in targeted treatments.
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Affiliation(s)
- Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Nguyen J, Barber TW, Cameron R, Haydon A, Mar V. Findings and Resolution of Melanoma Perineural Spread Along the Greater Auricular Nerve on FDG PET/CT and MRI. Clin Nucl Med 2021; 46:e329-e331. [PMID: 33591024 DOI: 10.1097/rlu.0000000000003534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT We report an unusual case of a 59-year-old man with recurrent right ear melanoma resulting in perineural spread to the right greater auricular nerve. Direct perineural spread to the greater auricular nerve is not commonly reported in melanoma. Our case demonstrates perineural spread along the greater auricular nerve on 18F-FDG PET/CT and MRI. This finding was supported by intraneural invasion noted at the surgical margin of the wide local excision of the right helix melanoma. Resolution of FDG activity and improved MRI appearances of the right greater auricular nerve were seen after immunotherapy treatment.
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Affiliation(s)
| | | | | | - Andrew Haydon
- Medical Oncology, Alfred Health, Melbourne, Victoria, Australia
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Murthy NK, Amrami KK, Spinner RJ. Perineural spread to the brachial plexus: a focused review of proposed mechanisms and described pathologies. Acta Neurochir (Wien) 2020; 162:3179-3187. [PMID: 32632655 DOI: 10.1007/s00701-020-04466-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/18/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perineural spread (PNS) is an emerging mechanism for progressive, non-traumatic brachial plexopathy. We aim to summarize the pathologies (tumor and infection) shown to have spread along or to the brachial plexus, and identify the proposed mechanisms of perineural spread. METHODS A focused review of the literature was performed pertaining to pathologies with identified perineural spread to the brachial plexus. RESULTS We summarized pathologies currently reported to have PNS in the brachial plexus and offer a structure for understanding and describing these pathologies with respect to their interaction with the peripheral nervous system. CONCLUSIONS Perineural spread is an underrepresented entity in the literature, especially regarding the brachial plexus. It can occur via a primary or secondary mechanism based on the anatomy, and understanding this mechanism helps to support biopsies of sacrificial nerve contributions, leading to more effective and timely treatment plans for patients.
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Murthy NK, Broski SM, Amrami KK, Markovic SN, Spinner RJ. Extensive Perineural Spread of Subungual Melanoma. World Neurosurg 2020; 145:98-101. [PMID: 32916345 DOI: 10.1016/j.wneu.2020.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Subungual melanoma (SUM) is a rare form of melanoma confined to the nailbed and is rarely of the desmoplastic subtype. The often subtle nature of SUM, initially starting as a small dark spot or line in the nailbed, means deeper invasion can occur before a patient seeks clinical evaluation for a large, ulcerated lesion. We report the only known case of perineural spread of SUM of the lower extremity and describe its extensive path of perineural spread from the toe. CASE DESCRIPTION A 72-year-old man with a distant history of SUM status post second ray amputation, presented for evaluation of ipsilateral foot drop. Imaging revealed nodular involvement of tibial, peroneal, and sciatic nerves. Biopsies revealed desmoplastic melanoma and he was treated with nivolumab. CONCLUSIONS We report the only known case of perineural spread of SUM of the lower extremity and describe the pathoanatomy of perineural spread. A high index of suspicion for recurrent disease should be maintained even many years after completion of treatment.
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Affiliation(s)
- Nikhil K Murthy
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.
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McCutcheon IE. Commentary: Rare Primary Embryonal Carcinoma in the Brachial Plexus: A Case Report and Literature Review. Neurosurgery 2020; 87:E156-E157. [DOI: 10.1093/neuros/nyz469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 11/13/2022] Open
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Cohen JV, Wang N, Venur VA, Hadfield MJ, Cahill DP, Oh K, Brastianos PK. Neurologic complications of melanoma. Cancer 2020; 126:477-486. [DOI: 10.1002/cncr.32619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 09/28/2019] [Accepted: 10/08/2019] [Indexed: 11/12/2022]
Affiliation(s)
- Justine V. Cohen
- Division of Medical Oncology and Neuro‐Oncology Massachusetts General Hospital Cancer Center Boston Massachusetts
| | - Nancy Wang
- Division of Neuro‐Oncology Massachusetts General Hospital Cancer Center Boston Massachusetts
| | - Vyshak A. Venur
- Division of Neuro‐Oncology Massachusetts General Hospital Cancer Center Boston Massachusetts
| | - Matthew J. Hadfield
- Division of Internal Medicine University of Connecticut Hartford Connecticut
| | - Daniel P. Cahill
- Division of Neurosurgery Massachusetts General Hospital Boston Massachusetts
| | - Kevin Oh
- Division of Radiation Oncology Massachusetts General Hospital Boston Massachusetts
| | - Priscilla K. Brastianos
- Division of Medical Oncology and Neuro‐Oncology Massachusetts General Hospital Cancer Center Boston Massachusetts
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Puffer RC, Marek T, Stone JJ, Raghunathan A, Howe BM, Spinner RJ. Extensive perineural spread of an intrapelvic sciatic malignant peripheral nerve sheath tumor: a case report. Acta Neurochir (Wien) 2018; 160:1833-1836. [PMID: 29974241 DOI: 10.1007/s00701-018-3619-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022]
Abstract
Perineural spread has been described in multiple neoplasms of neural and non-neural origin. The peripheral nervous system may represent a highway by which tumors can spread throughout the body. Malignant peripheral nerve sheath tumor (MPNST) is a neoplasm arising from peripheral nerves with high rates of local recurrence and distant metastases, leading to a poor 5-year overall survival. In many cases, the optimal treatment involves wide en bloc excision with negative margins as well as chemotherapy and radiation. Even in cases of negative surgical margins, recurrence rates are high, suggesting possible skip lesions or very distant infiltration along the involved nerve. We report a case of high-grade MPNST of the sciatic nerve with post-mortem dissection and histopathologic characterization of perineural spread of microscopic disease to sites significantly proximal and distal to areas with evidence of gross disease, which may help to explain the high rates of local and distal recurrence in MPNST.
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Affiliation(s)
- Ross C Puffer
- Department of Neurosurgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
| | - Tomas Marek
- Department of Neurosurgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Jonathan J Stone
- Department of Neurosurgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | | | | | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
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Perineural Spread of Nonmelanoma Skin Cancer to the Brachial Plexus: Identifying Anatomic Pathway(s). World Neurosurg 2018; 114:e818-e823. [DOI: 10.1016/j.wneu.2018.03.092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/11/2018] [Accepted: 03/12/2018] [Indexed: 11/20/2022]
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