Intramedullary spinal cord metastasis to the cauda equina in a patient with HER2-positive metastatic breast cancer: A case report

The rate of metastasis to the central nervous system is high in human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer patients. Metastatic cauda equina tumors are characterized by rapid progression of symptoms, thus signifying the requirement of their early treatment. However, these tumors are rarely reported, and their optimal treatment options have not been established yet. Here, we report a case study of a patient with HER2-positive breast cancer that metastasized to the cauda equina. The patient underwent urgent surgery to relieve the spinal cord compression. The pain in her back and lower limbs was greatly reduced. Unfortunately, her ability to walk did not improve sufficiently. Overall, surgical treatment may be a favorable option to improve a patient's quality of life.

Plexus and peripheral nerve metastasis

Cancer in the form of solid tumors, leukemia, and lymphoma can infiltrate and metastasize to the peripheral nervous system, including the cranial nerves, nerve roots, cervical, brachial and lumbosacral plexuses, and, rarely, the peripheral nerves. This review discusses the presentation, diagnostic evaluation, and treatment options for metastatic lesions to these components of the peripheral nervous system and is organized based on the anatomic distribution. As skull base metastases (also discussed in Chapter 14) result in cranial neuropathies, these will be covered in detail, as well as cancers that directly infiltrate the cranial nerves. Particular emphasis is placed on the clinical, imaging, and electrodiagnostic features that differentiate neoplastic plexopathies from radiation-induced plexopathies. Neurolymphomatosis, in which malignant lymphocytes invade the cranial nerves, nerve roots, brachial and lumbosacral plexuses, and peripheral nerves, is a rare manifestation of lymphoma and leukemia. Diagnoses of neurolymphomatosis are often missed or delayed given its varied presentations, resulting in poorer outcomes. Thus this disease will also be discussed in depth.

Review of periorbital nerve enlargement and biopsy techniques

Periorbital nerve enlargement commonly indicates perineural invasion of malignancy or inflammatory conditions. This study reviews the role of supraorbital and infraorbital nerve biopsies in patients presenting with radiographic enlargement and to elucidate the surgical technique involved. A retrospective chart review (1997-2014) was performed at a single tertiary center. Patients with radiographic confirmation of enlarged supraorbital/infraorbital nerves that underwent biopsy were included. Charts were reviewed for: patient demographics and history, clinical symptoms and findings, radiographic findings, surgical method, and treatment. Five patients (4 female, 1 male) met inclusion criteria. Average age was 72.4 years (range 36-90). Four patients had history of cutaneous malignancy. All presented with diplopia and/or dysesthesias. Clinical examination confirmed decreased V1 and/or V2 sensation for 4 patients. Imaging revealed enlargement of V1, V2, and/or V3 in all patients. Infraorbital nerve biopsies were performed in 3 patients via transconjunctival fornix-based orbitotomy with subperiosteal dissection along orbital floor followed by unroofing of infraorbital canal. The remaining 2 underwent supraorbital nerve biopsy via sub-brow incision onto superior orbital rim with reflection of periosteum. Biopsies confirmed squamous cell carcinoma(3), mucoepidermoid carcinoma(1), and idiopathic orbital inflammation(1). Three patients initiated treatment in <1 month. One decided to follow-up closer to home, one was lost to follow-up. For patients presenting with enlarged supraorbital/infraorbital nerves, biopsy can rapidly confirm the underlying condition and facilitate early treatment. A sub-brow approach offers direct access to supraorbital nerve while transconjunctival fornix-based anterior orbitotomy with canal unroofing allows access to infraorbital nerve.

Inhibition of NF-kappa B pathway leads to deregulation of epithelial-mesenchymal transition and neural invasion in pancreatic cancer

NF-κB has an essential role in the initiation and progression of pancreatic cancer and specifically mediates the induction of epithelial-mesenchymal transition and invasiveness. In this study, we demonstrate the importance of activated NF-κB signaling in EMT induction, lymphovascular metastasis, and neural invasion. Modulation of NF-κB activity was accomplished through the specific NF-κB inhibitor (BAY 11-7085), triptolide, and Minnelide treatment, as well as overexpression of IKBα repressor and IKK activator plasmids. In the classical lymphovascular metastatic cascade, inhibition of NF-κB decreased the expression of several EMT transcription factors (SNAI1, SNAI2, and ZEB1) and mesenchymal markers (VIM and CDH2) and decreased in vitro invasion, which was rescued by IKK activation. This was further demonstrated in vivo via BAY 11-7085 treatment in a orthotopic model of pancreatic cancer. In vivo NF-κB inhibition decreased tumor volume; decreased tumor EMT gene expression, while restoring cell-cell junctions; and decreasing overall metastasis. Furthermore, we demonstrate the importance of active NF-κB signaling in neural invasion. Triptolide treatment inhibits Nerve Growth Factor (NGF) mediated, neural-tumor co-culture in vitro invasion, and dorsal root ganglia (DRG) neural outgrowth through a disruption in tumor-neural cross talk. In vivo, Minnelide treatment decreased neurotrophin expression, nerve density, and sciatic nerve invasion. Taken together, this study demonstrates the importance of NF-κB signaling in the progression of pancreatic cancer through the modulation of EMT induction, lymphovascular invasion, and neural invasion.

Stromal-derived factor-1α/CXCL12-CXCR4 chemotactic pathway promotes perineural invasion in pancreatic cancer

Perineural invasion (PNI) is considered as an alternative route for the metastatic spread of pancreatic cancer cells; however, the molecular changes leading to PNI are still poorly understood. In this study, we show that the CXCL12/CXCR4 axis plays a pivotal role in the neurotropism of pancreatic cancer cells to local peripheral nerves. Immunohistochemical staining results revealed that CXCR4 elevation correlated with PNI in 78 pancreatic cancer samples. Both in vitro and in vivo PNI models were applied to investigate the function of the CXCL12/CXCR4 signaling in PNI progression and pathogenesis. The results showed that the activation of the CXCL12/CXCR4 axis significantly increased pancreatic cancer cells invasion and promoted the outgrowth of the dorsal root ganglia. CXCL12 derived from the peripheral nerves stimulated the invasion and chemotactic migration of CXCR4-positive cancer cells in a paracrine manner, eventually leading to PNI. In vivo analyses revealed that the abrogation of the activated signaling inhibited tumor growth and invasion of the sciatic nerve toward the spinal cord. These data indicate that the CXCL12/CXCR4 axis may be a novel therapeutic target to prevent the perineural dissemination of pancreatic cancer.

Is T-stage the only significant factor determining the extent of surgery for gallbladder cancer?

BACKGROUND/AIMS

T-stage is currently the only factor determining the extent of surgery of gallbladder cancer (GBCA). We hypothesized that perineural invasion could be another predictive factor determining the extent of surgery because it is very powerful prognostic factor for GBCA.

METHODOLOGY

A retrospective analysis was carried out of patients who underwent operation for gallbladder cancer between February 1991 and November 2011. The data were retrospectively analyzed and reviewed and the microscopic findings were checked by a pathologist.

RESULT

Simple and extended cholecystectomy was performed in 82 patients during the study period. In univariate analysis, CA 19-9 level, gross type, depth of invasion, lymph node metastasis, distant metastasis, perineural invasion, lymphatic invasion and vascular invasion were associated with survival (P < 0.05). In multivariate analysis, perineural invasion and vascular invasion had an impact on survival (P < 0.05).

CONCLUSIONS

T and N stage are powerful prognostic factor for GBCA, but perineural invasion and vascular invasion are also significant prognostic factors. To improve survival radical resection should be considered in early GBCA with perineural and vascular invasion.

A prospective evaluation of the clinical, histologic, and therapeutic variables associated with incidental perineural invasion in cutaneous squamous cell carcinoma

BACKGROUND

The prognosis and management of incidental perineural invasion (PNI) in patients with cutaneous squamous cell carcinoma (CSCC) has not been well defined.

OBJECTIVE

We sought to investigate the clinical, histologic, and treatment characteristics associated with incidental PNI, histologic PNI extending beyond the tumor bulk, in patients with CSCC.

METHODS

We conducted a multicenter prospective analysis of patients with CSCC undergoing Mohs micrographic surgery.

RESULTS

The incidence of PNI was 4.6% in 753 CSCC cases. PNI was significantly associated with tumors of the head and neck (P = .039), larger tumor diameter (P < .001), presence of clinically palpable lymphadenopathy (P = .012), and recurrent (P < .001) and painful (P < .001) tumors. Further, PNI was significantly associated with poor tumor differentiation (P < .001), greater tumor thickness (P < .001), a greater number of Mohs stages (P < .001), and larger estimated maximum Mohs margin (P < .001) required to clear the tumor.

LIMITATIONS

The low numbers of patients demonstrating incidental PNI limits this study.

CONCLUSIONS

The association of incidental PNI with clinicopathological indicators of poor prognosis suggests that incidental PNI may serve as a marker to improve the precision in the prognostic assessment of patients with CSCC.

Surgical treatment options and management strategies of metastatic renal cell carcinoma to the lumbar spinal nerve roots

Spinal nerve root metastasis of renal cell carcinoma is a rare occurrence. In addition to treatment of the primary lesion, surgical resection of the nerve root metastasis, occasionally with sacrifice of the involved nerve, is the accepted standard of treatment. Resection often resolves presenting motor and pain symptoms due to relief of neural compression. We describe two patients with nerve root metastasis of renal cell carcinoma and their management. While locally advanced and metastatic renal cell carcinoma has been shown to be chemo- and radio-resistant, immunotherapy is a promising treatment. Given the high prevalence of systemic disease in patients with intradural metastases, systemic (and possibly intracranial) imaging can be used to identify other potential areas of disease.

Surgical treatment of spinal intradural carcinoma metastases

BACKGROUND

Intradural metastases of nonneurogenic origin represent an extremely rare manifestation of systemic cancer. The respective literature is very scarce.

METHODS

We retrospectively evaluated nine patients with intradural metastases treated surgically from March 2006 until today at our department.

RESULTS

Four metastases were intramedullary and five intradural extramedullary. Localisation along the spine involved: cervical n = 3, thoracic n = 3, and conus/cauda n = 3. Five patients were female and four male, with a median age of 71 years. Histology showed: breast cancer n = 2, NSCLC (non-small cell lung cancer) n = 2, SCLC (small cell lung cancer) n = 1, colon carcinoma n = 1, malignant skin melanoma n = 1, squamous cell carcinoma of the skin n = 1, and ovarian carcinoma n = 1. Holospinal dissemination in terms of leptomeningeal carcinomatosis according to MRI or positive CSF (cerebrospinal fluid) cytology, respectively, was found in four patients. Gross total resection was achieved in four patients and debulking in five. Results of surgical decompression were: six patients (67%) exhibited immediate improvement of neurological symptoms and/or pain; four of them even improved according to the McCormick Scale score (44%); two patients (22%) were unchanged, and one (11%) exhibited worsening of neurological symptoms after surgery. Median survival time after surgery was 7.3 months.

CONCLUSIONS

Intradural metastases are associated with limited survival time. Accordingly, the aim of surgery is strictly palliative. The majority of patients benefit with respect to neurological deficit/pain (67%) independent of the extent of resection. Thus, decompressive surgery is recommended to increase the quality of life.

Perineural invasion and associated pain in pancreatic cancer

Perineural invasion (PNI) is a prominent characteristic of pancreatic cancer. PNI is a process whereby cancer cells invade the surrounding nerves, thus providing an alternative route for metastatic spread and pain generation. PNI is thought to be an indicator of aggressive tumour behaviour and has been shown to correlate with poor prognosis of patients with pancreatic cancer. Recent studies demonstrated that some signalling molecules and pathways that are involved in PNI are also involved in pain generation. Targeting these signalling pathways has shown some promise in alleviating pain and reducing PNI, which could potentially improve treatment outcomes for patients with pancreatic cancer.

Surgical treatment of rare cauda equina tumours

BACKGROUND

Cauda equina tumours (CET) are rare and usually benign. Treatment of schwannomas and benign ependymomas, which are the most frequent histopathological types of CET, is now well established. However, management of other presumed histopathological types of CET is still a matter of debate. The aim of this study was to assess the incidence and the surgical treatment of rare CET.

METHOD

A retrospective study was carried out on 176 adult patients surgically treated for CET in our two departments from 1994 to 2010. We reviewed pre- and postoperative symptoms, magnetic resonance imaging aspects, surgical findings, outcome including operative neurological morbidity, local recurrence rate and operative mortality, and incidence of rare CET.

FINDINGS

Seventeen percent (30 patients) of CETs operated on were neither schwannomas nor benign ependymomas. Half of these cases were benign tumours, with paragangliomas being the most common. Two patients were in poorer clinical condition after surgery, one patient experienced a local recurrence, and one died following surgery, from the progress of his disease (Von Hippel-Lindau disease). The other half were malignant tumours, with metastases being the most common. One third of the patients were worsened by surgery, and the mortality rate was 1/3 at 8 months (1-27 months).

CONCLUSIONS

Roughly one in six CET were neither schwannomas nor benign ependymomas. This study demonstrated the efficiency of surgery for rare benign CET with a low local recurrence rate. Surgical treatment of rare malignant CET led to a high rate of increased postoperative neurological deficit in patients with a reduced life expectancy.

Perineural invasion in pT3N0 rectal cancer: the incidence and its prognostic effect

BACKGROUND

The authors' purpose was to explore the incidence and prognostic significance of perineural invasion (PNI) in pT3N0 rectal cancer.

METHODS

Pathologic materials from resected specimens of 173 patients with pT3N0 rectal cancer were retrospectively collected. PNI-positivity was categorized into 2 groups: surrounding the nerve sheath (SS-PNI) and invading through the nerve sheath (TS-PNI). The rate of PNI-positivity was compared with PNI as initially recorded in the original reports. Patients' outcome was studied in groups with different PNI status, and multivariate analysis was performed to determine its prognostic value.

RESULTS

In this retrospective analysis, PNI-positivity was found in 24.3% of all cases, in which SS-PNI and TS-PNI were 11% and 13.3%, respectively, and was related to lymphovascular invasion. Only 7.5% of patients' specimens were reported as PNI-positive in the original reports. Detection of SS-PNI was likelier to be missed than TS-PNI. The rates of local recurrence, disease-free survival, and overall survival at 5 years were similar between the groups of SS-PNI and TS-PNI. The 5-year local recurrence rate was more than 2.5-fold higher in the PNI-positive group compared with the PNI-negative group (22.7% vs 7.9%, respectively; P = .017). Multivariate analysis proved that PNI-positivity was the only independent risk factor for predicting 5-year local recurrence rate, whereas only sampled lymph nodes was related to 5-year disease-free survival and overall survival.

CONCLUSIONS

PNI is a common pathologic feature in rectal cancer. The definition of PNI should include SS-PNI and TS-PNI. Rectal cancer patients who are PNI-positive are at higher risk of local recurrence and should be considered for more intensive treatment.

Adenocarcinoma of the prostate involving the lumbosacral plexus: MRI evidence to support direct perineural spread

BACKGROUND

Prostate adenocarcinoma, which may recur despite aggressive treatment, has the potential to spread to the lumbosacral plexus. This intraneural involvement is not widely known and is thought to be from direct perineural spread. We hypothesized that high-resolution imaging could provide supportive evidence for this mechanism.

METHODS

The clinical data and imaging studies (magnetic resonance imaging, MRI, and positron emission tomography/computed tomography, PET/CT) of patients evaluated at our institution between 2004 and 2009 for lumbosacral plexopathy due to intraneural prostate carcinoma were retrospectively reviewed.

RESULTS

Four patients presenting with painful lumbosacral plexopathy were found to have intraneural lumbosacral prostate adenocarcinoma. Two patients had involvement of the lumbosacral plexus ipsilateral to the lobe of the prostate most involved with adenocarcinoma at prostatectomy. High-resolution MRI and PET/CT studies revealed similar findings: abnormal soft tissue signal was followed from the prostate (n = 1) or prostatic bed (n = 3) area along the expected course of the pelvic plexus to the level of the sciatic notch, where it involved the sacral spinal nerves and sciatic nerve. Imaging findings were consistent with neoplastic infiltration, which was confirmed at biopsy in three patients.

CONCLUSIONS

The potential for prostate adenocarcinoma to spread to the lumbosacral plexus has, to our knowledge, not been readily appreciated. Because the imaging findings are often subtle, we believe that intraneural lumbosacral plexus involvement may not be uncommon. This study, with the use of high-resolution MRI and PET/CT studies, supports the direct perineural spread of prostate adenocarcinoma via the pelvic plexus to the lumbosacral plexus. This mechanism could also explain cases of leptomeningeal and/or dural-based prostate metastases.

[Multiple gliosarcoma metastases in the cauda equina roots]

The authors report a rare a case of gliosarcoma metastases in a 28-year-old male patient. The cauda equina roots were involved after brain tumor 16 months ago, which, on microscopic study, had a biphasic pattern and heterogeneous staining in the reaction with antibody to GFAP and vimentin; the tumor cells did not express EMA, EA, and desmin. Gliosarcoma was diagnosed, by taking into account morphological and immunohistochemical data. Tumor tissue of the cauda equine roots had the same immunophenotype as the brain tumor with a predominance of glial component, which permitted the source of metastases to be ascertained.

Large cell neuroendocrine carcinoma of the lung metastatic to the cauda equina

BACKGROUND CONTEXT

Large cell neuroendocrine carcinoma of the lung is an aggressive tumor with unique histopathological features. It is not known to metastasize to the spine.

PURPOSE

To report a metastatic case of this rare tumor to the cauda equina.

STUDY DESIGN

Case report.

METHODS

Retrospective case review and review of the literature.

RESULTS

The authors report a rare case of a large cell neuroendocrine lung metastasis to the lumbar spine, causing right foot drop. Magnetic resonance imaging revealed a heterogeneously enhancing intradural extramedullary mass at L2/L3 level compressing the surrounding nerve roots. During surgery, the identified nerve roots were encased by the tumor, and the dissection was tedious. Postoperatively, the patient reported significantly improved back pain and he had severe foot weakness. The functional outcome was poor because the patient lost entirely his foot function; however, his back pain improved significantly after surgery.

CONCLUSIONS

This is the first published study in which the authors described a metastasis of a rather uncommon lung cancer to the cauda equina. When a lesion of the cauda equina presents with a rapid progressive neurological deficit, leptomeningeal metastasis should be in the differential diagnosis.

[Cauda equina relapse after autologous stem cell transplantation in a patient with primary plasma cell leukemia]

We report a rare case showing involvement with the cauda equina after autologous peripheral blood stem cell transplantation for primary plasma cell leukemia (PCL). A 55-year-old man was diagnosed with PCL(IgA-k type, stage III)in November of 2006. He was treated with VAD chemotherapy consisting of vincristine, doxorubicin, and dexamethasone. After achieving hematological remission, he received tandem high-dose melphalan supported by autologous peripheral blood stem cell transplantation. Five months after his second transplant, he complained of lumbago and bilateral leg pain. M-protein and Bence-Jones protein were not detected in serum or urine. An axial magnetic resonance imaging study revealed enlargement of the cauda equina nerve roots on T-1 weighted image. A sagittal T-1 weighted gadolinium-enhanced imaging study showed hyperintensities along the cauda equina. Leptomeningeal enhancement was also seen below the level of Th6. A cytological examination of the cerebrospinal fluid (CSF) with May-Giemsa stain showed atypical plasma cells. Immunoelectrophoresis of the CSF revealed monoclonal IgA-k type protein. A diagnosis of central nervous system (CNS)relapse was made. The patient died of pneumonia two months after relapse. It should be kept in mind that CNS relapse can occur during hematological remission in patients with multiple myeloma including PCL.

Partial ulnar nerve transfer to the nerve to the biceps for the treatment of brachial plexopathy in metastatic breast carcinoma: case report

Brachial plexus neuropathy can cause progressive pain and disability in patients with breast cancer. Metastatic spread and radiation injury are the most common causes in these patients. We report a case of partial ulnar nerve transfer to the nerve to the biceps muscle to restore elbow flexion in a patient with combined radiation-induced and metastatic brachial plexopathy.

[Non-incidental papillary microcarcinomas of the thyroid]

The clinical significance of papillary microcarcinoma of the thyroid gland keeps being controversial. Its high prevalence in autopsies and as incidental findings in thyroidectomy specimens for benign pathology indicate an indolent clinical behavior. Nevertheless some of the microcarcinomas develop lymph node metastasis and local recurrence. To determine the clinical and pathological characteristics of non-incidental papillary microcarcinomas of the thyroid (PTM -NI). 18 patients with diagnosis of non-incidental papillary microcarcinoma (tumor < or = 1 cm) with nodular expression in the thyroid gland or with lymph node metastasis have been studied. Initial diagnosis, prediction factors and evolution have been evaluated. Of 18 patients with PTM-NI, 12 demonstrated lymph node metastasis. 6 patients had positive fine needle aspiration (FNA) of palpable thyroid nodules. Multifocality and extraglandular extension were associated with lymph node metastasis. Seven of the nine metastatic lymph nodes diagnosed by FNA were cystic. Histologically 83.3% of the nodules in the thyroid were non-encapsulated and showed papillary growth pattern. Multifocality and extrathyroid infiltration were associated with lymph node metastasis at presentation. 46% of the patients with thyroid nodules > or = 4 mm and lymph node involvement (N1) showed recurrence/persistence. The non-incidental intrathyroideal papillary microcarcinoma without capsular involvement, extraglandular extension or lymph node metastasis (N0) did not demonstrate recurrence. These results suggest two groups of non- incidental papillary microcarcinoma of the thyroid (PMT-NI), one intraglandular without risk of evolution -N0- and other extraglandular at risk of recurrence -N1-.

Salvage lymphadenectomy of the right recurrent nerve node with tracheal involvement after definitive chemoradiation therapy for esophageal squamous cell carcinoma: report of two cases

Thoracic esophageal cancers frequently metastasize to the right recurrent nerve nodes (RRNNs). In fact, huge RRNNs invading the trachea sometimes remain after definitive chemoradiation therapy (CRT), despite complete remission of the primary lesion. We performed salvage lymphadenectomy of a large RRNN combined with partial resection of the trachea in two patients. Using an anterior approach, we removed part of the sternum, clavicle, and the first and second costal cartilage; then, we removed the RRNNs with combined resection of the lateral quarter circumference of the trachea, the esophageal wall, and the recurrent nerve. Reconstruction was done with a musculocutaneous patch of major pectoral muscle to cover the tracheal defect. The only minor complication was venous thrombosis in one patient. Thus, combined removal of the RRNN and trachea was performed safely as a salvage operation after definitive CRT for esophageal squamous cell carcinoma.

[Olfactory neuroblastoma with spinal metastasis: case report]

Olfactory neuroblastoma is a rare tumor of the nasal cavity. It is a locally aggressive tumor with local recurrence, and distant metastasis occurs in 22-40% of patients. We report a case of olfactory neuroblastoma with cauda equina metastases. A 49-year old male had undergone surgery twice previously; the first for olfactory neuroblastoma in October, 1990, and the second for its intracranial and orbital metastasis in September, 1999. He complained of lumbago in autumn, 2005 and MRI showed two enhanced lesions in the cauda equina. The mass was partially removed and histologically diagnosed as olfactory neuroblastoma metastasis. Whole-spine irradiation of 32 Gy and lumber-spine irradiation of 10 Gy were performed. The mass at L2/3 was disappeared after the irradiation although the mass at L4/5 was not changed in size. The patient was discharged without neurological deficit and is now kept under observation as an outpatient. Olfactory neuroblastoma with spinal metastasis is rare and only 11 cases have been reported in the literature. A very poor prognosis was observed in the patients of olfactory neuroblastoma with spinal metastasis. Olfactory neuroblastoma is a radiosensitive tumor, and radiotherapy for spinal metastasis was reported to be effective. However, effectiveness of chemotherapy was still uncertain. The patient with olfactory neuroblastoma should be observed carefully even though no local recurrence had been detected over 10 years. Radiotherapy and further treatment including chemotherapy should be considered in case of spinal metastasis.

Metastatic hemangiopericytoma to the cauda equina: a case report

BACKGROUND CONTEXT

Hemangiopericytoma is an aggressive tumor associated with high recurrence and metastasis. Metastases are usually delayed, long after diagnosis of the primary lesion. Metastatic hemangiopericytoma to the spinal cord is especially rare.

PURPOSE

To report a rare clinical presentation of a metastatic intradural, intramedullary hemangiopericytoma to the cauda equina from a cerebellar hemangiopericytoma.

STUDY DESIGN

Case report with a review of the literature.

METHODS

Clinical history, physical findings, and magnetic resonance imaging studies of a patient with a metastatic intradural, intramedullary hemangiopericytoma to the cauda equina are reported.

RESULTS

A case report is presented of a female with an intradural, intramedullary lesion at the L4-S1 level, presenting initially with progressive pain and motor weakness affecting the left lower extremity. She had a history of a cerebellar hemangiopericytoma, which had been treated with total resection and radiotherapy 4 years earlier. This patient developed urinary urgency and frequency. Pathological analysis revealed a hemangiopericytoma, which had a similar character to a cerebellar lesion. After radiotherapy, the tumor was mostly diminished and her symptoms totally resolved.

CONCLUSIONS

Hemangiopericytomas have a strong tendency to both local recurrence and metastasis. Common metastatic sites are the skeletal system, lung, liver, and abdominal cavity. To the authors' knowledge, there have been no reports of spinal intradural, intramedullary metastasis of hemangiopericytoma.

Spinal metastasis of occult lung carcinoma causing cauda equina syndrome

Cauda equina syndrome (CES) may be caused by tumor, herniated disc, trauma and spinal infections. However, CES due to occult lung cancer has not been reported in the literature. A 50-year-old man presented with a subacute CES caused by an intradural metastasis of an adenocarcinoma of the lung to the lumbosacral cauda fibers. His lumbosacral magnetic resonance imaging (MRI), showed a well-demarcated, intradural extramedullary mass lesion resembling a neurinoma at the L4/5 level. The patient underwent an L4-L5 laminectomy. The operative findings were also suggestive of neurinoma with involvement of three nerve roots, and a well-demarcated tumor without infiltration into the subarachnoid space. Although the findings of the operation were suggestive of neurinoma, final pathological diagnosis revealed metastatic carcinoma. Immunohistochemistry revealed clear cell adenocarcinoma metastasis. Chest X-ray and high resolution contrasted pulmonary computed tomography were normal. Positron emission tomography (PET) showed a lung mass, at the left apex. The patient was treated with chemotherapy and post-operative spinal radiotherapy was also performed. The CES resolved after the operation and the patient was followed up for 2 years with no recurrence. MRI of intradural cauda equina metastasis may be similar to that of intradural nerve sheath tumor. Surgery and postoperative radiotherapy may be effective for the treatment of CES due to lung carcinoma. Definitive diagnosis is by histopathological examination with immunohistochemistry. If the primary cancer cannot be detected by conventional radiological techniques, PET may be helpful.

Perineural invasion in prostatic carcinoma treated with radical prostatectomy: the role of TR systematic biopsy

Perineural invasion (PNI) is a morphological entity which has been known for many years, though its significance in prostatic neoplasms has only been studied recently. Therefore, we tried to assess, with the help our experience, its presence and its significance. Ninety-four patients, aged between 49 and 74 (average 65.8)--with a PSA between 2.69 and 52 ng/ml (average 11.44)--underwent RP for prostatic carcinoma; 58 patients had stage T2 and 36 had T3. 48 patients had Gleason 7 or higher, and 46 had G 6 or lower. Fifty patients (53,1%) were PNI+ and 44 (46,9%) PNI-. Between the two groups there was no significant difference as to age (1" group: average age 67 years; 2nd group: 68) and PSA (1st group: average 9.73 ng/ml, 2nd group: average 8,17) (Z 0,639). The distribution according to the stage showed that 24 patients (48%) PNI+ were T2 and 26 (52%) PNI+ T3, 34 (77.2%) PNI- T2 and 10 (22%) PNI- T3 and therefore 72,23% of the T3's were PNI+ and 41.3% of the T2's were PNI+; 34 patients (70.8%) with G>7 were PNI+ and 14 (29.16%) PNI-, 16 patients (34,78%) with G<6 were PNI+ and 30 (65.2%) PNI-. Among the PNI+ 50 patients, 36 had undergone biopsy in our hospital, and therefore we re-examined the operation tissue and found out that 16 (44%) were biopsy PNI+ while for 22 (55.5%) it was not possible to assess the PNI on the biopsy tissue. PNI is an important morphological element in the staging of prostatic cancer and is connected with the disease negative prognostic factors: in fact, it can be traced with a high frequency in stage diseases and higher Gleasons. It does not seem to be connected with PSA, above all for values between 4 and 20 ng/ml. We think that a very important element to be stressed is the fact that this condition is not always detected with biopsy (about 45%) and this does not allow, in such cases, an adequate therapy plan. Also our experience seems to confirm that, therefore, in spite of the above said limits, it is advisable to search PNI both with biopsy--in order to have a further prognostic element and therefore arrange the most suitable therapy plan--and on the surgery piece, in order to better determine the biological nature of the disease and to be able to suggest adequate integrative therapies.

Peripheral nervous system involvement in patients with cancer

Involvement of the peripheral nervous system (PNS) is common in patients with cancer and any part, including motor neurons, sensory ganglia, nerve roots, plexuses, cranial and peripheral nerves, and neuromuscular junctions, can be affected. Different mechanisms can initiate damage associated with cancer-related PNS disorders. These include tumour infiltration, toxicity of treatments, metabolic and nutritional perturbations, cachexia, virus infections, and paraneoplastic neurological syndromes. The type of cancer, lymphoma, or solid tumour is a further determinant of a PNS disorder. In this Review we discuss the different causes and mechanisms of disorders of the PNS in patients with cancer and we will focus on their assessment and diagnosis.

Preoperative diagnosis of extrapancreatic neural invasion in pancreatic cancer

BACKGROUND & AIMS

Pancreatic cancer recurs in most patients after resection with curative intent. Recurrence is particularly common in patients with extrapancreatic neural invasion (EPNI), the presence of which correlates with poor prognosis. Macroscopic EPNI may be detected with conventional noninvasive imaging and endoscopic ultrasound (EUS) imaging, but microscopic EPNI has required postoperative pathologic examination of surgical specimens. We report the preoperative diagnosis of cancer infiltration into celiac ganglia. We hypothesized that microscopic pancreatic cancer metastasis to neural ganglia can be detected by EUS-guided biopsy examination.

METHODS

We performed a retrospective review of patients with pancreatic cancer undergoing EUS in whom celiac ganglia were sampled to exclude malignant infiltration.

RESULTS

Six patients with pancreatic cancer underwent EUS-guided fine-needle aspiration or trucut biopsy examination of presumed celiac ganglia. Metastatic cancer was found in ganglia of 2 patients. Specimen review identified adenocarcinoma and neural tissue in the absence of lymphocytes. At laparoscopy, 1 of the 2 patients with positive celiac biopsy specimens also had several unexpected peritoneal metastatic deposits. The other patient was considered to have locally advanced unresectable disease. Both patients are receiving supportive care.

CONCLUSIONS

EPNI may be shown preoperatively in patients with pancreatic cancer using EUS-guided sampling of celiac ganglia. A preoperative diagnosis of EPNI has the potential to improve staging accuracy and patient outcomes.

Endoneural metastasis of the sciatic nerve disclosing the relapse of a renal carcinoma, four years after its surgical treatment

METHODS

To report on an exceptional case of renal metastasis. Indeed, endoneural metastases of peripheral nerves are thought to be exceptional, and such an event has not yet been ascribed to a renal carcinoma.

RESULTS

We report on a sciatica leading to the discovery of a tumour of the right thigh which proved to be an endoneural metastasis of the sciatic nerve from a renal carcinoma surgically removed 4 years before.

CONCLUSION

A thorough palpation of peripheral nerve can help recognise such metastases in patients previously diagnosed with renal carcinoma.

Atypical fibroxanthoma with perineural or intraneural invasion: report of two cases

We report two cases of atypical fibroxanthoma (AFX) that both had the previously unreported feature of neural invasion (one perineural and the other intraneural). AFXs recur in approximately 10% of cases but only rarely metastasize. Features associated with recurrence are inadequate excision and invasion into fat. Features associated with metastasis include recurrence, vascular invasion, deep tissue invasion, and tumor necrosis. Both of these tumors invaded deeply into subcutaneous fat and reached the deep fascia. Some authors would regard such cases as malignant fibrous histiocytoma (MFH) because of such deep extension; however, the concept of AFX as a superficial variant of MFH is outmoded--AFX is a distinct clinicopathologic entity with established clinical, histological, and immunohistochemical features.

Lymphatic, blood vessel and perineural invasion identifies early-stage high-risk radically resected gastric cancer patients

The availability of different treatment options for radically resectable gastric cancer reopened the question of treatment selection and correct definition of high-risk categories. Lymphatic, blood vessel and perineural invasion (LBVI/PNI) seem to possess the necessary potential to provide useful information for the clinical management of this disease. Seven hundred and thirty-four patients with advanced gastric cancer who underwent curative gastrectomy were analysed according to the presence of LBVI/PNI. Patients were divided into two groups: group A for patients with LBVI/PNI (189 patients 26%) and group B for patients without LBVI/PNI (545 patients, 74%). The disease-free survival (DFS) for patients in group A was 32.1 months, whereas it was not reached for patients in group B (P=0.0001); the median overall survival was 45.5 months for patients in group A, whereas it was not reached for patients in group B (P=0.0001). At multivariate analysis, the presence of LBVI/PNI appeared an independent prognostic factor for DFS and OS. Our results were confirmed in subgroup analysis, separately considering stage I and early gastric cancer patients with and without LBVI/PNI. Taken together, our findings suggest the importance of LBVI/PNI in gastric cancer as it may provide additional information for identifying patients at high risk, who may be candidates for further medical treatment after or before surgery.

Nerve growth factor and tyrosine kinase A in human salivary adenoid cystic carcinoma: expression patterns and effects on in vitro invasive behavior

PURPOSE

Perineural invasion is a frequent occurrence in salivary adenoid cystic carcinoma (ACC) and may prevent complete surgical resection. Studies have indicated that nerve growth factor (NGF) and its high-affinity receptor tyrosine kinase A (TrkA) may play a role in perineural invasion in several malignancies in which perineural invasion is observed. The present study was conducted to investigate the expression of NGF and TrkA in salivary ACC and to examine the effects of NGF on adhesion, migration and invasion capacities of a salivary ACC cell line (SACC-83) in vitro.

PATIENTS AND METHODS

Expression of NGF and TrkA was explored using immunohistochemistry in paraffin-embedded tissues of 32 cases of salivary ACC. The effects of NGF on in vitro adhesion, migration, and invasion capacities of the SACC-83 cell line were examined using an MTT assay and a modified Boyden chamber assay respectively.

RESULTS

In ACC specimens, 31 (96.9%) and 32 (100%) tumors showed immunoreactivity for NGF and TrkA respectively. Significant correlations were found between NGF/TrkA expression levels and perineural invasion (P < .05). In cell adhesion assay, the percent adherences of SACC-83 cells co-cultured with 25 ng/ml NGF at 1.5 hours and 5, 25 ng/ml NGF at 6 hours were significantly higher than that co-cultured with 0 ng/ml NGF (P < .05). However, high concentration of NGF (500 ng/ml) resulted in a significant inhibition of invasion (P < .05).

CONCLUSION

Overexpression of NGF and TrkA in human salivary ACC tissues may constitute a reason for perineural invasion in salivary ACC.

Intraneural metastasis of a synovial sarcoma to a peripheral nerve

We describe a case of intraneural metastasis of a synovial sarcoma, the first published case of a metastasis of a soft-tissue sarcoma to a peripheral nerve.

Metastases to the peripheral nervous system

Cancer metastasis can affect any part of the nervous system. When the peripheral nervous system is involved, the usual targets are cranial nerves, nerve roots and plexi. However, peripheral nerves and muscles can also be affected by compression or infiltration of neoplastic cells. This review focuses in the diagnosis and treatment of metastatic complications of cancer involving plexi, peripheral nerves and muscles.

A xenograft nude mouse model for perineural invasion and recurrence in pancreatic cancer

OBJECTIVE

Pancreatic cancer recurrence after initially "curative" resection is an unresolved clinical problem in the management of patients with this disease. Perineural invasion correlates with and might be partially responsible for tumor recurrence and poor survival. However, no adequate preclinical animal model is yet available to study this aspect of pancreatic cancer biology.

METHODS

We modified our orthotopic xenograft model of pancreatic cancer in nude mice to develop a model for pancreatic cancer perineural invasion and recurrence.

RESULTS

After initial orthotopic transplantation, complete surgical resection of MIA PaCa-2 (undifferentiated) and Capan-2 (well-differentiated) tumors at 4, 6, and 8 weeks was attempted. All animals that had undergone tumor resection survived the operation. Animals that had the MIA PaCa-2 tumor resected after 6 weeks developed recurrent pancreatic cancer with local invasion and distant metastasis. Histological evaluation revealed extensive invasion of retroperitoneal nerves by the cancer cells.

CONCLUSION

Complete resection of orthotopically transplanted pancreatic cancer in nude mice leads to local tumor recurrence. This model may eventually prove valuable for studying the mechanisms of pancreatic cancer perineural invasion and recurrence.

Anaplastic oligodendroglioma presenting with drop metastases in the cauda equina

Metastatic involvement of the cerebro-spinal fluid (CSF) pathway in oligodendrogliomas is not uncommon; however, symptomatic involvement of the spinal cord is very rare: less of 10 cases have been published. To our knowledge, an intracranial oligodendroglioma presenting with symptoms of drop metastases in the cauda equina has never been reported. We report a case of 67-year-old woman who after 1 month of severe low back and legs pain developed symptoms of raised intracranial pressure. A spinal cord MRI showed multiple intradural nodular lesions at the level of the cauda equina, a MRI of the brain showed an intraventricular brain tumor. The histopathological diagnosis of both surgically treated lesions was anaplastic oligodendroglioma. The choices adopted in planning diagnostic and therapeutical procedures are discussed. The importance of the clinical and neuroradiological data in the diagnosis is stressed. Pathophysiology of the seeding of intracranial tumours via the cerebrospinal fluid is reviewed.

Case reports: fibrosarcoma metastatic to the sciatic nerve

Fibrosarcoma that metastasizes to the central nervous system has been documented in the literature. However, we know of no recorded case of spread to a major peripheral nerve. We report a unique occurrence of fibrosarcoma with metastatic involvement of the sciatic nerve, and a review of the literature.

Orbital Invasion by Periocular Basal Cell Carcinoma

OBJECTIVES

To present a large series of patients with orbital invasion by periocular basal cell carcinoma (BCC).

DESIGN

Retrospective, noncomparative, interventional case series.

PATIENTS

All cases diagnosed with orbital invasion by periocular BCC between January 1985 and July 2004 in 3 Orbital Units in Australia.

METHODS

The clinical records of all patients were reviewed.

MAIN OUTCOME MEASURES

Patients' demographics, clinical presentation, histologic subtypes, treatment modalities, recurrence rate, and tumor-related death.

RESULTS

There were 64 patients (49 males) with a mean age of 70+/-13 years. Most tumors (84.4%) were recurrent or previously incompletely excised, and the medial canthus was most frequently involved (56.2%). Signs suggestive of orbital involvement included a mass with bone fixation (35.7%), limitation of ocular motility (30.4%), and globe displacement (17.6%). There were no signs suggestive of orbital invasion in 35.7%. Most patients (51.6%) had infiltrative histologic findings, and perineural invasion was present in 19.3%. Treatment modalities were mainly exenteration alone or combined with radiotherapy. During a mean follow-up period of 3.6 years, 3 cases of recurrence (4.7%) were diagnosed. Only 1 patient (1.6%) died from tumor-related causes.

CONCLUSIONS

Orbital invasion by periocular BCC is an uncommon event that may be associated with significant ocular morbidity and, rarely, death. Because orbital invasion may often be clinically silent, clinicians need to be alert to the possibility in high-risk tumors and consider appropriate imaging. Surgical treatment with exenteration or excision, with or without radiotherapy, results in a low recurrence and mortality rate.

Neurological manifestations of neoplastic and radiation-induced plexopathies

Metastatic plexopathy is often a disabling accompaniment of advanced systemic cancer and may involve any of the peripheral nerve plexuses. Brachial plexopathy most commonly occurs in carcinoma of the breast and lung; lumbosacral plexopathy is most common with colorectal and gynecologic tumors, sarcomas, and lymphomas. Regardless of the location, neoplastic plexopathy is often characterized by severe, unrelenting pain. Later, weakness and focal sensory disturbances occur in the distribution of plexus involvement. In previously treated patients, the main differential diagnostic consideration is radiation-induced plexopathy. Treatment of metastatic plexopathy is palliative and includes radiotherapy to the tumor mass, chemotherapy, and symptomatic treatment. In selected cases, subtotal surgical resection of the tumor may be warranted. The response to therapy is modest and generally short-lived. Efforts should be made to provide adequate pain control, maximize remaining neurological function, and prevent complications of immobility produced by the neuromuscular dysfunction.

Disseminated enteropathy-type T-cell lymphoma: cauda equina syndrome complicating coeliac disease

A patient with coeliac disease developed a progressive cauda equina syndrome in the 2 months prior to his death, for which no cause could be identified. At post-mortem examination this proved to be due to disseminated enteropathy-type T-cell lymphoma. Although rare, disseminated enteropathy-type T-cell lymphoma should enter the differential diagnosis in any patient with coeliac disease developing new neurological signs.

Linear accelerator thalamotomy

BACKGROUND

The capability of performing functional radiosurgery lesions in the brain using a dedicated linear accelerator (LINAC) have not yet been demonstrated. This study evaluates modern LINAC technology for the creation of a sharp, small and functionally eloquent lesion in the thalamus.

METHODS

Three patients underwent thalamotomy using a dedicated linear accelerator to radiosurgery, 2 females and 1 male, ages were 52, 53, and 73 years. Two patients presented with unilateral poststroke central pain and 1 with unilateral upper extremity pain secondary to metastatic infiltration of the brachial plexus. Maximal doses varied from 150 to 200 Gy, delivered by a 5-mm diameter collimator and 5 to 8 noncoplanar arcs evenly distributed.

RESULTS

All patients gained substantial relief of their pain. They were able to reduce their medications and improve their activity levels. The patient with end-stage metastatic disease died of his malignancy 2 weeks after the treatment. One patient presented with recurrence of the pain 4 months after the treatment. No clinical complications were noticed.

CONCLUSIONS

A dedicated linear accelerator is able to perform a precise and circumscribed lesion in the thalamus for pain control. Moreover, it proved to be safe, because no complications were observed. For patients using chronic anticoagulant therapy or with severe disabilities caused by cardiac, pulmonary or malignant diseases, this technique represents an alternative of treatment to radiofrequency thalamotomy.

Gluteal muscular and sciatic nerve metastases in advanced urinary bladder carcinoma: case report

We present a case of gluteal muscular and sciatic nerve metastases from urinary bladder carcinoma. T2-weighted magnetic resonance images demonstrated diffuse swelling and an increase in the signal of the right gluteus maximus muscle without destruction of the original arrangement of muscular fibers. Further, remarkable thickening of the right sciatic nerve showing a relatively hypointense signal was detected. Postcontrast T1-weighted images showed strong enhancement of these structures. Fine-needle aspiration biopsy with ultrasonographic guidance confirmed metastatic carcinoma cells in the right gluteal muscle and the sciatic nerve. These radiologic findings may represent a rare pattern of metastasis from urinary bladder carcinoma.

Imagerie des complications neurologiques du carcinome bronchique

The natural history of bronchogenic carcinoma shows that 42% of patients are diagnosed with cancer-related neurological complications either at initial presentation or at follow-up that can be separated in 3 different categories: - locoregional involvement of cervicothoracic nerves (recurrent laryngeal nerves, phrenic and vagus nerves, brachial plexus and sympathetic cervical chains), - metastatic disease characterized by intracranial lesions (brain, meningeal, ependymal and pituitary metastases) and spinal (extradural, subarachnoid and medullary metastases) lesions, - paraneoplastic syndromes including limbic encephalitis, Lambert-Eaton syndrome and paraneoplastic cerebellar degeneration. These neurological disorders usually are associated with advanced cancer for which radical surgical management seldom is indicated. All imaging studies performed at the time of initial staging for bronchogenic carcinoma should therefore be carefully reviewed in order to detect signs that could suggest the presence of one or several neurological complications. The goals of this paper are to describe the clinical signs and to illustrate the imaging features of neurological complications related to bronchogenic carcinoma at conventional radiography, CT and MRI.