Case ReportPerineural spread of squamous cell carcinoma: From skin to skin through the brachial plexus
Introduction
Perineural spread is an alternative to the more common hematogenous or lymphogenous form of tumor spread. Perineural spread is most frequently reported in head and neck cancers with only a few cases in upper limb nerves. We present a patient with a history of squamous cell carcinoma in the left arm who developed a left brachial plexopathy and subsequently other histologically similar lesions in the soft tissues and skin of the left shoulder. We hypothesize that all of the findings including the secondary lesions could be explained anatomically as perineural spread from the original site along small and major branches of the upper arm nerves to a distant site. Our theory is supported by high resolution imaging. Although perineural spread is frequently reported in squamous cell carcinoma, it has not been described as the mechanism for spread to skin at a distant site.
Section snippets
Case report
An 86-year-old left-handed man with a 5-year history of a subcutaneous nodule in the left mid anterolateral arm presented to our institution with a progressive left brachial plexopathy. Six weeks prior to presentation, the nodule was resected and diagnosed as squamous cell carcinoma.
Discussion
We present this case of neoplastic brachial plexopathy with perineural spread of skin squamous cell carcinoma to a distant skin site to illustrate an alternate mechanism of tumor spread. This is an important distinction from metastasis from either hematogenous or lymphangitic spread. We believe the mid arm skin lesion had perineural invasion (Fig. 2G) involved and propagated along the inferior lateral cutaneous nerve. The tumor then spread to the radial nerve, the posterior cord and axillary
Conclusion
We present a case of extensive perineural spread of squamous cell carcinoma from the arm to the brachial plexus and beyond to the spinal nerves and along the axillary nerve back to the skin. A similar extensive case of perineural spread of skin cancer back to the skin through the brachial plexus has not been reported previously.
Disclosure
The authors report no conflict of interest regarding work presented in this manuscript.
Patient consent and confidentiality
The patients have consented to the submission of the case reports to the journal.
This study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2000 and 2009.
Acknowledgement
S.C. is supported by European Regional Development Fund – Project FNUSA-ICRC (No. CZ.1.05/1.1.00/02.0123)
References (4)
Thieme atlas of anatomy
(2010)- et al.
Intradural metastasis to the cauda equina from carcinoma of the anus
Spine
(1995)
Cited by (9)
Perineural Spread of Nonmelanoma Skin Cancer to the Brachial Plexus: Identifying Anatomic Pathway(s)
2018, World NeurosurgeryCitation Excerpt :Imaging did not show any abnormalities.18 The pathway of spread in the case of cSCC previously published by our group6 was from a skin lesion of the arm (i.e., cSCC) along the lateral cutaneous nerve to the radial nerve, posterior cord, axillary nerve. and the rest of the brachial plexus.
Neuromuscular complications in cancer
2016, Journal of the Neurological SciencesCitation Excerpt :Due to the site of lymph nodes and the vicinity of the lung lower brachial plexus lesions are more frequent in neoplastic involvement [126]. Tumor infiltrations via the skin have been described [127]. The brachial plexopathy often presents with dull pain, and neuropathic components can be associated.
A rare case of acral cutaneous squamous cell carcinoma with multiple late cutaneous metastases and extensive neurotropic spread
2016, JAAD Case ReportsCitation Excerpt :Perineural invasion (PNI) is seen in approximately 5% of cutaneous squamous cell carcinomas (cSCC).1 The trigeminal and facial nerves are most commonly involved, and few cases of cSCC with clinical PNI outside of the head and neck are reported.2,3 We present a patient with a history of an excised left wrist cSCC and subsequent motor neuropathy of the left arm.
Perineural Invasion in Cutaneous Squamous Cell Carcinoma
2019, Actas Dermo-SifiliograficasDiagnostic value of proximal cutaneous nerve biopsy in brachial and lumbosacral plexus pathologies
2023, Acta Neurochirurgica