Case Report
Perineural spread of squamous cell carcinoma: From skin to skin through the brachial plexus

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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)

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