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Management of Metastatic Tumors Invading the Peripheral Nervous System

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Management of Metastatic Tumors Invading the Peripheral Nervous System Neurosurg Focus 22 (6):E14, 2007 Management of metastatic tumors invading the peripheral nervous system JOHN GACHIANI, M.D.,1 DANIEL H. KIM, M.D.,3 ADRIANE NELSON, M.D.,2 AND DAVID KLINE, M.D.1 Departments of 1Neurosurgery and 2Pathology, Louisiana State University Health Sciences Center; 3Department of Neurosurgery, Ochsner Clinic Foundation, New Orleans, Louisiana Object. The authors present the results of a retrospective review of 37 surgically treated metastases to nerve (malignant peripheral non–neural sheath nerve tumors). Tumor frequencies, presentations, management, and prognosis are discussed. Methods. Thirty-seven patients who were treated for metastases to nerve between 1969 and 2006 at the Louisiana State University Health Sciences Center were identified in a review of patient records. Notes regarding patient history and physical examination findings were reviewed to provide informa- tion on presenting symptoms and signs. Imaging and histopathological examination results were also reviewed. Cases were analyzed depending on the primary tumor and the location of metastasis. Results. There included 37 surgically treated lesions, 16 of which originated in the breast and 10 of which originated in the lung. In two cases melanomas had metastasized to nerve, and one tumor each had metastasized from the bladder, rectum, skin, head and neck, and thyroid, and from a primary Ewing sarcoma. There was a single lymphoma that had metastasized to the radial nerve and one chor- doma and one osteosarcoma, each of which had metastasized to the brachial plexus. Conclusions. The nervous system is involved in numerous ways by oncological process. Direct involvement of the peripheral nervous system occurs mostly from direct extension, although it occa- sionally occurs because of distant spread from the primary tumor to nerve. Surgical excision of the metastatic lesion with margins has been useful mostly in the control of pain. Nevertheless, patients eventually succumb to their primary malignancy. KEY WORDS • malignant tumor • metastasis to nerve • non–neural sheath nerve tumor peripheral nerve tumor OST MALIGNANCIES OF THE PNS result from metas- level of the infraclavicular brachial plexus results from tases from carcinomas and lymphomas, rather direct extension of the primary tumor. M than lesions originating in nerve such as neu- Meller et al.8 have defined true isolated nerve metasta- rosarcomas.1,6,9 Infiltration of the PNS can result from a sis as occurring when there is a histologically identified variety of mechanisms, including direct extension of the tumor beneath the nerve sheath and between the fascicles, tumor and lymphatic spread into adjacent noncompart- without disintegration of the nerve trunk structure and in mentalized locations. In addition, tumors can invade the the absence of neoplasm in the adjacent soft tissues and PNS through hematogenous seeding. It is therefore not regional lymph nodes. Such isolated nerve metastases are surprising that most of the described metastases to the less common than tumors extending to adjacent plexi. In PNS occur in plexi in proximal noncompartmentalized this paper, the term “nerve metastases” is intended to anatomical locations such as the supraclavicular areas, the include non–neural sheath tumors that are direct exten- axilla, the pelvic sacral area, and the groin.8 The supra- sions into adjacent plexi as well as true isolated metas- clavicular brachial plexus is commonly involved by tases. metastases from tumors invading the nearby lymph nodes, There are numerous case reports as well as series com- as in breast cancer. In contrast, metastasis to the axillary pilations of tumors metastatic to the PNS. The types of tumors involved include tumors of the breast, lung, rectum, bladder, head and neck, and thyroid, as well as lymphomas, Abbreviations used in this paper: LSUHSC = Louisiana State chordoma, melanoma, nonmelanoma skin cancers, and University Health Sciences Center; PNS = peripheral nervous sys- osteosarcomas. Osteogenic or soft-tissue sarcomas displace tem. or adhere to the nerve and encase it and in a few cases Neurosurg. Focus / Volume 22 / June, 2007 1 Unauthenticated | Downloaded 09/30/21 06:17 PM UTC J. Gachiani et al. FIG. 1. A T2-weighted MR image showing invasion of branches of the brachial plexus by metastatic carcinoma. actually invade the nerve. Lymphomas and melanomas FIG. 2. A T2-weighted MR image obtained in a patient with can metastasize and secondarily involve a nerve by epi- breast cancer showing extensive involvement of the right brachial neurial invasion or infiltration of the subperineurial zone, plexus from the level of the spinal roots to the cord elements. Note the interfascicular epineurium, and eventually the actual the sharp distinction from the lung, which suggests a breast lesion fascicle(s).7 rather than a Pancoast tumor. Clinical expression of PNS involvement in patients with cancer occurs in 1.7 to 16% of cases.1 The clinical picture varies depending on the mechanism by which the for all tumors of vascular origin to delineate the feeding PNS is affected by the metastatic process. The mechanism vessels and the tumor vascularity. Myelograms were eval- can involve compression or infiltration of the nerve, dele- uated when they had been obtained in cases of tumors near terious effects of treatment, and metabolic and nutritional the spinal cord or nerve roots. factors, which frequently accompany malignancies, as well The role of needle biopsies in the diagnosis of non–neu- as paraneoplastic processes. Irrespective of the underlying ral sheath nerve tumors remains controversial. We have pathophysiological processes, there is a common denomi- had patients referred to us after either core needle or fine nator in the clinical presentation of the patients: neu- needle biopsies of these lesions with deficits resulting from ropathy. The manifestations include intractable pain and the biopsy. We do not generally advocate the use of nee- loss of function of the muscles served by the affected dle biopsy in the diagnosis of PNS tumors. The introduc- nerves. The results of a previous analysis of the presenta- tion of a neural deficit would be unwelcome in cases of tion of patients with nerve metastases who were treated at benign tumors. In addition, tumors can be heterogeneous LSUHSC showed that patients presented primarily with with certain sections being representative of a less malig- pain and/or weakness irrespective of any previous treat- nant histological type while other parts have obvious ment.4 malignant characteristics. The sampling error from such Treatment of the primary tumor usually involves local needle biopsies can thus lead to unfavorable decision surgical excision, radiotherapy, and systemic intravenous making in the management of PNS tumors. It is also not chemotherapy. uncommon for needle biopsies to be nondiagnostic. As a result, over the years we have favored open resection of suspected nerve metastases, in which we attempt to resect Clinical Material and Methods the lesion while preserving neurological function. In this retrospective study, charts were reviewed and The imaging modality of choice in the evaluation of findings documented for 37 patients who underwent sur- nontraumatic pathological conditions of the brachial plex- gery for malignancies metastatic to the PNS, also known us is MR imaging. Wittenberg and Adkins,11 in their re- as malignant peripheral non–neural sheath nerve tumors view of the imaging findings in 104 cases of nontraumat- or nerve metastases. Physical and neurological examina- ic brachial plexopathy, found that the most common causes tions were performed to assess the size and location of the were radiation fibrosis (31% of cases), metastatic breast tumor, localized tenderness on palpation of the mass, the (24%), and primary or metastatic lung cancer (19%), with presence or absence of a Tinel sign, and neurological defi- other types of tumors accounting for just over 25% (Figs. 1 cits. Findings on CT scans and/or MR images were re- and 2). viewed to document each tumor’s location, margins, and Radiation fibrosis occurs 5 to 30 months after comple- relationship to adjacent structures. Patients with nerve me- tion of radiation therapy. Findings on MR images of dif- tastases also underwent a metastasis evaluation, which fuse thickening and enhancement of the brachial plexus included lung and abdominal CT scans and technetium without any focal mass suggest fibrosis. In addition T1- liver, spleen, and bone scans. Angiograms were obtained and T2-weighted images show changes similar to muscle, 2 Neurosurg. Focus / Volume 22 / June, 2007 Unauthenticated | Downloaded 09/30/21 06:17 PM UTC Surgical management of metastasis to nerve Fig. 4. Photomicrograph demonstrating intraneural invasion by FIG. 3. Photomicrograph showing perineural invasion by metastatic carcinoma. metastatic carcinoma. Electromyography was also performed in each patient. with radiation damage showing low signal on T2-weight- Histological diagnoses based on light microscopy studies ed images and early infiltration by tumor showing higher and at times electron microscopy studies and special stain- intensity.11 Both types of lesions can show variable amounts ing in difficult-to-diagnose cases were reviewed (Figs. 3 of enhancement, hence contrast usage does not necessari- and 4). As noted previously, electromyography can help in ly facilitate differentiation between the two types of le- differentiating radiation from tumor plexopathy, with radi- sions.
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