Perineural Spread of Squamous Cell Carcinoma Involving the Spinal Accessory Nerve in an Immunocompromised Organ Transplant Recipient

Abstract

BACKGROUND. Squamous cell carcinoma is the second most common cutaneous malignancy in humans, affecting approximately 200,000 people in the United States each year. In immunocompromised patients, squamous cell carcinoma is the most common skin cancer, and it also tends to behave more aggressively than in immunocompetent patients. OBJECTIVE. We describe an immunocompromised patient, previously treated for a squamous cell carcinoma of the left posterior shoulder, who subsequently developed a cord-like, intraneural metastasis of the spinal accessory nerve. RESULTS. The patient presented with a 3-month history of lancinating pain of the left neck and shoulder. He had been treated previously for a squamous cell carcinoma of the left posterior shoulder, which subsequently recurred twice. On examination, a cord-like mass was palpable along the path of the spinal accessory nerve. Given the aggressive nature of this patient's squamous cell carcinoma, surgical exploration was performed. Frozen-section analysis of the spinal accessory nerve and of the multiple supraclavicular nerves revealed perineural and intraneural squamous cell carcinoma. CONCLUSION. To our knowledge, this is the first reported case of a primary cutaneous squamous cell carcinoma of the trunk or extremity metastasizing to a cranial nerve.

Perineural Tumor Spread

“…18,19 PNS along other nerve routes has been reported in few patients. 20,21 Perineural tumor spread is usually antegrade (toward the central nervous system), but retrograde spread may also occur.…”

Cranial Neuropathy as a Presenting Sign of Recurrent Aggressive Skin Cancer

“…Histologic perineural spread is asymptomatic and may be an incidental finding, because the diagnosis is made only upon microscopic examination of the cutaneous neoplasm. Clinical perineural spread is a later finding, typically occurring after more extensive neural invasion and presenting with localized symptoms of parasthesias, weakness, or pain 30,31 . Indicative of advanced disease, clinically manifest neurotropism should warrant timely, aggressive patient workup.…”

Recurrent Squamous Cell Carcinoma Presenting as Facial Nerve Palsy in the Setting of Organ Transplantation

“…Skin cancers that spread to the perineural space many times express “skip” lesions throughout the nerve suggesting noncontiguous spread of the cancer along the nerves. Therefore, recurrence of these cancers is still likely after a resection with negative margins 12,14 . Patients experiencing symptoms of facial paresthesias commonly present to a neurologist.…”

“…A large number of the patients in their study developed recurrent cancer around the primary lesion after intense treatment. Aggressive therapy, however, is encouraged for patients with perineural invasion 7,14 . Large‐field radiation therapy (75 Gy) with an altered fractionation schedule is necessary because of the propensity of perineural carcinoma to recur in not only a local but also a regional fashion 7,12 .…”

“…Bordea and colleagues, 4 reported 19.1% of their study population of transplant patients developed at least one skin malignancy, most commonly SCC. Renal‐transplant patients not only show an increased risk of developing skin cancers, but the cancers they develop exhibit a more aggressive clinical course, including perineural invasion 13,14 …”