Postoperative Imaging and Surveillance in Large Nerve Perineural Spread

Sommerville, Jennifer; Gandhi, Mitesh

doi:10.1055/s-0036-1571840

Cited by 22 publications

(20 citation statements)

References 17 publications

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“…Dedicated and clinically directed magnetic resonance neurography (MR Neurography) with pre‐ and post‐gadolinium sequences remains the gold‐standard investigation for PNS 13 . With reported sensitivity of 95% and specificity of 84%, 14 MRI can identify early changes within neural structures, with the key finding of asymmetrical thickening and post‐gadolinium enhancement on T1‐weighted sequences of the involved nerve, as shown in Figures 3 and 4.…”

Section: Discussionmentioning

confidence: 99%

“…12 Dedicated and clinically directed magnetic resonance neurography (MR Neurography) with pre-and post-gadolinium sequences remains the gold-standard investigation for PNS. 13 With reported sensitivity of 95% and specificity of 84%, 14 MRI can identify early changes within neural structures, with the key finding of asymmetrical thickening and post-gadolinium enhancement on T1-weighted sequences of the involved nerve, as shown in Figures 3 and 4. MR neurography has the added benefits of being able to assess the extent of PNS according to the zonal staging described by Williams et al, 7 and can also provide helpful ancillary information regarding denervation changes within affected muscles (e.g., muscles of mastication and facial expression) as can be seen in Figure 5.…”

Section: Appropriate Imagingmentioning

confidence: 99%

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Persisting facial nerve palsy or trigeminal neuralgia – red flags for perineural spread of head and neck cutaneous squamous cell carcinoma (HNcSCC)

Zhang

Phung

Gupta

et al. 2023

ANZ Journal of Surgery

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BackgroundPerineural spread (PNS) of head and neck cutaneous squamous cell carcinoma (HNcSCC) is a unique diagnostic challenge, presenting with insidious trigeminal (CN V) or facial nerve (CN VII) neuropathies without clinically discernible primary masses. These patients are often sub‐optimally investigated and misdiagnosed as Bell's palsy or trigeminal neuralgia. This case series highlights the red flags in history and pitfalls that lead to delays to diagnosis and treatment.MethodsA retrospective case series of 19 consecutive patients with complete clinical histories with HNcSCC PNS without an obvious cutaneous primary lesion at time of presentation to a quaternary head and neck centre in Australia were identified and included for analysis.ResultsFifteen had CN VII PNS, 17 had CN V PNS, and 13 had both. The overall median symptom‐to‐diagnosis time was 12‐months (IQR‐15 months). Eight patients had CN VII PNS and described progressive segmental facial nerve palsy with a median symptom‐to‐diagnosis time of 9‐months (IQR‐11.75 months). Eleven patients had primary CN V PNS and described well localized parathesia, formication or neuralgia with a median symptom‐to‐diagnosis time of 19‐months (IQR 27.5 months).ConclusionPNS is often mistaken for benign cranial nerve dysfunction with delays in diagnosis worsening prognosis. Red flags such as progressive CN VII palsy or persistent CN V paraesthesia, numbness, formication or pain, particularly in the presence of immuno‐compromise and/or a history of facial actinopathy should raise suspicion for PNS. Gadolinium‐enhanced MR Neurography should be obtained expediently in patients with persistent/progressive CN V/CN VII palsies in patients with red flags, with low threshold for referral to a Head and Neck Surgeon.

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Section: Discussionmentioning

confidence: 99%

Section: Appropriate Imagingmentioning

confidence: 99%

Persisting facial nerve palsy or trigeminal neuralgia – red flags for perineural spread of head and neck cutaneous squamous cell carcinoma (HNcSCC)

Zhang

Phung

Gupta

et al. 2023

ANZ Journal of Surgery

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“…These masses may have a significant cystic component [ 24 , 58 , 60 ]. A subcutaneous nodule in the cheek, forehead or frontal scalp may represent infraorbital or frontal nerve involvement, respectively [ 61 ]. Intraorbital PNS most commonly develops in the superomedial orbit as an enlarged cord at the supraorbital foramen and can extend posteriorly, resulting in globe dystopia and orbital apex syndrome [ 24 , 57 ].…”

Section: Clinical Features Of Pnsmentioning

confidence: 99%

Perineural invasion and perineural spread in periocular squamous cell carcinoma

Tong

Huilgol

James³

et al. 2022

Eye

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Perineural invasion (PNI) in cutaneous squamous cell carcinoma (SCC) of the periocular region is a prognostic marker of adverse tumour outcomes. PNI carries a well-established risk of tumour recurrence, regional metastasis and higher likelihood of mortality. This review will explore and stratify the risks conferred by histological PNI parameters. The radiological features of perineural spread (PNS) and the imaging sequences that delineate these findings will also be highlighted. Surgical excision with en face margin control is the preferred technique for achieving histological clearance. Adjuvant radiotherapy improves treatment outcomes in the setting of concomitant high-risk features. For locally advanced or metastatic cutaneous SCC, immunotherapy represents a novel treatment alternative. This review will provide an algorithm for the diagnosis and management of periocular SCC with PNI and PNS.

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“…PNS refers to the spread of cancer along named nerves away from the primary tumour, and affected patients present with focal neurological deficit(s) and/or indicative MRI findings. 1,3 In the head and neck, PNS most commonly involves the trigeminal (V; ophthalmic [V 1 ], maxillary [V 2 ], mandibular [V 3 ] branches) and facial nerves (VII), with the latter involved in 25-35% of cases. 2,4,5 Perineural invasion (PNI), by contrast, is an incidental finding in the histopathological analysis of excised specimens from asymptomatic patients that cannot be detected on imaging.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of facial nerve perineural spread from cutaneous squamous cell carcinoma using 3T MR neurography

Schachtel,

Panizza,

Gandhi

2023

J Med Imag Rad Onc

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IntroductionPerineural spread (PNS) is a rare but potentially fatal consequence of cutaneous squamous cell carcinoma (cSCC) of the head and neck. We aimed to evaluate the accuracy of 3T MR neurography in detecting and defining the extent of facial nerve (VII) PNS from cSCC, and highlight characteristic radiological features in peripheral branches to improve early diagnosis.MethodsSingle‐institution retrospective review of 38 patients with clinical, radiological, and/or histopathological findings consistent with VII PNS from cSCC who underwent pre‐operative 3T MR neurography.ResultsCompared to histopathology (gold standard), 3T MR neurography had a sensitivity of 89% and positive predictive value of 97%. In true‐positive cases (n = 33), zonal extent was correctly identified in 100%. Seventy‐nine% had simultaneous trigeminal nerve (V) PNS, mostly involving the auriculotemporal branch of the mandibular nerve (64%). When the causative lesion was absent (n = 23), the extra‐temporal VII demonstrated asymmetrical enhancement alone (n = 6), bulky expansion (n = 8), or extra‐neural spread (n = 9). Peripheral VII branch involvement, particularly the buccal and zygomatic, was readily identified using known anatomical landmarks.Conclusion3T MR neurography is highly accurate in evaluating VII PNS from cSCC, and thus should be specifically requested by physicians if suspicious for disease. Coexistent V PNS was common, highlighting the need to examine V branches to allow complete treatment planning. The unique radiological patterns identified showcases disease progression. As early detection improves patient outcomes, the radiologist must look for peripheral VII involvement in specific anatomical areas, which is within the capabilities of 3T MR neurography.

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Postoperative Imaging and Surveillance in Large Nerve Perineural Spread

Cited by 22 publications

References 17 publications

Persisting facial nerve palsy or trigeminal neuralgia – red flags for perineural spread of head and neck cutaneous squamous cell carcinoma (HNcSCC)

Persisting facial nerve palsy or trigeminal neuralgia – red flags for perineural spread of head and neck cutaneous squamous cell carcinoma (HNcSCC)

Perineural invasion and perineural spread in periocular squamous cell carcinoma

Evaluation of facial nerve perineural spread from cutaneous squamous cell carcinoma using 3T MR neurography

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