Download Perineural spread along trigeminal nerve: a review of cases

Perineural spread along trigeminal nerve: a review of cases
Poster No.:
C-1416
Congress:
ECR 2015
Type:
Educational Exhibit
Authors:
C. Perez Martin, B. Brea Alvarez, P. Servent Sáenz;
Majadahonda/ES
Keywords:
Education and training, Cancer, Diagnostic procedure, MR, CT,
Neuroradiology peripheral nerve, Head and neck, Anatomy
DOI:
10.1594/ecr2015/C-1416
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Learning objectives
To learn the anatomy of trigeminal nerve (CNV).
To review definition and pathogenesis of perineural spread (PNS)
To assess the proper technique and typical findings
Background
Perineural Spread (PNS) is a way of tumor dissemination along the tissue of the nerve
sheath, associated with different types of head and neck tumors.
It is important to recognize this entity because it has a detrimental influence on the
prognosis and it requires more extensive surgical resections and wider radiation fields
for complete control tumor.
The main pathways for PNS are cranial nerves, especially CNV, because it has greater
regional extension and is close to the anatomical areas of the tumors that most often
present PNS.
Perineural spread has a wide variety of clinical manifestations. Patients can experience
pain, burning, or dysesthetic sensations along the path of the involved nerve. With
advanced disease, complete denervation can lead to muscle atrophy. However, up
to 45% of patients with radiographic or histological perineural invasion are completely
asymptomatic.
Diagnose PNS can be very challenging due to the fact that not all patients report clinical
signs of perineural spread. The anatomy in the head and neck region of cranial nerves
is very complex and radiological signs can be very subtle.
Finally, there are certain histological types of tumors which are especially prone to
perineural spread. These are: epidermoid carcinomas, adenoid cystic carcinomas and
melanomas. Also certain locations are prone to perineural spread: nasopharynx, parotid
and sublingual glands and deep skin tumors.
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Findings and procedure details
To understand and define patterns of PNS it must be known the anatomy of the CNV.
(Fig.1 and Fig.2)
Trigeminal nerve:
The trigeminal nerve is a mixed nerve (both sensory and motor components) and has
four segments: Intra-axial, cisternal, interdural and extracranial. Although the spread can
reach all segments, interdural and extracranial are more often affected.
It has four nuclei (3 sensory, 1 motor) located in the brainstem and upper cervical cord,
and leaves the pons in a rather lateral position. It courses straight through the prepontine cistern to enter through the Meckel's Cave into the Gasserian ganglion. There,
the ophthalmic, maxillary, and mandibular branches of the trigeminal nerve leave the skull
through 3 separate foramina: the superior orbital fissure, the foramen rotundum, and the
foramen ovale, respectively.
Ophthalmic nerve V1
The ophthalmic nerve is the first branch of the trigeminal nerve. It arises from the convex
surface of the Gasserian ganglion, in the dura of the lateral wall of the cavernous venous
sinus under CN IV and above the maxillary nerve.
Just before it exits the skull through the superior orbital fissure, it gives off a dural branch,
and then divides into 3 branches: the frontal, lacrimal, and nasociliary.
Maxillary nerve V2
The maxillary nerve is divided into 3 branches: the zygomatic, sphenopalatine (or
pterygopalatine), and posterior superior alveolar nerves.
As it leaves the Gasserian ganglion, the maxillary nerve passes through the dura of
the lateral wall of the cavernous sinus. It exits the skull via the foramen rotundum and
crosses the pterygopalatine fossa (important location of perineural spread) to enter the
orbit through the inferior orbital fissure, where it becomes the infraorbital nerve.
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The zygomatic, sphenopalatine and posterior superior alveolar branches are given off in
the pterygopalatine fossa.
In the lateral wall of the orbit, it gives off a branch to the lacrimal nerve, which
carries postganglionic fibers from the sphenopalatine ganglion for lacrimation. The
zygomaticofacial is located in the lower part and supplies the skin of the cheek.
The sphenopalatine (or pterygopalatine) nerve are in fact 2 nerves that unite the
sphenopalatine ganglion to the maxillary nerve. They transmit afferent sensations from
the nose, palate, and pharynx. They also carry parasympathetic fibers to the lacrimal
nerve that go to the lacrimal gland. These preganglionic fibers are derived from CN VII
via the greater petrosal and vidian nerves.
Mandibular Nerve (V3) (2):
The mandibular nerve runs laterally along the skull base then exits the cranium by
descending through the foramen ovale into the masticator space. It divides into two
trunks: The anterior trunk or motor trunk to innervate masticator muscles and the posterior
trunk that is mainly sensorial nerve.
Auriculotemporal nerve - it emerges superficially between the ear and the mandibular
condyle, deep into the parotid gland and ends in 2 superficial temporal branches
Lingual nerve - This nerve runs parallel to the inferior alveolar nerve, is joined by the
chorda tympani nerve of the facial nerve (CN VII)
Inferior alveolar nerve - This nerve accompanies the inferior alveolar artery in the
mandibular foramen and enters into the mandibular canal to exit through the mental
foramen.
ZONAL CLASSIFICATION
The zonal classification allows us to describe the anatomical extent of perineural spread
view in RM. This system determines the surgery, subcranial vs. resection of skull base
(19) and has proven to be a predictor of overall survival (43).
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Three zones has been described, whose limits are defined by the affected cranial nerve
(V or VII) and the different branches of the V cranial nerve (V1, V2 or V3) (Table 1).
V1
V2
V3
Zone 1
to
the
superior to the external
to
the
external
orbital fissure
aperture of the
aperture of the
foramen rotundum foramen ovale
Zone 2
From zone 1 to the Gasserian ganglion cistern
Zone 3
Encompasses all nerves from the Gasser ganglion into the
cisterns or into the brainstem
(table 1)
CLINIC
Up to 45% of patients with PNS are asymptomatic even with extensive involvement. On
the other hand there are patients with suggestive clinical data of PNS without findings
on imaging studies (4, 5).
In general, clinical involvement is belated, subtle and nonspecific. (6). It should be
suspected when there is insidious involvement of cranial nerves , slowly progressive, or
when we find a unilateral involvement of multiple cranial nerves (Garcin syndrome) (6)
IMAGING TECHNIQUES
Imaging techniques used in the diagnosis of this entity are MRI, CT and PET-CT. The MR
is the choice for most contrast resolution. However, although its use is not yet widespread,
there are reports in the recent literature about the new PET-MRI that suggest it could
have even greater accuracy in the diagnosis of this entity (7).
MR
We recommend the use of isotropic volumetric sequences with high spatial resolution
T1-weighted (8). These can be applied with or without fat saturation. Fat saturation
techniques allow us to delineate enhancing lesions that are close to spaces that
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contain fat, as the orbits, the pterygopalatine fissure and neurovascular foramina. These
sequences are chosen by most radiologists (12,11). However, some authors prefer
sequences without fat saturation ("fat is a friend") (9,10) because they allow to see clearly
the fatty packages adjacent to foramina and because, even after gadolinium, the tumor
will never have the same hyperintensity as the fat ("evil gray"). Also, without fat saturation,
we avoid the susceptibility artifacts frequently observed in sequences with saturation.
The protocol in our center consists of T1-weighted sequences without fat saturation
before contrast administration and then T1-weighted sequences with fat saturation after
administration of gadolinium.
T2-weighted sequences are necessary when zone 3 is involved, for the study of cisternal
and intraaxial path cranial nerves. Furthermore, the additional use of fat saturation may
be useful to assess the inflammatory component associated with this entity, especially in
locations where nerves are related to fatty packages.
CT
CT assesses very well the morphology and size of the bony foramina and skull base
canals. PNS is associated with expansion and enlargement of foramina and it is not
frequent aggressive pattern like mottle or permeative.
PET-CT
PET-CT is useful in the study of head and neck cancers mainly because it has proven
to be superior to CT and MRI in the evaluation of lymph node and detection of residual
and recurrent tumors (13). However there is not concluding data on its sensitivity and
specificity in detecting PNS. Nevertheless the existence of any linear or curvilinear focus
of abnormal FDG uptake in the anatomical distribution territories of the cranial nerve is
sufficient to suspect the existence of PNS and correlate the findings with data from MRI
to confirm the diagnosis (14).
IMAGING FINDINGS:
PRIMARY FINDINGS
The primary findings are related to the direct affectation of the nerve by the tumor. We
can distinguish:
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- Full enhancement of the entire circumference of nerve in T1-weighted gadolinium
enhanced sequences (due to the breaking of the hematoneural barrier) and a thickening
of the normal nerve (11,15). Full enhancement of the pathological nerve should be
differentiated from the symmetrical peripheral enhancement and variable thickness of
a normal nerve (target appearance). This peripheral enhancement is secondary to the
perineural venous plexus and is seen frequently in the foraminal segments of the three
branches of the trigeminal nerve and in the geniculate ganglion.
- Loss of the perineural fat pad within foramina containing a cranial nerve branch. It
occurs as a result of tumor growth and its inflammatory component .
- Enlargement of the foramina.
- Spreading to the intracranial compartment. It is associated with infiltration of the
cavernous sinus, bulging of the lateral wall, adjacent dural thickening of the affected nerve
segments and thickening and/or enhancement of the cisternal and fascicularis segments
of affected cranial nerves
SECUNDARY FINDING:
As a result of the neural affectation it appears denervation atrophy. This finding is most
frequent in mastication muscles (by involvement of V3 CN) and tongue (by affecting the
hypoglossal muscle) and less common in the muscles of facial expression (16).
A series of images is presented, showing the various zones of perineural spread of the
branches of the trigeminal nerve (Fig. 3 to 12).
CONSIDERATIONS
In addition to the findings described above three considerations should be taken into
account:
- The findings of PNS may persist indefinitely despite clinical improvement. Therefore
recurrence should be suspected when there is growth of the lesion on the image or clinical
worsening (10).
- When making the staging of malignant tumors of the head and neck, especially those
associated with an increased incidence of PNS, the route of all cranial nerves should
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be exhaustively studied. Due to the extensive network of connections any nerve may be
potentially affected.
- The affectation of a nerve may seem discontinuous in the image even if exists
continuous histological involvement (19.57). It is called "skip metastases" (17,18). This
radiologic-histology discrepancy is due to the fact that there are segments of the nerve
where the tumor is so small that may not be visible on imaging studies (20).
Images for this section:
Fig. 1: Anatomy of the trigeminal nerve
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Fig. 2: Anatomy of the trigeminal nerve
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Fig. 3: 3 Axial T1 post gadolinium. Squamous cell carcinoma of the face spreading to the
V1 in the cavernous venous sinus and infiltration the midbrain.
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Fig. 4: CT coronal bone window . The orbital roof (frontal bone) shows focal areas of
thinning with bony erosion due to PNS of a Squamous cell carcinoma of the face along
V1 CN.
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Fig. 5: Coronal T1-weighted post-contrast MR. Note asymmetrical enhancing soft tissue
in the left cavernous sinus due to infiltration of V1 of a squamous cell carcinoma of the
face along V1 CN.
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Fig. 6: Axial T1 post gadolinium. Perineural spread of a melanoma in the nose throught
V2. Infiltration of left Meckel´s cave and midbrain, as well as thickening and enhancement
of the cisternal segment of trigeminal nerve.
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Fig. 7: Coronal T2-weighted image shows clear erosion and enlargement of the
infraorbital canal. Perineural spread of malignant melanoma was confirmed.
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Fig. 8: Sagital T1-weighted post gadolinium image. It is shown PNS along V1 and V2 skull
base and peripheral segments. Also you clearly depict implication of cisternal segment
of V CN secondary to adenoid cyst carcinoma
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Fig. 9: Axial T2-weighted image shows clear enlargement of the left infraorbital canal.
Perineural spread of malignant melanoma was confirmed.
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Fig. 10: Axial T1 post gadolinium. Perineural spread along V3 CN into foramen ovale
and cavernous sinus involvement. This patient had a nasopharynx cancer.
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Fig. 11: PNS along left greater petrosal superficial nerve and vidian nerve due to adenoid
cystic carcinoma of maxillary sinus
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Fig. 12: 12: CT coronal bone window. Clear enlargement of the left foramen oval. This
finding was secondary to PNS along V3 CN in a nasopharynx cancer.
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Conclusion
Perineural spread is a form of metastasis which occurs more frequently in tumors of the
head and neck. It often passes unnoticed in imaging studies, and yet, their presence
modifies treatment protocols, is associated with a higher rate of local recurrence and
is considered an independent prognostic factor in the TNM classification of malignant
tumors.
Certain tumor strains are associated with a higher prevalence of PNS. It is essential the
knowledge of this association and the anatomy of cranial nerves, specially CN V, and its
rich neural connections. MRI, with its higher resolution and multiplanar capability, allows
to study the neural path from the peripheral region to the core region, and to discard the
increase of thickness, enhancements, and complete obliteration of fat planes that are
characteristic primary findings of this type of tumor spread.
Personal information
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