Imaging Perineural Spread in the Head &

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1 Imaging Perineural Spread in the Head & Neck Tumours Vincent Chong, MD MBA FRCR Professor Department of Diagnostic Imaging National University Health System Singapore Overview: Perineural Spread Review some key concepts Surgical pathology Clinical implications Recognizing perineural spread Directly (neural involvement) Indirectly (denervation changes) 1

2 Perineural Involvement: Surgical Pathology Perineural infiltration (local disease) 36% major resections Most cases, tumour confined to 1 cm of affected nerve Perineural spread (beyond primary site) Distal spread >2 cm is unusual Grave prognostic implications Perineural Infiltration (Local): Adenoid Cystic Carcinoma 2

3 Perineural Infiltration (Local): Adenoid Cystic Carcinoma 3

4 4

5 Perineural Spread (Beyond Primary Tumour) Perineural Spread (Beyond Primary Tumour) Mastoid C2 5

6 Summary: Perineural Involvement Surgical Pathology Perineural Spread Versus Perineural Infiltration Nerve Involvement: Histopatholgy Tumour concentrated at margins Anoxia & infarcts in nerve trunks Myelin and axonal degenerate 6

7 Why Perineural Spread? Mechanical Explanation #1 Proximity of neural (rail) network #2 Path of least resistance Growth Factor Binding Sites: Chemical Explanation Axon Nerve growth factor Neural cell adhesion molecule (N-CAM) N-CAM 95% of adenoid cystic Ca 93% of SCCa Hutcheson et al. Neural cell adhesion expression in adenoid cystic carcinoma. Laryngoscope 2000; 110: Vural E et al. Correlation of neural cell adhesion molecules with perineural spread of squamous cell carcinoma of the head and neck. Otolaryn Head Neck Surg 2000; 122:

8 Growth Factor Binding Sites: Chemical Explanation Schwann cells Growth factor receptor p75 Desmoplastic melanomas Adenoid cystic carcinomas Basal cell carcinoma Iwamoto S et al. Evidence that p75 neurotrophin receptor mediates perineural spread of desmoplastic melanoma. J Am Acad Dermatol 1996; 35: Chang PC et al. Perineural spread of malignant melanoma of the head and neck. AJNR 2004; 25:5-11 Mechanical Explanation? Chemical Explanation? 8

9 Mechanical Explanation? Chemical Explanation? Clinical Significance: Prognosis Independent predictor of local recurrence Primary tumour biologically more aggressive 30% decrease in 5-year survival rate 3x increase in local recurrence 9

10 Detecting of PNS If this patient has perineural spread, where would you look? 1. Palatine canals 2. Pterygopalatine fossa 3. Both Detecting of PNS 10

11 11

12 Hard Palate Carcinoma 12

13 Hard Palate Carcinoma Hard Palate Carcinoma 13

14 Hard Palate Carcinoma: PNS usually seen as a recurrence 14

15 Hard Palate Carcinoma: PNS usually seen as a recurrence #Antegrade & Retrograde Spread: Lingual & Inferior Alveolar Nerves M Pterygoid M Lingual N Patient with submandibular gland muco-epidermoid carcinoma, operated, presented with paraesthesia over chin 15

16 #Antegrade & Retrograde Spread: Lingual & Inferior Alveolar Nerves #Antegrade & Retrograde Spread: Lingual & Inferior Alveolar Nerves 16

17 4/10/2013 #Antegrade & Retrograde Spread: Lingual & Inferior Alveolar Nerves #Antegrade & Retrograde Spread: Lingual & Inferior Alveolar Nerves 17

18 #Antegrade & Retrograde Spread: Lingual & Inferior Alveolar Nerves #Antegrade & Retrograde Spread: Lingual & Inferior Alveolar Nerves 18

19 Why does denervated muscle enhance? Why does denervated muscle enhance? Increased perfusion Vasodilatation due to decreased sympathetic tone Total capillaries remain the same Capillaries per unit mass of muscles increase ( overvascularization ) Carpenter S, Karpati G. Necrosis of capillaries in denervation atrophy of human muscle. Muscle Nerve 1982; 5: Hudlicka O. Do changes in the vascular bed contribute to the development of denervation atrophy in skeletal muscles? Basic Applied Myology 2007; 17:

20 Conclusion: Perineural Spread Surgical Pathology Perineural infiltration (local disease) Perineural spread (beyond primary site) Histopathology Tumour concentrated at nerve margins Anoxia & infarcts in nerve trunks Conclusion: Imaging PNS Nerve Thickened nerve Foraminal erosion Muscle changes Atrophy Contrast enhancement 20

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