Delayed diagnosis of cranial neuropathies from perineural spread of skin cancer

• Authors: Daniel Nelson, Emory University; Samuel Bidot, Emory University; Gregory Esper, Emory University; Nancy Newman, Emory University; Valerie Biousse, Emory University
• Journal Title: Taiwan Journal of Ophthalmology
• Volume: Volume 11, Number 1
• Publisher: Wolters Kluwer | 2021-01-01, Pages 86-88
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.4103/tjo.tjo_62_20
• Subjects: Health Sciences, Pathology; Health Sciences, Medicine and Surgery; Health Sciences, Opthamology
• Keywords: Cranial neuropathy; perineural invasion; perineural spread; squamous cell carcinoma

Abstract

Perineural spread (PNS) to cranial nerves (CNs) by cutaneous malignancies is difficult to diagnose given the indolent course and often late or absent findings on brain imaging. A 68-year-old white man with multiple cranial neuropathies secondary to PNS by squamous cell carcinoma had negative high-quality neuroimaging for 5.25 years. He first developed left facial numbness, followed 39 months later by a left CN VI palsy. Subsequent examinations over 2 years showed involvement of left seventh, right trigeminal V1-V3, and right sixth, and bilateral third nerve palsies. Repeat high-quality brain magnetic resonance imaging (MRIs) during this time showed no identifiable CNs abnormality. Full body positron emission tomography imaging and cerebrospinal fluid studies were normal. 5.25 years after initial sensory symptom onset, MRI showed new enhancement along the right mandibular branch of the trigeminal nerve with foramen ovale widening. Autopsy showed squamous cell carcinoma within both CNs sixth. A long interval to diagnosis of PNS is associated with high morbidity, emphasizing the need for earlier methods of detection when clinical suspicion is high.