Case ReportPerineural Spread of Renal Cell Carcinoma: A Case Illustration with a Proposed Anatomic Mechanism and a Review of the Literature
Introduction
Perineural spread (PNS) is a recognized mechanism of tumor spread. Prototype malignancies for perineural invasion (PNI) are adenocystic carcinoma,1 desmotropic melanoma,2 or squamous cell carcinoma3 involving the cranial nerves and prostate4 and pancreatic cancer5 invading the autonomic nerves, but almost every cancer has been shown to extend along the nerves, including other types of pelvic malignancy such as rectal,6 cervical,7 and bladder cancer.8 Although the propensity for nerve involvement is known, the extent is often underestimated. Our group previously demonstrated PNS of various pelvic malignancies to the lumbosacral plexus and beyond to other distant structures such as muscle and bone or intradurally. In pursuit of mapping patterns of PNS across different tumors, we wondered whether similar mechanisms9 would apply to renal cell carcinoma (RCC). We identified a case of an intradural metastasis of RCC 16 years after the primary tumor diagnosis, which we believe supports our theory that PNS of RCC occurs and is under-recognized.
Section snippets
Methods
This study was carried out to support the hypothesis that RCC could propagate via PNS. An institutional review board approval for this study was obtained before the study.
We first identified cases of spinal intradural metastases treated at the Mayo Clinic using an institutional database search tool, Advanced Cohort Explorer. We adapted the previously proposed definition of perineural tumor spread9 and looked for intradural-extramedullary (with or without intramedullary invasion) RCC metastases,
Results
Our institutional search revealed 3 cases of metastatic spinal intradural RCC. One was a lesion in the cervical spinal cord, which was explained as hematogenous and was excluded. A second case had a lesion in the conus medullaris and although there was subtle evidence of involvement of the spinal nerves on the affected side, this could not be definitively confirmed because of limitations of the imaging, and the case was excluded as well. Only 1 case met our strict criteria for inclusion. This
Case Illustration
A 61-year-old woman had a history significant for RCC confined to the kidney treated with a right nephrectomy at an outside facility in 1989. She presented to our institution in August 2000 complaining of back pain and nonspecific bilateral thigh discomfort, which originally was attributed to the right L3/4 arthritis discovered on imaging. The patient had no additional problems until the summer of 2005, when her back pain returned and radiated to the right buttock area. She also noticed right
Discussion
PNS is an under-recognized cause of morbidity in rectal,6 prostate,11, 12, 13, 14 cervical,7 and bladder cancer.8 These tumors spread from the primary site to the lumbosacral plexus along the pelvic autonomic nerves and then along the spinal nerves to intradural locations. This mechanism of spread was described previously across various pelvic malignancies,9 and we believe that similar pattern of spread occurs in renal cell cancer.
The nerve supply to the kidney is derived from the T10-L2 spinal
Conclusions
We believe RCC can propagate via PNS from the primary tumor along the autonomic nerves to the aorticorenal, celiac, and mesenteric ganglia and then along the thoracic and lumbar splanchnic nerves to the corresponding spinal nerves and intradurally. A similar mechanism of spread has been previously proposed for rectal, prostate, cervical, and bladder cancer.
References (54)
- et al.
Patterns of spread of head and neck adenoid cystic carcinoma
Clin Radiol
(2015) - et al.
Perineural growth in head and neck squamous cell carcinoma: a review
Oral Oncol
(2015) - et al.
Metastatic tumors in the pancreas in the modern era
J Am Coll Surg
(2010) - et al.
Endoneural metastasis of the sciatic nerve disclosing the relapse of a renal carcinoma, four years after its surgical treatment
Joint Bone Spine
(2006) - et al.
A rare case of metastatic renal cell carcinoma resembling a nerve sheath tumor of the cauda equina
J Clin Neurosci
(2004) - et al.
Solitary intradural extramedullary metastasis of renal cell carcinoma to the conus medullaris
Kaohsiung J Med Sci
(2011) - et al.
Surgical treatment options and management strategies of metastatic renal cell carcinoma to the lumbar spinal nerve roots
J Clin Neurosci
(2013) - et al.
Desmoplastic melanoma, neurotropism, and neurotrophin receptors–-what we know and what we do not
Adv Anat Pathol
(2015) - et al.
Perineural invasion as a predictor of extraprostatic extension of prostate cancer: a systematic review and meta-analysis
Scand J Urol
(2013) - et al.
Perineural invasion and associated pain in pancreatic cancer
Nat Rev Cancer
(2011)
Recurrent rectal cancer causing lumbosacral plexopathy with perineural spread to the spinal nerves and the sciatic nerve: an anatomic explanation
Clin Anat
Perineural spread of cervical cancer to the sciatic nerve
Skeletal Radiol
Perineural tumor spread of bladder cancer causing lumbosacral plexopathy: an anatomic explanation
Acta Neurochir (Wien)
Perineural spread of pelvic malignancies to the lumbosacral plexus and beyond: clinical and imaging patterns
Neurosurg Focus
Intradural spinal metastases: a surgical series of 15 patients
Acta Neurochir (Wien)
Recurrent prostatic adenocarcinoma with perineural spread to the lumbosacral plexus and sciatic nerve: comparing high resolution MRI with torso and endorectal coils and F-18 FDG and C-11 choline PET/CT
Abdom Imaging
Prostate cancer with perineural spread and dural extension causing bilateral lumbosacral plexopathy: case report
J Neurosurg
Adenocarcinoma of the prostate involving the lumbosacral plexus: MRI evidence to support direct perineural spread
Acta Neurochir (Wien)
Neoplastic lumbosacral radiculoplexopathy in prostate cancer by direct perineural spread: an unusual entity
Muscle Nerve
A review of the thoracic splanchnic nerves and celiac ganglia
Clin Anat
Interaction between parasympathetic and sympathetic nerves in prevertebral ganglia: morphological evidence for vagal efferent innervation of ganglion cells in the rat
Microsc Res Tech
Extrinsic innervation of the rat kidney: a retrograde tracing study
Am J Physiol
The nerve supply of the kidneys
Acta Anat (Basel)
The innervation of the kidney, ureter, testicle and epididymis
J Anat
The hot foot syndrome: Evans' sign and the old way
Pain Res Manag
The expression and prognostic value of alpha-, beta- and gamma-catenins in renal cell carcinoma
Anticancer Res
Impact of preoperative radiological and postoperative pathological findings on survival of patients after radical nephrectomy performed with the indication of renal cell carcinoma
Turk J Urol
Cited by (10)
Diagnostic value of proximal cutaneous nerve biopsy in brachial and lumbosacral plexus pathologies
2023, Acta NeurochirurgicaThe spectrum of brachial plexopathy from perineural spread of breast cancer
2022, Journal of NeurosurgeryIntradural Extramedullary Spinal Metastases from Non-neurogenic Primary Tumors: A Systematic Review
2022, Anticancer Research
Conflict of interest statement: S.C. is supported by European Regional Development Fund - Project FNUSA-ICRC (No. CZ.1.05/1.1.00/02.0123).