Metastatic Plexopathy Research Articles

Intense 18F-Flourodeoxyglucose Uptake in Brachial Plexus of Patients with Brachial Plexopathy.

Brachial plexopathy is a significant cause of pain and disability in patients with breast cancer. Major causes of brachial plexopathy in patients with breast cancer are metastatic invasion or radiation damage to the plexus. Differentiation between the two pathologies is important for appropriate treatment planning. The complicated anatomy of the plexus makes this a difficult area to image accurately. Magnetic resonance imaging (MRI) is the imaging modality of choice for diagnostic evaluation of these cases. We presented a case to demonstrate the role of 18F-flourodeoxyglucose positron emission tomography/computerized tomography for confirming metastatic brachial plexopathy when MRI findings were suspicious and for differentiating radiation-induced brachial plexopathy from metastatic plexopathy.

Metastatic Brachial Plexopathy in a Case of Recurrent Breast Carcinoma Demonstrated on (18)F-FDG PET/CT.

This case highlights the importance of recognition of the pattern of metastatic brachialplexopathy in breast cancer patients undergoing 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) for evaluation of recurrent disease.This pattern can be appreciated on maximum intensity projection (MIP) and coronal 18F-FDG PET/CTimages as a linear extension of tracer activity from superomedial aspect(supra/infraclavicular) to lateral aspect of the axilla closely related to the subclavian/axillary vessels). A 35-year-old woman diagnosed with infiltrating ductal carcinoma of the right breast had undergone six cycles of neoadjuvant chemotherapy, followed by wide local incision and radiotherapy. She had local recurrence, for which she was operated upon and given chemotherapy. She presented to her oncologist with pain and swelling in the right breast, nodules in the right axilla and restriction of movement of the right upper limb. The patient was referred for 18F-FDG PET/CT to evaluate the extent of recurrent/metastatic disease. Whole-body PET/CT was acquired 1 h following the intravenous injection of 296 MBq of 18F-FDG on a Biograph mCT scanner (Siemens). Evaluation of the MIP image revealed abnormal FDG accumulation at multiple sites in the thorax, along with a linear pattern of FDG uptake in the right lateral aspect of the upper chest (Fig. 1a, arrow). The coronal fused PET/CT image revealed a linear pattern of FDG uptake corresponding to an ill-defined mass extending from just behind the right clavicle into the right axilla (arrow). In addition, abnormal FDG accumulation was seen in a soft tissue density mass in the upper outer quadrant of the right breast, skin of the right breast laterally, both pectoral muscles (discrete foci) and in a few subpectoral nodes. Soft tissue nodular opacities in both lungs showed FDG accumulation suggestive of pulmonary metastasis (Fig. 1b, thick arrow). The patient was referred for magnetic resonance imaging (MRI) to demonstrate the brachial plexus involvement. Coronal diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) revealed a mass in the right axilla, with a b value of 1,000, infiltrating the cord and branches of the right brachial plexus visualised as linear hyperintensities (Fig. 1c, arrow). Fig. 1 Whole-body 18F-FDG PET/CT. a MIP image. b Coronal fused PET/CT image. c DWIBS image Brachial plexopathy in breast cancer patients can be metastatic (because major lymph drainage routes for the breast course through the axilla) or radiation induced, the former being the commoner of the two [1, 2]. Differentiation between the two pathologies is important for appropriate treatment planning. 18F-FDG PET/CT is a useful tool in the evaluation of patients with recurrent or metastatic breast cancer. Recognition of the pattern of brachial plexus involvement is thus essential for accurate interpretation of the 18F-FDG PET/CT study. To date, two case reports and one small case series [3–5] have demonstrated the feasibility of PET for confirming metastatic brachial plexopathy when MRI was suspicious of the same or when the patient was symptomatic for the same. This case highlights the possibility of metastatic brachial plexopathy even when the patient may not be overtly symptomatic for the same. The typical pattern as seen on MIP and coronal images is linear, extending from the superomedial aspect (supra/infraclavicular) to the lateral aspect of axilla closely related to the subclavian/axillary vessels). The commonest finding on computed tomography (CT) is that of an axillary mass, but may range from no remarkable abnormality to minimal thickening [2, 6]. Moreover, CT would not be able to differentiate metastatic from radiation plexopathy [2]. MRI is the first-line imaging modality for evaluating brachial plexopathy [7] and can delineate both normal and abnormal anatomy of the brachial plexus, with the ability to differentiate nerves from the surrounding vessels and soft tissue with greater detail than CT [7–10]. In this case, DWIBS was used to demonstrate the presence of a right axillary mass (discrete mass in relation to the plexus), which is the commonest finding on MRI in patients with metastatic plexopathy

Metastatic brachial plexopathy from breast cancer detected by 18F-FDG PET/MRI

A 62-year-old woman with history of ductal-invasive arcinoma of the left breast, treated with surgery (left astectomy and left axillary lymphadenectomy) and adjuvant hemotherapy and radiotherapy 17 years before, underwent maging for restaging due to increased serum tumor markers evels (CEA and CA 15-3) and onset of pain on the left rm. Whole-body computed tomography (CT) and other conentional imaging methods were negative. The patient even nderwent a fused 18F-FDG PET/MRI which showed some areas of ncreased 18F-FDG uptake corresponding to an abnormal thickenng of the left brachial plexus at MRI. No other areas of abnormal 8F-FDG uptake were evident in the rest of the body (Fig. 1). Based on these 18F-FDG PET/MRI findings, the patient underwent histology which demonstrated the presence of a metastatic plexopathy from breast cancer and she was addressed to chemotherapy. PET/MRI is of special interest for neuroscience, given that PET and MRI are the neuroimaging methods of choice for many clinical and scientific applications. The first clinical studies conducted have tested the performance of PET/MRI in oncology indications, neurodegenerative disorders and epilepsy, using different PET tracers.1,2 The case which we have briefly presented illustrated the usefulness of fused 18F-FDG PET/MRI in evaluating neoplastic processes involving the peripheral nerves.3 This emerging technique

Neurologic Manifestations of Neoplastic and Radiation-Induced Plexopathies

Metastatic plexopathy is often a disabling accompaniment of advanced systemic cancer, and may involve any of the peripheral nerve plexuses. Brachial plexopathy most commonly occurs in carcinoma of the breast and lung; lumbosacral plexopathy is most common with colorectal and gynecologic tumors, sarcomas, and lymphomas. Neoplastic plexopathy is often characterized initially by severe, unrelenting pain followed by development of weakness and focal sensory disturbances. In previously treated patients, the main differential diagnostic consideration is radiation-induced plexopathy, which can be difficult to distinguish from tumor plexopathy. Diagnosis is usually made following an analysis of the clinical, neuroimaging, and electrophysiologic features. Treatment of metastatic plexopathy has included surgical resection of tumor in selected cases, radiotherapy to the plexus, systemic chemotherapy, interventional pain management procedures, and symptomatic treatment. These measures often offer temporary (months) relief or improvement. Physicians treating these patients should focus on effective management of pain and prevention of complications of immobility produced by the neuromuscular dysfunction.

MRI of the brachial plexus: A pictorial review

Magnetic resonance imaging (MRI) of the brachial plexus is the imaging modality of first choice for depicting anatomy and pathology of the brachial plexus. The anatomy of the roots, trunks, divisions and cords is very well depicted due to the inherent contrast differences between the nerves and the surrounding fat. In this pictorial review the technique and the anatomy will be discussed. The following pathology will be addressed: neurogenic tumors of the brachial plexus and sympathetic chain, superior sulcus tumors, other tumors in the vicinity of the brachial plexus, the differentiation between radiation and metastatic plexopathy, trauma, neurogenic thoracic outlet syndrome and immune-mediated neuropathies.

Fluorodeoxyglucose and 11C-Choline positron emission tomography for distinction of metastatic plexopathy and neuritis: a case report

IntroductionFluorodeoxyglucose positron emission tomography scanning has an established role in the diagnostic work-up of many malignant diseases and also in the evaluation of cancer treatment response. Fluorodeoxyglucose positron emission tomography may, however be non-specific as infectious processes are depicted as well.Case presentationWe present a patient with longstanding leg pain and weakness due to plexopathy developed a few years after treatment for prostate cancer. Prostate-specific antigen was raised and magnetic resonance imaging showed contrast uptake in thickened sacral nerves, suspicious for metastasis. While fluorodeoxyglucose positron emission tomography showed increased uptake in the plexus region, 11C-Choline- positron emission tomography did not show any uptake. It was concluded that the FDG uptake reflected plexus neuritis and no tumor. Treatment for pain relief was started.Conclusion11C-Choline- positron emission tomography can be used to detect metastasis in patients with plexopathy suspicious for malignancy, while fluorodeoxyglucose positron emission tomography is more sensitive to inflammatory processes.

Non-traumatic brachial plexopathies, clinical, radiological and neurophysiological findings from a tertiary centre

Objective To establish the clinical characteristics, aetiology, neuro-physiological characteristics, imaging findings and other investigations in a cohort of patients with non-traumatic brachial plexopathy (BP). Methods A 3-year retrospective study of patients with non-traumatic BP identified by electromyography (EMG) and nerve conduction studies (NCS). Clinical information was retrieved from patients’ medical charts. Results Twenty-five patients were identified. Causes of BP included neuralgic amyotrophy (NA) (48%), neoplastic (16%), radiation (8%), post infectious (12%), obstetric (4%), rucksack injury (4%), thoracic outlet syndrome (4%) and iatrogenic (4%). Patients with NA presented acutely in 50%. The onset was subacute in all others. Outcome was better for patients with NA. All patients with neoplastic disease had a previous history of cancer. MRI was abnormal in 3/16 patients (18.8%). PET scanning diagnosed metastatic plexopathy in two cases. Conclusions NA was the most common cause of BP in our cohort and was associated with a more favourable outcome. The authors note potentially discriminating clinical characteristics in our population that aid in the assessment of patients with brachial plexopathies. We advise NCS and EMG be performed in all patients with suspected plexopathy. Imaging studies are useful in selected patients.

P15.28 A normal MRI of brachial plexus does not rule out a metastatic plexopathy in a suspected case: Lessons to be learnt

P15.28 A normal MRI of brachial plexus does not rule out a metastatic plexopathy in a suspected case: Lessons to be learnt

Neurological Manifestations of Neoplastic and Radiation-Induced Plexopathies

Metastatic plexopathy is often a disabling accompaniment of advanced systemic cancer and may involve any of the peripheral nerve plexuses. Brachial plexopathy most commonly occurs in carcinoma of the breast and lung; lumbosacral plexopathy is most common with colorectal and gynecologic tumors, sarcomas, and lymphomas. Regardless of the location, neoplastic plexopathy is often characterized by severe, unrelenting pain. Later, weakness and focal sensory disturbances occur in the distribution of plexus involvement. In previously treated patients, the main differential diagnostic consideration is radiation-induced plexopathy. Treatment of metastatic plexopathy is palliative and includes radiotherapy to the tumor mass, chemotherapy, and symptomatic treatment. In selected cases, subtotal surgical resection of the tumor may be warranted. The response to therapy is modest and generally short-lived. Efforts should be made to provide adequate pain control, maximize remaining neurological function, and prevent complications of immobility produced by the neuromuscular dysfunction.

Use of positron emission tomography in evaluation of brachial plexopathy in breast cancer patients

18-Fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) has previously been used successfully to image primary and metastatic breast cancer. In this pilot study, 19 breast cancer patients with symptoms/signs referrable to the brachial plexus were evaluated with 18FDG-PET. In 11 cases computerized tomography (CT) scanning was also performed. Of the 19 patients referred for PET study, 14 had abnormal uptake of 18FDG in the region of the symptomatic plexus. Four patients had normal PET studies and one had increased FDG uptake in the chest wall that accounted for her axillary pain. CT scans were performed in 9 of the 14 patients who had positive brachial plexus PET studies; six of these were either normal or showed no clear evidence of recurrent disease, while three CTs demonstrated clear brachial plexus involvement. Of two of the four patients with normal PET studies, one has had complete resolution of symptoms untreated while the other was found to have cervical disc herniation on magnetic resonance imaging (MRI) scan. The remaining two patients almost certainly had radiation-induced plexopathy and had normal CT, MRI and PET study. These data suggest that 18FDG-PET scanning is a useful tool in evaluation of patients with suspected metastatic plexopathy, particularly if other imaging studies are normal. It may also be useful in distinguishing between radiation-induced and metastatic plexopathy. © 1999 Cancer Research Campaign

Radiation-Induced or Metastatic Brachial Plexopathy?

Fourteen patients with presumed radiation plexopathy and 11 patients with metastatic involvement of the brachial plexus were studied. In both groups, plexopathy began after a mean interval of six years, the initial symptom usually being sensory. Almost half the patients with radiation damage had no significant pain; metastatic plexopathy characteristically was very painful. Plexus disease was progressive for an average of nine years in the radiation group, but metastatic plexopathy also sometimes progressed for years without distant metastasis. Sensation, muscle power, and stretch reflexes were affected similarly in both groups. All patients with radiation damage were alive as of this study; almost all with metastatic plexopathy were dead. No single clinical symptom or sign permitted distinction between the two groups.