Clinical Neurology and Neurosurgery 128 (2015) 90–93
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case Report
Perineural spread of squamous cell carcinoma: From skin to skin through the brachial plexus Stepan Capek a,b , Kimberly K. Amrami c , Benjamin M. Howe c , Diva R. Salomao d , P. James B. Dyck e , Robert J. Spinner a,∗ a
Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Rochester, MN, USA International Clinical Research Center, St. Anne’s University Hospital Brno, Pekarska 53, Brno, 656 91, Czech Republic c Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA d Department of Pathology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA e Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA b
a r t i c l e
i n f o
Article history: Received 3 October 2014 Accepted 9 November 2014 Available online 15 November 2014 Keywords: Perineural tumor spread Squamous cell carcinoma Skin cancer Brachial plexopathy Skin metastasis
1. Introduction
2. Case report
Perineural spread is an alternative to the more common hematogenous or lymphogenous form of tumor spread. Perineural spread is most frequently reported in head and neck cancers with only a few cases in upper limb nerves. We present a patient with a history of squamous cell carcinoma in the left arm who developed a left brachial plexopathy and subsequently other histologically similar lesions in the soft tissues and skin of the left shoulder. We hypothesize that all of the findings including the secondary lesions could be explained anatomically as perineural spread from the original site along small and major branches of the upper arm nerves to a distant site. Our theory is supported by high resolution imaging. Although perineural spread is frequently reported in squamous cell carcinoma, it has not been described as the mechanism for spread to skin at a distant site.
An 86-year-old left-handed man with a 5-year history of a subcutaneous nodule in the left mid anterolateral arm presented to our institution with a progressive left brachial plexopathy. Six weeks prior to presentation, the nodule was resected and diagnosed as squamous cell carcinoma.
∗ Corresponding author at: Mayo Clinic, Gonda 8-214, Rochester, MN, 55905, USA. Tel.: +1 507 284 2376; fax: +1 507 280 5206. E-mail addresses: [email protected] (S. Capek), [email protected] (K.K. Amrami), [email protected] (B.M. Howe), [email protected] (D.R. Salomao), [email protected] (P.J.B. Dyck), [email protected] (R.J. Spinner). http://dx.doi.org/10.1016/j.clineuro.2014.11.004 0303-8467/© 2014 Elsevier B.V. All rights reserved.
2.1. History The patient reported having a hard cigar-sized subcutaneous nodule in the mid left anterolateral arm since 2009. He had a history of multiple unspecified skin cancers involving his scalp, which were treated locally. In September 2012 he noticed intermittent paresthesias and hypesthesia over his left upper arm and shoulder. In October 2012 he developed continuous numbness and a wrist drop, which progressed to fingers extension weakness and numbness over the left lateral forearm extending to the thumb and the dorsum of the hand the following month. An EMG performed in November 2012 showed a left radial neuropathy with involvement of the triceps. Magnetic resonance imaging (MRI) of the brachial plexus was interpreted as normal. In February 2013 he developed shoulder abduction weakness. Electrodiagnostic testing performed in April 2013 demonstrated predominantly a
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posterior cord brachial plexopathy with lesser involvement of the medial cord; needle EMG showed 3+ fibrillations in the deltoid, triceps and brachioradialis muscles. The patient was treated for an inflammatory lesion. In September 2013 electrodiagnostic testing demonstrated progression of the brachial plexopathy involving the posterior and the medial cord. In May 2014 he had a Mohs procedure for the left mid-arm lesion with skin grafting from the thigh. The specimen revealed squamous cell carcinoma. 2.2. Physical examination In July 2014 examination at our institution revealed an approximately 5 cm × 5 cm skin defect in his left anterolateral arm. An approximately 1 cm × 1 cm pink skin lesion on his left shoulder was worrisome for a cutaneous malignancy (Fig. 1A and B). Muscle testing revealed infraspinatus MRC grade 4/5, deltoid 3/5, triceps 0/5, biceps 4/5, brachioradialis 0/5, supinator 0/5, wrist and finger extensors 0/5, pronator teres 4/5, finger flexors (med.) 3–4/5, finger flexors (uln.) 2–3/5, thenar muscles 2/5, hypothenar muscle 1/5, and interossei 1–2/5. There was atrophy in radial-innervated muscles and decreased sensation in the radial nerve distribution. The left triceps reflex was absent, the biceps reflex was normal. 2.3. Evaluation EMG testing revealed a left brachial plexopathy that most severely involved the posterior cord with dense fibrillation potentials and no activation in the extensor digitorum communis, deltoid and brachioradialis muscles. Thermoregulatory sweat tests showed focal anhidrosis in the left dorsal forearm (distribution of radial cutaneous branches). 2.4. Imaging High resolution MRI revealed enlarged, T2 hyperintense C5T1 spinal nerves (Fig. 1C) and medial and posterior cords, which avidly enhanced on gadolinium images (Fig. 1D and E). An enlarged radial nerve demonstrated perifascicular enhancement, which could be followed in continuity to the lower arm. In the area of the resection of the subcutaneous lesion, the subcutaneous fat demonstrated reticular enhancement merging with the radial nerve (Fig. 1F–H). The enlarged axillary nerve demonstrated a similar pattern as the radial nerve. In the upper arm a peripherally enhancing 18 mm × 13 mm mass continuous with the axillary nerve was observed (Fig. 2A and B). Increased linear T2 signal and post-gadolinium enhancement was observed running from this tumor mass upwards to the subcutaneous fat, piercing the posterior part of the deltoid muscle in the area where the posterior branch of the axillary nerve is predicted (Fig. 2B–E). The median nerve in the upper arm was atypically bright on T2 sequences (Fig. 1F). The deltoid muscle demonstrated atrophy associated with chronic denervation and intramuscular edema consistent with ongoing denervation. The lateral portion of the brachialis and brachioradialis muscles demonstrated chronic denervation with muscle atrophy and fatty replacement. The 18 FDG PET/CT demonstrated visually increased uptake in the upper arm mass and slightly increased uptake in the brachial plexus, below the definitive SUV value (Fig. 2F). 2.5. Procedures Initially, the patient underwent a non-diagnostic biopsy of the superficial radial nerve in the forearm that showed severe loss of myelinated nerve fibers and active axonal degeneration (79%). After completing the FDG PET/CT scan, he underwent a biopsy of the upper arm soft tissue mass located deep to the deltoid muscle,
Fig. 1. Clinical presentation and tumor perineural spread to the brachial plexus. The photographs of the patient (A and B) demonstrating the wrist drop, weakness and atrophy of the triceps muscle and weakness of the deltoid muscle. The post resection wound in the anterolateral arm is visible (B). The photograph of the left shoulder (A) shows a 1 cm × 1 cm large skin lesion diagnosed as squamous cell carcinoma on biopsy. The sagittal fat saturated T2-weighted FSE image (C) reveals the C5-T1 spinal nerves demonstrating increased signal; the subclavian artery and vein are seen (C – letter “A”, letter “V”). The coronal gadolinium enhanced spoiled gradient recall echo (SPGR) image (D) of the left brachial plexus demonstrates the enhancing and enlarged posterior cord (D – arrowhead) and the enhancing posterior division to the medial cord (D – arrow) highly worrisome for perineural tumor spread, the subclavian artery and vein are visible (D – letter “A”, letter “V”). The sagittal gadolinium enhanced SPGR image (E) demonstrates enhancement and enlargement of the radial (E – arrowhead) and axillary nerves (E – arrow), the axillary artery and vein are visible (E – letter “A”, letter “V”). The axial fat saturated T2 FSE image of the left arm (F) shows increased signal in the radial (F – arrow) and median (F – arrowhead) nerves and the post contrast SPGR image (G) at the same level demonstrates perifascicular enhancement of the radial (G – arrow) and to lesser degree the median nerves (G – arrowhead), which is typical for perineural tumor spread. The humerus is in the center (F–H – letter “H”). The axial post contrast SPGR image (H) of the left midarm demonstrates the site of the resection (H – dashed line) and reticular enhancement in the subcutaneous fat (H – arrowheads) interpreted as perineural tumor spread from the original tumor site to the radial nerve (H – arrow) along the fine branches of the inferior lateral cutaneous nerve.
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S. Capek et al. / Clinical Neurology and Neurosurgery 128 (2015) 90–93
Fig. 2. Spread of the tumor to the skin and an overview illustration. The axial T2 image of the left shoulder (A) demonstrates the bright and enlarged axillary nerve (A – arrow) continuous with the upper arm soft tissue tumor mass (A – arrowhead). An area of increased signal where posterior branch of the axillary nerve is presumed can be seen (A – thick arrows). The axial post contrast SPGR image at the same level (B) demonstrates the enlarged and enhancing axillary nerve and the soft tissue mass with peripheral enhancement (B – hollow arrowhead). An area of continuous enhancement (B–E – arrowhead) could be traced from the soft tissue tumor bulk going upwards to the area of the secondary skin cancer. The coronal FDG PET/CT image demonstrates increased uptake in the soft tissue mass (F – arrow) in the left upper arm and in the brachial plexus (F – arrowhead). The artist’s interpretation (G) of the proposed mechanism of perineural tumor spread from the original tumor site to the brachial plexus and back to the skin (G – highlighted in green). (G – With permission ©Mayo Foundation for Medical Education and Research 2014, all rights reserved.)
which demonstrated squamous cell carcinoma. Next, the shoulder skin lesion was biopsied and afterwards treated locally with cryoablation. The biopsy revealed squamous cell carcinoma as well. 2.6. Further management The patient was scheduled for radiation treatment at his local hospital. 3. Discussion We present this case of neoplastic brachial plexopathy with perineural spread of skin squamous cell carcinoma to a distant skin site to illustrate an alternate mechanism of tumor spread. This is an important distinction from metastasis from either hematogenous or lymphangitic spread. We believe the mid arm skin lesion had perineural invasion (Fig. 2G) involved and propagated along the inferior lateral cutaneous nerve. The tumor then spread to the radial nerve, the posterior cord and axillary nerve and then more diffusely to other parts of the brachial plexus including the spinal nerves. Perineural spread along the axillary nerve also explains the soft tissue “metastasis” deep to the deltoid muscle as well as the shoulder cutaneous squamous cell carcinoma, both of which were biopsied. These lesions are both in the axillary nerve territory: the
“sub-deltoid” nodule is continuous with the anterior branch of the axillary nerve, and the shoulder skin lesion is supplied by the superior lateral cutaneous nerve derived from the posterior branch [1] (Fig. 2A–E). Analogous spread to the plexus has been reported in the lumbosacral plexus [2]. What we consider unique and unreported is the secondary spread of skin cancer in the opposite direction back to the skin. The propensity of squamous cell carcinoma to seed in the skin along the cutaneous nerves can be demonstrated and further supported by zosteriform metastases [3]. Yamato et al. [4] reported a similar case of perineural spread of epithelioid sarcoma with tumorous skin ulcers. We wonder if this case represents another case of perineural tumor spread to the skin. We considered the possibility that the shoulder skin squamous cell carcinoma is a new synchronous occurrence but felt this was unlikely given the compelling evidence provided to support perineural spread.
4. Conclusion We present a case of extensive perineural spread of squamous cell carcinoma from the arm to the brachial plexus and beyond to the spinal nerves and along the axillary nerve back to the skin. A
S. Capek et al. / Clinical Neurology and Neurosurgery 128 (2015) 90–93
similar extensive case of perineural spread of skin cancer back to the skin through the brachial plexus has not been reported previously. Disclosure The authors report no conflict of interest regarding work presented in this manuscript. Patient consent and confidentiality The patients have consented to the submission of the case reports to the journal. This study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2000 and 2009.
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Acknowledgement S.C. is supported by European Regional Development Fund – Project FNUSA-ICRC (No. CZ.1.05/1.1.00/02.0123) References [1] Schünke M. Thieme atlas of anatomy. Stuttgart/New York: Thieme; 2010. [2] Cho DY, Wang YC, Chen JT. Intradural metastasis to the cauda equina from carcinoma of the anus. Spine 1995;20(21):2341–4. [3] Cohen JL, Barankin B, Zloty DM, Mikhail GR. Metastatic zosteriform squamous cell carcinoma in an immunocompetent patient. J Cutan Med Surg 2004;8(6):438–41. [4] Yamato M, Nishimura G, Yamaguchi T, Tamai K, Saotome K. Epithelioid sarcoma with unusual radiological findings. Skeletal Radiol 1997;26(10): 606–10.
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Case Report
Perineural spread of squamous cell carcinoma: From skin to skin through the brachial plexus Stepan Capek a,b , Kimberly K. Amrami c , Benjamin M. Howe c , Diva R. Salomao d , P. James B. Dyck e , Robert J. Spinner a,∗ a
Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Rochester, MN, USA International Clinical Research Center, St. Anne’s University Hospital Brno, Pekarska 53, Brno, 656 91, Czech Republic c Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA d Department of Pathology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA e Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, MN, USA b
a r t i c l e
i n f o
Article history: Received 3 October 2014 Accepted 9 November 2014 Available online 15 November 2014 Keywords: Perineural tumor spread Squamous cell carcinoma Skin cancer Brachial plexopathy Skin metastasis
1. Introduction
2. Case report
Perineural spread is an alternative to the more common hematogenous or lymphogenous form of tumor spread. Perineural spread is most frequently reported in head and neck cancers with only a few cases in upper limb nerves. We present a patient with a history of squamous cell carcinoma in the left arm who developed a left brachial plexopathy and subsequently other histologically similar lesions in the soft tissues and skin of the left shoulder. We hypothesize that all of the findings including the secondary lesions could be explained anatomically as perineural spread from the original site along small and major branches of the upper arm nerves to a distant site. Our theory is supported by high resolution imaging. Although perineural spread is frequently reported in squamous cell carcinoma, it has not been described as the mechanism for spread to skin at a distant site.
An 86-year-old left-handed man with a 5-year history of a subcutaneous nodule in the left mid anterolateral arm presented to our institution with a progressive left brachial plexopathy. Six weeks prior to presentation, the nodule was resected and diagnosed as squamous cell carcinoma.
∗ Corresponding author at: Mayo Clinic, Gonda 8-214, Rochester, MN, 55905, USA. Tel.: +1 507 284 2376; fax: +1 507 280 5206. E-mail addresses: [email protected] (S. Capek), [email protected] (K.K. Amrami), [email protected] (B.M. Howe), [email protected] (D.R. Salomao), [email protected] (P.J.B. Dyck), [email protected] (R.J. Spinner). http://dx.doi.org/10.1016/j.clineuro.2014.11.004 0303-8467/© 2014 Elsevier B.V. All rights reserved.
2.1. History The patient reported having a hard cigar-sized subcutaneous nodule in the mid left anterolateral arm since 2009. He had a history of multiple unspecified skin cancers involving his scalp, which were treated locally. In September 2012 he noticed intermittent paresthesias and hypesthesia over his left upper arm and shoulder. In October 2012 he developed continuous numbness and a wrist drop, which progressed to fingers extension weakness and numbness over the left lateral forearm extending to the thumb and the dorsum of the hand the following month. An EMG performed in November 2012 showed a left radial neuropathy with involvement of the triceps. Magnetic resonance imaging (MRI) of the brachial plexus was interpreted as normal. In February 2013 he developed shoulder abduction weakness. Electrodiagnostic testing performed in April 2013 demonstrated predominantly a
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posterior cord brachial plexopathy with lesser involvement of the medial cord; needle EMG showed 3+ fibrillations in the deltoid, triceps and brachioradialis muscles. The patient was treated for an inflammatory lesion. In September 2013 electrodiagnostic testing demonstrated progression of the brachial plexopathy involving the posterior and the medial cord. In May 2014 he had a Mohs procedure for the left mid-arm lesion with skin grafting from the thigh. The specimen revealed squamous cell carcinoma. 2.2. Physical examination In July 2014 examination at our institution revealed an approximately 5 cm × 5 cm skin defect in his left anterolateral arm. An approximately 1 cm × 1 cm pink skin lesion on his left shoulder was worrisome for a cutaneous malignancy (Fig. 1A and B). Muscle testing revealed infraspinatus MRC grade 4/5, deltoid 3/5, triceps 0/5, biceps 4/5, brachioradialis 0/5, supinator 0/5, wrist and finger extensors 0/5, pronator teres 4/5, finger flexors (med.) 3–4/5, finger flexors (uln.) 2–3/5, thenar muscles 2/5, hypothenar muscle 1/5, and interossei 1–2/5. There was atrophy in radial-innervated muscles and decreased sensation in the radial nerve distribution. The left triceps reflex was absent, the biceps reflex was normal. 2.3. Evaluation EMG testing revealed a left brachial plexopathy that most severely involved the posterior cord with dense fibrillation potentials and no activation in the extensor digitorum communis, deltoid and brachioradialis muscles. Thermoregulatory sweat tests showed focal anhidrosis in the left dorsal forearm (distribution of radial cutaneous branches). 2.4. Imaging High resolution MRI revealed enlarged, T2 hyperintense C5T1 spinal nerves (Fig. 1C) and medial and posterior cords, which avidly enhanced on gadolinium images (Fig. 1D and E). An enlarged radial nerve demonstrated perifascicular enhancement, which could be followed in continuity to the lower arm. In the area of the resection of the subcutaneous lesion, the subcutaneous fat demonstrated reticular enhancement merging with the radial nerve (Fig. 1F–H). The enlarged axillary nerve demonstrated a similar pattern as the radial nerve. In the upper arm a peripherally enhancing 18 mm × 13 mm mass continuous with the axillary nerve was observed (Fig. 2A and B). Increased linear T2 signal and post-gadolinium enhancement was observed running from this tumor mass upwards to the subcutaneous fat, piercing the posterior part of the deltoid muscle in the area where the posterior branch of the axillary nerve is predicted (Fig. 2B–E). The median nerve in the upper arm was atypically bright on T2 sequences (Fig. 1F). The deltoid muscle demonstrated atrophy associated with chronic denervation and intramuscular edema consistent with ongoing denervation. The lateral portion of the brachialis and brachioradialis muscles demonstrated chronic denervation with muscle atrophy and fatty replacement. The 18 FDG PET/CT demonstrated visually increased uptake in the upper arm mass and slightly increased uptake in the brachial plexus, below the definitive SUV value (Fig. 2F). 2.5. Procedures Initially, the patient underwent a non-diagnostic biopsy of the superficial radial nerve in the forearm that showed severe loss of myelinated nerve fibers and active axonal degeneration (79%). After completing the FDG PET/CT scan, he underwent a biopsy of the upper arm soft tissue mass located deep to the deltoid muscle,
Fig. 1. Clinical presentation and tumor perineural spread to the brachial plexus. The photographs of the patient (A and B) demonstrating the wrist drop, weakness and atrophy of the triceps muscle and weakness of the deltoid muscle. The post resection wound in the anterolateral arm is visible (B). The photograph of the left shoulder (A) shows a 1 cm × 1 cm large skin lesion diagnosed as squamous cell carcinoma on biopsy. The sagittal fat saturated T2-weighted FSE image (C) reveals the C5-T1 spinal nerves demonstrating increased signal; the subclavian artery and vein are seen (C – letter “A”, letter “V”). The coronal gadolinium enhanced spoiled gradient recall echo (SPGR) image (D) of the left brachial plexus demonstrates the enhancing and enlarged posterior cord (D – arrowhead) and the enhancing posterior division to the medial cord (D – arrow) highly worrisome for perineural tumor spread, the subclavian artery and vein are visible (D – letter “A”, letter “V”). The sagittal gadolinium enhanced SPGR image (E) demonstrates enhancement and enlargement of the radial (E – arrowhead) and axillary nerves (E – arrow), the axillary artery and vein are visible (E – letter “A”, letter “V”). The axial fat saturated T2 FSE image of the left arm (F) shows increased signal in the radial (F – arrow) and median (F – arrowhead) nerves and the post contrast SPGR image (G) at the same level demonstrates perifascicular enhancement of the radial (G – arrow) and to lesser degree the median nerves (G – arrowhead), which is typical for perineural tumor spread. The humerus is in the center (F–H – letter “H”). The axial post contrast SPGR image (H) of the left midarm demonstrates the site of the resection (H – dashed line) and reticular enhancement in the subcutaneous fat (H – arrowheads) interpreted as perineural tumor spread from the original tumor site to the radial nerve (H – arrow) along the fine branches of the inferior lateral cutaneous nerve.
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S. Capek et al. / Clinical Neurology and Neurosurgery 128 (2015) 90–93
Fig. 2. Spread of the tumor to the skin and an overview illustration. The axial T2 image of the left shoulder (A) demonstrates the bright and enlarged axillary nerve (A – arrow) continuous with the upper arm soft tissue tumor mass (A – arrowhead). An area of increased signal where posterior branch of the axillary nerve is presumed can be seen (A – thick arrows). The axial post contrast SPGR image at the same level (B) demonstrates the enlarged and enhancing axillary nerve and the soft tissue mass with peripheral enhancement (B – hollow arrowhead). An area of continuous enhancement (B–E – arrowhead) could be traced from the soft tissue tumor bulk going upwards to the area of the secondary skin cancer. The coronal FDG PET/CT image demonstrates increased uptake in the soft tissue mass (F – arrow) in the left upper arm and in the brachial plexus (F – arrowhead). The artist’s interpretation (G) of the proposed mechanism of perineural tumor spread from the original tumor site to the brachial plexus and back to the skin (G – highlighted in green). (G – With permission ©Mayo Foundation for Medical Education and Research 2014, all rights reserved.)
which demonstrated squamous cell carcinoma. Next, the shoulder skin lesion was biopsied and afterwards treated locally with cryoablation. The biopsy revealed squamous cell carcinoma as well. 2.6. Further management The patient was scheduled for radiation treatment at his local hospital. 3. Discussion We present this case of neoplastic brachial plexopathy with perineural spread of skin squamous cell carcinoma to a distant skin site to illustrate an alternate mechanism of tumor spread. This is an important distinction from metastasis from either hematogenous or lymphangitic spread. We believe the mid arm skin lesion had perineural invasion (Fig. 2G) involved and propagated along the inferior lateral cutaneous nerve. The tumor then spread to the radial nerve, the posterior cord and axillary nerve and then more diffusely to other parts of the brachial plexus including the spinal nerves. Perineural spread along the axillary nerve also explains the soft tissue “metastasis” deep to the deltoid muscle as well as the shoulder cutaneous squamous cell carcinoma, both of which were biopsied. These lesions are both in the axillary nerve territory: the
“sub-deltoid” nodule is continuous with the anterior branch of the axillary nerve, and the shoulder skin lesion is supplied by the superior lateral cutaneous nerve derived from the posterior branch [1] (Fig. 2A–E). Analogous spread to the plexus has been reported in the lumbosacral plexus [2]. What we consider unique and unreported is the secondary spread of skin cancer in the opposite direction back to the skin. The propensity of squamous cell carcinoma to seed in the skin along the cutaneous nerves can be demonstrated and further supported by zosteriform metastases [3]. Yamato et al. [4] reported a similar case of perineural spread of epithelioid sarcoma with tumorous skin ulcers. We wonder if this case represents another case of perineural tumor spread to the skin. We considered the possibility that the shoulder skin squamous cell carcinoma is a new synchronous occurrence but felt this was unlikely given the compelling evidence provided to support perineural spread.
4. Conclusion We present a case of extensive perineural spread of squamous cell carcinoma from the arm to the brachial plexus and beyond to the spinal nerves and along the axillary nerve back to the skin. A
S. Capek et al. / Clinical Neurology and Neurosurgery 128 (2015) 90–93
similar extensive case of perineural spread of skin cancer back to the skin through the brachial plexus has not been reported previously. Disclosure The authors report no conflict of interest regarding work presented in this manuscript. Patient consent and confidentiality The patients have consented to the submission of the case reports to the journal. This study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2000 and 2009.
93
Acknowledgement S.C. is supported by European Regional Development Fund – Project FNUSA-ICRC (No. CZ.1.05/1.1.00/02.0123) References [1] Schünke M. Thieme atlas of anatomy. Stuttgart/New York: Thieme; 2010. [2] Cho DY, Wang YC, Chen JT. Intradural metastasis to the cauda equina from carcinoma of the anus. Spine 1995;20(21):2341–4. [3] Cohen JL, Barankin B, Zloty DM, Mikhail GR. Metastatic zosteriform squamous cell carcinoma in an immunocompetent patient. J Cutan Med Surg 2004;8(6):438–41. [4] Yamato M, Nishimura G, Yamaguchi T, Tamai K, Saotome K. Epithelioid sarcoma with unusual radiological findings. Skeletal Radiol 1997;26(10): 606–10.
