Perineural Spread of Prostate Cancer...comparing high resolution MRI with torso and endorectal coils...

©2017 MFMER | slide-1

Perineural Spread of Prostate Cancer

Daniel A Adamo MD1, Ann T Packard MD1, Adam T Froemming MD1, Bernard F King MD1, Mark A Nathan MD1, Benjamin M Howe MD1, Stephen M Broski MD1, Jonathan J Stone MD2, Robert J Spinner MD2

Society of Abdominal Radiology, March 4-9, 2018 Scottsdale, AZ.

1 - Department of Radiology, Mayo Clinic, Rochester, MN 2 – Department of Neurosurgery, Mayo Clinic, Rochester, MN


Disclosures

• No relevant financial disclosures


Goals and Objectives • Describe the innervation and relevant neuroanatomy of the prostate

gland and lumbosacral plexus.

• Review the imaging features and patterns of perineural tumor spread of prostate carcinoma.

• Identify potential pitfalls and mimickers which could lead to misdiagnosis of perineural tumor spread.

Target Audience

• Radiologists and trainees who interpret pelvic and prostate MRI,

and FDG and Choline PET CT/MRI.


Background

• Spread of tumor along nerves, known as perineural spread (PNS), is a well known phenomenon in head and neck malignancies

• Perineural invasion (PNI) in prostate cancer is present in 7-43% of all prostate biopsies1. In the setting of PNI, extension along nerves is a logical method of metastatic spread of tumor.

• However, PNS of prostate cancer is a poorly described, yet increasingly recognized phenomenon in pelvic malignancies, including prostate carcinoma 2,3,4.


Prostate Neuroanatomy

• Innervation of the prostate is supplied by the inferior hypogastric (pelvic) plexus

• Inferior Hypogastric/Pelvis plexus

• Mixed sympathetic and parasympathetic innervation

• Derived from S2-S4 pelvic splanchnic nerves

• Also gets contributions from superior hypogastric plexus

• Extends to other pelvic organs

• Rectal plexus, Vesicoureteric plexus, uterovaginal plexus/prostatic plexus

• Located beside the rectum approximately 7cm from anal verge 5,6

The pelvic plexus.

The Surgical Anatomy of the Prostate

Reeves, Fairleigh, MB, BS, Prostate Cancer, Chapter 29, 253-263

Copyright © 2016 Copyright © 2016 Elsevier Ltd. All rights reserved.


Sympathetic and parasympathetic contributions to the pelvic autonomic nervous plexus.

Surgical, Radiographic, and Endoscopic Anatomy of the Male Pelvis

Chung, Benjamin I., MD, Campbell-Walsh Urology, 68, 1611-1630.e1

Copyright © 2016 Copyright © 2016 by Elsevier, Inc. All rights reserved.

Inferior

hypogastric

plexus

Inferior hypogastric plexus

Innervation of the lower urinary tract and male genitalia. (Redrawn with permission from Dyck P,

Thomas PK, 2005, Peripheral Neuropathy, Saunders, Elsevier.) Bladder, prostate and urethra

Standring, Susan, MBE, PhD, DSc, FKC, Hon FAS, Hon FRCS, Gray's Anatomy, Chapter 75,

1255-1271.e1

Copyright © 2016 © 2016, Elsevier Limited. All rights reserved.


Lumbosacral plexus anatomy

• Ventral rami of L1-L4 spinal nerves contribute to the lumbar plexus just posterior to psoas muscle7.

• Lumbar plexus communicates with sacral plexus via the lumbosacral trunk/cord.

• Ventral rami of L4-S3 nerve roots converge just anterior to piriformis to form sacral plexus8.

Simplified diagram of lumbosacral plexus. Contribution of L1 root is not

shown. Lumbosacral trunk or cord is shown. Peripheral Nerve Injuries

Jobe, Mark T., Campbell's Operative Orthopaedics, Chapter 62, 3161-

3224.e7

Copyright © 2017 Copyright © 2017 by Elsevier, Inc. All rights reserved.

Lumbosacral cord

Lumbar

plexus

Sacral

Plexus


Perineural Invasion (PNI) and Spread

• Diagnosis of PNI9

• Tumor cells in any of the 3 layers of the nerve sheath.

• Tumor foci outside of the nerve with involvement of ≥33% of the nerve's circumference are sufficient features for calling PNI9.

• Literature is controversial regarding the prognostic significance of PNI at biopsy10, though some suggest that disease free survival, cancer specific survival, and overall survival are worse in those with PNI11.

• Traditional theories suggested PNS occurred due to tumor spreading along the “path of least resistance.”

• New evidence suggests signaling between tumors cells and nerves plays a key role in driving PNS.


Imaging Findings of PNS

• Nerve thickening/enlargement

• Widening of neural foramen

• Loss of fat surrounding nerve

• Abnormal T2 signal

• Contrast enhancement

• Increased radiotracer activity on PET CT/MRI12

Axial T1W

Axial T2WFS

Axial post gad SPGR


Perineural tumor spread 65-year-old male with

biopsy-proven

perineural spread of

prostate cancer.

Enlargement and

gadolinium

enhancement of the

left sciatic nerve (A)

and left S2 and S3

nerves (B).

Increased FDG uptake

along the left sacral

nerves (C, D).

B

C D

A

Axial post gad SPGR Coronal post gad SPGR

Axial fused FDG PET/MRI Coronal fused FDG PET/MRI


63-year-old male with

history of prostate

cancer status post

remote prostatectomy

with biochemical

recurrence.

Enhancing soft tissue

infiltrating along the left

mesorectal fascia (A)

and proximal left sciatic

nerve B).

Abnormal choline

uptake in the same

distribution (C, D).

A B

C D

Perineural tumor spread

Axial post gad SPGR Axial post gad SPGR

Axial fused C11-choline PET/CT

Coronal fused C11-choline PET/CT


77 yo M history of prostate CA with prostatectomy presenting with right lumbosacral plexopathy in the setting of biochemical recurrence of prostate carcinoma.

Nerve thickening, increased T2 signal (A, D) contrast enhancement (B, E) and increased C-11 choline activity on PET/CT (C, F) along the right S1 nerve extending along the right sciatic nerve.


A B C

D E F

Axial T2WFS MRI Axial post gad SPGR Axial fused C11-choline PET/CT

Coronal T2WFS Coronal post gad SPGR Coronal fused C11-choline PET/CT


Perineural tumor spread A- axial post gad SPGR

C- axial T2WFS

E- axial T2WFS

B- axial fused FDG PET/MRI

D- axial fused FDG PET/MRI

F- axial fused FDG PET/MRI

G- coronal postgad T1WFS

H- coronal fused FDG-PET/MRI

65 year old with history of prostatectomy

presenting with right lumbosacral plexopathy in

the setting of biochemical recurrence.

Thickening, enhancement (A, G), and

increased T2 signal (C) along the right S2 and

S3 nerves extending along the sciatic nerve (E).

Associated increased FDG uptake in the same

distribution (B, D, F, H).


A B C

D E F

G

78 year old status post prostatectomy with biochemical recurrence of prostate carcinoma.

Thickening of the right mesorectal fascia (A) with associated contrast enhancement (D) and C11-

choline uptake (B). Additional enhancement (C, F) and C11-choline uptake (E, G) along the right S3

nerve root.

Coronal C11-choline PET/CT

Axial T2W MRI Axial C11-choline PET/CT Coronal post gad T1FS

Axial C11-choline PET/CT Axial post gad SPGR Coronal post gad T1FS




A, B- Axial fused C11-choline PET/CT

C, D, E – coronal fused C11-choline PET/CT

A B

C D E

86 year old with

hormone refractory

metastatic prostate

carcinoma.

Soft tissue thickening

and increased C11-

choline uptake within

the right mesorectal

fascia (A, C)

extending posteriorly

to involve the right

sciatic nerve (B, D)

and right S3 nerve

(E).



79 year old with biochemical

recurrence of prostate cancer

after prostatectomy.

Increased choline uptake

along the left S1 (B, C)and S2

nerves (A, D), extending to

the sacral plexus (D), sciatic

nerve (D, E), and in the left

mesorectal fascia (E).

A B

C D E

C, D, E – axial fused C11-choline PET/CT

A, B– coronal fused C11-choline PET/CT


Potential Pitfalls and mimickers

• Peripheral nerve sheath tumors

• Inflammatory or Demyelinating Conditions

• Guillain-Barré syndrome

• Charcot-Marie-Tooth Disease

• Systemic Diseases

• Amyloidosis

• Ischemic lumbrosacral plexus neuropathy

• Diabetic plexopathy

• Radiation neuropathy12


Demyelination A B

C 69 year old male with history of prostate cancer status post

prostatectomy presenting with right lower extremity

weakness.

Thickening and increased T2 signal (A) of the proximal right

sciatic nerve, with associated contrast enhancement (B).

No abnormal FDG uptake in right sciatic nerve (C).

Biopsy and EMG consistent with chronic inflammatory

demyelinating polyradiculopathy.

Coronal T2WFS Coronal post gad SPGR

Axial fused FDG PET/CT


Demyelination

Coronal T2WFS Post gad T1WFS Coronal fused C11-choline PET/CT

79 year old with history of prostate cancer status post prostatectomy presenting with

new onset right lumbosacral plexopathy.

Thickening, increased T2 signal (A), and enhancement (B) of the lumbosacral

plexus and L5 nerves. No associated increased C11-choline uptake (C).

Biopsy demonstrated segmental demyelination and inflammation with no evidence of

malignant cells.

A B C


Malignant Peripheral Nerve Sheath Tumor

Axial post gad SPGR Axial fused FDG PET/MRI Axial fused C11-choline PET/CT

78 year old with history of pelvic radiation for prostate cancer presenting with left lumbosacral plexopathy.

Marked thickening, increased T2 signal (A), enhancement (D) and increased FDG (B, E) and choline

(C, F) uptake along the S1, S2 nerves extending to the sciatic nerve (A, C). Biopsy showed malignant

peripheral nerve sheath tumor.

A B C

D E F

Coronal fused FDG PET/MRI Coronal fused C11-choline PET/CT Coronal T2WFS


Conclusions

• Although poorly understood, perineural spread of prostate carcinoma is an increasingly recognized phenomenon.

• With advances in modern prostate imaging, including increased usage of PET/MRI, we suspect perineural spread will be an increasingly common finding.

• Close attention should be given to the lumbosacral plexus on prostate imaging, especially in the setting of biochemical recurrence of prostate CA with or without plexopathy symptoms.


References 1. Harnden, P., et al. (2007). "The prognostic significance of perineural invasion in prostatic cancer biopsies: a systematic review."

Cancer 109(1): 13-24.

2. Babu, M. A., et al. (2013). "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 38(5):

1155-1160.

3. Ladha, S. S., et al. (2006). "Neoplastic lumbosacral radiculoplexopathy in prostate cancer by direct perineural spread: an unusual

entity." Muscle Nerve 34(5): 659-665.

4. Hebert-Blouin, M. N., et al. (2010). "Adenocarcinoma of the prostate involving the lumbosacral plexus: MRI evidence to support direct

perineural spread." Acta Neurochir (Wien) 152(9): 1567-1576.

5. Capek, S., et al. (2015). "Prostate cancer with perineural spread and dural extension causing bilateral lumbosacral plexopathy: case

report." J Neurosurg 122(4): 778-783.

6. Baader B, Herrmann M: Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the

pelvis. Clin Anat 16:119–130, 2003

7. Kirchmair L, Lirk P, Colvin J, Mitterschiffthaler G, Moriggl B. Lumbar plexus and psoas major muscle: not always as expected. Reg

Anesth Pain Med 2008; 33(2):109–114.

8. Petchprapa CN, Rosenberg ZS, Sconfienza LM, Cavalcanti CF, Vieira RL, Zember JS. MR imaging of entrapment neuropathies of the

lower extremity: part 1—the pelvis and hip. RadioGraphics 2010;30 (4):983–1000.

9. Liebig, C., et al. (2009). "Perineural invasion in cancer: a review of the literature." Cancer 115(15): 3379-3391.

10. Merrilees, A. D., et al. (2008). "Parameters of perineural invasion in radical prostatectomy specimens lack prognostic

significance." Mod Pathol 21(9): 1095-1100.

11. DeLancey, J. O., et al. (2013). "Evidence of perineural invasion on prostate biopsy specimen and survival after radical

prostatectomy." Urology 81(2): 354-357.

12. Soldatos, T., et al. (2013). "High-resolution 3-T MR neurography of the lumbosacral plexus." Radiographics 33(4): 967-

987.

Correspondence: Daniel Adamo MD, [email protected] 200 1st St. SW, Rochester, MN 55906

mailto:[email protected]

Perineural Spread of Prostate Cancer...comparing high resolution MRI with torso and endorectal coils...

Documents

Transcript of Perineural Spread of Prostate Cancer...comparing high resolution MRI with torso and endorectal coils...