Abstract
A 66-year-old gentleman presented with gradual onset, painful, right eye visual loss with right maxillary paraesthesia on a background of previous Basal Cell Carcinoma (BCC) excision and mild cognitive impairment.
Neurological examination demonstrated binocular diplopia with metamorphopsia, and right eye proptosis associated with numbness in the first two divisions of the right Vth cranial nerve. Visual fields assessment was difficult due to cognitive impairment.
Investigations demonstrated non-specific mild bilateral optic atrophy on Ocular Computed Tomography (OCT). MRI brain showed abnormal enhancement of right infraorbital nerve and right optic nerve with involvement of the ophthalmic and maxillary division of the trigeminal nerve which was highly suspicious for perineural invasion (PNI) of tumour. A right infraorbital nerve biopsy confirmed intra and perineural spread of a moderately differentiated keratinising squamous cell carcinoma (SCC). The patient was managed with palliative radiotherapy and succumbed to his illness eventually.
Discussion Perineural invasion can occur in cutaneous SCCs when associated with other poor prognostic features including head and neck location and poor histologic differentiation on biopsy1. Since majority of patients present without symptoms of neural involvement, physicians must be vigilant in the search for this type of tumor spread.
Conclusion PNI of SCC of the head and neck has been associated with poor prognosis.1Patients may initially be asymptomatic and cranial nerve deficits become apparent only at an advanced stage of cancer spread.2 Early detection of PNI could help in treatment planning with curative intent.
References
Mendenhall WM, et al. Cutaneous head and neck basal and squamous cell carcinomas with perineural invasion. Oral Oncol. 2012 Oct;48(10):918–922.
Thompson AK, et al. Risk factors for cutaneous squamous cell carcinoma recurrence, metastasis, and disease-specific death: a systematic review and meta-analysis. JAMA Dermatol 2016;152:419.
