British Journal of Radiology (2004) 77, 688-690
© 2004 British Institute of Radiology
doi: 10.1259/bjr/16836733
Residual or recurrent head and neck cancer presenting with nerve root compression affecting the upper limbs
R L Mendes, FRCR
1
C M Nutting, FRCR
1,2 and
K J Harrington, FRCR
1,2
1 Head and Neck Unit, Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ and 2 Institute of Cancer Research, Fulham Road, London, UK
Correspondence: Dr K J Harrington
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Abstract
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Nerve root and spinal cord compression are oncological emergencies that require early detection and prompt management. These phenomena are most frequently diagnosed in patients with haematogenous metastases from lung, breast and prostate cancers and are rarely seen in patients with squamous cell cancer of the head and neck (SCCHN). SCCHN tends to spread by direct extension and lymphatic metastasis, with haematogenous dissemination occurring late in the natural history of the disease. In this paper, we report three patients with residual or relapsed SCCHN who presented with symptoms and signs of nerve root compression affecting the upper limbs caused by locoregional lymphatic spread of disease.
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Case 1
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A 73-year-old man presented with a T2 N0 squamous cancer of the left oral tongue. He was treated by wide local excision. An elective neck dissection was not performed and he was not referred for adjuvant radiotherapy (RT). 8 months later he relapsed in a left level III neck node and underwent left radical neck dissection. Pathologically a single involved node contained metastatic squamous cell cancer with extracapsular spread. Post-operative RT to a dose of 50 Gy in 20 fractions was delivered to the left neck. 4 months later the patient presented with severe neck pain and left arm weakness. Plain radiographs (Figure 1
) and a CT scan (Figure 2) showed a pathological fracture of the C4 vertebra caused by direct invasion by a pre-vertebral soft tissue mass that was encroaching on the spinal canal. The lesion was not considered to be amenable to neurosurgical intervention. Despite some overlap with the previous treatment fields to the left neck, palliative RT was delivered to C3 to C6 to a dose of 20 Gy in 5 fractions at 5 cm by a direct posterior field. The pain in the neck and the arm improved after radiotherapy but the patient still required both opiate and non-steroidal anti-inflammatory medication. There was no improvement in the weakness in his left arm. There was further evidence of disease progression in the left neck and so palliative chemotherapy consisting of cisplatin (75 mg m–2 day 1) and 5-fluorouracil (1 g m–2 days 1–4) was commenced. This treatment was complicated by neutropaenic sepsis, Grade 3 mucositis and diarrhoea. No further chemotherapy was given. The patient's condition deteriorated gradually and he died 4 months later.
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Figure 1. Lateral cervical radiograph demonstrating pathological fracture of the C4 vertebra in Case 1.
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Figure 2. Transverse CT section through the C4 vertebral level in Case 1. There is soft tissue infiltration by a pre-vertebral mass that extends to involve the left intervertebral foramina and the spinal canal.
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Case 2
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A 63-year-old man presented with a T1a N0 moderately differentiated squamous cell cancer of the left vocal cord. He was treated with radical RT to a dose of 50 Gy in 16 fractions using 6 MV photons. He developed subglottic recurrence 8 months later and underwent a salvage total laryngectomy. 14 months later he relapsed in the left neck and underwent left modified radical neck dissection. This revealed metastatic squamous cell cancer of the head and neck (SCCHN) in lymph nodes in levels II, III and IV with extensive extracapsular spread. While awaiting the start of adjuvant post-operative RT, he developed severe left shoulder pain, mid-cervical tenderness and proximal lower motor neurone weakness in both arms (left>right). Spinal MRI showed a large left-sided paravertebral mass centred at C5 with direct posterior extension compressing the spinal cord and bilateral nerve roots (Figure 3). At this time he was experiencing severe pain requiring opiate, non-steroidal anti-inflammatory and anti-neuropathic (gabapentin, amitryptiline) medication. Despite some overlap with the previous treatment fields, he received palliative RT to the cervical and upper thoracic spine to a dose of 20 Gy in 5 fractions at 5 cm using 6 MV photons. This treatment resulted in moderate improvement in his pain, although he continued to require opiate analgesia for pain. There was no change in the neurological status in his upper limbs. His general condition deteriorated progressively and he died 6 weeks later.
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Figure 3. Sagittal MRI demonstrating vertebral body involvement centred at C5 with direct posterior extension compressing the spinal cord and bilateral nerve roots.
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Case 3
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A 53-year-old woman presented with a T3 N2c squamous cell cancer of the right pyriform fossa with evidence of right retropharyngeal nodal involvement in front of the C1 vertebra. She received 2 cycles of 3 weekly induction chemotherapy with cisplatin (75 mg m–2 day 1) and 5-fluorouracil (1 g m–2 days 1–4) followed by radical chemoradiation (65 Gy in 30 fractions to the primary site and involved nodes and 50 Gy in 25 fractions to elective nodal areas with concomitant cisplatin 100 mg m–2 in weeks 1 and 5 of radiotherapy). 5 months later, she presented with worsening cervical and thoracic back pain and tingling and weakness in both hands. Spinal MRI showed a large vertebral metastasis destroying the T2 vertebra with a pre-vertebral and intercanicular soft tissue component extending from T1 to T4. There was also separate vertebral involvement at C2 and C4. The disease was inoperable and despite some overlap with the previous treatment fields, the patient received palliative RT to a dose of 20 Gy in 5 fractions at 5 cm using 6 MV photons. Her pain and neurological symptoms improved initially but she rapidly developed intractable headache and deteriorating neurological function. On repeat MRI she was shown to have a massive recurrence in the right retropharyngeal area with direct invasion of the skull base, right cerebellopontine cistern and right temporal lobe. She received further supportive care and died 4 weeks later.
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Discussion
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There have been few reports in the literature of neurological complications of head and neck cancer. Spinal cord compression due to SCCHN is rare because of the low incidence of haematogenous spread. In a retrospective study of 759 patients, Ampil et al [1] reported an incidence of spinal cord compression of about 1%. Leung et al [2] reported the incidence of spinal cord compression in a series of 90 patients with disseminated nasopharyngeal cancer to be 1.4%. In both of these series, the tumour was disseminated and the site of the neurological problem was distant from the head and neck region. We are unaware of any previous reports of residual or relapsed SCCHN presenting with local nerve root compression affecting the upper limbs.
The lymphatic drainage pathways from primary mucosal sites in the head and neck pass through the deep cervical lymph node chain that lies adjacent to the cervical vertebral bodies. This series demonstrates that persistent or relapsing lymphadenopathy following primary treatment for head and neck cancer can lead to nerve root/cord compression either by invasion of vertebrae or by tumour infiltration through the neural foraminae. In each of the above cases, the initial presenting features were local pain and neurological symptoms and signs affecting the upper limbs. Despite the presence of radiological evidence of spinal cord compression, none of the patients presented with significant long tract signs affecting the lower limbs or had appreciable bowel or bladder dysfunction. The sites of nerve root and/or spinal cord compression were limited to the cervical and upper thoracic spine, in keeping with a pattern of direct local lymphatic, as opposed to systemic haematogenous, spread.
It is important to note that both patients who underwent salvage surgery for relapsed disease in cervical lymph nodes (Cases 1 and 2) had evidence of extracapsular spread and in Case 3 its presence could be inferred from the pattern of local invasion of the residual/relapsing disease. Therefore, these patients presented with disease arising in the soft tissues of the neck causing local neurological problems, in contrast to the usual pattern of cord compression from breast, lung, prostate and renal cancers that generally spread haematogenously to the thoracolumbar vertebral bodies [3].
In treating nerve root and spinal cord compression, the most important factors in determining neurological recovery are the level of neurological function at the beginning of therapy and the availability of further therapeutic manoeuvres. Prompt diagnosis is essential if neurological function is to be conserved successfully. Pain is the most frequent presenting symptom of nerve root or spinal cord compression [4]. It is often radicular in nature and may be associated with motor and sensory changes in the arms and legs and autonomic dysfunction. In addition, with paraspinal cervical disease, a Horner's syndrome may develop due to sympathetic chain involvement. MRI remains the best method of diagnosing spinal cord compression [5]. Patients with such symptoms should be commenced on high-dose dexamethasone until the MRI is performed and treatment is commenced.
In patients with residual or recurrent SCCHN, salvage surgery may be complicated by the fact that patients have had previous surgery and/or radiotherapy to the site and this can significantly increase the difficulty of the procedure. In all of the patients presented here, the diffuse nature of the recurrence in the neck precluded the use of surgery as a salvage option. In a small surgical series examining the role of surgery in spinal cord compression by SCCHN, Preciado et al [6] proposed that surgery should be offered to patients with unstable spines, in patients with no improvement after 2 days of radiotherapy and those with a life expectancy of greater than 6 months. These criteria cannot easily be applied to patients with nerve root and/or spinal cord compression of the type that we describe here. Radiotherapy is the mainstay of treatment for most cases of nerve root or spinal cord compression. Unfortunately, when treating patients in this scenario, the choices are difficult, as the cord has often received radiation doses that approach tolerance as part of the initial treatment. In addition, palliative regimens to treat cord compression are usually hypofractionated, which can further increase the risk of radiation-induced myelopathy [7]. Although there is a theoretical risk of radiation-induced myelopathy if the cord is re-treated, failing to give palliative radiotherapy may be associated with worsening symptoms and subsequent disease-related cord dysfunction. Despite areas of overlap with previous treatment fields, none of the patients in our series developed either radiation-induced myelopathy or disease-related signs of cord compression, suggesting that careful re-treatment is relatively safe. However, residual or recurrent head and neck cancer causing nerve root/cord compression may well be relatively radioresistant, especially if the disease has previously been treated by radiotherapy (as was the case in two of these patients). This may explain the poor symptomatic response of the patients to palliative radiotherapy.
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Conclusion
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Patients with residual or relapsed SCCHN who present with symptoms (and/or signs) of nerve root and/or spinal cord compression have a poor prognosis. Extracapsular spread in residual or recurrent nodal disease appears to represent a significant risk factor for the development of cervical nerve root compression. The delivery of palliative radiotherapy may be difficult because of potential overlap with previous irradiation fields and may have limited efficacy because of the presence of radioresistant disease.
Received for publication August 4, 2003.
Accepted for publication November 25, 2003.
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References
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- Leung SF, Teo PM, Shiu WW, Tsao SY, Leung TW. Clinical features and management of distant metastases of nasopharyngeal carcinoma. J Otolaryngol 1991;20:27–9.[Medline]
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- Gilbert RW, Kim J-H, Posner JB. Epidural spinal cord compression from metastatic tumour: diagnosis and treatment. Ann Neurol 1978;3:40–51.[CrossRef][Medline]
- Kamholtz R, Sze G. Current imaging in spinal metastatic disease. Semin Oncol 1991;18:158–69.[Medline]
- Preciado DA, Sebring LA, Adams GL. Treatment of patients with spinal metastases from head and neck neoplasms. Arch Otolaryngol Head Neck Surg 2002;128:539–43.[Abstract/Free Full Text]
- Maranzano E, Bellavita R, Floridi P, Celani G, Righetti E, Lupattelli M, et al. Radiation-induced myelopathy in long-term surviving metastatic spinal cord compression patients after hypofractionated radiotherapy: a clinical and magnetic resonance imaging analysis. Radiother Oncol 2001;60:281–8.[CrossRef][Medline]
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Abstract
Case 1
