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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 4  |  Page : 465-467

Malignant infiltration of peripheral nerves: As initial presenting manifestation of lymphoreticular malignancies


1 Department of Neurology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India
2 Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India

Date of Web Publication19-Sep-2014

Correspondence Address:
Meena Angamuthu Kannan
Department of Neurology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad
India
Meena Angamuthu Kannan
Department of Neurology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.141288

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How to cite this article:
Kannan MA, Uppin MS, Jabeen SA, Mridula RK, Challa S, Borgohain R, Kannan MA, Uppin MS, Jabeen SA, Mridula RK, Challa S, Borgohain R. Malignant infiltration of peripheral nerves: As initial presenting manifestation of lymphoreticular malignancies. Neurol India 2014;62:465-7

How to cite this URL:
Kannan MA, Uppin MS, Jabeen SA, Mridula RK, Challa S, Borgohain R, Kannan MA, Uppin MS, Jabeen SA, Mridula RK, Challa S, Borgohain R. Malignant infiltration of peripheral nerves: As initial presenting manifestation of lymphoreticular malignancies. Neurol India [serial online] 2014 [cited 2020 Oct 23];62:465-7. Available from: https://www.neurologyindia.com/text.asp?2014/62/4/465/141288


Sir,

Neurologic complications in patients with cancer account for 20-25% of cases. Most often the peripheral nervous system (PNS) in patients with cancer is related to the adverse effects of chemotherapy. [1] Rarely PNS involvement may be due to infiltration, invasion and compression of nerves, particularly in leukemia (neuroleukemiosis) and lymphoma (neurolymphomatosis), and multiple myeloma (MM). [2] Diagnosis of such complications requires a high index of suspicion and is based on clinical, imaging as well as pathological studies obtained from nerves or the extraneural tissue and CSF. [3] This report presents three unusual patients in whom the initial manifestation was infiltrative peripheral neuropathy. The clinical characteristic and the associated malignancy are given in [Table 1][Figure 1], [Figure 2].
Figure 1: I - (a) Bone marrow aspirate showing lymphoblasts (Giemsa, 100) (b) Trephine biopsy showing infiltrate of blasts in marrow (c) Blasts were positive for CD3 (HRP-Polymer; 40). II - (a) Sural nerve showing dense infiltrate around epineurial vessel. (b) Longitudinal section showing myelin ovoids (H and E, 100) (c) Infi ltrate showing intense positivity for myeloperoxidase (HRP-Polymer; 100). III - (a-c) Infiltration of leptomeninges, dorsal root ganglia and endoneurium of peripheral nerve. (d and e) Loss of myelin and axons in peripheral nerve. (f) Presence of aspergillus hyphae in the pulmonary vessels (H and E, 100)

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Figure 2: (a) Sural nerve biopsy showing dense infi ltrate around epineurial vessels extending to perineurium. (H and E, ×40). (b) The infiltrate predominantly comprised of plasma cells (H and E, ×100). (c) Kpal stain showing acute degeneration of the fibers (Kpal, ×100). (d) Immunohistochemistry with kappa light chain showing positivity in plasma cells and (e) Negativity for lambda chains

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Table 1: Clinical characteristics and the underlying malignancy

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Malignant cell infiltration of peripheral nerve associated with lymphoproliferative malignancies are exceedingly rare and may rarely be the first manifestation or the sole relapse site of the cancer. [2],[3] There is limited information available on the mode of presentation, clinical course, diagnostic yield of various procedures, and response to therapy in patients with malignant cell infiltrative peripheral neuropathy. Lack of awareness of the condition may contribute to a diagnostic delay. [4] In published reports patients developed leukemic infiltration of peripheral nerves, while in remission. [2] Infiltrative peripheral neuropathy as the presenting feature of leukemia as seen in case 1 and 2 in this series is even rarer. Recognition of such presentation is important because exclusion of leukemia or hematologic malignancies is not usually part of the diagnostic algorithm of peripheral neuropathy. The most distinctive pattern of neuropathy in MM unrelated to therapy is a sensory-motor and autonomic neuropathy due to light chain amyloidosis. Malignant cell infiltration of peripheral nerves can herald a relapse in a MM patients considered to be in full remission. [5]

Early recognition and treatment of this rare neurologic manifestation cancer may improve outcome. Magnetic resonance neurography and positron emission tomography scan may provide a clue to the possibility of malignant cell infiltration of peripheral nerves. Cerebrospinal fluid shows increased protein and mild pleocytosis. The diagnosis of peripheral neuroinfiltration may be established by sural nerve biopsy since the process involves virtually all roots, plexuses, and nerves. In conclusion, the three patients in this report suggest that malignant cell infiltration of the peripheral nerve may be the presenting feature of lymphoreticular malignancy and should be included in the diagnostic algorithm of peripheral neuropathy.

 
  References Top

1.Ramchandren S, Dalmau J. Metastases to the peripheral nervous system. J Neurooncol 2005;75:101-10.  Back to cited text no. 1
    
2.Aregawi DG, Sherman JH, Douvas MG, Burns TM, Schiff D. Neuroleukemiosis: Case report of leukemic nerve infiltration in acute lymphoblastic leukemia. Muscle Nerve 2008;38:1196-200.  Back to cited text no. 2
    
3.Reddy CG, Mauermann ML, Solomon BM, Ringler MD, Jerath NU, Begna KH, et al. Neuroleukemiosis: An unusual cause of peripheral neuropathy. Leuk Lymphoma 2012;53:2405-11.  Back to cited text no. 3
    
4.Hughes R, Sharrack B, Rubens R. Carcinoma and the peripheral nervous system. J Neurol 1996;243:371-6.  Back to cited text no. 4
    
5.Denier C, Lozeron P, Adams D, Decaudin D, Isnard-Grivaux F, Lacroix C, et al. Multifocal neuropathy due to plasma cell infiltration of peripheral nerves in multiple myeloma. Neurology 2006;66:917-8.  Back to cited text no. 5
    


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