MR imaging of perineural tumor spread

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Malignant disease

The most common malignancies associated with head and neck PNS are tumors of salivary, mucosal, and cutaneous origin [8], [9], [10], [11], [12], [13], [14], [15]. For salivary gland origin, typical primary sites include the parotid gland and minor salivary glands, mainly in the palate. Any histologic subtype can spread perineurally but adenoid cystic carcinoma is most notorious. Squamous cell carcinoma (SCC) of primary mucosal origin, and cutaneous SCC or desmoplastic melanoma are also commonly

Trigeminal nerve

The most commonly affected nerves in PNS are the trigeminal and facial. All three trigeminal divisions may be involved, sometimes more than one simultaneously. The maxillary (V2) and mandibular (V3) divisions are most commonly involved, but occasionally for a lesion in the appropriate location, the ophthalmic division (CN V1)may be affected [7], [19]. Fig. 5, Fig. 6, Fig. 7, Fig. 8 depict the anatomy relevant to PNS along the trigeminal nerve.

The ophthalmic division of the trigeminal nerve, V1,

Imaging of perineural tumor spread

Imaging of PNS with MR imaging is analogous to imaging with CT but is far more sensitive. Many cases of PNS are probably missed because the imaging technique is inadequate. First, the field of view must be small enough to allow visualization of the often very small structures involved: 18 cm should be the largest field of view used in imaging PNS. For pulse sequences, a minimum set of sequence would include axial T1- and T2-weighted images and axial and coronal postcontrast T1-weighted images.

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      Tumor may also access the intracranial structures by extending through neurovascular foramina and fissures, often by PNS. Although direct extension usually involves the ASB, the focus of PNS is on the CSB.62 PNS comprises the extension of malignancy along the scaffolding of a nerve or nerve plexus63 either within the perineural space or within the nerve fascicles.

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      For tumors of the parotid gland with microscopic PNI, we consider coverage to the facial nerve up to the stylomastoid foramen and the parapharyngeal space as the nerve tracks up to the skull base at the internal acoustic meatus. In those tumors that are of ACC histologic subtype, or feature gross PNI, we suggest additional coverage of the mandibular nerve from the auriculotemporal nerve up to the foramen ovale11,12 (Fig 6). The submandibular gland (SMG) is a paired structure, located in the submandibular fossa of the mandible (Fig 7A-A″).

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    This article was originally published in Magnetic Resonance Imaging Clinics of North America 10:3, 2002.

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