Non-small cell lung cancer presenting as a bilateral metastatic brachial plexopathy
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Ÿ Neuroanatomy, 2002, Volume1, Pages 26-28.

Case Report
Non-small cell lung cancer presenting as a bilateral
metastatic brachial plexopathy

Necdet Karli (1)
Kader Karli Oguz (2)
Mehmet Zarifoglu (1)
Nebahat Bilici (1)
Ozgur Cakir (3)
(1) Department of Neurology, University of Uludag,
School of Medicine, Gorukle, Bursa, Turkey.
(2) Department of Radiology, Hacettepe University,
School of Medicine, Sihhiye, Ankara, Turkey.
(3) Department of Radiology, University of Uludag,
School of Medicine, Gorukle, Bursa, Turkey
Correspondence Address
Kader Karli Oguz, MD.
Hacettepe University, School of Medicine
Dept of Radiology 06100 Sihhiye Ankara Turkey

Abstract
Squamous cell carcinoma may present with atypical peripheric nerve symptoms. Lung
cancers are the second most common cancer which metastasize to the brachial plexus.
Metastatic brachial plexopathy (BP) is almost always unilateral. We document MR
images of a case with squamous cell lung cancer presenting as bilateral metastatic BP.
Although very rare, bilateral plexopathy may be the presenting situation of lung cancer.
Key words: plexopathy, bilateral, metastasis, lung cancer
Introduction
Brachial plexopathies (BP) develop when lesions occur
anywhere along the course of the brachial plexus which
provides motor and sensory innervation of the upper
extremity. These lesions are often due to trauma, radiation,
and primary or secondary tumors. Secondary tumors of
brachial plexus are more common than primary tumors and
all are malignant [1]. Breast and lung cancers are the most
common malignancies which metastasize to the brachial
plexus and usually invade the brachial plexus by contiguous
spread from the lung [2]. Brachial plexopathy due to
metastasis is almost always unilateral [3, 4].
Herein, we demonstrate a case of a non-small cell lung
cancer presenting as bilateral BP.
Case Report
A 54-year-old man with severe pain and weakness in his
neck, shoulders and arms was referred to our institution
for a detailed evaluation. He had a mild pain started 3
months prior to admission in the left side of his neck and
left shoulder, radiating to the medial side of the left arm.
In two weeks, the pain had increased in severity and a mild
weakness had developed in the left forearm and hand
muscles. At the time of admission, with further increase in
intensity of the pain on left side, a severe pain had developed
in the same region on the right with accompanying weakness
in proximal arm muscles. Cervical spine MRI performed
prior to admission was normal. The patient had a 60 packmonth
(1200 cigarettes/month) smoking history for nearly
40 years.
On examination, left hand intrinsic, triceps, and wrist flexor
and extensor muscles were severely atrophic. Right deltoid
and trapezius muscles were severely, biceps was mildly
atrophic. The weakness of the muscles were variable in a
range between 1/5 and 3/5 on examination. Sensation was
decreased in the left C8 and right C6 dermatomes. Deep
tendon reflexes were normal.
The first electromyography (EMG) showed mildly reduced
right ulnar sensory amplitude. Needle EMG revealed chronic
neurogenic motor unit potentials in right C4-8 innervated
muscles. Reduction in the recruitment was significant in
right C4 and C5 myotomes, concluding that these were the
most severely affected ones. In left arm C6-8 and T1
muscles were affected and C7-8 were the most severe ones.
Consequently an electrodiagnosis of bilateral plexopathy
was made.
Lumbar puncture revealed no abnormality. Brachial plexus
MRI revealed a solitary mass measuring 4x4x4.5 cms in
diameter in the left brachial plexus, located posterolaterally,
involving the middle and lower trunks on coronal images.
The uncapsulated mass was hypointense on T1-weighted
spin echo (T1W SE) and hyperintense on T2W TSE images
relative to the brain parenchyme and had irregular border.
The mass showed marked enhancement (Figs. 1a, b, c).
Extension of the mass into the spinal canal, invasion of the
C6-7 ventral roots and destruction of C6 and C7 vertebras
were observed. There was another mass, 1,5x2,5x3 cms in
size with similar imaging features on the right upper cervical
plexus at the level of C4-5 vertebras and ventral cervical
roots (Figs. 3a, b).
Published online December 17, 2002 © neuroanatomy.org
26 http://www.neuroanatomy.orgISSN 1303-1775 (printed) 1303-1783 (electronic)
A lung CT disclosed a mass lesion in the upper lobe of the
right lung (Fig. 2). The pathological examination yielded
poorly differentiated squamous cell carcinoma.
The patient underwent radiotherapy for the primary and
secondary tumor sites with pain control measures. The
strength of the left arm muscles increased about 20%. He
mentioned almost complete pain relief.
Three weeks later, second EMG showed a 30% and 70%
decrease in right first digit median and ulnar sensory
amplitudes, and 50% and 30% decrease in left median and
ulnar motor amplitudes respectively. Needle examination
revealed an additional involvement of right C4 and left C5
muscles. Right C8 and left C7-8 muscles were worse when
compared to the previous EMG.
One month after his admission to our hospital, he
complained about weakness in his left leg. A repeat cervical
MRI showed progression of the left brachial plexus mass.
Collaps of the C6 and C7 vertebras as well as compression
of the spinal cord by the tumor at the corresponding levels
of C6 and C7 vertebras was observed on sagittal T2W TSE
images (Figs. 3a, b)
The patient failed to respond additional chemotheraphy
and muscle power decreased in all limbs. Six months after
diagnosis he died.
Discussion
In a study of 104 patients with non-traumatic BP, radiation
fibrosis was demonstrated as most common cause followed
by primary and metastatic cancers [4]. Secondary tumors
of brachial plexus are more common than primary tumors
and all are malignant [1]. It was reported that breast and
lung cancers were the most common metastatic cancers to
the brachial plexus. Seventy percent of the tumors were of
breast or lung origin and usually invaded the brachial
plexus by contiguous spread from the lung [2]. Brachial
plexus involvement by a metastatic disease is almost always
unilateral. We are aware of another report by Thyagarajan
et al., in which a bilateral BP due to breast cancer was
presented [3].
Our patient presented with unilateral symptoms mimicking
cervical radiculopathy. EMG and the repeat MR
examination of the brachial plexus after an unremarkable
cervical spine MR performed at the time of relatively mild
symptoms established the diagnosis of bilateral involvement
of the brachial plexus by metastases in our case. Brachial
plexopathy due to any cause is rare. A literature search
discloses a few reports of a few causes [5, 6]. Tzur et al
reported a case due to e. coli sepsis, which presented with
pain in neck and shoulder, weakness of shoulder girdle
and proximal arm muscles and worsened in a few days [7].
Bilateral brachial neuritis can mimick metastatic plexopathy
[6]. Usually, brachial neuritis is more acute and follows a
history of viral illness or immunization [7].
Radiation therapy may cause bilateral BP [2, 8]. But history
of a tumor and radiotheraphy, nature of the pain, myokymia
in the EMG, and findings in radiologic examinations usually
help to differentiate radiation plexopathy from metastatic
plexopathy.
Patient’s history of 60-pack-month smoking increased the
possibility of a metastatic lesion. Brachial plexus MRI
revealed mass lesions in both brachial plexuses. MRI
provides the best anatomical detail and can identify tumor
infiltration of the brachial plexus [7]. Thyagarajan et al.
stated that the masses were usually adjacent to the brachial
plexus rather than in it [3]. This may explain normal sensory
amplitudes (except ulnar nerve) in the first EMG in this
case.
Lung cancer is the most common primary tumor invading
the brachial plexus after breast cancer [1, 3, 4, 9]. Nonsmall
cell lung cancers are the most common lung cancers
which metastasize to the brachial plexus. Only two bilateral
cases out of a total 175 BP patients have been reported in
Figure 1 T1-weighted SE (TR/TE, 650/15) coronal (a) and T2-weighted TSE (TR/TE, 3590/100) axial (b) images show bilateral metastatic
masses on the brachial plexus which invades the C5-C7 vertebras. The neural foramina, and marked heterogenous enhancement is seen on
postcontrast T1-weighted SE (TR/TE, 650/15) axial image (c).
Figure 2 On CT scan, mass of upper lobe bronchus which was proven
to be non-small cell lung carcinoma is demonstrated.
27 Neuroanatomy, 2002, Volume1, Pages 26-28. Karli et al.
a b c
two large series by Thyagarajan [3] and Wittenberg [4].
Breast cancer and radiation therapy were the causes in those
two cases [3, 4]. In Thyagarajan’s study, all 4 metastatic BP
cases out of 71 patients were unilateral [3].
Vargo et al. [10] reported a patient with pancoast tumor
presenting as a left C8 cervical radiculopathy. Their case
was poorly differentiated carcinoma most likely of squamous
type similar to our case. This report together with our case
emphasize that lung cancers, especially squamous cell
carcinomas may present with atypical neurologic
complications.
Tumors, predominantly lung cancers, usually invade medial
and lower trunks [6]. In the present case, metastatic mass
on the same side with the primary tumor, involved the right
upper brachial plexus. On the contralateral side, involvement
of the middle and lower trunks was present. The distribution
pattern suggests that metastases to the brachial plexus in
this case was either lymphatic or hematogenous rather than
contiguous spreading.
As patients who have squamous cell carcinomas may present
with unusual peripheric nerve symptoms, an MR
examination for brachial plexuses and further radiologic
examinations to document primary tumor should be
performed in selected cases.
28 Neuroanatomy, 2002, Volume1, Pages 26-28. Karli et al.
[1] Wilbourn AJ. Brachial plexus disorders. In: Dyck PJ, Thomas PK, eds.
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[2] Kori SH, Foley KM, Posner JB. Brachial plexus lesions in patients with
cancer: 100 cases. Neurology. 1981 (31) 45-50.
[3] Thyagarajan D, Cascino T, Harms G. Magnetic resonance imaging in brachial
plexopathy of cancer. Neurology. 1995 (45) 421-427.
[4] Wittenberg KH, Adkins MC. MR Imaging of nontraumatic plexopathies:
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[5] England JD, Summer AJ. Neuralgic amyotrophy. An increasingly diverse
entity. Muscle Nerve. 1987 (10) 60-68.
[6] Jaeckle KA. Nerve plexus metastases. Neurol Clin. 1991 (9) 857-866.
[7] Tzur A, Shahin R. Bilateral brachial plexopathy after e. coli sepsis. Isr. J.
Med. Sci. 1997 (33) 687-689.
[8] Churn M, Clough V, Slater A. Early onset of bilateral plexopathy during
mantle radiotherapy. Clin. Oncol. 2000 (12) 289-291.
[9] Lusk MD, Kline DG, Garcia CA. Tumors of the brachial plexus. Neurosurgery.
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Arch. Phys. Med. Rehabil. 1990 (71) 606-609.
Ÿ
References
Figure 3 Sagittal T1-weighted SE (TR/TE, 650/15) (a) and T2-
weighted TSE (TR/TE, 3590/100) (b) images show involvement of the
vertebras and compression of the spinal cord. a b
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