Morphology of the entering and exiting nerve as a differentiating feature of benign from malignant peripheral nerve sheath tumours of the brachial plexus

Objective To identify if morphology of the entering and exiting nerve involved by a nerve sheath tumour in the brachial plexus can help differentiate between benign (B) and malignant (M) peripheral nerve sheath tumours (PNSTs). Materials and methods Retrospective review of 85 patients with histologically confirmed primary PNSTs of the brachial plexus over a 12.5-year period. Clinical data and all available MRI studies were independently evaluated by 2 consultant musculoskeletal radiologists blinded to the final histopathological diagnosis assessing for maximal lesion dimension, visibility and morphology of the entering and exiting nerve, and other well-documented features of PNSTs. Results The study included 47 males and 38 females with mean age 46.7 years (range, 8-81 years). There were 73 BPNSTs and 12 MPNSTs. The entering nerve was not identified in 5 (7%), was normal in 17 (23%), was tapered in 38 (52%) and showed lobular enlargement in 13 (18%) BPNSTs compared with 0 (0%), 0 (0%), 2 (17%) and 10 (83%) MPNSTs respectively. The exiting nerve was not identified in 5 (7%), was normal in 20 (27%), was tapered in 42 (58%) and showed lobular enlargement in 6 (8%) BPNSTs compared with 4 (33%), 0 (0%), 2 (17%) and 6 (50%) MPNSTs respectively. Increasing tumour size, entering and exiting nerve morphology and suspected MRI diagnosis were statistically significant differentiators between BPNST and MPNST (p < 0.001). IOC for nerve status was poor to fair but improved to good if normal/tapered appearance were considered together with improved specificity of 81-91% for BPNST and sensitivity of 75-83%. Conclusions Morphology of the adjacent nerve is a useful additional MRI feature for distinguishing BPNST from MPNST of the brachial plexus.