Cranial nerve lesions due to base of the skull metastases in prostate carcinoma

Neoplastic nerve lesions

Though metastasis and malignant infiltration of the peripheral nervous system is relatively rare, physicians should have a familiarity with their presentations to allow for prompt diagnosis and initiation of treatment. This article will review the clinical presentations, diagnostic evaluation, and treatment of neoplastic involvement of the cranial nerves, nerve roots, peripheral nerves, and muscle. Due to the proximity of the neural structure traversing the skull base, metastasis to this region results in distinctive syndromes, most often associated with breast, lung, and prostate cancer. Metastatic involvement of the nerve roots is uncommon, apart from leptomeningeal carcinomatosis and bony metastasis with resultant nerve root damage, and is characterized by significant pain, weakness, and numbness of an extremity. Neoplasms may metastasize or infiltrate the brachial and lumbosacral plexuses resulting in progressive and painful sensory and motor deficits. Differentiating neoplastic involvement from radiation-induced injury is of paramount importance as it dictates treatment and prognosis. Neurolymphomatosis, due to malignant lymphocytic infiltration of the cranial nerves, nerve roots, plexuses, and peripheral nerves, deserves special attention given its myriad presentations, often mimicking acquired demyelinating neuropathies.

Adenocarcinoma of Unknown Primary Site with Bone Marrow and Orbital Metastases Suggestive of a Prostatic Origin

Prostate cancer may occasionally present as an adenocarcinoma with an undetermined primary site. We report a case in which bone marrow invasion and orbital metastasis were the first evidence of malignancy. Recognition of metastatic prostate cancer is important since it can be managed safely and effectively with hormonal therapy.

Single Skull Metastasis 15 Years after Primary Treatment of Prostate Cancer and with Undetectable PSA Levels: A Case Report and Review of the Literature

Prostate cancer is the first cause of skull metastases in men, accounting for 12–18% of all cases. This condition is generally a late event in the course of the disease, involving patients with disseminated lesions. Quite rarely is skull involvement the first and single site of distant recurrence. We report the case of a patient who developed a single skull lesion 15 years after primary treatment of prostate cancer, in the presence of undetectable PSA levels. Pathological assessment performed after resection of the lesion revealed a metastasis from prostate carcinoma. Basing on this experience the appearance of craniofacial pain or a nerve deficit in patients with a history of prostate cancer should alert the clinician to exclude distant recurrence of disease, even in the presence of undetectable PSA levels and even if many years have elapsed since the treatment of the primary tumor. Knowledge of these manifestations will reduce any diagnostic delay and lead to the effective delivery of appropriate treatment.

Insidious enemy: downside to prolonged survival in prostate cancer

An 83-year-old man, a prostate cancer survivor of 10 years with multiple vertebral metastases presented with sudden onset of double vision. On examination he was found to have an isolated partial left abducens palsy with no other neurological deficits. Despite having microvascular risk factors, given his history of prostate cancer, aMRI brain scan was requested to look for a neurological cause. The scan revealed a metastatic lesion in the clivus encasing the cavernous sinus and carotid artery. He was referred to his oncologist for further management, however he opted out of further treatment and succumbed to his illness a month later. This case report includes a literature review of cases with clivus metastases secondary to prostate cancer. It highlights the importance of carefully examining eye movements and having a high index of suspicion for the subtlest sign that may suggest brain metastases in elderly patients with prostate cancer with prolonged survival.

Incomplete cavernous sinus syndrome as the initial manifestation of a previously undetected metastatic prostate adenocarcinoma

BACKGROUND

Cavernous sinus syndrome presents as unilateral ophthalmoplegia associated with sympathetic denervation, pain, paresthesias, and V1 and V2 distribution numbness. The etiology may be vascular, inflammatory, infectious, and, less commonly, neoplastic (metastatic).

METHODS

We report a patient with incomplete cavernous sinus syndrome as the initial manifestation of previously undetected metastatic prostate adenocarcinoma.

RESULTS

A 59-year-old man presented with a 2-month history of left hemicranial headaches with ptosis and binocular diplopia. Clinical evaluation found left third, fourth, and sixth cranial nerve palsy with mydriasis and ptosis. An MRI showed an enhancing lesion at the clivus with infiltration of left cavernous sinus. A trans-sphenoidal biopsy was performed, leading to diagnosis of metastatic prostate adenocarcinoma. The patient underwent treatment and achieved clinical improvement.

CONCLUSIONS

In middle-aged men, it is important to include metastatic prostate adenocarcinoma in the differential diagnosis of cavernous sinus syndrome, even in the absence of primary tumor diagnosis.

Calvarial-orbital Metastasis of Prostate Carcinoma which was Diagnosed with Sixth Cranial Nerve Palsy

Sixth nerve palsy is frequently due to infectious orbital lesions, trauma, elevated intracranial pressure, brainstem lesions, and vasculopathies. Here, we describe a rare cause of sixth cranial nerve (CN) palsy secondary to calvarial and orbital metastasis of prostate carcinoma. The diagnosis of the prostate carcinoma with sixth CN palsy is a very rare condition. A 66-year-old male patient presented with complaints of blurred vision, double vision, and inability to move outward in the right eye for 3 weeks. Magnetic resonance imaging revealed a right orbitocalvarial mass and the mass surgically removed completely. Pathologic findings were compatible with prostate adenocarcinoma metastasis. After surgical removal, significant improvement in sixth CN palsy was observed.

Calvarial metastasis from endometrial carcinoma: Case report and review of the literature

Hematogenous bone metastases from endometrial carcinoma are not frequent and their treatment is a matter of debate. We describe an extremely rare case of calvarial metastasis from endometrial carcinoma in an 80-year-old woman treated by means of one-step surgical radical resection and heterologous cranioplasty, along with a review of the literature regarding epidemiology, clinico-radiological features, prognosis, and management of skull metastases.

Fractionated stereotactic radiosurgery for patients with skull base metastases from systemic cancer involving the anterior visual pathway

BACKGROUND

To analyze the tumor control, survival outcomes, and toxicity after stereotactic radiosurgery (SRS) for skull base metastases from systemic cancer involving the anterior visual pathway.

PATIENTS AND METHODS

We have analyzed 34 patients (23 females and 11 males, median age 59 years) who underwent multi-fraction SRS for a skull base metastasis compressing or in close proximity of optic nerves and chiasm. All metastases were treated with frameless LINAC-based multi-fraction SRS in 5 daily fractions of 5 Gy each. Local control, distant failure, and overall survival were estimated using the Kaplan-Meier method calculated from the time of SRS. Prognostic variables were assessed using log-rank and Cox regression analyses.

RESULTS

At a median follow-up of 13 months (range, 2-36.5 months), twenty-five patients had died and 9 were alive. The 1-year and 2-year local control rates were 89% and 72%, and respective actuarial survival rates were 63% and 30%. Four patients recurred with a median time to progression of 12 months (range, 6-27 months), and 17 patients had new brain metastases at distant brain sites. The 1-year and 2-year distant failure rates were 50% and 77%, respectively. On multivariate analysis, a Karnofsky performance status (KPS) >70 and the absence of extracranial metastases were prognostic factors associated with lower distant failure rates and longer survival. After multi-fraction SRS, 15 (51%) out of 29 patients had a clinical improvement of their preexisting cranial deficits. No patients developed radiation-induced optic neuropathy during the follow-up.

CONCLUSIONS

Multi-fraction SRS (5 x 5 Gy) is a safe treatment option associated with good local control and improved cranial nerve symptoms for patients with a skull base metastasis involving the anterior visual pathway.

Fractionated external beam radiotherapy of skull base metastases with cranial nerve involvement

BACKGROUND AND PURPOSE

Skull base metastases frequently appear in a late stage of various tumor entities and cause pain and neurological disorders which strongly impair patient quality of life. This study retrospectively analyzed fractionated external beam radiotherapy (EBRT) as a palliative treatment approach with special respect to neurological outcome, feasibility and acute toxicity.

PATIENTS AND METHODS

A total of 30 patients with skull base metastases and cranial nerve disorders underwent EBRT with a mean total dose of 31.6 Gy. Neurological status was assessed before radiotherapy, during radiotherapy and 2 weeks afterwards categorizing orbital, parasellar, middle fossa, jugular foramen and occipital condyle involvement and associated clinical syndromes. Neurological outcome was scored as persistence of symptoms, partial response, good response and complete remission. Treatment-related toxicity and overall survival were assessed.

RESULTS

Before EBRT 37 skull base involvement syndromes were determined with 4 patients showing more than 1 syndrome. Of the patients 81.1 % responded to radiotherapy with 10.8 % in complete remission, 48.6 % with good response and 21.6 % with partial response. Grade 1 toxicity of the skin occurred in two patients and grade 1 hematological toxicity in 1 patient under concurrent chemoradiotherapy. Median overall survival was 3.9 months with a median follow-up of 45 months.

CONCLUSION

The use of EBRT for skull base metastases with symptomatic involvement of cranial nerves is marked by good therapeutic success in terms of neurological outcome, high feasibility and low toxicity rates. These findings underline EBRT as the standard therapeutic approach in the palliative setting.

Atrophy of the tongue as the presenting feature of metastatic prostate cancer

Prostate cancer is the most frequently diagnosed solid organ cancer in men and is the second leading cause of cancer-related deaths in men in the United Kingdom. Commonly, it metastasizes to bones and lymph nodes, however, in advanced hormonerefractory disease it may involve the skull base leading to associated cranial nerve palsies. Cranial nerve palsy as the presenting feature of advanced hormone-sensitive prostate cancer is extremely rare. To the best of our knowledge, we report the first case of solitary hypoglossal nerve palsy as the presenting feature of advanced prostate cancer. Neurologists, neurosurgeons and otolaryngologists may be the first clinicians to see such a patient; therefore, prostate cancer should be amongst the differential diagnoses considered in middle-aged and elderly men presenting with a cranial neuropathy and evidence of skull metastasis.

Prevention of CSF Leakage by Staged Operation for Clival Metastatic Tumor

The transoral approach is a direct route to the clivus. However, application of this approach is infrequent because of the risk of cerebrospinal fluid (CSF) fistula and subsequent meningitis. We report a case of clival metastatic tumor treated by staged operation without CSF leakage. A 39-year-old man was found to have a tumor in clivus extending to the intradural space. Two-staged resection through the lateral suboccipital and transoral approach was performed and the dural defect was replaced by a fascia in the first operation. CSF leakage was prevented by this procedure. The patient received radiotherapy postoperatively.

Small cell bronchogenic carcinoma presenting as collet-siccard syndrome

Skull base metastases though a rare entity, is a known end stage presentation of Bronchogenic carcinoma. Skull base metastases can present as various cranial dysfunction syndromes, namely: Collet-Siccard syndrome, Villaret syndrome, Occipital condyle syndrome, Jugular foramen syndrome, and Parasellar syndrome. Skull base metastases need to be differentiated from Primary Temporal Bone malignancy. We in this article present a case report of Skull base metastases from Bronchogenic carcinoma with associated metastases to external auditory canal and upper cervical lymph nodes; hitherto unreported association.

Multiple cranial neuropathy as the initial presentation of metastatic prostate adenocarcinoma: case report and review of literature

The skull base is an atypical metastatic site for prostate carcinoma. It is usually encountered late in the disease process in patients with known advanced disease. However, skull base involvement causing cranial nerve palsies may rarely be the presenting sign of prostate carcinoma. Such patients may present to a number of specialties including neurosurgery and can pose a diagnostic challenge in the absence of lower urinary tract symptoms. Here, we describe an unusual case of prostate adenocarcinoma presenting as a central skull base tumour with multiple cranial neuropathy.

Occipital condyle syndrome: self diagnosed

We present the case of a 71-year-old man who presented to us with unilateral lower motor neuron hypoglossal palsy along with the characteristic occipital headache. He himself forwarded a paper on occipital condyle syndrome to the clinician who initially reviewed him. Later the patient underwent a series of investigations that confirmed the diagnosis of underlying prostatic carcinoma with widespread metastasis to bones including the base of the skull. Seven months after the diagnosis he is doing well, his headache is much better and the tongue deviation is stable. He was initially treated with tapering doses of dexamethasone and is currently receiving the depo gonadorelin analogue leuprorelin.

Management of metastatic prostate cancer: the crucial role of geriatric assessment

Prostate cancer predominantly affects older men, with a median age at diagnosis of 68 years. Due to the increased life expectancy, management of prostate cancer in senior adults (aged >70 years) represents a major public health problem. This patient population may not receive optimal therapy for their disease, if decisions are made based on their chronological age alone. More so than age alone, health status is a major factor affecting individual life expectancy. Comorbidity is the key predictor of health status and should weigh more heavily on the treatment decision than age alone. Other important parameters to consider in senior adults are the degree of dependence in activities of daily living, the nutritional status and the presence or not of a geriatric syndrome. Although clinical trials are rarely designed specifically for senior adults, evidence suggests that healthy senior adults have similar treatment outcomes to their younger counterparts. The urological approach in senior adults with advanced prostate cancer should be fundamentally the same as in younger patients. In hormone-sensitive metastatic prostate cancer, androgen deprivation represents the first-line treatment. In senior adults, care should be given to the increased risk of metabolic syndrome, cardiovascular mortality and bone fracture. In hormone-refractory metastatic prostate cancer, chemotherapy with docetaxel (75 mg/m(2) every 3 weeks) plus low-dose prednisone is the standard and shows the same efficacy in healthy senior adults as in younger patients. The tolerance of docetaxel (3-weekly schedule) has not been specifically studied in vulnerable and frail senior adults. The place of weekly docetaxel in this setting should be further evaluated. Palliative treatments (palliative surgery, radiopharmaceutics, radiotherapy, medical treatments for pain and symptoms, pharmacological palliative therapies) should also be integrated in the global management of these patients. In conclusion, treatment decisions in senior adults should be adapted to health status. Healthy senior adults should be treated the same as younger patients. The development of guidelines for the management of localized and advanced prostate cancer in senior adults is underway.

Clivus metastasis of squamous cell carcinoma: a rare location

Lung cancer is the most frequently encountered cancer in humans and commonly metastasizes to brain and bone. Metastasis to the clivus is very rare and there have been no previous reports. A 51-year-old woman was admitted to our hospital complaining of headache, and left shoulder, arm and back pain. The chest X-ray showed a left paracardiac mass measuring 4x4 cm in diameter and the thorax computed tomographic examination revealed a 4x4 cm mass in the left lower lobe, left hilar and mediastinal lymphadenopathy, and multiple lytic lesions in the thoracic vertebral bodies. Head magnetic resonance imaging showed a mass in the clivus with bony destruction. Bronchoscopic examination revealed an exophytic endobronchial lesion in the left lower bronchus lumen and a biopsy was taken from this lesion. The histopathological diagnosis was "poorly differentiated squamous cell carcinoma". A punch biopsy was taken from the clivus via the transnasal-transphenoidal route. Histopathological findings of this biopsy were similar to the primary site tumor. We report a rare case of clivus metastasis from squamous cell lung cancer.

Skull-base metastases

Metastasis to the skull-base particularly affects patients with carcinoma of the breast and prostate. Clinically, the key feature is progressive ipsilateral involvement of cranial nerves. Five syndromes have been described according to the metastatic site including the orbital, parasellar, middle-fossa, jugular foramen and occipital condyle syndromes. Magnetic resonance imaging (MRI) is nowadays the most useful examination to establish the diagnosis but plain films, CT scans with bone windows and isotope bone scans remain helpful to demonstrate bone erosion. Normal imaging studies do not exclude the diagnosis. The treatment depends on the nature of the underlying tumor. Radiotherapy is generally the standard treatment, while some patients with chemosensitive or hormonosensitive lesions benefit from chemotherapy or hormonotherapy and selected patients from surgical removal. Gamma Knife radiosurgery is sometimes a useful alternative, particularly for previously irradiated skull-base regions, and for small tumors (diameter < 30 mm). The overall prognosis is poor, with an overall median survival of about 2.5 years, probably because skull-base metastases appear late in the course of the disease.

Differentiating imaging findings in primary and secondary tumors of the jugular foramen

The preoperative diagnosis of a jugular foramen tumor may be challenging, since a large variety of unusual lesions may be located in this region. These tumors may be classified as primary lesions (which are located in the jugular foramen or extend from the jugular foramen into the surrounding structures) and as secondary lesions (that extend from the surrounding structures into the jugular foramen). Primary tumors include glomus jugulare tumors, schwannomas, meningiomas and peripheral primitive neuroectodermal tumors, while secondary tumors comprise chordomas, chondrosarcomas, chondroblastomas, giant-cell tumors, cholesterol granulomas, giant cholesterol cyst, endolymphatic sac tumors, reactive myofibroblastic tumors, temporal bone carcinomas and metastases. Accurate preoperative radiological suspicion is of great value for preoperative patient counseling and has a direct impact on the surgical planning in these cases. The present study describes and discusses the main differentiating imaging features of lesions involving the jugular foramen, whose accurate preoperative radiological evaluation is essential for proper surgical planning.

Cranial nerve deficits in patients with metastatic prostate carcinoma

BACKGROUND

Cranial nerve lesions due to metastases from prostate carcinoma to the skull base are an uncommon yet clinically significant finding.

METHODS

The authors report the clinical features, treatment, and outcomes for 15 patients who presented with cranial nerve palsies complicating metastatic prostate carcinoma. Patient charts identified from a Fox Chase Cancer Center treatment data base were reviewed.

RESULTS

All patients had hormone-refractory disease at the time of symptom onset. Twelve of 15 patients had received prior chemotherapy, and 13 of 15 patients had received prior radiation therapy to areas of bony pain. Symptoms varied from recognized clinical syndromes involving multiple cranial nerves to isolated cranial nerve lesions. All patients had lesions at the skull base that were visualized on computed tomography scans or magnetic resonance images. All patients were treated with palliative radiation therapy to either the whole brain or the skull base. Fourteen of 15 patients had a clinical (either partial or complete) response to radiation therapy. All responding patients subsequently died of prostate carcinoma without worsening of residual or development of new cranial nerve symptoms. Ten of 15 patients (67%) died within 3 months of developing symptoms, and the remaining 5 patients lived between 9 months and 31 months from onset of symptoms.

CONCLUSIONS

The authors concluded that palliative radiation therapy should be considered in this heterogeneous group of patients given the potential for significant symptom improvement.

Cranial nerve palsies in metastatic prostate cancer—results of base of skull radiotherapy

We studied the rate of response to palliative external beam radiation therapy (20 Gy/5 or 30 Gy/10 fractions) to the base of skull in 32 prostate cancer patients with cranial nerve dysfunction. Sixteen patients (50%; 95% CI, 34-66%) had a useful response to therapy. The median survival post-therapy was 3 months.

Bilateral third and unilateral sixth nerve palsies as early presenting signs of metastatic prostatic carcinoma

PURPOSE

To report four cases of cranial nerve palsy, which presented to the ophthalmologist as the only or one of the earliest manifestations of prostatic carcinoma. This is an infrequent complication of metastatic prostatic carcinoma usually only occurring late in the disease process in those with a history of prostatic carcinoma.

METHODS

The case records of four patients with a history of a cranial nerve palsy who attended the ophthalmology department and who had a recent or subsequent diagnosis of prostatic carcinoma were reviewed.

RESULTS

Diplopia caused by lesions affecting the third and sixth nerves sometimes in association with sensory symptoms may be a manifestation of metastatic prostatic carcinoma. These findings are consistent with base of the skull metastases from the condition. Two patients are still alive 54 months and 12 months after the diagnosis. One of the patients died 13 months after the diagnosis of prostatic carcinoma was made and the other died 21 months after the diagnosis from an unrelated hypertensive brain haemorrhage.

CONCLUSIONS

Any patient presenting with diplopia must have an adequate past medical history taken and in an elderly gentleman this should include symptoms of prostatic disease. If indicated urological referral and measurement of prostate specific antigen may be performed. In patients whose cranial nerve palsy is complicated by other sensory signs or those in whom no sign of recovery occurs in 2 months, a contrast CT scan asking for bone windows to be included may be helpful in delineating any pathology. Radiotherapy may be useful for the treatment of metastatic prostatic carcinoma causing cranial nerve palsies with some patients experiencing either complete or partial resolution of their symptoms. The effect of newer hormonal agents or chemotherapy on this aspect of the disease is not well documented in current literature.

Features of unusual metastases from prostate cancer

A retrospective study of CT examinations on 508 patients with prostate carcinoma was performed in order to document the presence or absence of uncommon nodal and extranodal metastases according to pre-defined criteria. 45 atypical metastases were demonstrated in 36 patients. There were 23 atypical nodal metastases including unusual distribution (19/23), large volume (7/23) and atypical morphology or contrast enhancement pattern (8/23). 22 atypical extranodal metastases included orbit/skull base (11), pulmonary (4), liver (3), intracranial (2), ocular (1) and adrenal (1). Atypical prostate carcinoma metastases are usually encountered in the presence of known advanced disease but can be the presenting feature of malignancy or the only sign of distant spread. Knowledge of atypical manifestations of metastatic disease will reduce diagnostic delay, allow accurate staging and lead to the effective and timely delivery of appropriate treatment.

Metastatic prostatic adenocarcinoma presenting as a pituitary mass: shrinkage of the lesion and clinical improvement with medical treatment

BACKGROUND

Metastatic involvement of the pituitary gland is a very unusual presentation of prostatic cancer. We report a favorable response to medical treatment in such a patient.

METHODS AND RESULTS

A 77-year-old man presented with blindness, ophthalmoplegia in his left eye, and mild impairment of memory and mental status. Neuroradiological studies showed a huge intra- and suprasellar lesion that destroyed the sellar floor and extended into the sphenoid sinus. Transsphenoidal biopsy of the lesion demonstrated a prostatic adenocarcinoma. Postoperative studies revealed an enlarged prostate gland and multiple lytic bone lesions. The patient was treated with a combination of leuprolide acetate plus flutamide. Four months later, the patient exhibited a marked improvement in his neurologic status and regained vision in the right eye (visual acuity 6/20). Repeat magnetic resonance imaging of the sellar region confirmed a striking shrinkage of the prostatic metastasis. The clinical status remained stable for 22 months, after which time the disease progressed and the patient died 25 months after beginning treatment.

CONCLUSIONS

A favorable response to combined androgen blockade suggests that medical therapy should be considered the therapy of first choice when surgical removal of the metastatic lesion in the pituitary is impossible or too risky.

Case report: confusion responding to dexamethasone in a patient with cancer of the prostate

A case report is presented of confusion (delirium) in a 78-year-old man with cancer of the prostate, but no cerebral secondaries, which cleared rapidly after the administration of dexamethasone.

[Cerebral metastasis from prostatic neoplasm simulating meningioma. Report of a case]

The clinical aspects of the meningiomas are well described. However, there is an important number of reports on a variety of other lesions simulating meningioma, including the prostate cancer. The authors describe one additional patient with prostate cancer who at presentation had clinical and radiographic signs suggesting meningioma. The literature on the subject is reviewed and summarized.

Blindness secondary to prostate cancer

We report a case of blindness, secondary to hormone-refractory prostate cancer, occurring 7 years after the diagnosis of metastatic prostate cancer and 3.5 years after the clinical onset of the hormone-refractory state. Prolonged suppression of the disease with chemotherapy may have contributed to the unusual clinical findings. We discuss the role of supportive care in the management of prostate cancer.

Progression delay of prostate tumor skeletal metastasis effects by bisphosphonates

Prostate tumor cell metastasis to the axial skeleton was induced in male Copenhagen rats using the intravenous injection of syngeneic metastatic R3327-MATLyLu tumor cells and concomitant caval vein clamping. The proliferation of tumor cells in the lumbar region was monitored by the progression, within 19 days post tumor cell injection, of hindleg paralysis which appeared in these animals. Histology confirmed the presence of tumor cells within the lumbar spine in 100% of cases displaying hindleg paralysis. Treatment with either of the bisphosphonate drugs, Cl2MDP or APD, suppressed and delayed the development of hind leg paralysis. Bisphosphonate treatment may be expected to delay the onset of axial skeletal metastasis effects in prostate cancer patients.