Metastasis of soft-tissue myoepithelial carcinoma to clivus

Gamma knife radiosurgery for clival metastasis: case series and systematic review

PURPOSE

Clival metastatic cancer is rare and has limited literature to guide management. We describe management of clival metastasis with Gamma Knife radiosurgery (GKRS). We augment our findings with a systematic review of all forms of radiation therapy for clival metastasis.

METHODS

Records of 14 patients with clival metastasis who underwent GKRS at the University of Pittsburgh Medical Center from 2002 to 2023 were reviewed. Treatment parameters and clinical outcomes were assessed. A systematic review was conducted using evidence-based guidelines.

RESULTS

The average age was 61 years with male predominance (n = 10) and average follow-up of 12.4 months. The most common primary cancers were prostate (n = 3) and lung (n = 3). The average time from cancer diagnosis to clival metastasis was 34 months. The most common presenting symptoms were headache (n = 9) and diplopia (n = 7). Five patients presented with abducens nerve palsies, and two presented with oculomotor nerve palsies. The median tumor volume was 9.3 cc, and the median margin dose was 15 Gy. Eleven patients achieved tumor control after one procedure, and three with progression obtained tumor control after repeat GKRS. One patient recovered abducens nerve function. The median survival from cancer diagnosis and GKRS were 49.7 and 15.3 months, respectively. The cause of death was progression of systemic cancer in six patients, clival metastasis in one, and unknown in four. The systematic review included 31 studies with heterogeneous descriptions of treatment and outcomes.

CONCLUSION

Clival metastasis is rare and associated with poor prognosis. GKRS is a safe, effective treatment for clival metastasis.

Clival Metastases: Single-Center Retrospective Case Series and Literature Review

Background/Objectives: Clivus metastases from distant neoplasms are uncommon occurrences both in clinical practice and the neurosurgical literature. Surgical management is debated, particularly about the role of surgery and the preferable approach. The aim of this study was to report our surgical experience and review the concerning literature. Methods: Our institutional registry was retrospectively reviewed, and patients who underwent surgical treatment for clival metastasis from 1998 to 2023 were included. A PRISMA systematic review of the literature was performed. Results: Four patients were enrolled, and all of them underwent an endoscopic endonasal approach (EEA). Three presented with cranial nerve (CN) VI palsy. The aim of surgery was biopsy in all cases. No complications were reported. Mean overall survival (OS) was 6 ± 1 months. The systematic review retrieved 27 papers reporting 39 patients who underwent the surgical treatment of clivus metastases. Most of them (79.5%) presented with CN palsies, and EEA was the preferred approach in 92.3% of the cases, to perform a biopsy in most patients (59%). Two hemorrhagic complications (5.1%) were reported, and the mean OS was 9.4 ± 5.6 months. Conclusions: Clival metastases are uncommonly observed, in most cases, during advanced stages of oncological disease. The aim of surgery should be the confirmation of diagnosis and symptomatic relief, balancing the risk-benefit ratio in a multidisciplinary context. EEA is the approach of choice, and it should be carried out in experienced tertiary skull base centers.

Impending Doom: A Rare Case of Metastatic Myoepithelial Carcinoma

Myoepithelial carcinoma is a rare malignant tumor arising from myoepithelial cells. The usual sites of occurrence are the oral cavity and pharynx with the majority of tumors arising from the salivary gland. However, there have been reported cases of myoepithelial carcinoma seen in the superficial soft tissue, upper respiratory tract, breast, skin, and GI tract. Deep soft tissue myoepithelial carcinoma is relatively uncommon. 

Due to the rarity of this malignancy, consensus on appropriate therapy remains sparse. However, complete resection and/or adjuvant chemotherapy and radiotherapy have been advocated for non-metastatic localized diseases. Sadly, the reported outcome in patients with metastatic disease remains dismal.

In this case, we report a 79-year-old male incidentally found to have a deep soft tissue mass in the sacral area with a coexistent left axillary lymphadenopathy with biopsy and immunohistochemistry confirmation of metastatic myoepithelial carcinoma. He had a rapid clinical deterioration with subsequent fatality.

Metastatic Lesions of the Clivus: A Systematic Review

BACKGROUND

Metastatic lesions of the clivus are extremely rare, having previously been estimated as representing 0.02% of all intracranial tumors. Owing to its close intracranial relationship with the clivus before entering the cavernous sinus, clinical palsies of the sixth cranial nerve have been classically associated with destructive lesions of this structure.

METHODS

A comprehensive search of PubMed was conducted for studies of patients with metastasis to the clivus from primary cancer at any site. Studies reported in English in the past 20 years from our last search on April 12, 2021 were included. The data collected included patient age, sex, symptoms at presentation, histopathology and treatment timeline of the primary tumor, treatment, follow-up, and mortality.

RESULTS

After the literature review, 46 studies reporting on 58 patients with clivus metastasis were included in the final analysis. The mean age of the patients was 57.5 years, and 39 were male (67.2%). The most common sites of the primary tumor were the prostate (22%), gastrointestinal tract (15%), lung (13%), and kidney (11%). In 43% of patients, symptoms of clivus metastasis had presented before the diagnosis of primary cancer was known, and 71% of the patients had presented with sixth nerve palsy. Of the 58 patients, 53% had undergone surgery, and 37% had received adjuvant radiotherapy. Of the 58 patients, 25% had received radiotherapy alone. The endoscopic transsphenoidal approach to the clivus was almost uniquely used for surgical management. Survival data were available for 31 patients. Death had occurred at a mean of 9.4 months after the presentation of clivus metastasis. A strong correlation was found between the interval from primary cancer to the presentation of clivus metastasis and mortality.

CONCLUSIONS

Although an extremely rare occurrence, clivus metastasis should be considered in patients with a history of malignancy, in particular, prostate malignancy, presenting with new-onset isolated sixth nerve palsy.

Primary Myoepithelial Carcinoma of the Clivus: A Rare Presentation

Myoepithelial tumor (MET) of bone is an unusual tumor of uncertain differentiation and histogenesis. Although its presence in various bones has been reported sparsely, the presentation in clivus as primary myoepithelial carcinoma (MEC) has never been reported. They resemble their salivary gland counterparts morphologically and immunohistochemically, but harbor distinct molecular phenotype. At present, moderate nuclear atypia is the acceptable criteria to differentiate MEC from myoepithelioma. Because of their rarity, wide histopathological spectrum, and intraosseous location, MET of bone is easily confused with a variety of primary bone and cartilaginous tumors. Application of immunohistochemistry and, if required, molecular testing are required for making a correct diagnosis. In this article, we describe an extremely rare case of a primary MEC arising from the clivus, which owing to unusual location and immunohistochemical profile was diagnostically challenging.

Endoscopic Resection of Pediatric Skull Base Tumors: An Evidence-Based Review

Objectives  To perform a systematic review examining experiences with endoscopic resection of skull base lesions in the pediatric population, with a focus on outcomes, recurrence, and surgical morbidities. Methods  PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases were evaluated. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool, Grades of Recommendation, Assessment, Development and Evaluation (GRADE), and Methodological Index for Non-Randomized Studies (MINORS) criteria. Patient characteristics, pathology, site of primary disease, presenting symptoms, stage, procedure specific details, and complications were evaluated. Results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis guidelines. Results  Ninety-three studies met criteria for inclusion, encompassing 574 patients with skull base tumors. The GRADE and MINORS criteria determined the overall evidence to be moderate quality. The most common benign and malignant pathologies included juvenile nasopharyngeal angiofibromas ( n  = 239) and chondrosarcomas ( n  = 11) at 41.6 and 1.9%, respectively. Of all juvenile nasopharyngeal angiofibroma tumors, most presented at stage IIIa and IIIb (25.8 and 27.3%, respectively). Nasal obstruction (16.5%) and headache (16.0%) were common symptoms at initial presentation. Surgical approaches included endoscopic endonasal ( n  = 193, 41.2%) and endoscopic extended transsphenoidal ( n  = 155, 33.1%). Early (< 6 weeks) and late (>6 weeks) complications included cerebrospinal fluid leak ( n  = 36, 17.3%) and endocrinopathy ( n  = 43, 20.7%). Mean follow-up time was 37 months (0.5-180 months), with 86.5% showing no evidence of disease and 2.1% having died from disease at last follow-up. Conclusion  Endoscopic skull base surgery has been shown to be a safe and effective method of treating a variety of pediatric skull base tumors. If appropriately employed, the minimally invasive approach can provide optimal results in the pediatric population.

Metastasis of malignant myoepithelial carcinoma to the brain

Myoepithelial tumours are a rare form of salivary gland neoplasm and intracranial metastases have rarely been described. The authors present the case of a 61-year-old patient with a history of primary myoepithelial carcinoma of the right foot. Metastases were found in the third ventricle, left temporal lobe and right frontal lobe. The third ventricular and left temporal lobe tumours were resected in a two-stage operation. Pathology of the third ventricular lesion was most consistent with metastasis. MRI of the spine 2 weeks after his operation revealed an intradural mass with several lesions in the lumbar thecal space suggesting further metastases. The patient succumbed to his disease 2 months after his two-stage operation and 5 years after his initial diagnosis. This appears to be the first case in the literature of multiple primary myoepithelial carcinoma metastases to the brain. Further information is needed to provide diagnostic and therapeutic recommendations.

Neoadjuvant radiation therapy for the management of myoepithelial carcinoma of the upper extremity

Myoepithelial tumors of the soft tissue are a rare tumor displaying myoepithelial elements and lacking obvious ductal differentiation. The rarity of these precludes any evidence-based consensus regarding optimal management. Nevertheless, the current approach to these lesions begins with amputation or complete excision. The efficacy of neoadjuvant or adjuvant radiation therapy or chemotherapy has not been established. Here, we present the first report to the authors' knowledge of neoadjuvant radiation therapy for the treatment of this rare soft tissue neoplasm and review the management and outcomes of published cases of myoepithelial carcinoma. A patient with a soft tissue myoepithelial carcinoma that declined both amputation and chemotherapy was treated with neoadjuvant radiation therapy and wide surgical excision followed by a brachytherapy boost to the resected tumor bed. Neoadjuvant radiation therapy resulted in an excellent response with extensive treatment-related changes consisting predominantly of fibrosis, hyalinization and hemorrhage and only 10% residual viable myoepithelial carcinoma present in the surgical specimen.

Unusual Spread of Renal Cell Carcinoma to the Clivus with Cranial Nerve Deficit

Renal cell carcinoma (RCC) has unusual presentation affecting elderly males with a smoking history. The incidence of RCC varies while the incidence of spread of RCC to the clivus is rare. The typicality of RCC presentation includes hematuria, flank pain, and a palpable flank mass; however, RCC can also present with clival metastasis. The unique path of the abducens nerve in the clivus makes it susceptible to damage in metastasis. We report a case of a 54-year-old African American female that was evaluated for back pain, weakness, numbness, and tingling of bilateral lower extremities and subsequently disconjugate gaze and diplopia. Brain MRI confirmed metastasis to the clivus. She was started on radiotherapy and was planned for chemotherapy and transfer to a nursing home. When a patient presents with sudden unusual cranial nerve pathology, the possibility of metastatic RCC should be sought.

Myoepithelial carcinoma inside of maxilla bone: A case report

Myoepithelial carcinoma (MC) is a rare type of carcinoma occurring mainly in the parotid gland, while other carcinomas occur in submandibular or the accessory glands of the oral cavity. They may arise from the glands of the respiratory tract. However, primary MC of the bone is extremely rare. In the present study, a rare case of a 41-year-old woman with MC in the maxilla bone was reported. Following misdiagnosis as a bone cyst, a local excision was performed. The patient then presented with an extremely high malignancy and showed no response to chemoradiation treatment. The bone cyst was thought to be MC, thus early diagnosis with complete surgical excision was highly important. After confirmation of MC, a secondary extensive surgery may be crucial, following the primary local surgical resection.

Myoepithelioma of the Orbital Apex and Middle Cranial Fossa: Case Report and Review of the Literature

Myoepitheliomas are rare tumours that originate from glandular tissues such as the parotid or salivary glands, and less commonly from soft tissues of the head, neck, and other parts of the body. Intraorbital myoepitheliomas generally arise from the lacrimal gland. Intracranial myoepitheliomas are rare. We report a myoepithelioma of the orbital apex that did not originate from the lacrimal gland. It extended to the middle cranial fossa from the orbital apex and involved the dura and adjacent bone. A diagnostic biopsy via a lateral orbitotomy preceded resection. We review the natural course and histopathology of myoepithelial neoplasms, the surgical nuances of approaching an orbital apex tumour with maximal functional preservation, and the optimal management practices of these rare lesions.

Metastatic disease to the clivus mimicking clival chordomas

Objectives/Hypothesis A comprehensive review of the literature of clival metastases and presentation of two additional cases. Study Design Literature review and report of two cases. Methods A literature review of the MEDLINE database (1950 to January 19, 2013) was performed to identify all cases of patients with metastatic disease to the clivus. Additionally, two novel cases are presented. Results In total, 47 cases were identified in the literature, including the two cases presented in this study. Metastatic disease to the clivus is the initial presenting symptom of the primary malignancy in 36% (13/36) of the cases. When there was a history of malignancy, the median interval of time to clival metastases was 24 months (range 1 to 172 months). Clinical symptoms manifested often as cranial neuropathies, with at least abducens palsies as the initial presenting symptom in 61.9% (26/42) of patients. Tumor pathology was diverse, but several pathologies were seen more commonly: prostate carcinoma (18.1%, 9/47), hepatocellular carcinoma (10.6%, 5/47), and thyroid follicular carcinoma (8.5%, 4/47). Conclusion Although clival metastases are extremely rare, they are an important part of the differential of clival masses as they can be the presenting symptom of distant malignancy. Level of Evidence 4.