Isolated clival metastasis as the cause of abducens nerve palsy in a patient of breast carcinoma: A rare case report

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.

Abducens nerve palsy due to clivus metastasis in a patient with breast carcinoma: A rare case

INTRODUCTION

Breast cancer, comprising 25 % of all diagnosed cancers, predominantly affects women globally. While bone metastasis is common, occurrences at the clivus or skull base are rarely documented. Treatment varies from surgery in early stages to a multifaceted approach for advanced cases, incorporating chemotherapy, radiotherapy, and surgery based on staging and histology.

CLINICAL PRESENTATION

A 40-year-old female presented with a rapidly enlarging lump in her left breast and diplopia on right gaze. Histology was positive for invasive breast cancer (no special type) and Contrast-Enhanced Computed Tomography demonstrated metastatic deposits in multiple vertebrae and bilateral ilium. Further, magnetic resonance imaging of the brain and orbits revealed metastatic deposits in the clivus which extended up-to medial wall of the cavernous sinus, causing compression of the right abducens nerve. Multidisciplinary Tumor Board review recommended chemoradiotherapy.

DISCUSSION

Metastases from breast cancer can occur locally or to distant sites like lymph nodes, bones, lungs, liver, and brain. Unusual symptoms, such as new-onset diplopia, trigger further investigation. Although bone metastases occur in 50-65 % of cases, clivus metastasis is rare. Treatment aims at extending survival, symptom management, and enhancing quality of life through chemotherapy and radiotherapy. Outcomes hinge on metastatic burden and regional therapy responsiveness. Distant metastases substantially reduce the 5-year survival rate from 80 % to approximately 25 %, but cases often improve with regional interventions.

CONCLUSION

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

MRI Diagnosis of Clival Cancer and Sixth Nerve Palsy

BACKGROUND

Imaging diagnosis of clival cancer may be difficult, in part because of normal variation in marrow signal with aging. Identifying whether clival cancer has damaged the sixth cranial nerve is a further challenge because minimal clival abnormalities could impinge on the nerve, which travels very close to the clivus.

METHODS

Two neuroradiologists, who were unaware of previous imaging and clinical diagnoses, reviewed MRI studies of 25 patients with cancer but no clival involvement and no sixth nerve palsy, 24 patients with clival cancer but without sixth nerve palsy, and 31 patients with clival cancer and sixth nerve palsy. The radiologists were tasked with determining whether there was clival cancer, whether there was a sixth nerve palsy and its laterality, and with indicating the pulse sequences used to make those determinations.

RESULTS

Both neuroradiologists correctly identified all 25 cases with a normal clivus. In about half of those cases, they depended on finding a homogeneously bright marrow signal; in the remaining cases, they excluded cancer by determining that the clivus was not expanded and that there were no focal signal abnormalities. Both neuroradiologists correctly identified clival cancer in 54 (98%) of the 55 cases with and without sixth nerve palsy. In doing so, they relied mostly on clival expansion but also on focal signal abnormalities. Both neuroradiologists were at least 80% correct in identifying a sixth nerve palsy, but they often incorrectly identified a palsy in patients who did not have one. When there was a one-sided signal abnormality or the clivus was expanded in one direction, both neuroradiologists were accurate in identifying the side of the sixth nerve palsy.

CONCLUSION

Current MRI pulse sequences allow accurate differentiation of a normal from a cancerous clivus. When the marrow signal is not homogeneously bright in adults, cancer can be diagnosed on the basis of clival expansion or focal signal abnormalities. MRI is less accurate in predicting the presence of a sixth nerve palsy. However, the side of a unilateral palsy can be predicted when the clivus is clearly expanded in one direction or there is a focal signal abnormality on one side.

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.

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.

Isolated unilateral sixth nerve palsy in a patient with nasopharyngeal carcinoma

Objective: To describe an isolated unilateral sixth nerve palsy, as a rare neuro-ophthalmic presentation of nasopharyngeal carcinoma. Methods: We report a 54-year-old female, known case of nasopharyngeal carcinoma who was treated with chemo-radiotherapy, and presented with isolated right sixth nerve palsy. Magnetic resonance imaging (MRI) indicated extension of tumor to intracranial fossa with clival involvement. Results: The patient was referred to an otolaryngologist for further evaluation and necessary intervention due to invasion of the cancer to intracranial fossa with involvement of right abducens nerve. Conclusions: Although, isolated sixth nerve palsies in adults over the age of 50 are usually ischemic; but in enduring cases, neoplastic processes should be considered.

Plexus and peripheral nerve metastasis

Cancer in the form of solid tumors, leukemia, and lymphoma can infiltrate and metastasize to the peripheral nervous system, including the cranial nerves, nerve roots, cervical, brachial and lumbosacral plexuses, and, rarely, the peripheral nerves. This review discusses the presentation, diagnostic evaluation, and treatment options for metastatic lesions to these components of the peripheral nervous system and is organized based on the anatomic distribution. As skull base metastases (also discussed in Chapter 14) result in cranial neuropathies, these will be covered in detail, as well as cancers that directly infiltrate the cranial nerves. Particular emphasis is placed on the clinical, imaging, and electrodiagnostic features that differentiate neoplastic plexopathies from radiation-induced plexopathies. Neurolymphomatosis, in which malignant lymphocytes invade the cranial nerves, nerve roots, brachial and lumbosacral plexuses, and peripheral nerves, is a rare manifestation of lymphoma and leukemia. Diagnoses of neurolymphomatosis are often missed or delayed given its varied presentations, resulting in poorer outcomes. Thus this disease will also be discussed in depth.

Clival Metastasis of a Duodenal Adenocarcinoma: A Case Report and Literature Review

BACKGROUND

Clival metastases of adenocarcinomas are exceptionally rare tumors, especially when they arise from the small intestine. We present the first, to our knowledge, report of a metastasis of a duodenal adenocarcinoma to the clivus. We also present a systematic review detailing metastasis to the clivus.

METHODS

Studies were identified using the search terms "clival metastasis," "skull base metastasis," and "clivus" in PubMed. We collected the following information: histopathology of the primary tumor, symptoms, history, treatment, and follow-up.

RESULTS

A comprehensive review of the literature yielded 56 cases. Patients developed the first symptoms of clival metastasis at a mean age of 58 years. The most common primary neoplasms originated from the prostate, kidney, or liver. Most patients presented with an isolated sixth nerve palsy or diplopia. The time interval from diagnosis of the primary tumor to symptomatic presentation of clival metastasis ranged from 2 months to 33 years. Sixteen patients initially presented with symptoms of clival metastasis without a previously diagnosed primary tumor. Survival data were available for 35 patients, of which 63% died within a range of 2 days to 31 months after initial presentation.

CONCLUSIONS

Most primary neoplasms originated from the prostate, kidney, and liver, which differ from previous reports on skull base metastases. Abducens nerve palsy is often the first presentation of clival metastasis. Clival metastasis from duodenal carcinoma, although very rare, should be considered in the differential diagnosis of bony lesions of the clivus in a patient with a history of duodenal adenocarcinoma.

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.