Synchronous skull base and spinal metastases in a patient with treatment-resistant, high-grade serous adenocarcinoma of tubo-ovarian origin.

Brain metastases (BMs) arising from ovarian cancer remain rare. Spinal cord metastases are even rarer, accounting for just 0.4% of total metastatic spinal cord compressions. In this report, we describe a case of a woman in her 70s who developed sequential brain and spinal cord metastases during her treatment for high-grade serous ovarian cancer, without a germline or somatic BRCA mutation. Following completion of neoadjuvant chemotherapy, interval debulking surgery and adjuvant chemotherapy, relapsed disease was ultimately identified as a single BM, curiously mimicking an acoustic neuroma. Subsequently, spinal cord metastases rapidly developed. Throughout, multidisciplinary team meetings guided decisions on patient management. In this report, we highlight the rarity of such a presentation and discuss the possible role of disease pathophysiology, associated systemic anticancer therapy resistance, and treatment possibilities for both cerebral and spinal metastases.

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.

Skull Base Metastasis of Breast Cancer With Oculomotor and Trochlear Nerve Palsy.

Skull base metastatic tumors are rare. Breast cancer in particular can cause bone metastases after a long period of time. A 70-year-old woman presented with multiple cranial nerve palsy. Magnetic resonance imaging revealed a lesion that extended from the orbit to the base of the skull, and the patient was referred to our department. Ophthalmological evaluation showed left visual acuity impairment, left oculomotor nerve palsy, and left trochlear nerve palsy. Endoscopic biopsy performed 5 years after the completion of breast cancer treatment revealed skull base metastases. In unilateral multiple cranial nerve palsy, the possibility of skull base metastases should be considered.

Symptom Outcomes of Cancer Patients With Clival Metastases Treated With Radiotherapy: A Study of 44 Patients.

BACKGROUND/AIM: To describe clinical features, radiotherapy (RT), and symptom outcomes in cancer patients with cranial nerve palsies associated with clival metastases. PATIENTS AND METHODS: This is a retrospective review of patients with primary metastatic cancers who developed clival metastases and received RT (2000-2020). RESULTS: Of the 44 patients with primary cancers (manly breast, prostate and multiple myeloma cancers) and distal clival metastases, 32 patients (73%) also had cervical spine metastases. Of the 23 RT-treated patients, 65% and 35% received clivus only and whole brain RT, respectively. Post-RT symptom improvement was observed in patients with diplopia (5/6; 83%), headache (8/10; 80%), chin numbness (2/4; 50%), blurry vision (2/5; 40%), lateral gaze deficit (2/6; 33%), and tongue deviation (1/4; 25%). CONCLUSION: Early detection and cranial nerve examination, in addition to RT treatment, should be considered in patients with breast, prostate, and multiple myeloma cancers, who developed cervical spine metastases.

Recurrent endometrial carcinoma metastasis to the temporal bone and skull base.

A 62-year old woman presented with a 1-month history of left otalgia, facial palsy and hearing loss. She had a background of non-insulin-dependent diabetes mellitus and stage 2 endometrial adenocarcinoma, treated 18 months ago. Computed tomography scan showed erosion of the skull base and temporal bone. She was referred to the otolaryngology team with a diagnosis of necrotising otitis externa. On clinical examination, there was an exophytic, necrotic lesion in the ear canal arising from the posterior canal wall. A subsequent magnetic resonance imaging scan showed a lesion located in the left jugular foramen extending into the middle ear, with characteristics consistent with a glomus jugulo-tympanicum. Interestingly, histology of the lesion showed malignant cells with immunohistochemical staining suggestive of an adenocarcinoma. This is the first reported case of metastatic endometrial carcinoma involving the jugular foramen and temporal bone. Although a diagnosis is rare, it is important to consider it when other differential diagnoses are not fitting. Imaging should always be interpreted with caution, correlating to the clinical findings.

Pneumatosis intestinalis in a radioactive iodine-refractory metastasic thyroid papillary carcinoma with BRAFV600E mutation treated with dabrafenib-trametinib: a case report.

BACKGROUND: Pneumatosis intestinalis (PI) is a rare entity which refers to the presence of gas within the wall of the small bowel or colon which is a radiographic sign. The etiology and clinical presentation are variable. Patients with PI may present either with chronic mild non-specific symptoms or with acute abdominal pain with peritonitis. Some cases of intestinal pneumatosis have been reported as adverse events of new oncological treatments such as targeted therapies that are widely used in multiple tumors. CASE PRESENTATION: A 59-year-old caucasian female with radioactive iodine-refractory metastatic thyroid papillary carcinoma with BRAFV600E mutation was treated with dabrafenib and trametinib as a compassionate use. After 4 months treatment, positron emission tomography-computed tomography (PET-CT) showed PI. At the time of diagnosis, the patient was asymptomatic without signs of peritonitis. The initial treatment was conservative and no specific treatment for PI was needed. Unfortunately, after dabrafenib-trametinib withdrawal, the patient developed tumor progression with significant clinical worsening. CONCLUSIONS: This case report is, in our knowledge, the first description of PI in a patient treated with dabrafenib-trametinib. Conservative treatment is feasible if there are no abdominal symptoms.

Stereotactic radiosurgery as a primary treatment for metastatic skull base alveolar soft part sarcoma: a case report.

Alveolar soft part sarcoma (ASPS) is a rare malignancy that typically arises in the trunk or extremities and preferentially metastasises to the brain. Radical resection is generally recommended for cranial metastatic ASPS, but stereotactic radiosurgery (SRS) is a recognised alternative for tumours in surgically challenging locations. Here, we present the case of a 22-year-old female, who underwent SRS and systemic therapy with pazopanib for a metastatic ASPS in the left temporal bone. The tumour was successfully controlled without further intervention over 23 months following SRS, which should be considered for metastatic ASPS when surgical resection is not appropriate.

Acute Management of Gamma Knife Radiosurgery for Asymptomatic Obstructive Hydrocephalus Associated with Posterior Fossa Metastases.

OBJECTIVE: We retrospectively assessed the effectiveness and safety of Gamma Knife radiosurgery (GKRS) for asymptomatic obstructive hydrocephalus associated with posterior fossa metastases, which was known empirically but not well discussed. METHODS: We reviewed the medical records of 27 patients who underwent GKRS for asymptomatic obstructive hydrocephalus related to posterior fossa metastases. RESULTS: Cumulative control rates of hydrocephalus were 11.1%, 51.9%, 70.4%, and 74.6% at 1, 2, 3, and 6 months after GKRS. Primary gastrointestinal tract cancer (P = 0.001) was significantly correlated with unfavorable management. Evans ratio at GKRS (median 0.31) improved significantly compared with that at 1-3 months after GKRS (median 0.26) (P < 0.0001) and maintained at 6 to 12 months. Cumulative local tumor control rates were 91.7%, 70.8%, and 64.4% at 3, 6, and 12 months after GKRS. Primary gastrointestinal tract cancer (P = 0.018) and no conventional systemic agents (P = 0.027) were significantly correlated with unfavorable control. Cumulative incidence rates of adverse radiation effects were 0.0%, 16.7%, and 24.2% at 6, 9, and 12 months after GKRS. Primary gastrointestinal tract cancer (P < 0.0001) and single and 2- or 3-fraction GKRS (P < 0.0001) were significantly correlated with unfavorable outcomes. All but 1 patient avoided surgical procedure for hydrocephalus after GKRS. CONCLUSIONS: The present findings suggest that GKRS is an effective and safe treatment for asymptomatic obstructive hydrocephalus caused by posterior fossa metastases, and all but 1 could avoid invasive surgical procedures for hydrocephalus. Posterior fossa metastases from gastrointestinal tract cancer resulted in unsatisfactory outcomes for control of hydrocephalus, tumor progression, and adverse radiation effects.

Management of Skull Base Metastases.

Autopsy studies suggest that skull base metastases are likely underrecognized in patients with cancer. Patients frequently present with one or a combination of skull base clinical syndromes that manifest as pain or cranial neuropathy. Once a skull base metastasis is suspected, establishing a histologic diagnosis, dedicated imaging, and restaging (if appropriate) are the first steps in management. A multidisciplinary approach should then be used to identify the optimal histology-based treatment strategy, taking into account the burden of systemic disease. Finally, definitive treatment may include one or a combination of surgical management, radiation therapy, or chemotherapy."

Diffuse large B cell lymphoma involving Meckel's cave masquerading as biopsy-negative giant cell arteritis: a case report.

BACKGROUND: Given the absence of consensus diagnostic criteria for giant cell arteritis, clinicians may encounter difficulty with identification of new-onset headache in patients older than age 50 years presenting with visual changes and elevated inflammatory markers, particularly if temporal artery biopsies are performed and negative. CASE PRESENTATION: We present a case of a 57-year-old white man with headache, diplopia, and jaw paresthesia initially diagnosed and managed as steroid-refractory biopsy-negative giant cell arteritis. Further investigation disclosed evidence of soft tissue infiltration into Meckel's (trigeminal) cave bilaterally. Positron emission tomography suggested the presence of a lymphoproliferative disorder. Histology confirmed the diagnosis of diffuse large B cell lymphoma. CONCLUSIONS: Metastatic involvement in Meckel's cave in diffuse large B cell lymphoma is extremely rare and presents a diagnostic challenge. Patients with suspicion of giant cell arteritis should undergo advanced imaging, particularly those with negative biopsy, atypical features, or lack of response to standard therapy, in order to assess for the presence of large-vessel vasculitis or other mimicking pathologies.

Infratemporal fossa surgical approaches to primary/recurrent malignancies of salivary origin: paradigm surgical shift, patient selection, and oncologic outcomes.

PURPOSE OF REVIEW: To review, the surgical approaches available on diagnosing a patient with salivary gland malignancy in the infratemporal fossa (ITF). To comment on patient evaluation and method of treatment selection. To identify and report on patient outcome data and make recommendations on future needs. RECENT FINDINGS: There is a need to define the anatomic boundaries contents of the ITF, masticator space, parapharyngeal space (PPS), pterygopalatine fossa, ventral skull base, and paramedian skull base, as evidence from publications. The pathological subtypes identified mainly include adenoid cystic and mucoepidermoid carcinomas. The source of these tumours originates from primary disease in the sinonasal tract and nasopharynx superiorly, and the PPS/deep lobe of parotid inferiorly. Current surgical options available, in suitable selected patient, available in tertiary head and neck cancer hospitals, which have available facilities and staffing is the endoscopic endonasal approach. This approach offers patients a 'complete margin-free surgical excision', minimal complications, shorter hospital stay, and no delay with commencement of any adjuvant treatment compared with the traditional 'open transcutaneous' approach. SUMMARY: The current evidence specifically to the surgical management of salivary gland malignancy involving the ITF is sparse, with great difficult identifying treated patients and their details among a heterogeneous group of patients with many lesions. There is a need for patient data that have specific pathologic conditions to be amalgamated from such centers and publish on outcome events.

Unusual skull base metastasis from neuroendocrine tumor: a case report.

BACKGROUND: With increasing treatment options available, neuroendocrine tumor has become a chronic disease and may present later on with atypical manifestation of disease spread once resistant to treatment. CASE PRESENTATION: A 74-year-old white British woman undergoing treatment for metastatic well-differentiated neuroendocrine tumor for the past 9 years presented with a brief history of mild frontal headache, and progressive left ptosis and ocular palsy. She had no visual loss, and had neither speech nor motor deficit. At the outset, it was crucial to exclude acute or missed stroke. An urgent magnetic resonance imaging of her head revealed an unusual skull base metastasis extending into the cavernous sinus, with no peritumoral edema. Following discussion at a specialist neuro-oncology meeting and a neuroendocrine tumor multidisciplinary team meeting, she proceeded to have conventional fractionated radiotherapy followed by subsequent palliative chemotherapy. CONCLUSIONS: Intracranial metastasis is rare in patients with neuroendocrine tumor, particularly in those with well-differentiated histology; skull base metastasis is even more uncommon. Management of intracranial metastasis from a rare tumor should always be discussed in a specialist multidisciplinary meeting. Surgery or radiotherapy, including stereotactic radiosurgery, should be considered in skull base metastases. Hormonal abnormalities may occur following radiotherapy to skull base metastases and should be monitored closely in the first few months post treatment.

Jugular Foramen Metastasis from Lung Cancer: A Case of "A Mass without His Syndrome".

Jugular foramen (JF) metastasis is rare and often presents as JF syndrome. A 73-year-old male complained of left-sided mastoid pain that irradiated to the neck since the past 3 months. Onset of facial nerve (FN) palsy and persistence of the symptomatology despite corticosteroid therapy demanded radiologic evaluation. Computed tomography and magnetic resonance imaging showed a wide osteolytic lesion of the left JF with involvement of the third segment of the FN. The patient underwent transmastoid incisional biopsy. Histopathological examination showed an adenocarcinoma that was suggested to be of respiratory origin. A primary pulmonary lesion and metastasis to other sits were detected. The patient died 1 month after the initiation of the chemotherapy. Persistent mastoid pain and progressive FN palsy must be considered indicative of JF malignant lesions. Despite early diagnosis, secondary lesions of the JF are characterized by a poor prognosis; however, accurate diagnosis may avoid unnecessary aggressive surgery.

Chondrosarcoma of right big toe with metastases to left orbital and left infra temporal region.

To report a case of chondrosarcoma of right big toe with left orbital and left infra temporal metastases. Chondrosarcoma is the second most frequent primary malignant tumour of the bone. A 56 year old man had history of trauma on his right big toe, which was amputated and the biopsy in 2011 at Sindh Institute of Urology and Transplantation (SIUT) revealed chondrosarcoma with clear margins. Eventually the patient was presented with swelling of the left eye, pain and gradual loss of vision of that eye. Later a CT scan of his chest, brain and orbit showed pulmonary and pleural based nodule, with mediastinal and hilar lymphadenopathy representing metastatic deposit in left orbit, extending to left infra temporal region. A treatment of palliative chemotherapy was started with doxorubicin and ifosfamide, after which he was referred for radiotherapy. At that time he had loss of vision, pain and exopthalamus, and palliative radiotherapy was delivered to the left orbit with the prescribed dose of30 Gy/300cGy×10 fraction. Thereafter his case will be followed up at the oncology OPD after a 03 month interval.

Bone Subtraction Iodine Imaging Using Area Detector CT for Evaluation of Skull Base Invasion by Nasopharyngeal Carcinoma.

BACKGROUND AND PURPOSE: Conventional CT has generally lower detectability of bone marrow invasion than MR imaging due to lower tissue contrast. The purpose of this study was to compare the diagnostic performance of conventional CT alone or in combination with bone subtraction iodine imaging using area detector CT for the evaluation of skull base invasion in patients with nasopharyngeal carcinoma. MATERIALS AND METHODS: Forty-four consecutive patients who underwent contrast-enhanced CT using 320-row area detector CT and contrast-enhanced MR imaging for nasopharyngeal carcinoma staging between April 2012 and November 2017 were enrolled in this retrospective study. Bone subtraction iodine images were generated by subtracting pre- and postcontrast volume scans using a high-resolution deformable registration algorithm. Two blinded observers evaluated skull base invasion at multiple sites (sphenoid body, clivus, bilateral base of the pterygoid process, and petrous bone) using conventional CT images alone or in combination with bone subtraction iodine images. Examination of MR and CT images by an experienced neuroradiologist was the reference standard for evaluating sensitivity, specificity, and area under the receiver operating characteristic curve. RESULTS: Twenty-six patients (59%) showed skull base invasion at 84 sites on the reference standard. Conventional CT plus bone subtraction iodine images showed higher sensitivity (92.9% versus 78.6%, P = .02) and specificity (95.6% versus 86.1%, P = .01) than conventional CT images alone for evaluating skull base invasion. The area under the receiver operating characteristic curve for conventional CT plus bone subtraction iodine (0.98) was significantly larger (P < .001) than the area under the receiver operating characteristic curve for conventional CT alone (0.90). CONCLUSIONS: Conventional CT plus bone subtraction iodine performs more closely to the accuracy of combining CT and MR imaging compared with conventional CT alone.