Elsevier

World Neurosurgery

Volume 100, April 2017, Pages 62-68
World Neurosurgery

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

https://doi.org/10.1016/j.wneu.2016.12.078Get rights and content

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.

Introduction

Tumors of the small intestine infrequently metastasize to the skull, and migration to the clivus is extremely rare. Here we describe clival metastasis of an adenocarcinoma of the duodenum, which to our knowledge has never been reported in the literature. The clivus is known to be implicated in approximately 1% of intracranial tumors.1 A relatively broad spectrum of differential diagnoses may be suspected in clival neoplasms, such as meningioma, chordoma, lymphoma, pituitary adenoma, nasopharyngeal carcinomas, bone marrow reconversion, and metastatic lesions.2 Metastatic lesions most commonly arise from prostate, breast, lung, thyroid, melanoma, or hepatocellular carcinoma.1, 2, 3 Because there are currently no systematic reviews detailing the characteristics of metastasis to the clivus, here we review the presentation, diagnosis, treatment, and prognosis of clival metastasis.

Section snippets

Methods

We describe a case of a patient with a duodenal metastasis to the clivus and review studies on metastatic disease of the clivus. Studies were identified using the search terms “clival metastasis,” “skull base metastasis,” and “clivus” in the electronic database PubMed. Searches were restricted to articles with an abstract in the English language published after 1950. All searches were undertaken between March and August 2016. Any relevant references were cascaded to increase detection of

Report of Case

A 67-year-old man presented in August 2015 with headaches, double vision, and progressive nasal deviation of his left eye for the previous 5 months. Medical history was significant for stage IIIB duodenal carcinoma T4 N2 M0 status post-Whipple resection in September 2013, followed by chemotherapy. Neurologic examination showed bilateral sixth nerve palsies, worse on the left side. Sinonasal endoscopy of both nasal cavities revealed no concerning lesions.

Diagnostic workup included magnetic

Literature Review

A comprehensive review of the literature yielded 56 cases, with a 30% female and 70% male population. Patients developed the first symptoms of clival metastasis at a mean age of 58 years (range, 3–83). Table 1 provides an overview of reported clival metastases, along with their clinical characteristics. The most common primary neoplasms originated from the prostate (23%), kidney (9%) liver (9%), lung (7%), thyroid (7%), and stomach (7%). Most patients presented with an isolated sixth nerve

Discussion

This study describes an unusual case of a metastasis of a duodenal adenocarcinoma to the clivus. Primary duodenal adenocarcinomas are rare malignancies that constitute 0.4% of all tumors of the gastrointestinal tract,38 and have a 3- and 5-year survival rate of 34.4% and 28.6%, respectively.39 Adenocarcinomas of the small bowel usually metastasize to the liver, pelvis, and lung, and the skull base is less commonly involved (<2%).40 Clival metastases can arise from diverse sources of primary

Presentation

In this review, >40% of patients presented with isolated sixth nerve palsy. This is a typical presentation because clival masses can compress the abducens nerve in Dorello canal, which channels this nerve from the pontine cistern to the cavernous sinus. When more cranial nerves are involved, the lesion likely extends to the cavernous sinus.30 In our review, multiple nerve palsies, headache, and diplopia occurred in 10%–15% of patients. Less common symptoms included fever, neck pain, vertigo,

Diagnosis

There is not an ideal imaging modality for visualizing the skull base. Diagnosis of skull base lesions often involves CT, MRI, positron emission tomography scan with CT (PET-CT), and radionuclide bone scans labeled with technetium or gallium.44 However, imaging studies of clival metastasis are typically inconclusive because it is challenging to distinguish metastases from other lesions, such as chordomas and chondrosarcomas.45 Furthermore, positive radiologic findings can be absent in a

Treatment and Prognosis

The histologic features of the primary neoplasm should determine the treatment of clival metastasis. There are no data on the treatment of clival metastasis from duodenal adenocarcinomas because of the rarity of this lesion. Overall, skull base metastasis responds well to surgery or radiotherapy, leading to disease-free survival in some cases. Our review found that most clival metastases are treated with radiotherapy. Small tumors (<30 mm), or previously irradiated skull base lesions, may

Study Limitations

This review only details cases with known histopathology of the primary tumor. By doing so, we only included lesions with a known primary tumor, or symptomatic lesions caused as a result of cranial nerve or brainstem compression. In theory, we may have missed patients with small, asymptomatic tumors with known primary gastrointestinal adenocarcinoma (including duodenal carcinoma). However, we did not find any such cases described in the literature, suggesting that such cases may be

Conclusions

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. Abducens nerve palsy is often the first presentation of clival metastasis.

References (56)

  • R.S. McDermott et al.

    Cranial nerve deficits in patients with metastatic prostate carcinoma: clinical features and treatment outcomes

    Cancer

    (2004)
  • C.E. McAvoy et al.

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

    Eye (Lond)

    (2002)
  • A.G. Kolias et al.

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

    Acta Neurochir (Wien)

    (2010)
  • J.E. O'Boyle et al.

    Sixth nerve palsy as the initial presenting sign of metastatic prostate cancer. A case report and review of the literature

    J Clin Neuroophthalmol

    (1992)
  • C. Ruchti et al.

    Follicular tumour in the sellar region without primary cancer of the thyroid. Heterotopic carcinoma?

    Am J Clin Pathol

    (1987)
  • M.M. Casals et al.

    Metastatic follicular thyroid carcinoma masquerading as a chordoma

    Thyroid

    (1995)
  • K.W. Altman et al.

    Metastatic follicular thyroid carcinoma to the paranasal sinuses: a case report and review

    J Laryngol Otol

    (1997)
  • A. Lee et al.

    Sixth cranial nerve palsy caused by gastric adenocarcinoma metastasis to the clivus

    J Korean Neurosurg Soc

    (2015)
  • S. Harada et al.

    Basal skull metastasis of stomach cancer presenting with Garcin's syndrome–a case report

    No Shinkei Geka

    (1987)
  • O. Hirai et al.

    Skull base metastasis from gastric cancer–case report

    Neurol Med Chir (Tokyo)

    (1992)
  • R.S. Sim et al.

    A case of metastatic hepatocellular carcinoma of the sphenoid sinus

    J Laryngol Otol

    (1994)
  • S.R. Kim et al.

    Hepatocellular carcinoma metastasising to the skull base involving multiple cranial nerves

    World J Gastroenterol

    (2006)
  • M. Kim et al.

    Nervous system involvement by metastatic hepatocellular carcinoma

    J Neurooncol

    (1998)
  • T.F. Kelley et al.

    Endoscopic trans-sphenoidal biopsy of the sphenoid and clival mass

    Am J Rhinol

    (1999)
  • Z.S. Mendelson et al.

    Endoscopic palliative decompression of the cavernous sinus in a rare case of a metastatic renal cell carcinoma to the clivus

    Br J Neurosurg

    (2015)
  • M. Fumino et al.

    A case of renal cell carcinoma with metastasis in clivus presenting as diplopia

    Hinyokika Kiyo

    (1998)
  • I. Sepúlveda et al.

    Skull base clear cell carcinoma, metastasis of renal primary tumor: a case report and literature review

    Case Rep Oncol

    (2013)
  • K. Endo et al.

    Renal cell carcinoma with skull base metastasis preceded by paraneoplastic signs in a chronic haemodialysis patient

    Intern Med

    (2001)
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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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