Literature ReviewClival Metastasis of a Duodenal Adenocarcinoma: A Case Report and Literature Review
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.
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2018, Handbook of Clinical NeurologyCitation Excerpt :Cancers that result in clival metastases include renal cell carcinoma (Fumino et al., 1998; Mendelson et al., 2015), prostate carcinoma (Malloy, 2007; Pallini et al., 2009), lung cancer (Marchese-Ragona et al., 2008; Pallini et al., 2009), hepatocellular carcinoma (Escarda et al., 2006; Pallini et al., 2009), duodenal adenocarcinoma (Dekker et al., 2017), and breast cancer (Ng et al., 2011; Kapoor et al., 2015), among others (Okudo and Anusim, 2016). Of these, the most common primary neoplasms to metastasize to the clivus include prostate, kidney, and liver (Dekker et al., 2017). The median survival for patients with clival metastases is 2–3 years (Marchese-Ragona et al., 2008).
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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.