Skull Base Metastasis from Gastric Cancer —
Osamu
HIRAI,
Case Report—
Haruhiko
KIKUCHI
and
Nobuo
HASHIMOTO
Department of Neurosurgery, Faculty of Medicine, Kyoto University, Kyoto
Abstract A 48-year-old
male
the sphenoid
sinus,
abducens
nerve
the course. system,
Key words:
which
paralysis
This
caused
presented
gastric multiple
gastric
with
a metastatic
skull
base tumor
originated
from
adenocarcinoma
and
were
no
cancer, bone
cancer,
there
which
symptoms
rarely
metastases
of upper
to the central
produced
the neurological
bone
on the right of the clivus
tumor,
skull
base
The
initial
gastrointestinal
metastasizes
which
metastasis,
located
of the stomach.
nervous
symptom
tract
and was
throughout
system
or osseous
symptoms.
tumor
Introduction Metastatic bone disease can originate from almost any malignancy, but the most common primary foci are breast and prostate cancer.') Skull metastasis demonstrates the same characteristic.4,5,9> Gastric cancer is one of the least frequent primary tumors causing intracranial metastases, but meningeal car cinomatosis has been reported. 1,6,10) Vertebral metastases may occur, although usually in the ter minal stages. Here, we ducens nerve the right of tumor was a gastric
report a patient presenting with ab paralysis caused by a tumor located on the upper clivus. Unexpectedly, the metastatic carcinoma derived from a
Case
Report
A 48-year-old male was well until April 17, 1990, when he noticed double vision followed by weakness of the left upper extremity. He consulted a local doc tor who found right abducens nerve paralysis. Mag netic resonance (MR) images on May 22 were thought to be normal (Fig. 1). He suffered from severe low back pain when washing his face on May 31. An orthopedist discovered a fracture of the L3 vertebral body on plain lumbar x-ray films. He also complained of numbness of the right face. Medical Received Author's
Fig. 1
cancer.
January present
20, 1992; address:
Accepted
O. Hirai,
M.D.,
April
20,
Department
MR image (scout view, TR 200 msec/TE 30 msec) taken at a local hospital, showing no ap parent abnormality. Note that the high inten sity of the marrow fat in the upper clivus has disappeared.
treatment did not ameliorate these symptoms, so he was admitted to our department on June 27. Physical examination revealed right abducens nerve paralysis, hypesthesia of the right face, and absence of ciliary and corneal reflexes of the right eye. Slight weakness of the left upper extremity with atrophy of the deltoid muscle, and hypesthesia along the left ulnar nerve were also noted. Laboratory in
1992 of Neurosurgery,
Saiseikai
Izuo
Hospital,
Osaka,
Japan.
Fig.
2
T,-weighted hancement mass
in the
the sphenoid
MR taken clivus
image
with
1.5 months and
the
Gd-DTPA later, posterior
Fig. 3
en
showing
a
half
of
Gastric cancer
fiber endoscopy, at the greater
revealing
an advanced
curvature.
sinus.
vestigations demonstrated marked increases in lactic dehydrogenase, alkaline phosphatase, alpha-fetopro tein, and CA19-9 (carbohydrate antigen) levels, all signs of malignancy. MR images demonstrated an abnormal intensity mass located in the upper portion of the clivus ex tending to the right side of the sphenoid sinus. The images were quite different to those taken 1.5 months before. The mass was strongly enhanced by intravenous injection of gadolinium-diethylene triaminepenta-acetic acid (Gd-DTPA) (Fig. 2). Other small osteolytic lesions were noted within the oc cipital and the parietal bones. Right external carotid angiograms showed obvious tumor stains. Although chest polytomograms showed no lung metastasis, plain thoracic and lumbar x-ray films demonstrated destruction of the Th8 and L3 vertebral bodies. Systemic bone scintigrams demonstrated multiple metastases to the skeletal system, including skull vertebrae, scapula, and humerus. Abdominal echograms and computed tomo graphic scans suggested gastric cancer. A fiber endoscopic study of the stomach confirmed an ad vanced cancer of Borrmann type III at the greater curvature (Fig. 3). Lumbar puncture yielded a watery-clear fluid without increased pressure, and cytological examination demonstrated no malignant cells. He developed severe intractable back pain from the beginning of July, possibly caused by the vertebral metastases. On July 18, a biopsy of the in tracranial tumor was made and the pituitary gland removed to relieve pain through a transsphenoidal approach. A hemorrhagic tumor was found in the
Fig. 4
Photomicrograph showing poorly cinoma.
of
HE stain,
the intracranial differentiated
tumor, adenocar
x 100.
posterior half of the sphenoid sinus extending into the right cavernous sinus. Histological examination of the surgical specimen indicated poorly differen tiated adenocarcinoma, quite similar to the gastric en doscopic biopsy (Fig. 4). Hypophysectomy achieved transient pain relief, but the neurological status remained unchanged. An anticancer chemosensitivity assay (deoxyribonucleic acid synthesis inhibition assay) indicated 5 fluorouracil, cis-platinum, and epirubicin treatment. Despite the intensive treatment provided, his general condition progressively deteriorated and he died of cachexia on August 4. Autopsy was not performed. Discussion Metastases may occur cluding the skull base.') parasellar
region.2)
anywhere The most
Several
in the frequent
examples
skull, in site is the
of metastatic
tumors have occurred in the sphenoid bone, dorsum sellae, and clivus.8 The initial symptoms of abducens nerve paralysis and subsequent facial numbness in this case were undoubtedly due to a metastatic de posit on the upper clivus, although not detected by the first MR study. Retrospective analysis of the images, however, found a low-intensity area re placing the high intensity of marrow fat normally seen in the clivus (Fig. 1). Unfortunately, Gd-DTPA enhancement was not performed. The subsequent paresis of the left upper extremity and intractable back pain were possibly caused by vertebral metas tases. The patient therefore suffered from multiple metastases to the osseous system, and the cranial nerve involvement was one manifestation. The most common sources of bone metastases are breast, prostate, kidney, and thyroid tumors.') Kistler and Pribram4) reported 11 cases with metastatic disease of the sella turcica, originating in the prostate, breast, lung, thyroid, or lymphosar coma malignancies. Two patients had no history of malignancy of a primary organ. Gastric cancer demonstrates one of the least frequent incidences of metastasis to the osseous system, although ver tebrae are occasionally compromised in the terminal stages. Moore') found no bone metastases in 1600 patients with gastric cancer at the Mayo Clinic. This extreme rareness was rationalized by a malignant condition of the stomach following a rapid course resulting in death unless immediate treatment was given. Central nervous system metastases from gastric cancer of the gastrointestinal tract are also unusual, with meningeal carcinomatosis being the most com mon form .1,6,11) Harada et al.') reported a rare case of skull base metastasis from stomach cancer presenting with Garcin's syndrome. The multiple cranial nerve palsies were caused by meningeal dissemination, although cerebrospinal fluid analysis revealed no ab normality. The mechanism of the peculiar metastasis in this case is difficult to elucidate. Multiple metastases were found at the terminals of branches of the right exter nal carotid artery, so the usual hematogenous spread of adenocarcinoma cells via the systemic circulation is the most likely. Whatever the mechanism , the present case demonstrated an extremely unusual pathogenesis. Advanced therapeutic regimens, including radia
tion therapy, chemotherapy, and immunotherapy, will provide more means to treat metastatic diseases. The recent development of neuroradiological diagnosis may identify more metastatic neurological diseases without a known history of malignancy. The primary source of cancer may occur in organs un likely to produce intracranial metastases. Metastatic disease should always be considered for the differen tial diagnosis, and prompt management is man datory for patients with unusual clinical features such as those described in the present case.
References 1)
2)
3)
4) 5)
6)
7)
8)
9) 10)
Fisher MA, Weiss RB: Carcinomatous
meningitis
in
gastrointestinal malignancies. South Med J 72: 930 932, 1979 Gamache FW, Posner JB, Patterson RH: Metastatic brain tumors, in Youmans JR (ed): Neurological Surgery, vol 5. Philadelphia, WB Saunders, 1982, pp 2872-2898 Harada S, Toya S, lisaka Y, Ohtani M, Nakamura Y: Basal skull metastasis of stomach cancer present ing with Garcin's syndrome. A case report. No Shinkei Geka 15: 765-769, 1987 (in Japanese) Kistler M, Pribram HW: Metastatic disease of the sella turcica. AJR 123: 13-21, 1975 Kucharczyk W, Smith RML: Magnetic resonance im aging of sellar and parasellar lesions, in Wilkins RH, Rengachary SS (eds): Neurosurgery Update I. New York, McGraw-Hill, 1990, pp 57-68 Meissner GF: Carcinoma of the stomach with me ningeal carcinosis. Report of four cases. Cancer 6: 313-318, 1953 Moore AB: A roentgenologic study of metastatic malignancy of the bones. Amer J Roentgen 6: 589 593, 1919 Newton TH, Potts DG (eds): Radiology of the Skull and Brain. The Skull. St Louis, CV Mosby, 1971, pp 295, 355, 390, 395 Posner JB: Neurological complications of systemic cancer. Med Clin North Am 55: 625-646, 1971 Posner JB, Chernik NL: Intracranial metastasis from systemic cancer, in Schoenberg BS (ed): Advances in Neurology, vol 19. New York, Raven Press, 1978, pp 579-592
Address of
reprint requests Neurosurgery,
Kitamura,
Taisho-ku,
to: O. Hirai, M.D., Department Saiseikai Izuo Hospital, 3-4-5 Osaka
551,
Japan.
Osamu
HIRAI,
Case Report—
Haruhiko
KIKUCHI
and
Nobuo
HASHIMOTO
Department of Neurosurgery, Faculty of Medicine, Kyoto University, Kyoto
Abstract A 48-year-old
male
the sphenoid
sinus,
abducens
nerve
the course. system,
Key words:
which
paralysis
This
caused
presented
gastric multiple
gastric
with
a metastatic
skull
base tumor
originated
from
adenocarcinoma
and
were
no
cancer, bone
cancer,
there
which
symptoms
rarely
metastases
of upper
to the central
produced
the neurological
bone
on the right of the clivus
tumor,
skull
base
The
initial
gastrointestinal
metastasizes
which
metastasis,
located
of the stomach.
nervous
symptom
tract
and was
throughout
system
or osseous
symptoms.
tumor
Introduction Metastatic bone disease can originate from almost any malignancy, but the most common primary foci are breast and prostate cancer.') Skull metastasis demonstrates the same characteristic.4,5,9> Gastric cancer is one of the least frequent primary tumors causing intracranial metastases, but meningeal car cinomatosis has been reported. 1,6,10) Vertebral metastases may occur, although usually in the ter minal stages. Here, we ducens nerve the right of tumor was a gastric
report a patient presenting with ab paralysis caused by a tumor located on the upper clivus. Unexpectedly, the metastatic carcinoma derived from a
Case
Report
A 48-year-old male was well until April 17, 1990, when he noticed double vision followed by weakness of the left upper extremity. He consulted a local doc tor who found right abducens nerve paralysis. Mag netic resonance (MR) images on May 22 were thought to be normal (Fig. 1). He suffered from severe low back pain when washing his face on May 31. An orthopedist discovered a fracture of the L3 vertebral body on plain lumbar x-ray films. He also complained of numbness of the right face. Medical Received Author's
Fig. 1
cancer.
January present
20, 1992; address:
Accepted
O. Hirai,
M.D.,
April
20,
Department
MR image (scout view, TR 200 msec/TE 30 msec) taken at a local hospital, showing no ap parent abnormality. Note that the high inten sity of the marrow fat in the upper clivus has disappeared.
treatment did not ameliorate these symptoms, so he was admitted to our department on June 27. Physical examination revealed right abducens nerve paralysis, hypesthesia of the right face, and absence of ciliary and corneal reflexes of the right eye. Slight weakness of the left upper extremity with atrophy of the deltoid muscle, and hypesthesia along the left ulnar nerve were also noted. Laboratory in
1992 of Neurosurgery,
Saiseikai
Izuo
Hospital,
Osaka,
Japan.
Fig.
2
T,-weighted hancement mass
in the
the sphenoid
MR taken clivus
image
with
1.5 months and
the
Gd-DTPA later, posterior
Fig. 3
en
showing
a
half
of
Gastric cancer
fiber endoscopy, at the greater
revealing
an advanced
curvature.
sinus.
vestigations demonstrated marked increases in lactic dehydrogenase, alkaline phosphatase, alpha-fetopro tein, and CA19-9 (carbohydrate antigen) levels, all signs of malignancy. MR images demonstrated an abnormal intensity mass located in the upper portion of the clivus ex tending to the right side of the sphenoid sinus. The images were quite different to those taken 1.5 months before. The mass was strongly enhanced by intravenous injection of gadolinium-diethylene triaminepenta-acetic acid (Gd-DTPA) (Fig. 2). Other small osteolytic lesions were noted within the oc cipital and the parietal bones. Right external carotid angiograms showed obvious tumor stains. Although chest polytomograms showed no lung metastasis, plain thoracic and lumbar x-ray films demonstrated destruction of the Th8 and L3 vertebral bodies. Systemic bone scintigrams demonstrated multiple metastases to the skeletal system, including skull vertebrae, scapula, and humerus. Abdominal echograms and computed tomo graphic scans suggested gastric cancer. A fiber endoscopic study of the stomach confirmed an ad vanced cancer of Borrmann type III at the greater curvature (Fig. 3). Lumbar puncture yielded a watery-clear fluid without increased pressure, and cytological examination demonstrated no malignant cells. He developed severe intractable back pain from the beginning of July, possibly caused by the vertebral metastases. On July 18, a biopsy of the in tracranial tumor was made and the pituitary gland removed to relieve pain through a transsphenoidal approach. A hemorrhagic tumor was found in the
Fig. 4
Photomicrograph showing poorly cinoma.
of
HE stain,
the intracranial differentiated
tumor, adenocar
x 100.
posterior half of the sphenoid sinus extending into the right cavernous sinus. Histological examination of the surgical specimen indicated poorly differen tiated adenocarcinoma, quite similar to the gastric en doscopic biopsy (Fig. 4). Hypophysectomy achieved transient pain relief, but the neurological status remained unchanged. An anticancer chemosensitivity assay (deoxyribonucleic acid synthesis inhibition assay) indicated 5 fluorouracil, cis-platinum, and epirubicin treatment. Despite the intensive treatment provided, his general condition progressively deteriorated and he died of cachexia on August 4. Autopsy was not performed. Discussion Metastases may occur cluding the skull base.') parasellar
region.2)
anywhere The most
Several
in the frequent
examples
skull, in site is the
of metastatic
tumors have occurred in the sphenoid bone, dorsum sellae, and clivus.8 The initial symptoms of abducens nerve paralysis and subsequent facial numbness in this case were undoubtedly due to a metastatic de posit on the upper clivus, although not detected by the first MR study. Retrospective analysis of the images, however, found a low-intensity area re placing the high intensity of marrow fat normally seen in the clivus (Fig. 1). Unfortunately, Gd-DTPA enhancement was not performed. The subsequent paresis of the left upper extremity and intractable back pain were possibly caused by vertebral metas tases. The patient therefore suffered from multiple metastases to the osseous system, and the cranial nerve involvement was one manifestation. The most common sources of bone metastases are breast, prostate, kidney, and thyroid tumors.') Kistler and Pribram4) reported 11 cases with metastatic disease of the sella turcica, originating in the prostate, breast, lung, thyroid, or lymphosar coma malignancies. Two patients had no history of malignancy of a primary organ. Gastric cancer demonstrates one of the least frequent incidences of metastasis to the osseous system, although ver tebrae are occasionally compromised in the terminal stages. Moore') found no bone metastases in 1600 patients with gastric cancer at the Mayo Clinic. This extreme rareness was rationalized by a malignant condition of the stomach following a rapid course resulting in death unless immediate treatment was given. Central nervous system metastases from gastric cancer of the gastrointestinal tract are also unusual, with meningeal carcinomatosis being the most com mon form .1,6,11) Harada et al.') reported a rare case of skull base metastasis from stomach cancer presenting with Garcin's syndrome. The multiple cranial nerve palsies were caused by meningeal dissemination, although cerebrospinal fluid analysis revealed no ab normality. The mechanism of the peculiar metastasis in this case is difficult to elucidate. Multiple metastases were found at the terminals of branches of the right exter nal carotid artery, so the usual hematogenous spread of adenocarcinoma cells via the systemic circulation is the most likely. Whatever the mechanism , the present case demonstrated an extremely unusual pathogenesis. Advanced therapeutic regimens, including radia
tion therapy, chemotherapy, and immunotherapy, will provide more means to treat metastatic diseases. The recent development of neuroradiological diagnosis may identify more metastatic neurological diseases without a known history of malignancy. The primary source of cancer may occur in organs un likely to produce intracranial metastases. Metastatic disease should always be considered for the differen tial diagnosis, and prompt management is man datory for patients with unusual clinical features such as those described in the present case.
References 1)
2)
3)
4) 5)
6)
7)
8)
9) 10)
Fisher MA, Weiss RB: Carcinomatous
meningitis
in
gastrointestinal malignancies. South Med J 72: 930 932, 1979 Gamache FW, Posner JB, Patterson RH: Metastatic brain tumors, in Youmans JR (ed): Neurological Surgery, vol 5. Philadelphia, WB Saunders, 1982, pp 2872-2898 Harada S, Toya S, lisaka Y, Ohtani M, Nakamura Y: Basal skull metastasis of stomach cancer present ing with Garcin's syndrome. A case report. No Shinkei Geka 15: 765-769, 1987 (in Japanese) Kistler M, Pribram HW: Metastatic disease of the sella turcica. AJR 123: 13-21, 1975 Kucharczyk W, Smith RML: Magnetic resonance im aging of sellar and parasellar lesions, in Wilkins RH, Rengachary SS (eds): Neurosurgery Update I. New York, McGraw-Hill, 1990, pp 57-68 Meissner GF: Carcinoma of the stomach with me ningeal carcinosis. Report of four cases. Cancer 6: 313-318, 1953 Moore AB: A roentgenologic study of metastatic malignancy of the bones. Amer J Roentgen 6: 589 593, 1919 Newton TH, Potts DG (eds): Radiology of the Skull and Brain. The Skull. St Louis, CV Mosby, 1971, pp 295, 355, 390, 395 Posner JB: Neurological complications of systemic cancer. Med Clin North Am 55: 625-646, 1971 Posner JB, Chernik NL: Intracranial metastasis from systemic cancer, in Schoenberg BS (ed): Advances in Neurology, vol 19. New York, Raven Press, 1978, pp 579-592
Address of
reprint requests Neurosurgery,
Kitamura,
Taisho-ku,
to: O. Hirai, M.D., Department Saiseikai Izuo Hospital, 3-4-5 Osaka
551,
Japan.
