Cavernous sinus syndrome caused by metastatic colon carcinoma

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.

Cavernous sinus involvement in human papillomavirus associated oropharyngeal squamous cell carcinoma: case report of an atypical site of distant metastasis

BACKGROUND

HPV-associated OSCC (HPV-OSCC) has been determined to be a distinct disease entity from non-HPV associated OSCC. Patients affected by HPV-OSCC generally have a more favourable prognosis, with improved rates of locoregional control and survival compared with their non-HPV counterparts. Despite this, HPV-OSCC has a similar rate of distant metastases. Interestingly, recent evidence has emerged that demonstrates more frequent atypical metastasis patterns when compared to non-HPV associated disease. To the best of our knowledge, this report describes the first case of a confirmed HPV-OSCC with distant metastasis to the cavernous sinus.

CASE PRESENTATION

A 62-year-old non-smoking male presented to the head and neck oncology clinic with a five-month history of enlarging right neck mass causing neck pain, dysphagia, and dysphonia. HPV-associated base of tongue squamous cell carcinoma (cT4aN2c) was diagnosed, and he was treated with primary chemoradiation. Shortly after treatment, he presented with progressive bilateral cranial nerve palsies including left cranial nerve III and right cranial nerve VI involvement. Imaging identified masses in the left cavernous sinus with extension of tumor into the sella and in the right cavernous sinus at the level of Dorello's canal. Endoscopic Image Guided Transsphenoidal biopsy of the left sellar mass confirmed distant metastases from the previously treated HPV-OSCC primary to the cavernous sinus. The patient was palliated with carboplatin and paclitaxel.

CONCLUSION

The presented report is the first documented case of confirmed HPV-associated oropharyngeal squamous cell carcinoma metastasizing to the cavernous sinus, and the only HPV confirmed head and neck cancer case to present with metastasis to the cavernous sinus and limited extracranial disease. This case demonstrates the importance of recognizing presentations of atypical metastasis that are possible in HPV-associated oropharyngeal cancer. Given the rarity of metastasis to this region, vigilance in follow up is instrumental in early identification and treatment for these patients.

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.

Cavernous sinus syndrome associated with metastatic colorectal cancer and perineural spread along the trigeminal nerve

Purpose

We report the case of a patient with cavernous sinus syndrome associated with biopsy-confirmed metastasis from colorectal cancer.

Observations

A patient known for laryngeal carcinoma and metastatic colorectal carcinoma presented with symptoms of left trigeminal neuralgia and progressive, near-complete ophthalmoplegia. Magnetic resonance imaging (MRI) revealed a mass in the left cavernous sinus, extending into Meckel's cave with perineural spread along the mandibular branch of the left trigeminal nerve. A transsphenoidal biopsy was performed and demonstrated metastatic colon adenocarcinoma. We review the existing literature on colorectal cancer associated cavernous sinus syndrome.

Conclusions and importance

Cavernous sinus metastasis from colorectal cancer is exceedingly rare. We report the second case of this entity with histopathologic confirmation, and the first case with concurrent perineural spread involving the trigeminal nerve. Cavernous sinus metastasis may represent a poor prognostic factor in colorectal cancer.

Venous drainage of the spine and spinal cord: a comprehensive review of its history, embryology, anatomy, physiology, and pathology

Venous drainage of the spine and spinal cord is accomplished through a complex network of venous structures compartmentalized to intrinsic, extrinsic, and extradural systems. As the literature on this topic is scarce, the following review was performed to summarize the available literature into a single coherent format. The medical literature on the spinal venous system was reviewed using online sources as well as historical documents that were not available online in regard to history, embryology, anatomy, and physiology with a particular emphasis on the pathology affecting this system. The spinal venous system is complex and variable. Proper understanding of all aspects is critical for the management of the pathology that results from its failure.

A brief review of different types of sweat-gland carcinomas in the eyelid and orbit

Sweat-gland carcinoma is a rare cutaneous appendage malignant tumor. Primary sweat-gland cancer can arise in the eyelid and orbit and is extremely rare. It has been classified into different types, and is usually locally recurrent after surgery. The tumors also appear in the orbit, which is characterized by metastasis. Therefore, great attention should be paid to the development of sweat-gland carcinomas. Specifically, our report briefly reviews the types of sweat-gland carcinomas that occur in the eyelid and orbit according to pathological classifications.

Sellar and parasellar metastatic tumors

The sellar and parasellar (SPS) region is a complex area rich in vital neurovascular structures and as such may be the location of first manifestation of a systemic malignancy. Metastases to this region are rare; breast cancer is the most common source among those that metastasize to the SPS region. Ophthalmoplegia, headache, retroorbital or facial pain, diabetes insipidus, and visual field defects are the most commonly reported symptoms. Lack of specific clinical and radiological features renders SPS metastases difficult to differentiate from the other frequently encountered lesions in this area, especially when there is no known history of a primary disease. Currently accepted management is multimodality therapy that includes biopsy and/or palliative surgical resection, radiation, and chemotherapy. Although no significant survival benefits have been shown by the surgical series, surgical resection may improve quality of life. Here we review the relevant literature and present six illustrative cases from our own institution.

Sixth nerve palsy as the presenting symptom of metastatic colon carcinoma

Isolated cranial mononeuropathies in patients over 50 years of age most commonly result from microvascular ischemic demyelination. A 51-year-old female without vasculopathic risk factors presented with isolated sixth nerve palsy. Magnetic resonance imaging (MRI) of the brain and orbits revealed a cavernous sinus lesion that was diagnosed as a meningioma. Laboratory tests showed abnormal liver function, and an abdominal computerized tomogram demonstrated an obstructive colonic mass with liver metastasis. The pathology tests of specimens taken during a laparotomy diagnosed colon adenocarcinoma. The MRI interpretation was changed to cavernous sinus metastasis from a primary adenocarcinoma of the colon. This case had common cranial nerve symptoms but with a very rare etiology, emphasizing the importance of a high index of suspicion of remote origins in patients with isolated sixth nerve palsy and no atherosclerotic risk factors.