Metastatic Breast Carcinoma of the Jugular Foramen: A Rare Cause of Villaret's Syndrome
The differential diagnosis of skull bases masses is diverse and includes benign and malignant neoplasms, vascular anomalies, congenital lesions as well as infectious and inflammatory processes. Metastatic masses of the skull base are a rare manifestation of systemic malignancies. The most common types of primary cancer to metastasize to the skull base are prostate, lymphoma, breast, and lung. The majority of these patients have confirmed metastatic disease at the time of diagnosis of their skull base lesions.
Metastatic breast carcinoma of the skull base has previously been described; most commonly involving the paranasal sinuses and orbit. Previous authors have described five patterns of skull base metastasis based on clinical syndromes: orbital, parasellar, middle-fossa (Gasserian), jugular foramen, and occipital condyle. The jugular foramen is the rarest site of metastatic disease presentation. Villaret's Syndrome refers to cranial nerve IX, X, XI, and XII; as well as sympathetic chain neuropathies. The most common causes of Villaret's syndrome are benign neoplasms (meningioma, paraganglioma, schwannoma) and vascular abnormalities (carotid aneurysm and jugular vein thrombosis).
A 62-year-old female patient with a distant history of right breast cancer (status post total mastectomy, axillary lymph node dissection and radiation therapy) was seen with regards to a chief complaint of hoarseness and dysphagia. On exam she was found to have cranial nerve IX, X, XI, XII, as well as sympathetic chain neuropathy; consistent with a diagnosis of Villaret's Syndrome. Computed tomography of the neck identified a small, poorly circumscribed mass at the right jugular foramen (image below). A transcervical approach to the jugular foramen was performed to obtain a tissue biopsy. Pathologic examination revealed the diagnosis of invasive ductal breast carcinoma.
Breast cancer is the most common malignancy among women. Advanced breast cancer is well known to metastasize hematogenously; most commonly to lungs, bone, and brain. Previous case reports of metastatic breast cancer of the head and neck have been described; most commonly involving the anterior cranial base. This is the first described case of metastatic breast cancer presenting as Villaret's Syndrome. Head and neck manifestations of systemic breast carcinoma as well as the differential diagnosis of Villaret's Syndrome are discussed.