Adenocarcinoma of the Lung Presenting as Isolated Hypoglossal Nerve Palsy

Background: Metastasis from primary lung or breast cancer is rarely found at the skull base, but in such circumstances may present with acute neurological symptoms.

Objective: To review a case of lung adenocarcinoma with metastasis to the hypoglossal canal.

Case Presentation: The authors present the case of a 63-year-old male who presented to an emergency department with acute onset of weakness of the tongue with deviation to the right side, and during workup for stroke was found to have a lesion in the right hypoglossal canal on MRI imaging. On further workup, he was found to have new lesions in the lungs and right femoral head as well. He was referred for surgical biopsy and underwent an endonasal endoscopic approach to the occipital condyle and excision of this lesion. The clivus was exposed with an incision through the right nasopharynx, and the lesion was debulked. Final pathology of the lesion was consistent with a poorly differentiated adenocarcinoma consistent with lung origin, with corresponding positive stains for CK7, EMA, napsin-A, TTF-1, and vimentin. Following recovery from the procedure, the patient was referred to medical and radiation oncology services, who plan to evaluate the patient for possible enrollment in clinical trials versus stereotactic radio surgery/body radiation therapy.

Conclusion: High-grade lung adenocarcinomas may uncommonly present with neurological symptoms due to metastasis to the skull base. In these cases, endoscopic endonasal surgical approaches represent an acceptable modality for biopsy and excision.