Decision Making in Clival Mass Lesions: Risk Factors for Malignant Disease and an Illustrative Case Example

Introduction: Clival tumors are rare and heterogeneous. Although some benign prototypical sellar lesions may present as clival tumors, the overall prevalence of malignant diseases is increased.

Objective: To define and present a novel algorithm for the work-up and management of clival masses through an illustrative case of clival metastasis.

Methods: Case report of metastatic colorectal adenocarcinoma to the sella and clivus. Clinical management strategies for clival mass lesions were populated by literature review and refined by senior author consensus. Focused systematic review to characterize the present case in the context of clival metastases from gastrointestinal malignancies.

Results: An 83-year-old woman presented with 4 weeks of headaches and blurry vision. Exam was significant for partial right abducens and left oculomotor palsies. MRI identified a large, weakly enhancing sellar and clival mass with sphenoid sinus extension ([Fig. 1A]). An aggressive subtotal endoscopic endonasal resection was completed with removal of all sphenoid, clival, and sellar disease, but without cavernous sinus wall resection ([Fig. 1B]). Pathology confirmed colorectal adenocarcinoma; body CT identified an ascending colon mass with metastases to liver and mesenteric nodes. Palliative oncologic therapies were recommended, but she elected hospice, and died within 3 months of presentation. Gastrointestinal clival metastases are exceedingly rare among sellar and clival pathologies ([Fig. 2]), with 8 prior cases reported, most of which presented with diplopia from abducens nerve involvement ([Table 1]). General recommendations for the diagnostic work-up and initial management of new clival mass lesions are reported as a novel, consolidated algorithm ([Fig. 3]).

Conclusion: Clival masses are uncommon skull base lesions that are commonly associated with more aggressive diseases, such as chordomas and metastases. We present a framework for diagnostic and therapeutic decision-making in these vulnerable and challenging patients, alongside an unusual case example that illustrates the importance of increased suspicion for more malignant clinical entities in this setting.

Fig. 1.

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Table 1.

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Artikel online veröffentlicht:
05. Februar 2024