CC-BY-NC-ND 4.0 · J Neurol Surg Rep 2018; 79(02): e55-e62
DOI: 10.1055/s-0038-1655773
Case Report
Georg Thieme Verlag KG Stuttgart · New York

Anterior Clinoid Metastasis Removed Extradurally: First Case Report

Mirza Pojskić
1  Department of Neurosurgery, Philipps University of Marburg, Marburg, Germany
,
Blazej Zbytek
2  Department of Pathology and Laboratory Medicine, Center for Adult Cancer Research, University of Tennessee Health Science Center, Memphis, Tennessee, United States
3  Pathology Group of the MidSouth, Memphis, Tennessee, United States
,
Kenan I. Arnautović
4  Semmes Murphey Neurologic & Spine Institute, Memphis, Tennessee, United States
5  Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States
› Author Affiliations
Further Information

Address for correspondence

Kenan I. Arnautović, MD, PhD
Semmes Murphey Neurologic & Spine Institute
6325 Humphreys Blvd., Memphis, TN 38120
United States   

Publication History

06 September 2017

10 April 2018

Publication Date:
31 May 2018 (online)

 

Abstract

Background We report a case of isolated metastasis on the anterior clinoid process (ACP) mimicking meningioma.

Clinical Presentation A 58-year-old male presented with headaches, right-sided visual disturbances, and blurred and double vision. The cause of double vision was partial weakness of the right III nerve, resulting from compression of the nerve by “hypertrophied” tumor-involved right anterior clinoid. Medical history revealed two primary malignant tumors—male breast cancer and prostate cancer (diagnosed 6 and 18 months prior, respectively). The patient was treated with chemotherapy and showed no signs of active disease, recurrence, or metastasis. Postcontrast head magnetic resonance imaging (MRI) showed extra-axial well-bordered enhancing mass measuring 1.6 × 1.1 × 1 × 1 cm (anteroposterior, transverse, and craniocaudal dimensions) on the ACP, resembling a clinoidal meningioma. Extradural clinoidectomy with tumor resection was performed via right orbitozygomatic pretemporal skull base approach. Visual symptoms improved. Follow-up MRI showed no signs of tumor residual or recurrence.

Conclusion This is the first case report of a metastasis of any kind on ACP. Metastasis should be included as a part of the differential diagnosis of lesions of the anterior clinoid. Extradural clinoidectomy is a safe and effective method in the treatment of these tumors.


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Background and Importance

We report a first case of isolated metastasis on the anterior clinoid process (ACP) mimicking a meningioma, which should be added to the differential diagnosis of the processes of ACP. The most common lesions of the anterior clinoid process are meningiomas.[1] [2] There are 11 different pathological entities described so far on the ACP other than meningioma ([Table 1]).[3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33]

Table 1

Nonmeningioma pathology of the anterior clinoid process

Nonmeningioma pathology of the ACP

Author and year

Symptoms

Treatment and outcome

Mucocele

21 cases

Nundkumar et al, 2012[24]

Sudden painless loss of vision

Endoscopic transnasal approach, complete recovery

Johnson et al, 1986[18]

Retrobulbar pain with loss of vision

Pterional approach; incomplete recovery

Schwaighofer et al, 1989[27]

Retro-orbital pain with loss of vision

Frontal craniotomy, complete recovery

Dunya et al, 1996[11]

Double vision

Endoscopic transsphenoidal, subjective improvement

Garaventa et al, 1997[13]

Retro-orbital pain with loss of vision

Endoscopic transnasal, complete recovery

Chou et al, 1999[8]

Progressive loss of vision

Supraorbital craniotomy, complete recovery

Chung et al, 1999[9]

Headache, diplopia

Pterional approach, slight recovery with light perception

Lim et al, 1999[21]

Diplopia, III nerve palsy

Frontotemporal orbitozygomatic approach, recovery of III nerve palsy

Hejazi et al, 2001[14]

Ophthalmoplegia, visual loss

Transnasal, complete recovery

Righini et al, 2006[26]

Monocular blindness

Endoscopic, complete recovery

Deshmukh and DeMonte, 2007[10]

Blind spot

Conservative treatment with oral antibiotics for sinusitis, complete recovery

Thurtell et al, 2007[28]

Painful visual loss

Pterional approach, no recovery

Vaphiades et al, 2007[31]

Painless visual loss

Endoscopic transnasal, slight recovery

Kwon et al, 2009[20]

Sudden onset of blurry vision

Transnasal, slight recovery

Arnavielle et al, 2010[4]

Painful optic neuropathy

Endoscopic, complete recovery

Chagla et al, 2010[5]

Headache, visual loss

Supraorbital craniotomy, slight recovery

Forer et al, 2010[12]

Unilateral ophthalmoplegia, eye redness

Image-guided endoscopic, complete recovery

Moisseiev et al, 2013[23]

Visual loss

Surgery, not specified

Wang et al, 2013[32]

Retro-orbital pain, double vision, III, IV, VI nerve palsy

Pterional approach, incomplete recovery

Aoyama et al, 2014[3]

Headache, visual loss

Craniotomy (not specified), slight improvement

Hopf-Jensen et al, 2014[17]

III nerve palsy, diplopia

Pterional approach, intradural clinoidectomy, complete recovery

Cavernous hemangioma

2 cases

Mansour et al, 2017[22]

Incidental finding

Pterional approach, no complications

Yamashita et al, 2006[33]

Headache, visual impairment

Pterional approach, complete recovery

Isolated fibrous dysplasia of the ACP

1 case

Chang, 2009[6]

One-sided blindness

Extradural clinoidectomy via pterional approach in “no drill” technique, no recovery

Pilocytic astrocytoma

1 case

Hong et al, 2014[16]

One-sided visual loss

Frontotemporal craniotomy, improved vision

Inflammatory pseudotumor

1 case

Kasliwal et al, 2008[19]

Visual diminution and proptosis

Surgical decompression, high-dose steroids, complete recovery

Pyocele

1 case

O'Donnell et al, 2013[25]

Fever, decreased vision, III and VI nerve palsy

Intravenous antibiotics followed by surgery, approach not specified, complete recovery

Dermoid cyst

1 case

Higgins and Schimdt, 1996[15]

Not specified

Stereotactic biopsy followed by craniotomy and resection, not specified

Necrotizing sarcoid granuloma

1 case

Tobias et al, 2003[29]

Left visual deterioration and proptosis

Frontotemporal craniotomy with extradural removal of the ACP; corticosteroid therapy, visual improvement, stable disease

Bony protuberance of the ACP leading to aneurysm of the ICA due to trauma

Cheong et al, 2011[7]

Severe headache after craniofacial injury

Clipping and wrapping of the traumatic aneurysm, complete recovery

DAVF draining into the superficial middle cerebral vein

1 case

Ushikoshi et al, 2013[30]

Sudden onset of altered consciousness

Frontotemporal craniotomy, clipping of the DAVF, complete recovery

Metastasis of the breast cancer

1 case

Pojskić et al (this case)

Blurry and double vision on the right side

Orbitozygomatic pretemporal craniotomy, extradural clinoidectomy, complete recovery

Abbreviations: ACP, anterior clinoid process; DAVF, dural arteriovenous fistula; ICA, internal carotid artery.


Clinoidectomy is the key element of the surgical treatment of neoplastic lesions of the ACP. It was developed initially as an intradural technique for approach to internal carotid artery and ophthalmic aneurysms.[34] [35] It can be performed either intra- or extradural. Total clinoidectomy has been advocated in all neoplastic lesion of the clinoid, since at least a quarter of patients with radiographically negative imaging of ACP will have tumor involvement on pathological analysis.[36]


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Clinical Presentation

Appropriate consent was obtained from the patient.

Symptoms

A 58-year-old male presented with headaches, right-sided blurred vision, and double vision. The cause of double vision was partial weakness of the right III nerve resulting from compression of the nerve by “hypertrophied” tumor-involved right anterior clinoid. His previous medical history revealed existence of two primary malignant tumors: breast cancer (diagnosed 6 months prior) and prostate cancer (diagnosed 18 months prior). The patient was under treatment with chemotherapy due to breast cancer and showed no signs of active disease.


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Magnetic Resonance Imaging Presentation

Postcontrast magnetic resonance imaging (MRI) of the head showed an extra-axial, well-bordered enhancing mass measuring 1.6 × 1.1 × 1.1 cm of the ACP with involvement of the right optic canal (OC) along its superior lateral margin with dural tail typical for a meningioma. No other intracranial lesions were present. Meningioma was considered a primary differential diagnostic possibility preoperatively ([Fig. 1]). The surgery was indicated due to symptomatic lesion, which progressively affected the vision on the right eye and to obtain the histological diagnosis.

Zoom Image
Fig. 1 Preoperative postcontrast magnetic resonance imaging (MRI) of the brain. (A) T1-weighted postcontrast axial view demonstrating a contrast-enhancing lesion on the right anterior clinoid process. (B) T1-weighted postcontrast axial view. (C) T1-weigted postcontrast coronal view, lesion on the right clinoid process resembling a clinoidal meningioma. (D) Preoperative T-2 weighted coronal MRI of the brain showing anterior clinoid involved by tumor adjacent to right optic nerve. (E) Computed tomography (CT) scan of the head, axial view. (F) Intraoperative microsurgical drilling of the right anterior clinoid. (G) Microsurgical dissection of the clinoid from periorbita. (H) Tumor inside the clinoid below the right optic nerve (labeled CN II). (I) Resection of the tumor extending into the right sphenoid sinus below the right optic nerve (CN II). Note also the right internal carotid artery (ICA) genu. (J) Microsurgical picture after resection of the tumor-involved right anterior clinoid. Please note the CN II optic nerve, ICA genu, III, IV, V1, and V2 nerves, and sphenoid sinus (SS) after removal of the tumor.

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Surgical Technique

Extradural clinoidectomy with tumor resection was performed by the senior author (K.I.A). The details of the orbitozygomatic pretemporal approach have been previously described.[1] [2] [37] [38] [39] Skin incision and preparation of the temporalis muscle and orbitozygomatic craniotomy with drilling of the sphenoid ridge were performed in usual manner.[37] The superior orbital fissure (SOF) was identified and unroofed, removing the bone overlying the superolateral margin of the SOF with rongeurs and a diamond burr. The meningo-orbital artery was coagulated and divided. Frontobasal and temporal dura were retracted with dural tack up sutures. Dura propria of the temporal lobe was peeled off from the SOF and the anteromedial aspect of the lateral wall of the cavernous sinus, exposing the third and the fourth cranial nerve as well as V1 and V2 of the fifth cranial nerve. Intraoperatively, the right III nerve was compressed by the hypertrophied tumor-involved anterior clinoid, but there was no evidence of dural or cavernous sinus tumor involvement.

The OC was then unroofed from a lateral to medial direction by using a 2-mm diamond burr with constant-cooling irrigation.[40] The tumor was involving the right anterior clinoid. The dorsal cortex of the clinoid was preserved and the tumor was involved in the central portion, penetrating ventrally and medially toward the sphenoid sinus. The opening of the sphenoid sinus was thusly done to ensure complete tumor resection and later obliterated with a small piece of muscle. Also, the third root of the ACP, the optic strut, was drilled off. During this procedure, constant awareness was maintained to protect the optic nerve, the carotid artery, and the oculomotor nerve with reference to the ACP. After removing the tumor that infiltrated the ACP, it was sent for histological analysis ([Fig. 1f–j]).


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Pathohistology

Pathohistological report showed the diagnosis of the metastasis of the known infiltrating ductal carcinoma of the breast ([Fig. 2]).

Zoom Image
Fig. 2 Pathohistology specimens. (A) Tumor in the breast. Tumor consists of highly pleomorphic epithelial cells and corresponds to infiltrating ductal carcinoma of breast, poorly differentiated (Nottingham combined grade III). Hematoxylin and eosin (H&E). Magnification 200 × . (B) Tumor in clinoid bone. Tumor consists of highly pleomorphic epithelial cells in desmoplastic stroma. H&E. Magnification 100 × . (C) Tumor in clinoid bone. Tumor cells are strongly cytokeratin 7 positive. Cytokeratin 7 immunostaining. Magnification 200 × .

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Follow-Up

The postcontrast MRI showed no signs of the residual tumor ([Fig. 3]). Blurred vision improved and double vision resolved completely. The patient continued to receive chemotherapy for infiltrating ductal carcinoma of the breast by his oncologist. Also, radiation treatment was initiated.

Zoom Image
Fig. 3 Postoperative postcontrast magnetic resonance imaging (MRI) of the brain. (A) T1-weighted postcontrast axial view demonstrating a complete resection of the metastasis. (B) T1-weighted postcontrast axial view. (C) T1-weigted postcontrast coronal view, complete resection of the anterior clinoid. (D) Computed tomography (CT) scan of the head, axial view, demonstrating complete removal of the anterior clinoid process.

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Discussion

A literature review of the past 30 years using the PubMed database did not display any results for metastasis of the clinoid process. The most common lesions of ACP are meningiomas. There were more than 20 studies that included patients with surgically treated meningiomas of the ACP.[1] [2] [29] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] The second most common lesion of the ACP is mucocele.[24] [Table 1] provides the overview of isolated nonmeningioma lesions of the ACP reported so far in the literature.

Magnetic Resonance Imaging Presentation

Meningiomas demonstrate homogeneous enhancement on postcontrast MRI.[59] Generally, there are several lesions that can mimic meningiomas, which usually present with pseudo-dural tail: breast cancer metastasis,[60] cavernous hemangiomas,[22] [61] dural plasmocytoma,[62] [63] large capillary hemangioma,[64] carcinoid tumor metastasis,[65] pilocytic astrocytoma,[16] liposarcoma,[66] and metastatic thyroid carcinoma.[67]


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Breast Cancer and Brain Metastases

Breast cancer represents the second most frequent cause of brain metastases, occurring in 10 to 16% of patients.[68] Subgroups of patients with triple-negative and human epidermal growth factor receptor 2 (HER2)-positive breast cancer have an increased risk of developing brain metastases.[69] Surgical resection of the brain metastasis is an important treatment option in patients with single or few (≤ 3) lesions.[70] [71] [72] However, the breast cancer metastasis or any other metastasis on the ACP has not been reported so far to our knowledge.


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Surgical Technique

The extradural removal of the anterior clinoid process was initially described by Dolenc for vascular lesions of the cavernous sinus.[73] Its use for pituitary adenomas, craniopharyngiomas, and clinoidal and tuberculum sellae meningiomas has been described.[1] [2] Approach can be pterional,[74] orbitozygomatic,[37] [75] modified pterional,[76] modified orbitozygomatic,[40] pretemporal transzygomatic transcavernous,[39] [77] temporopolar epidural transcavernous transpetrous,[78] extended lateral supraorbital,[79] and endoscopic transsphenoidal.[24]

Extradural clinoidectomy has several advantages over intradural clinoidectomy. First, anatomical orientation is easily attained by identifying the dural extension into the SOF and the OC, and therefore a total ACP removal is possible. In contrast, when the intradural technique is used, both the extent of bone removal and the exposure that is gained may be limited. Second, the dura protects the intradural structures. Third, the procedure is performed during extradural exposure and also much faster than the intradural technique.[76]

With our first case report on the isolated metastasis of the anterior clinoid process, we provide an additional argument in favor of extradural clinoidectomy and in particular for malignant tumor pathology, since extradural resection minimizes the possibility of intradural tumor spread. Metastasis should now be included in the differential diagnosis of the lesions of the ACP. The possible spread of the metastatic disease intracranially in case of opening of the dura should be taken into consideration when planning a surgery.


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Conclusions

This is the first case report of an ACP metastasis. It was treated successfully with extradural clinoidectomy. Metastasis should now be included in the differential diagnosis on the lesions of the anterior clinoid process. Extradural clinoidectomy is a safe and effective method in the treatment of these tumors, minimizing the risk of intradural tumor spread.


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Conflict of Interest

No financial or material support was accepted as part of this study. None of the authors have any financial relationships to disclose.

Acknowledgments

The authors wish to thank Andrew J. Gienapp, BA (Department of Medical Education, Methodist University Hospital, Memphis, Tennessee, United States, and Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States), for copy editing, preparation of the manuscript, table, and figures for publishing, and publication assistance with this manuscript.


Address for correspondence

Kenan I. Arnautović, MD, PhD
Semmes Murphey Neurologic & Spine Institute
6325 Humphreys Blvd., Memphis, TN 38120
United States   


Zoom Image
Fig. 1 Preoperative postcontrast magnetic resonance imaging (MRI) of the brain. (A) T1-weighted postcontrast axial view demonstrating a contrast-enhancing lesion on the right anterior clinoid process. (B) T1-weighted postcontrast axial view. (C) T1-weigted postcontrast coronal view, lesion on the right clinoid process resembling a clinoidal meningioma. (D) Preoperative T-2 weighted coronal MRI of the brain showing anterior clinoid involved by tumor adjacent to right optic nerve. (E) Computed tomography (CT) scan of the head, axial view. (F) Intraoperative microsurgical drilling of the right anterior clinoid. (G) Microsurgical dissection of the clinoid from periorbita. (H) Tumor inside the clinoid below the right optic nerve (labeled CN II). (I) Resection of the tumor extending into the right sphenoid sinus below the right optic nerve (CN II). Note also the right internal carotid artery (ICA) genu. (J) Microsurgical picture after resection of the tumor-involved right anterior clinoid. Please note the CN II optic nerve, ICA genu, III, IV, V1, and V2 nerves, and sphenoid sinus (SS) after removal of the tumor.
Zoom Image
Fig. 2 Pathohistology specimens. (A) Tumor in the breast. Tumor consists of highly pleomorphic epithelial cells and corresponds to infiltrating ductal carcinoma of breast, poorly differentiated (Nottingham combined grade III). Hematoxylin and eosin (H&E). Magnification 200 × . (B) Tumor in clinoid bone. Tumor consists of highly pleomorphic epithelial cells in desmoplastic stroma. H&E. Magnification 100 × . (C) Tumor in clinoid bone. Tumor cells are strongly cytokeratin 7 positive. Cytokeratin 7 immunostaining. Magnification 200 × .
Zoom Image
Fig. 3 Postoperative postcontrast magnetic resonance imaging (MRI) of the brain. (A) T1-weighted postcontrast axial view demonstrating a complete resection of the metastasis. (B) T1-weighted postcontrast axial view. (C) T1-weigted postcontrast coronal view, complete resection of the anterior clinoid. (D) Computed tomography (CT) scan of the head, axial view, demonstrating complete removal of the anterior clinoid process.