British Journal of Neurosurgery

ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20

Endoscopic palliative decompression of the cavernous sinus in a rare case of a metastatic renal cell carcinoma to the clivus Zachary S. Mendelson, Amit A. Patel, Jean Anderson Eloy & James K. Liu To cite this article: Zachary S. Mendelson, Amit A. Patel, Jean Anderson Eloy & James K. Liu (2015) Endoscopic palliative decompression of the cavernous sinus in a rare case of a metastatic renal cell carcinoma to the clivus, British Journal of Neurosurgery, 29:3, 430-431, DOI: 10.3109/02688697.2014.987217 To link to this article: http://dx.doi.org/10.3109/02688697.2014.987217

Published online: 09 Dec 2014.

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Date: 09 November 2015, At: 02:38

British Journal of Neurosurgery, June 2015; 29(3): 430–431 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.987217

SHORT REPORT

Endoscopic palliative decompression of the cavernous sinus in a rare case of a metastatic renal cell carcinoma to the clivus Zachary S. Mendelson1, Amit A. Patel2, Jean Anderson Eloy1,2,3 & James K. Liu1,2,3 1Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA, 2Department of Otolaryngology –

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Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA, and 3Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ, USA

tumor within the cavernous sinus, lateral to the carotid artery (Fig. 1). The tumor was noted to be very hemorrhagic, and hemostasis was achieved once the majority of the tumor was removed from the clivus. Histopathologic examination revealed findings consistent with clear cell renal carcinoma with direct invasion into the bone and positive immunostaining with paired-box gene 8 (PAX8). Postoperatively, the patient had near-complete resolution of her cranial neuropathies with only a mild residual left cranial nerve III weakness remaining. Because of the histopathologic findings, a CT of the abdomen was performed which revealed a large left renal mass consistent with primary renal cell carcinoma. Follow-up positron emission tomography (PET)/CT for staging showed diffusely metastatic disease to the ribs, pelvis, and spine. The patient proceeded to undergo palliative radiation therapy. This study received approval from the Institutional Review Board.

Abstract We present a rare case of acute cavernous sinus syndrome due to a renal cell carcinoma metastasis to the clivus. This case highlights the role of palliative endoscopic endonasal decompression of the cavernous sinus to relieve cranial neuropathies, obtain tissue diagnosis, and for cytoreduction in preparation for additional adjuvant therapy. Keywords: cavernous sinus syndrome; clival lesion; endoscopic skull base surgery; renal cell carcinoma; skull base tumor

Clinical details We report the use of endoscopic endonasal skull base surgery for achieving a successful palliative decompression of the cavernous sinus to relieve cranial neuropathies. A 59-yearold female with a medical history notable for hypertension presented to an outside hospital complaining of progressive headaches and drooping of her left eye with double vision. Physical examination showed palsies of left cranial nerves III, IV, VI, and V2, manifesting as an acute onset of left-sided ptosis, diplopia, and decreased sensation over the left cheek. Based on the clinical symptomatology, the patient appeared to exhibit an acute cavernous sinus syndrome and possibly clinical pituitary apoplexy prior to obtaining formal imaging studies. Subsequent computed tomography (CT) angiogram and post-gadolinium magnetic resonance imaging (MRI) scan revealed a mildly enhancing clival lesion with extension into the sphenoid sinuses and left cavernous sinus with encasement of the left carotid artery (Fig. 1). The lesion was isointense on T1-weighted images and hyperintense on T2-weighted images. Given the acute nature of the cranial neuropathies, the patient underwent an endoscopic endonasal transclival resection of the tumor to decompress the cavernous sinus and also provide tissue diagnosis of the lesion. A subtotal resection was performed with remaining residual

Discussion We describe the first case of metastatic renal cell carcinoma to the clivus presenting with acute cavernous sinus syndrome that was treated endoscopically. This was the first clinical manifestation of this patient’s renal cell carcinoma, since the patient had no history of malignancy. Renal cell carcinoma is an uncommon malignancy known for its protean manifestations and unusual sites of metastasis. Metastasis from renal cell carcinoma generally occurs in locoregional lymph nodes, lungs, liver, bones, and the brain. Other sites of spread have been described, but are increasingly infrequent.1 Clival metastases have been reported previously; however, in the majority of cases, treatment was limited to palliative radiation or open surgery, or presented as a sequelae to a known malignancy.2 Although radiation therapy can be considered as the primary treatment after biopsy,3 these tumors are generally radioresistant and persistent mass effect on the cranial

Correspondence: James K. Liu, MD, Director, Center for Skull Base and Pituitary Surgery, Department of Neurological Surgery, Rutgers New Jersey Medical School, 90 Bergen St., Suite 8100, Newark, NJ 07103, USA. Tel: ⫹(973) 972-2906. Fax: ⫹(973) 972-2333. E-mail: [email protected] Received for publication 13 August 2014; accepted 2 November 2014

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Fig. 1. Preoperative MRI (A: sagittal T1-post gadolinium) and CT angiogram (B: coronal, C: axial) demonstrate a mildly enhancing, erosive clival lesion compressing the left cavernous sinus. Postoperative post-gadolinium T1-weighted MRI (D: sagittal view; E: coronal view) demonstrates resection of the clival mass and decompression of the cavernous sinus. There was residual tumor within the left cavernous sinus lateral to the carotid artery. Histopathologic examination demonstrated findings consistent with clear cell renal carcinoma. F: Clear cell carcinoma with cellular and nuclear pleomorphism, also a nested appearance, hematoxylin and eosin, 10⫻.

nerves in the cavernous sinus may not be resolved. This case illustrates the role of endoscopic skull base surgery in the management of radioresistant metastatic lesions to the skull base for palliative decompression of the cavernous sinus to improve cranial nerve function.

Acknowledgments The authors would like to thank Dr. Leroy R. Sharer for his assistance with histopathologic imaging.

Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.

References 1. Cairns P. Renal cell carcinoma. Cancer Biomark 2010;9:461–73 2. Sepulveda I, Platin E, Klaassen R, et al. Skull base clear cell carcinoma, metastasis of renal primary tumor: a case report and literature review. Case Rep Oncol 2013;6:416–23 3. Simo R, Sykes AJ, Hargreaves SP, et al. Metastatic renal cell carcinoma to the nose and paranasal sinuses. Head Neck 2000;22:722–7.

Endoscopic palliative decompression of the cavernous sinus in a rare case of a metastatic renal cell carcinoma to the clivus.

We present a rare case of acute cavernous sinus syndrome due to a renal cell carcinoma metastasis to the clivus. This case highlights the role of pall...
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