Otology & Neurotology 36:e144–e145 ß 2014, Otology & Neurotology, Inc.
Imaging Case of the Month
Metastatic Breast Cancer Presenting as a Jugular Foramen Mass Kevin A. Peng, Nopawan Vorasubin, yAli R. Sepahdari, and Akira Ishiyama Departments of Head and Neck Surgery; and yRadiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, U.S.A.
The differential diagnosis for destructive lesions in the posterior temporal bone is broad and includes endolymphatic sac tumors, paragangliomas, meningiomas, schwannomas, and metastases (1). Endolymphatic sac tumors, which are aggressive papillary tumors arising in the temporal bone, are closely associated with von Hippel–Lindau disease (2). These tumors typically display both cystic and solid components with areas of intrinsic hyperintensity on T1-weighted magnetic resonance imaging (MRI), whereas calcifications are commonly seen on computed tomography (CT) imaging (3). Paragangliomas, including glomus jugulare, typically have a more permeative pattern of bone destruction and may display a classic salt-and-pepper appearance on T2-weighted images and typically lack areas of sclerosis (4). A 44-year-old woman was referred to the Head and Neck Surgery Clinic with a 2-month history of vertigo and mild subjective hearing loss in the left ear. In addition, she reported left aural fullness and a sensation of pressure in the left side of her head. Two years prior, she had been diagnosed as having stage IIA breast cancer treated with partial mastectomy, axillary lymph node dissection, and adjuvant chemotherapy with radiation. She was started on tamoxifen but stopped hormonal therapy because of adverse effects. Audiometry showed normal hearing on the right and a predominantly high-frequency sensorineural hearing loss on the left, with preservation of word discrimination. Vestibular testing, including electronystagmography, was within normal limits. CT and MRI revealed an enhancing osteolytic mass centered in the left jugular foramen with areas of sclerosis (Figs. 1, 2) that corresponded to a hypermetabolic focus in the left temporal bone on positron emission tomography.
FIG. 1. Axial CT, bone window reconstruction. A, Images at the level of the jugular bulb show irregular bone erosion at the lateral plate of the left jugular fossa (arrow) in the expected region of the mastoid canaliculus. Compare with the normal right side. B, A more inferior section at the level of the occipital condyles shows predominantly lytic bone erosion (short arrow) but with areas of sclerosis (long arrow).
The patient underwent a transmastoid biopsy of the left jugular foramen mass. After the endolymphatic system was exposed, a soft tissue mass was noted, and it appeared to wrap around the endolymphatic duct. The mass was extremely friable and vascular, and biopsies were taken. Histopathologic analysis revealed metastatic carcinoma, ER/PR positive, HER2/neu negative, consistent with breast metastasis with a hormonal profile identical to her prior breast malignancy. Postoperatively, the patient underwent radiation to the left temporal bone
FIG. 2. Axial MRI. A, T2-weighted image shows a homogeneous mildly hyperintense mass involving the jugular fossa (arrow). No internal flow voids are seen. B, T1-weighted image shows isointense signal. No intrinsically bright regions are evident. C, Postcontrast T1-weighted image shows intense uniform enhancement.
Address correspondence and reprint requests to Akira Ishiyama, Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, U.S.A.; E-mail: [email protected] The authors disclose no conflicts of interest.
e144
Copyright © 2015 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
BREAST CANCER PRESENTING AS A JUGULAR FORAMEN MASS at a dose of 2,000 cGy and has noted improvement in vertigo since. Although endolymphatic sac tumors may be the most memorable among destructive lesions affecting the posterior aspect of the temporal bone and the jugular foramen, metastases, particularly in patients with an antecedent history of malignancy, must always be considered. Carcinomas of the breast are the most common malignancy to metastasize to the temporal bone, usually affecting the petrous apex (5). Tissue diagnosis is paramount to diagnosis, and intraoperative pathologic consultation may guide the decision between complete surgical resection and adjunctive therapy.
e145
REFERENCES 1. Patel NP, Wiggins RH 3rd, Shelton C. The radiologic diagnosis of endolymphatic sac tumors. Laryngoscope 2006;116:40–6. 2. Megerian CA, McKenna MJ, Nuss RC, et al. Endolymphatic sac tumors: histopathologic confirmation, clinical characterization, and implication in von Hippel–Lindau disease. Laryngoscope 1995;105: 801–8. 3. Lo WW, Applegate LJ, Carberry JN, et al. Endolymphatic sac tumors: radiologic appearance. Radiology 1993;189:199–204. 4. Vogl TJ, Bisdas S. Differential diagnosis of jugular foramen lesions. Skull Base 2009;19:3–16. 5. Gloria-Cruz TI, Schachern PA, Paparella MM, et al. Metastases to temporal bones from primary nonsystemic malignant neoplasms. Arch Otolaryngol Head Neck Surg 2000;126:209–14.
Otology & Neurotology, Vol. 36, No. 9, 2015
Copyright © 2015 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
Imaging Case of the Month
Metastatic Breast Cancer Presenting as a Jugular Foramen Mass Kevin A. Peng, Nopawan Vorasubin, yAli R. Sepahdari, and Akira Ishiyama Departments of Head and Neck Surgery; and yRadiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, U.S.A.
The differential diagnosis for destructive lesions in the posterior temporal bone is broad and includes endolymphatic sac tumors, paragangliomas, meningiomas, schwannomas, and metastases (1). Endolymphatic sac tumors, which are aggressive papillary tumors arising in the temporal bone, are closely associated with von Hippel–Lindau disease (2). These tumors typically display both cystic and solid components with areas of intrinsic hyperintensity on T1-weighted magnetic resonance imaging (MRI), whereas calcifications are commonly seen on computed tomography (CT) imaging (3). Paragangliomas, including glomus jugulare, typically have a more permeative pattern of bone destruction and may display a classic salt-and-pepper appearance on T2-weighted images and typically lack areas of sclerosis (4). A 44-year-old woman was referred to the Head and Neck Surgery Clinic with a 2-month history of vertigo and mild subjective hearing loss in the left ear. In addition, she reported left aural fullness and a sensation of pressure in the left side of her head. Two years prior, she had been diagnosed as having stage IIA breast cancer treated with partial mastectomy, axillary lymph node dissection, and adjuvant chemotherapy with radiation. She was started on tamoxifen but stopped hormonal therapy because of adverse effects. Audiometry showed normal hearing on the right and a predominantly high-frequency sensorineural hearing loss on the left, with preservation of word discrimination. Vestibular testing, including electronystagmography, was within normal limits. CT and MRI revealed an enhancing osteolytic mass centered in the left jugular foramen with areas of sclerosis (Figs. 1, 2) that corresponded to a hypermetabolic focus in the left temporal bone on positron emission tomography.
FIG. 1. Axial CT, bone window reconstruction. A, Images at the level of the jugular bulb show irregular bone erosion at the lateral plate of the left jugular fossa (arrow) in the expected region of the mastoid canaliculus. Compare with the normal right side. B, A more inferior section at the level of the occipital condyles shows predominantly lytic bone erosion (short arrow) but with areas of sclerosis (long arrow).
The patient underwent a transmastoid biopsy of the left jugular foramen mass. After the endolymphatic system was exposed, a soft tissue mass was noted, and it appeared to wrap around the endolymphatic duct. The mass was extremely friable and vascular, and biopsies were taken. Histopathologic analysis revealed metastatic carcinoma, ER/PR positive, HER2/neu negative, consistent with breast metastasis with a hormonal profile identical to her prior breast malignancy. Postoperatively, the patient underwent radiation to the left temporal bone
FIG. 2. Axial MRI. A, T2-weighted image shows a homogeneous mildly hyperintense mass involving the jugular fossa (arrow). No internal flow voids are seen. B, T1-weighted image shows isointense signal. No intrinsically bright regions are evident. C, Postcontrast T1-weighted image shows intense uniform enhancement.
Address correspondence and reprint requests to Akira Ishiyama, Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, U.S.A.; E-mail: [email protected] The authors disclose no conflicts of interest.
e144
Copyright © 2015 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
BREAST CANCER PRESENTING AS A JUGULAR FORAMEN MASS at a dose of 2,000 cGy and has noted improvement in vertigo since. Although endolymphatic sac tumors may be the most memorable among destructive lesions affecting the posterior aspect of the temporal bone and the jugular foramen, metastases, particularly in patients with an antecedent history of malignancy, must always be considered. Carcinomas of the breast are the most common malignancy to metastasize to the temporal bone, usually affecting the petrous apex (5). Tissue diagnosis is paramount to diagnosis, and intraoperative pathologic consultation may guide the decision between complete surgical resection and adjunctive therapy.
e145
REFERENCES 1. Patel NP, Wiggins RH 3rd, Shelton C. The radiologic diagnosis of endolymphatic sac tumors. Laryngoscope 2006;116:40–6. 2. Megerian CA, McKenna MJ, Nuss RC, et al. Endolymphatic sac tumors: histopathologic confirmation, clinical characterization, and implication in von Hippel–Lindau disease. Laryngoscope 1995;105: 801–8. 3. Lo WW, Applegate LJ, Carberry JN, et al. Endolymphatic sac tumors: radiologic appearance. Radiology 1993;189:199–204. 4. Vogl TJ, Bisdas S. Differential diagnosis of jugular foramen lesions. Skull Base 2009;19:3–16. 5. Gloria-Cruz TI, Schachern PA, Paparella MM, et al. Metastases to temporal bones from primary nonsystemic malignant neoplasms. Arch Otolaryngol Head Neck Surg 2000;126:209–14.
Otology & Neurotology, Vol. 36, No. 9, 2015
Copyright © 2015 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
