Ann Otol Rhinal LaryngollOO:1991
IMAGING CASE STUDY OF THE MONTH
SPHENOID SINUS METASTASIS DISPLACING THE CAVERNOUS SINUS ANTONIO P. G. VIGLIOTTI, MD KENNETH
D.
JAMES
DOLAN, MD
A.
KENNEY, JR
B-CHEN WEN, MD IOWA CITY, IOWA
The following case is presented to illustrate the effect of a sphenoid sinus metastasis upon vision, oculomotor function, and the cavernous sinus.
and hypertrophic. Histologic study revealed poorly differentiated epidermoidal carcinoma similar to the sebaceous carcinoma removed from the eyelid. Radiotherapy of the lesion was then recommended. Follow-up 1 year later demonstrated no progression of symptoms.
CASE REPORT
The patient was a 70-year-old man who at the age of 3 had had a traumatic loss of the left eye. In mid-September 1988 he started seeing "weaving lines" on the temporal side of the right visual field with blurred vision. By the end of September, an ophthalmologist estimated his visual acuity as 20/100 and discovered a small mass in the inferior right eyelid. The ophthalmologist thought it was a chalazion and prescribed topical treatment. During the first week of October, the patient's vision progressively decreased and he became blind. He also had paralysis of all the external ocular muscles. On October 12, 1988, the small mass was removed. Unexpectedly, the pathology report described a "sebaceous carcinoma with epidermoid transdifferentiation." The patient was then referred to The University of Iowa Hospitals and Clinics.
RADIOGRAPHIC FINDINGS
An enhanced axial computed tomography (CT) examination of the head showed a right-sided parasphenoid mass with a low-density center and an enhanced margin (Fig lA). The superior orbital vein was normal in size. A bone window view of the same CT slice revealed complete opacity of the right sphenoid sinus (Fig IB). Both modalities showed a left ocular prosthesis. Direct coronal CT views of the sphenoid sinus were also obtained. A view in the plane of the midsella using a soft tissue window (Fig 2A) showed the right low-density parasellar mass. The mass displaced the cavernous sinus laterally and elevated the adjacent carotid artery. Another soft tissue window view made 8 mm posterior to the previous view showed elevation of the posterior clinoid process by the parasphenoid mass (Fig 2B). Complete opacity of the sphenoid sinus was present. A bone window view of this CT slice demonstrated erosion of the right lateral sphenoid sinus wall adjacent to the superior orbital fissure (Fig 2C).
At admission on October 17, 1988, he was found to be cachectic and dehydrated. The globe of the right eye was resistant to retropulsion. There was no chemosis, proptosis, or periorbital edema. The eyelid was drooping and the pupil was dilated to 6 mm and unreactive to light. The external ocular movements were only 50/0 to 100/0 in all directions. The fundus showed a pink disc with minimal or modest inferotemporal pallor. There was decreased sensation along the V-I distribution; V-2 and V-3 were intact, as were the other cranial nerves. The right eyelid was swollen and ulcerated, with yellowish fluid draining from it. The conjunctiva was injected. The rest of the findings on physical examination were unremarkable. A differential diagnosis of cavernous sinus thrombosis, lymphoma, Wegener's granulomatosis, mucormycosis, or aspergillosis was made.
DISCUSSION
Sebaceous gland carcinomas are rare tumors arising almost exclusively from the skin of the eyelids. The most common sites are the meibomian glands and the sebaceous glands of Zeis. Less often the site of origin is in the caruncle or the skin of the eyebrow. Clinically the lesion presents as a small hard nodule with a rubbery consistency like an atypical or recurrent chalazion. It shows a tendency to invade the overlying epithelium in a pagetoid manner, forming nests of cells that may completely replace the entire thickness of the epithelium (intraepithelial carcinoma), and clinically appears as a
On October 18, 1988, the patient underwent a right-sided sphenoidotomy and biopsy. Pus was not present in the cavity. The mucosa was thickened
From the Department of Radiology, The University of Iowa School of Medicine, Iowa City, Iowa. REPRINTS - Kenneth D. Dolan, MD, Dept of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242.
162
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163
Fig 1. Axial computed tomograms, A) Soft tissue window through lower sphenoid plane with enlargement of right cavernous sinus (arrow). B) Bone mode window through same plane showing opaque right sphenoid sinus and left ocular prosthesis.
diffuse plaquelike thickening. This tumor presents four histologic patterns: nodular, comedocarcinoma, papillary, and mixed. The tumor may also show various grades of differentiation, from well to poorly differentiated. The highest grade has a tendency to perineural invasion and invasion of the lymphatic channels. Rao et all reported on 104 patients with sebaceous gland carcinoma. In approximately 20 % of the patients, the orbit was directly invaded by tumar, and 23 % had enlarged nodes in the preauricular or cervical area. In some cases, the primary tumor was relatively small, with a very large preauricular node. The tumors may metastasize to the lungs, liver, brain, or skull. 1 Unfavorable prognostic factors are site of origin in the upper lid, a primary tumor greater than 10 mm in diameter, symptoms of more than 6 months' duration, an infiltrative growth pattern, and highgrade invasion of local structures, including the orbit, vessels, and lymphatic channels. Sphenoid sinus tumors are rare, as demonstrated by the paucity of information available in the literature. Primary carcinoma of the sinuses as well as metastatic carcinoma to the sinuses most often involves the maxilla, ethmoid sinus, sphenoid sinus, and frontal sinus, in descending order. 2 Sphenoid sinus tumors comprise fewer than 1 % of all sinus malignancies." Carcinomas of the sphenoid sinus may start in the sphenoid or represent extension from the ethmoid sinus, maxillary sinus, or nasopharynx." Carcinoma of the sphenoid sinus commonly penetrates the sella or lateral walls and roof of the sinus; therefore, the neurovascular structures
adjacent to the sphenoid sinus are at risk of damage by extramucosal extension. The abducens nerve is paralyzed more frequently than any other cranial nerves supplying the extraocular muscles. Although the sphenoid sinus has a low incidence of malignant disorder, it is the most commonly involved sinus when cranial neuropathy is present." Sinus carcinomas invade the cranial nerve perineural sheath. 6 This decreases the probability of surgical cure, but radiotherapy may arrest the progress of the lesion. Tumors of the head and neck can involve the cavernous sinus by destroying the basisphenoid or by extension through the foramina at the base of the skull by spreading along the blood vessels and spreading intracranially along the peripheral nerves.?" A pathologic cavernous sinus process produces incomplete or complete ophthalmoplegia that is usually painful and is commonly associated with deficits in the first or second division of the trigeminal nerve." The added finding of visual loss further localizes the lesion to the anterior cavernous sinus and orbital apex. Metastases to the sphenoid sinus commonly cause an acute, painful, rapidly progressive ophthalmoplegia. In patients with this symp.. tom the use of high-resolution CT is crucial to the diagnosis of cavernous sinus metastasis, since it can confirm the presence of a mass. to Computed tomography may reveal a change in size, density, or configuration indicative of cavernous sinus abnormality. Contour bulging is the most sensitive indicator of cavernous sinus disease. Contrast enhancement is essential for evaluation of the cavernous sinus. 1l · 12 Chung et al l3 emphasized the need for both axial and coronal CT projections in the study of the cavernous sinus.
Downloaded from aor.sagepub.com at UNIV WASHINGTON LIBRARIES on March 17, 2015
164
Vigliotti et al, Imaging Case Study of the Month
Fig 2. Coronal computed tomograms. A) Soft tissue window view through middle of sella turcica showing lateral bulge in cavernous sinus produced by large low-density mass (arrow). Internal carotid artery is elevated (arrowhead). B) Another view, 8 mm posterior to A, showing elevation of right posterior clinoid process (arrowhead). C) Anterior view, with use of bone mode, showing erosion through right lateral sphenoid sinus wall (long arrows) in superior orbital fissure area. Small erosion is present in floor of sphenoid sinus (short arrow).
Our patient represents a case in which an unusual sebaceous gland tumor spread from the lid area, presumably by a venous route, to the sphenoid sinus, where the tumor enlarged and eroded through the lateral sinus wall into the orbital apex. Oculomotor and ophthalmic nerve involvement produced
ophthalmoplegia and visual loss. The lesion also invaded the cavernous sinus, producing bulging, posterior clinoid elevation, and carotid artery displacement. The cavernous sinus was not completely obstructed, as evidenced by a lack of dilatation of the superior ophthalmic vein.
REFERENCES 1. Rao NA, Hidayat AA, McLean IW, Zimmerman LE. Sebaceous gland carcinoma of the ocular adnexa: a clinicopathologic study of 104 cases with five year follow-up data. Hum Pathol 1982;13:113-22.
2. Batson av. The function of the vertebral veins and their role in the spread of metastases. Ann Surg 1940;112:138-44. 3. Suen JY, Myers EN. Cancer of the head and neck. New York, NY: Churchill Livingstone, 1981:242-79. 4. Van Wart CA, Dedo HH, McCoy EG. Carcinoma of the sphenoid sinus. Ann Otol Rhinol Laryngol 1973;82:318-22.
5. Wesberger EC, Dedo HH. Cranial neuropathies in sinus disease. Laryngoscope 1977;87:357-63. 6. Calcaterra TC, Cherney EF, Hanafee WF. Normal variations in size and neoplastic changes of skull foramina. Laryngoscope ·1973;83:1385-97. 7. Del Regato JA, Spjut HJ. Cancer: diagnosis, treatment, and prognosis. 5th ed. St Louis, Mo: CV Mosby, 1977:53. 8. Dodd CD, Dolan PA, Ballantyne AI, Ibanez Me, Chau P. The dissemination of tumors of the head and neck via the cranial nerves. Radiol Clin North Am 1970;8:445-61.
Downloaded from aor.sagepub.com at UNIV WASHINGTON LIBRARIES on March 17, 2015
Vigliotti et al, Imaging Case Study of the Month 9. Thomas JE, Voss RE. The parasellar syndrome: problems in determining etiology. Mayo Clin Proc 1970;45:617-23. 10. Post MJ, Mendez DR, Kline LB, Acker JD, Glaser JS. Metastatic diseases to the cavernous sinus: clinical syndrome and CT diagnosis. J Comput Assist Tornogr 1985;9:115-20. 11. Kline LB, Acker ]D, Post M], Vitek J]. The cavernous sinus: a computed tomographic study. AJNR 1981;2:299-305.
165
12. Hasso AN, Pop PM, Thompson JR, et a1. High resolution thin section computed tomography of the cavernous sinus. Radiographies 1982;2:83-100. 13. Chung]W, Chang KH, Han MH, Kim BH, Son CS. Computed tomography of cavernous sinus diseases. Neuroradiology 1988;30:319-28.
FIRST INTERNATIONAL CONFERENCE ON ACOUSTIC NEUROMA The First International Conference on Acoustic Neuroma will be held Aug 25-29, 1991, in Copenhagen, Denmark. For further information, contact Copenhagen Acoustic Neuroma Conference, Secretariate, ENT Department, Gentofte University Hospital, DK-2900 Hellerup, Copenhagen, Denmark.
Downloaded from aor.sagepub.com at UNIV WASHINGTON LIBRARIES on March 17, 2015
IMAGING CASE STUDY OF THE MONTH
SPHENOID SINUS METASTASIS DISPLACING THE CAVERNOUS SINUS ANTONIO P. G. VIGLIOTTI, MD KENNETH
D.
JAMES
DOLAN, MD
A.
KENNEY, JR
B-CHEN WEN, MD IOWA CITY, IOWA
The following case is presented to illustrate the effect of a sphenoid sinus metastasis upon vision, oculomotor function, and the cavernous sinus.
and hypertrophic. Histologic study revealed poorly differentiated epidermoidal carcinoma similar to the sebaceous carcinoma removed from the eyelid. Radiotherapy of the lesion was then recommended. Follow-up 1 year later demonstrated no progression of symptoms.
CASE REPORT
The patient was a 70-year-old man who at the age of 3 had had a traumatic loss of the left eye. In mid-September 1988 he started seeing "weaving lines" on the temporal side of the right visual field with blurred vision. By the end of September, an ophthalmologist estimated his visual acuity as 20/100 and discovered a small mass in the inferior right eyelid. The ophthalmologist thought it was a chalazion and prescribed topical treatment. During the first week of October, the patient's vision progressively decreased and he became blind. He also had paralysis of all the external ocular muscles. On October 12, 1988, the small mass was removed. Unexpectedly, the pathology report described a "sebaceous carcinoma with epidermoid transdifferentiation." The patient was then referred to The University of Iowa Hospitals and Clinics.
RADIOGRAPHIC FINDINGS
An enhanced axial computed tomography (CT) examination of the head showed a right-sided parasphenoid mass with a low-density center and an enhanced margin (Fig lA). The superior orbital vein was normal in size. A bone window view of the same CT slice revealed complete opacity of the right sphenoid sinus (Fig IB). Both modalities showed a left ocular prosthesis. Direct coronal CT views of the sphenoid sinus were also obtained. A view in the plane of the midsella using a soft tissue window (Fig 2A) showed the right low-density parasellar mass. The mass displaced the cavernous sinus laterally and elevated the adjacent carotid artery. Another soft tissue window view made 8 mm posterior to the previous view showed elevation of the posterior clinoid process by the parasphenoid mass (Fig 2B). Complete opacity of the sphenoid sinus was present. A bone window view of this CT slice demonstrated erosion of the right lateral sphenoid sinus wall adjacent to the superior orbital fissure (Fig 2C).
At admission on October 17, 1988, he was found to be cachectic and dehydrated. The globe of the right eye was resistant to retropulsion. There was no chemosis, proptosis, or periorbital edema. The eyelid was drooping and the pupil was dilated to 6 mm and unreactive to light. The external ocular movements were only 50/0 to 100/0 in all directions. The fundus showed a pink disc with minimal or modest inferotemporal pallor. There was decreased sensation along the V-I distribution; V-2 and V-3 were intact, as were the other cranial nerves. The right eyelid was swollen and ulcerated, with yellowish fluid draining from it. The conjunctiva was injected. The rest of the findings on physical examination were unremarkable. A differential diagnosis of cavernous sinus thrombosis, lymphoma, Wegener's granulomatosis, mucormycosis, or aspergillosis was made.
DISCUSSION
Sebaceous gland carcinomas are rare tumors arising almost exclusively from the skin of the eyelids. The most common sites are the meibomian glands and the sebaceous glands of Zeis. Less often the site of origin is in the caruncle or the skin of the eyebrow. Clinically the lesion presents as a small hard nodule with a rubbery consistency like an atypical or recurrent chalazion. It shows a tendency to invade the overlying epithelium in a pagetoid manner, forming nests of cells that may completely replace the entire thickness of the epithelium (intraepithelial carcinoma), and clinically appears as a
On October 18, 1988, the patient underwent a right-sided sphenoidotomy and biopsy. Pus was not present in the cavity. The mucosa was thickened
From the Department of Radiology, The University of Iowa School of Medicine, Iowa City, Iowa. REPRINTS - Kenneth D. Dolan, MD, Dept of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242.
162
Downloaded from aor.sagepub.com at UNIV WASHINGTON LIBRARIES on March 17, 2015
Vigliotti et al, Imaging CaseStudy of the Month
163
Fig 1. Axial computed tomograms, A) Soft tissue window through lower sphenoid plane with enlargement of right cavernous sinus (arrow). B) Bone mode window through same plane showing opaque right sphenoid sinus and left ocular prosthesis.
diffuse plaquelike thickening. This tumor presents four histologic patterns: nodular, comedocarcinoma, papillary, and mixed. The tumor may also show various grades of differentiation, from well to poorly differentiated. The highest grade has a tendency to perineural invasion and invasion of the lymphatic channels. Rao et all reported on 104 patients with sebaceous gland carcinoma. In approximately 20 % of the patients, the orbit was directly invaded by tumar, and 23 % had enlarged nodes in the preauricular or cervical area. In some cases, the primary tumor was relatively small, with a very large preauricular node. The tumors may metastasize to the lungs, liver, brain, or skull. 1 Unfavorable prognostic factors are site of origin in the upper lid, a primary tumor greater than 10 mm in diameter, symptoms of more than 6 months' duration, an infiltrative growth pattern, and highgrade invasion of local structures, including the orbit, vessels, and lymphatic channels. Sphenoid sinus tumors are rare, as demonstrated by the paucity of information available in the literature. Primary carcinoma of the sinuses as well as metastatic carcinoma to the sinuses most often involves the maxilla, ethmoid sinus, sphenoid sinus, and frontal sinus, in descending order. 2 Sphenoid sinus tumors comprise fewer than 1 % of all sinus malignancies." Carcinomas of the sphenoid sinus may start in the sphenoid or represent extension from the ethmoid sinus, maxillary sinus, or nasopharynx." Carcinoma of the sphenoid sinus commonly penetrates the sella or lateral walls and roof of the sinus; therefore, the neurovascular structures
adjacent to the sphenoid sinus are at risk of damage by extramucosal extension. The abducens nerve is paralyzed more frequently than any other cranial nerves supplying the extraocular muscles. Although the sphenoid sinus has a low incidence of malignant disorder, it is the most commonly involved sinus when cranial neuropathy is present." Sinus carcinomas invade the cranial nerve perineural sheath. 6 This decreases the probability of surgical cure, but radiotherapy may arrest the progress of the lesion. Tumors of the head and neck can involve the cavernous sinus by destroying the basisphenoid or by extension through the foramina at the base of the skull by spreading along the blood vessels and spreading intracranially along the peripheral nerves.?" A pathologic cavernous sinus process produces incomplete or complete ophthalmoplegia that is usually painful and is commonly associated with deficits in the first or second division of the trigeminal nerve." The added finding of visual loss further localizes the lesion to the anterior cavernous sinus and orbital apex. Metastases to the sphenoid sinus commonly cause an acute, painful, rapidly progressive ophthalmoplegia. In patients with this symp.. tom the use of high-resolution CT is crucial to the diagnosis of cavernous sinus metastasis, since it can confirm the presence of a mass. to Computed tomography may reveal a change in size, density, or configuration indicative of cavernous sinus abnormality. Contour bulging is the most sensitive indicator of cavernous sinus disease. Contrast enhancement is essential for evaluation of the cavernous sinus. 1l · 12 Chung et al l3 emphasized the need for both axial and coronal CT projections in the study of the cavernous sinus.
Downloaded from aor.sagepub.com at UNIV WASHINGTON LIBRARIES on March 17, 2015
164
Vigliotti et al, Imaging Case Study of the Month
Fig 2. Coronal computed tomograms. A) Soft tissue window view through middle of sella turcica showing lateral bulge in cavernous sinus produced by large low-density mass (arrow). Internal carotid artery is elevated (arrowhead). B) Another view, 8 mm posterior to A, showing elevation of right posterior clinoid process (arrowhead). C) Anterior view, with use of bone mode, showing erosion through right lateral sphenoid sinus wall (long arrows) in superior orbital fissure area. Small erosion is present in floor of sphenoid sinus (short arrow).
Our patient represents a case in which an unusual sebaceous gland tumor spread from the lid area, presumably by a venous route, to the sphenoid sinus, where the tumor enlarged and eroded through the lateral sinus wall into the orbital apex. Oculomotor and ophthalmic nerve involvement produced
ophthalmoplegia and visual loss. The lesion also invaded the cavernous sinus, producing bulging, posterior clinoid elevation, and carotid artery displacement. The cavernous sinus was not completely obstructed, as evidenced by a lack of dilatation of the superior ophthalmic vein.
REFERENCES 1. Rao NA, Hidayat AA, McLean IW, Zimmerman LE. Sebaceous gland carcinoma of the ocular adnexa: a clinicopathologic study of 104 cases with five year follow-up data. Hum Pathol 1982;13:113-22.
2. Batson av. The function of the vertebral veins and their role in the spread of metastases. Ann Surg 1940;112:138-44. 3. Suen JY, Myers EN. Cancer of the head and neck. New York, NY: Churchill Livingstone, 1981:242-79. 4. Van Wart CA, Dedo HH, McCoy EG. Carcinoma of the sphenoid sinus. Ann Otol Rhinol Laryngol 1973;82:318-22.
5. Wesberger EC, Dedo HH. Cranial neuropathies in sinus disease. Laryngoscope 1977;87:357-63. 6. Calcaterra TC, Cherney EF, Hanafee WF. Normal variations in size and neoplastic changes of skull foramina. Laryngoscope ·1973;83:1385-97. 7. Del Regato JA, Spjut HJ. Cancer: diagnosis, treatment, and prognosis. 5th ed. St Louis, Mo: CV Mosby, 1977:53. 8. Dodd CD, Dolan PA, Ballantyne AI, Ibanez Me, Chau P. The dissemination of tumors of the head and neck via the cranial nerves. Radiol Clin North Am 1970;8:445-61.
Downloaded from aor.sagepub.com at UNIV WASHINGTON LIBRARIES on March 17, 2015
Vigliotti et al, Imaging Case Study of the Month 9. Thomas JE, Voss RE. The parasellar syndrome: problems in determining etiology. Mayo Clin Proc 1970;45:617-23. 10. Post MJ, Mendez DR, Kline LB, Acker JD, Glaser JS. Metastatic diseases to the cavernous sinus: clinical syndrome and CT diagnosis. J Comput Assist Tornogr 1985;9:115-20. 11. Kline LB, Acker ]D, Post M], Vitek J]. The cavernous sinus: a computed tomographic study. AJNR 1981;2:299-305.
165
12. Hasso AN, Pop PM, Thompson JR, et a1. High resolution thin section computed tomography of the cavernous sinus. Radiographies 1982;2:83-100. 13. Chung]W, Chang KH, Han MH, Kim BH, Son CS. Computed tomography of cavernous sinus diseases. Neuroradiology 1988;30:319-28.
FIRST INTERNATIONAL CONFERENCE ON ACOUSTIC NEUROMA The First International Conference on Acoustic Neuroma will be held Aug 25-29, 1991, in Copenhagen, Denmark. For further information, contact Copenhagen Acoustic Neuroma Conference, Secretariate, ENT Department, Gentofte University Hospital, DK-2900 Hellerup, Copenhagen, Denmark.
Downloaded from aor.sagepub.com at UNIV WASHINGTON LIBRARIES on March 17, 2015
