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Multiple cranial neuropathy as the initial presentation of metastatic prostate adenocarcinoma: case report and review of literature

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Acta Neurochirurgica Aims and scope

Abstract

The skull base is an atypical metastatic site for prostate carcinoma. It is usually encountered late in the disease process in patients with known advanced disease. However, skull base involvement causing cranial nerve palsies may rarely be the presenting sign of prostate carcinoma. Such patients may present to a number of specialties including neurosurgery and can pose a diagnostic challenge in the absence of lower urinary tract symptoms. Here, we describe an unusual case of prostate adenocarcinoma presenting as a central skull base tumour with multiple cranial neuropathy.

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Authors and Affiliations

  1. Department of Neurosurgery, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK

    Angelos G. Kolias, Christopher Derham, Harutomo Hasegawa, Roddy O’Kane & Nicholas I. Phillips

  2. Department of Neuroradiology, Leeds General Infirmary, Great George Street, Leeds, UK

    Kshitij Mankad

  3. Department of Neuropathology, Leeds General Infirmary, Great George Street, Leeds, UK

    Azzam Ismail

Authors
  1. Angelos G. Kolias
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  2. Christopher Derham
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  3. Kshitij Mankad
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  4. Harutomo Hasegawa
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  5. Roddy O’Kane
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  6. Azzam Ismail
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  7. Nicholas I. Phillips
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Correspondence to Angelos G. Kolias.

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Comments

The authors report on a rare case of a central skull base metastatic prostate carcinoma presenting with progressive multiple unilateral cranial neuropathy as an initial presentation of the disease.

Such patients have longer survival than patients with advanced disease and late intracranial extension. This tumour mimics meningioma and may be extremely large on initial presentation with only minor morbidity. Metastatic prostate cancer should be considered in the differential diagnosis of males > 50 yrs old who present with atypical clinical and radiological features of meningioma. Differential diagnosis goes also toward bone invasive nonsecretory pituitary adenomas, prolactinomas, chordomas and chondrosarcomas. However, the direction and the rate of tumour growth can influence time appearance of maior problems, quality of life and total survival time.

Despite the fact, that metastatic prostate carcinoma has available many non-surgical treatment modalities, the role of modern neurosurgery is not always solely directed toward biopsy (transnasal or opened, navigated or not), but also to palliative surgeries in certain situations where impending neurological deficit can be prevented or temporarely stopped in patient with favourable Gleason and Karnofsky scores.

The natural history in general is characterised by progressive tumour growth, with eventual compression of adjacent structures. The present tumour was favourably centred around the clivus and extended toward paranasal sinuses. The relation of the tumour to the brainstem soon becomes most critical (compression and displacement) after hormonal therapy, chemotherapy and radiation were given. Large middle fossa mass may result in depressed or altered consciousness. Exophthalmus and visual deterioration can result from orbital invasion. Optic nerve can be released by unroofing of the optic canal, removing the anterior clinoid and cutting the dura propria as a part of pterional approach. Epidural phase of pterional approach can expose and externaly decompress the trigeminal ganglia, enables reduction of the middle fossa mass and secondary trigeminal pain can be alleviated by resection of Meckel's cave dura, transpetrous approach through Kawase's triangle can enable removal of some posterior fossa mass. Namely, these tumours are softer and less bloody and the removal can be aided by ultrasonic aspirator.

The role of palliative neurosurgery depends mainly on patient's general somatic condition and the amount of the total therapy already given, but also on neurosurgical expertise given acceptable safety in this delicate location to fulfil the criterium Primum nil nocere.

Roman Bošnjak,

University of Ljubljana, Slovenia

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Kolias, A.G., Derham, C., Mankad, K. et al. Multiple cranial neuropathy as the initial presentation of metastatic prostate adenocarcinoma: case report and review of literature. Acta Neurochir 152, 1251–1255 (2010). https://doi.org/10.1007/s00701-010-0630-9

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  • DOI: https://doi.org/10.1007/s00701-010-0630-9

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