A 78-year-old man with a history of benign prostatic hyperplasia had double vision for 7 weeks. He also had pain in the right side of the face, altered taste, headaches that were worse when he was lying down, and lower abdominal lymphadenopathy.
His clinicians, at Brigham and Women’s Hospital in Boston, Massachusetts, say neurological examination revealed palsies of the right V, VI, VII, and XII cranial nerves. Magnetic resonance imaging revealed a clival mass and multiple lesions in the vertebrae. Radionuclide studies showed extensive tumor burden in the patient’s liver and peritoneum.
Because it is the most common cause of clival metastases, the clinicians initially suspected prostate cancer was the source of the symptoms. Moreover, the patient’s prostate-specific antigen was modestly elevated, a finding the clinicians called a red herring. The patient was instead diagnosed with a clival tumor, which is extremely rare—and made even more rare due to upper gastrointestinal (GI), the clinicians say. Only 5 cases have been reported of upper GI malignancy with clival metastasis.
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The clivus is a bony structure located where the occipital and sphenoid bones meet, close to the long course of the abducens nerve. Double vision, caused by palsy at that nerve, is a prominent sign of a clival lesion, seen in > 40% of cases, the clinicians note. They suggest considering clival pathology as the cause of an abducens palsy or multiple cranial neuropathies.
The patient underwent several cycles of radiation therapy but ultimately decided on hospice care.
Source:
Lee C, Thon JM, Dhand A. BMJ Case Rep. 2017;2017: pii: bcr-2017-222725
doi: 10.1136/bcr-2017-222725.
