Download Rare Metastatic Lesions of the Internal Auditory Canal

RareMetastaCcLesionsoftheInternalAuditoryCanal
RichardJ.Wiet,MD1,2;RobertA.Balsta,MD1,2;R.MarkWiet,MD3;
RichardByrne,MD4;ArnoldRivera,MD5;JennaLiole,BS1
1EarIns>tuteofChicago,2Northwestern
University Feinberg School of Medicine –Dept. of Otolaryngology,
3 Rush University Medical Center – Dept. of Otorhinolaryngology, 4 Rush University Medical Center – Dept. Neurosurgery,
5 University of Missouri –Dept. of Otolaryngology Abstract
Thegoalofthisstudyistoelucidatethekeydifferencesbetweenthemore
commonves>bularschwannoma(VS)oftheinternalauditorycanal(IAC),andthe
raremetasta>clesiontotheIAC.
Studydesign:Retrospec>vecaseseries
Selng:Ter>aryreferralcenter
Methods:History,histology,audiogram,MRIscans,cerebrospinalfluid(CSF)
cytologywereviewedofpa>entswhohadmetasta>clesionstotheIAC.
Dis>nguishingpaoernsofthemetasta>ccasestotheIACwereanalyzed.
Results:Eachpa>enthadahistoryofpriormalignancy.Themostfrequent
metastasescamefromthebreast-threeoftheseventotalcases.Otherprimary
malignanciesoriginatedfromtheparo>d,gastric,andthecolon.Theprimary
malignancyloca>onforonecasecouldnotbeiden>fied.Allsevenpa>ents
complainedofsomedegreeofhearingloss,fiveaccompaniedwithdizziness,and
threewithfacialparesis.Fourpa>entshadbilateralneoplasmswithintheIAC.
LeptomeningealcarcinomatosiswasfoundintwoCSFsamples.Avariedformof
adenocarcinomawasiden>fiedinthreemetastasesfollowedbyinfiltra>ng
lobularcarcinomapleomorphicvariant;invasive,andhighgradeductal
carcinoma;andmoderatelydifferen>atedsquamouscellcarcinoma.Thedura>on
betweendiagnosisofmetastasistotheIAC,andiden>fica>onoftheprimarysite
rangedfrom24to48months.
Conclusion:Metasta>cdiseasetotheIAC/CPangleshouldbesuspectedincases
withsuddenhearingloss,ageexceeding55years,facialnerveneuropathy,anda
historyofpriormalignancy.CSFcytologyshouldbeconsideredasadiagnos>ctool
incasessuspectedofmetasta>cdisease.
IntroducCon
Refinementsinneuroradiologyhavecontributedtothediagnosisofmoresubtle
internalauditorycanal(IAC)lesionsthroughmagne>cresonanceimaging(MRI).
Subtlelesionsmaybedifficulttodifferen>atebetweenthemorecommon
ves>bularschwannomaandametasta>clesion.Apasthistoryofaprior
malignancy,e.g.,lungcarcinomaorbreast,mandatesconsidera>onformetastasis
totheIACfromadistantsite.Metastasiscanoccurbytheseedingofmalignant
cellsintotheleptomeningesfromasolidtumor.Metastasismaypresentwithor
withoutanaccompaniedcranialnerveneuropathysuchasfacialparesis.
Ves>bularschwannomaandmetasta>clesionstotheIACmayappearnearly
iden>caloninfusedMRI.Therehavebeenfewmetasta>cIACcasesreportedin
theliterature.Itissuspectedthattheactualincidencemaybeunderes>mated.
Theobjec>veofthisstudyistoelucidatefactorssuppor>ngthesuspicionofa
metasta>ctumortotheIAC.
MethodsandMaterials
SevencasesofmetastasistotheIACwereobtainedfromEarIns>tuteofChicago
(EIC),fromRushUniversityMedicalCenterandfromtheU.ofMissouri.An
addi>onalcasewassubmioedbyA.Rivera,formerfellowofEIC.Caseswere
monitoredoveranumberofmonths.
Results
Please,refertothetablebelow.Primaryistheoriginalmalignantsite,andthe
metasta>csideistheloca>onofthetumorwithintheleAorrightIAC/CPA.
“None”underCSFcytologydenotesatestwasnotperformedordisclosed.“NA”
indicatesnotavailablefromtherecord.
Case Age Sex Primary
Discussion
MetastasistotheIACfromadistantsiteistypicallyknownasleptomeningeal
carcinomatosis.Metasta>cseedingoftheleptomeningesoccursbyhematogenousspread,
ordissemina>onthroughveinsorlympha>cs.Themostfrequentprimarysitesof
malignancythatmetastasizetotheIACarethelungs,followedbythebreast,andGItract.1
Malignantreportablecasesnumberinthelowhundredsmakingdetec>ondifficult.Similar
configura>onsbetweenmetasta>clesionsandVS,ongadoliniumenhancedMRIoftheIAC,
haveledtorecommenda>onsforhighresolu>onMRI,wheresegmentsofthecranialnerves
maybethickened.2Proteininthesubarachnoidspacefromfluidaoenuatedinversion
techniquescanalsosuggestmetasta>cdisease.3Perfusionweightedimaging(PWI)MRI,
withlowperfusionparametersraisethesuspicionofmetasta>cfocus.4PET/CTscansare
notaccurateatthebaseoftheskull.BilateralIACmetastases,asseenwithcases3,4,5and
6,canoAenbeconfusedwithNeurofibromatosisII,especiallyinyoungpa>ents.
Lumbarpuncturemayassistindiagnosis,ascytologymaybeposi>veformalignantcells.
However,20-50%ofpa>entswithleptomeningealcarcinomatosismayhavenega>ve
cytology(asincase6).ElevatedlymphocyteandproteininCSFareconsistentbutnot
diagnos>cofmetastasis.Recently,CSFbiomarkersaidinreducingtheamountof
malignancyneededforaposi>vereading.Forexample,CSFanalysiswithcarcinoembryonic
an>gen(CEA)canbeusedasabiochemicalmarkerwhensuspiciousofadenocarcinoma.5
Neweremphasisisplacedoncancergenomics,classifyingtheDNAofeachlesiontotailor
treatmentsanddefinethemechanismofbrainmetastasis.6
Generally,metastasistotheIACoccursinolderindividualswithahistoryofcancer.Fiveof
ourcaseswereolderthan50.7Cranialnerve7deficitisafrequentsignofleptomeningeal
carcinomatosisoftheIAC;threeofourcasespresentedwithfacialweakness.Rapid
unilateralorbilateralhearinglosswasthemosttypicalcomplaintinourcaseseries.Sudden
orrapidlyprogressivehearinglossistypicallythefirstsign,andfacialnervepalsy,whichis
lesscommon,canoAensuggestmalignancy.8Inourcases,allpa>entswiththeexcep>onof
1,diedwithin12monthsaAerdiagnosis.
Figure1.
Case3:MetastaCc
breastcarcinoma
infiltraCngmiddleear
andpermeaCng
ganglion(1031k)
MRIfromcase4witharrowsindicaCngmetastaCc
diseasebilaterallytotheIACs
Figure2.
Case3:NeoplasCccells
areposiCvefor
cytokeraCn(x200)
ImagesprovidedbyPaoloGaouso,MD,RushUniversityPathology
Figure1:1031k,Figure2:855k
Conclusions
IndividualswithIACmetasta>cdiseasetypicallyhaveapasthistoryofaprimarymalignancy
elsewhere.Whenpresentedwithsuchacase,theclinicianshouldbesuspiciousof
malignancyespeciallywhenthereisasuddendropinhearingwithassociatedwithfacial
neuropathyinanolderindividual.ThetreatmentforIACmetastasiscanvary,butgenerally
radiotherapyandchemotherapyispreferred.Surgeryisretainedforyoungerindividuals
withasinglelesionsymptoma>cfromseverever>go,orrequiredforofficialdiagnosisand
treatmentmodality.Thesurvivalofpa>entsdiagnosedwithIACmetastasesisoAena
maoerofmonths.
MetastaCc ENTSymptoms
(Side)
CSFCytology
Approximate
monthsbetween
MetastaCc&
Primaryfinding
Approximate
Histology
monthsbetween
Metastasis&
Death
1
59
M
Paro>d
IAC(R)
Dizziness,hearingloss
None
24
19
Highgradeductalcarcinoma
2
74
M
Unknown
IAC(L)
Dizziness,hearingloss,facialweakness
None
48
8
Moderatelydifferen>atedsquamouscell
carcinoma
3
41
F
Breast
IAC(B)
Dizziness,earfullness,headaches,bilateral>nnitus,hearingloss
Posi>ve(metasta>cbreast
carcinoma)
28
5
Adenocarcinomamammarytype
4
68
F
Colon
IAC(B)
Dizziness,facialweakness,suddenhearingloss
Posi>ve(Probable
Malignancy)
NA
1
Colonadenocarcinoma.
5
50
M
Gastric
IAC(B)
Dizziness,facialweakness,bilateralsuddenhearingloss,bilateral>nnitus None
NA
0.5
Adenocarcinoma
6
59
F
Breast
IAC(B)
Dizziness,hearingloss,seizures
Nega>ve
30
Aliveasof2011
Lobularcarcinomapleomorphicvariant
7
33
F
Breast
IAC/CPA(R)
HearingLoss,Intermioenthoarsenessanddysphasia
None
24
Aliveasof2015
InvasiveDuctalcarcinoma
References
Contact
RichardJ.Wiet,MD
11SaltCreekLn.Ste.101
HinsdaleIL,60521
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