Dr. Hines of University of Kentucky Medical Center has no relevant financial relationships to disclose.)
Dr. Villano of University of Kentucky Medical Center has no relevant financial relationships to disclose.)
Dr. Lukas of Northwestern University Feinberg School of Medicine received honorariums from AbbVie as a guest speaker, from NewLink Genetics and Reneuron for consulting work, and from Monetris as an advisory board member.)
This article includes discussion of calvarial, skull base, dural, and nasopharyngeal metastases; calvarial and skull base metastases; bone metastases; and skull metastases. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
This article describes the clinical manifestations, epidemiology, diagnosis, and management of calvarial and skull base metastatic lesions. It also discusses various skull base syndromes and provides examples. The authors add information about the role of stereotactic radiotherapy and roles for surgical intervention in skull base metastases.
• Several skull base syndromes have been described that are uncommon and require a high index of suspicion.
• Lung, breast, prostate, multiple myeloma and solitary plasmacytoma, and head/neck cancer account for most of the cases of skull metastases.
• Radiation therapy remains the mainstay of palliative care in most patients.
Historical note and terminology
The calvarium is composed of the bones forming the convexity of the skull, periosteum, and soft tissue coverings. It consists of parts of the frontal, parietal, temporal, and occipital bones. The calvarial bone consists of inner and outer tables that enclose bone marrow containing diploë (the spongy trabecular bone of the cortical bone of the skull) in between. The skull base separates the brain from the neck, orbit, and sinuses below. It is composed of the frontal bone, the ethmoid bone, the greater and lesser wings of the sphenoid bone, the temporal bone, and the body of the sphenoid and basilar part of the occipital bone (that constitutes the clivus). The skull base is divided into the anterior, middle, and posterior cranial fossa. The roof of the orbit and the cribriform plate form the anterior fossa. The middle fossa consists of body and wings of sphenoid bone and squamous part of the temporal bone and includes the contents of the sella turcica and cavernous sinus. The posterior fossa is composed of clivus, occipital bones, and petrous parts of the temporal bone. The posterior fossa is the deepest and largest of all cranial fossa (Netter 2011; Chamoun et al 2012).
Both the calvarium and skull base can be affected by a variety of benign, tumor-like, and malignant processes. Autopsy series reveal relatively high incidence up to 3% of temporal bone metastases, and other studies have reported 22.2% to 24% incidence of patients with known history of cancer (Chamoun et al 2012).
|Image: Poorly differentiated carcinoma from an unknown primary presenting with occipital condyle syndrome (|
|Image: Solitary lung cancer metastasis to the sphenoid bone with secondary extension into the local dura (C|
|Image: Breast cancer metastatic to the sphenoid and ethmoid bones with direct extension into the orbital ap|
Metastatic tumors to the orbit were first described by Horner in 1864 (Goldberg et al 1990). Orbital metastases occur in up to 2% to 3% of patients with cancer, and multiple case reports have appeared in the last few decades (Eckardt et al 2011; Li et al 2011).
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