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Case Report Prostate Cancer Metastatic Prostate Cancer Manifesting as Cavernous Sinus Syndrome—Case Report and Review of the Literature Brandon Kuiper, 1 Aline Babikian, 1 and Wilfred Delacruz 2 1. San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, US; 2. Hematology/Oncology Service, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, US C avernous sinus syndrome (CSS) is a rare clinical entity which results in compression of the neurovascular structures in the cavernous sinus, potentially leading to headache, ophthalmoplegia, and neuropathy. The most common causes are tumor, trauma, inflammation, aneurysm, and infection. We report the case of an 82-year-old male with osseous-predominant metastatic prostate cancer who was admitted for intractable right-sided periorbital pain and diplopia. He also developed a headache with associated mild ptosis and weak cranial nerve (CN) VI function. He later developed complete right eye ptosis, complete CN VI paralysis, and palsies of CNs III and IV. Magnetic resonance imaging (MRI) of the sella turcica confirmed a distinct enhancing lesion in the cavernous sinus and he was diagnosed with CSS as a result of bony metastasis from his prostate cancer. He was started on high-dose steroids, and underwent directed radiation therapy. Bone metastasis is common with prostate cancer with predilection for more proximal structures such as the iliac bones and lumbar spine. Cases of CSS stemming from metastatic prostate cancer are rare. Thus, the development of CN palsy and ophthalmoplegia along with orbital pain should trigger a thorough investigation of the etiology of CSS which should include primary malignancies and metastasis from more distant structures such as the prostate. Keywords Cavernous sinus syndrome, cranial nerve palsy, ophthalmoplegia, metastatic prostate cancer Disclosure: Brandon Kuiper, Aline Babikian, and Wilfred Delacruz have nothing to disclose in relation to this article. No funding was received for the publication of this article. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Compliance with Ethical Guidelines: All procedures were followed in accordance with the responsible committee on human experimentation and with the Helsinki Declaration of 1975 and subsequent revisions and informed consent was received from the patient involved in this case report. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: February 2, 2017 Accepted: April 25, 2017 Citation: Oncology & Hematology Review, 2017;13(1):59–63 Corresponding Author: Brandon Kuiper, Department of Internal Medicine, San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, 3551 Roger Brooke Drive, Ft. Sam Houston, TX 78234-6200, US. E: TOU CH MED ICA L MEDIA Cavernous sinus syndrome (CSS) is a rare clinical entity characterized by headache, ophthalmoplegia, and neuropathy due to compression of vascular and nerve bundles that course through a narrow anatomical region in the skull. 1,2 Myriad conditions lead to this syndrome including bacterial or fungal infection, thrombus, aneurysm, pituitary enlargement due to tumor or apoplexy, and primary or metastatic cancers. 1–3 Prostate cancer has predisposition for bone metastasis, and bone is the predominant site of metastasis; however, skull involvement is less common. Metastatic prostate cancer in the skull has been reported in 8–32% of patients after autopsy. 4,5 A retrospective review of bone scans of patients with metastatic prostate cancer shows skull involvement in 14% of all metastatic sites. 6 Bony metastasis causing CSS is rare. The exact incidence is unknown; although, several case reports of radiographically confirmed CSS due to metastatic prostate cancer have been published, and are summarized in Table 1. 7–22 CSS can cause excruciating pain and disconcerting cranial nerve (CN) deficits, so its specific cause should be emergently evaluated. We report the case of metastatic prostate cancer causing CSS and present a review of the literature regarding the diagnosis and treatment of this rarely encountered condition. Case summary An 82-year-old gentleman with a history of castrate-resistant metastatic prostate cancer presented to his oncologist for evaluation of worsening headache, mild ptosis, and diplopia. Three weeks earlier he underwent intramedullary rod placement in his femur to stabilize an impending pathologic fracture, with a hospital course complicated by postoperative atrial fibrillation, anemia requiring blood transfusion, and suspected hypertensive emergency. During the admission he complained of progressive right-sided retro-orbital pain, mild right eye ptosis, and increasing inability to abduct the right eye. Symptoms persisted despite improvement in blood pressures. He was evaluated by the Ophthalmology Department which attributed his symptoms to residual effects of the hypertensive emergency. The Neurology Department was also consulted and felt his symptoms were consistent with dural inflammation from known bony metastasis of the calvarium and skull base, though no definitive lesion occupying the cavernous sinus was detected on initial magnetic resonance imaging (MRI). A secondary consideration was Tolosa–Hunt syndrome, an ophthalmoplegia due to idiopathic granulomatous inflammation. 23 He was started on 60 mg of prednisone daily and discharged to undergo rehabilitation for his recent surgery. 59