Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 4, 2010, pp. 666-668

Neurology India, Vol. 58, No. 4, July-August, 2010, pp. 666-668

Letter To Editor

Occipital condyle syndrome as a rare metastatic presentation of small cell lung carcinoma

Bahl Ankur, Suresh P, Talwar Vineet, Doval DC

Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi- 110085

Correspondence Address:Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi- 110085, drankurbahl@gmail.com

Date of Acceptance: 02-Jul-2009

Code Number: ni10177

PMID: 20739821

DOI: 10.4103/0028-3886.68686

Sir,

Occipital condyle syndrome (OCS) is a rare clinical syndrome and consists of unilateral occipital region pain associated with same side hypoglossal nerve palsy and most commonly occurs due to the skull base metastasis. ^[1] Metastatic diseases to the occipital condyle have been reported rarely. Till now only two cases of lung carcinoma (one small cell lung carcinoma and other squamous cell carcinoma) causing OCS have been. ^[2]

This 63-year-old man, a known diabetic and hypertensive, presented with complaints of severe constant pain in left occipital area, radiating over the head since one month. There was history of heaviness of the tongue with difficulty in eating and radiating pain down the spine on coughing. Clinically there was wasting of the left half of the tongue with deviation to the same side with no evidence of any other cranial nerve palsy. There was evidence of diabetic neuropathy.

Biochemical and hematological investigations were normal. Serum ionized calcium and alkaline phosphatase were raised (1.7 mmol/l and 700 U/L, respectively). Contrast enhanced computed tomography (CECT) head was suggestive of metastatic lesion involving the skull and the scalp tissue. Magnetic Resonance imaging (MRI) head revealed enhancing soft tissue lesions in skull vault (calvarium) in left parietal region posteriorly with destruction of linear table, focal thickening of underlying dura, enhancing soft tissue mass in left jugular fossa infiltrating CP angle cistern, and lacunar infarct in right basal ganglia. MRI spine showed enhancing soft tissue mass lesion at C1 level, left occipital condyle, adjoining part of occipital bone and collapse of D8 vertebra [Figure - 1]. Left parietal craniotomy was done and per operative finding revealed involvement of extra calvarial soft tissue, bone in the form of osteolysis and invasion of dura by the tumor. Histopathology report of the excised tissue was suggestive of small to medium sized malignant cuboidal cells with ovoid hyperchromatic nuclei suggestive of small cell carcinoma [Figure - 2]. Immunohistocytochemistry (IHC) revealed CK, CD 56 and synaptophysin as positive while TTF-1 and chromogranin were negative. Technetium methylidene diphosphonate (Tc-99 MDP) bone scan showed increased uptake in collapsed D8 vertebra and in right sacro-iliac joint. CECT chest was done to find out the primary lesion which revealed soft tissue mass in right upper lobe with bilateral enlarged mediastinal lymph nodes in pre, para tracheal, pre carinal, AP window, and pre vascular regions. CT-guided fine needle aspiration cytology (FNAC) of the lung was suggestive of small cell carcinoma. Liver showed multiple hypodense lesions in both lobes on CECT abdomen.

He was managed as SCLC extensive stage with osseous, hepatic metastasis. He was given iv bisphosphonates and palliative radiation to the occiput and cervical spine. On completion of involved field radiotherapy (IFRT), he was started on carboplatin and etoposide-based palliative chemotherapy.

Like all bones, skull is a common site of metastasis from systemic cancers. Skull base metastasis from distant tumors occurs in 4% of all the cancer patients. ^[3] The two most causes of skull metastasis are breast and prostate cancer accounting for 40% and 12% of the cases. ^[3] In one case series prostate cancer was the most common cause of skull metastasis in men while breast cancer was leading cause in women. ^[4] However, dissemination to the skull base may occur in many other cancers. ^[1],[5],[6] OCS is rare and is usually associated with skull base metastasis and often underdiagnosed. Till date only two case reports of lung malignancy (one squamous cell carcinoma and other small cell carcinoma) with skull metastasis causing OCS have been reported. ^[2] In almost all the patients, headache preceded the tongue paresis often by days to weeks as in our patient. ^[7] As with our patient, diagnosing the underlying cause of OCS can be challenging as our patient was only symptomatic for OCS and there were no sign and symptoms suggestive of underlying lung malignancy.

References

Copyright 2010 - Neurology India

The following images related to this document are available:

Photo images