So… I’m doing my last couple weeks of internal medicine in medical school and, last night, I admitted a pretty interesting case that hasn’t turned out like I expected.

44 yo M c metastatic collecting duct carcinoma of the kidney p/w HA x 4wks and progressive double vision starting 1 week ago. Right-sided 8/10 frontal-temporal pounding HA all the time. HA not worse in AM. No N/V.

Prior MRI and CTs 5 weeks ago, show lytic bone lesions, presumed to be metaststic disease, in clivus (L>R) and petrous bone. Tumor surrounds carotid artery (not sure which side).  Tumor is confined to the skull and does not affect brain matter. Ten days ago, the patient had a normal neurological examination.

Afebrile in NAD. AAO3, FC, SF, Disconjugate gaze, PERRLA 4>2 BL, Vision 20/20 in both eyes (when closing the other one); No papilledema. Left eye EOMI, Rt eye lateral rectus palsy, Smile symmetric , hearing symmetric, uvula deviates to right , tongue deviates to left, shrug/SCMs full strength.  Strength intact throughout. Sensory grossly intact. Reflexes 2+ and symmetric throughout. No drift, dysmetria, clonus, hoffmans. Toes downgoing bl. No meningismus.

Typical ED admit labs are all WNLs. No leukocytosis. LP: normal glucose, protein, cell counts. Cytology wasn’t sent.

I admitted and got an MRI expecting to see extraaxial compression of CNs by tumor or mass effect. But there was no change noted in the MRI. No spread of tumor, no meningeal enhancement, no new mets, no restricted diffusion, nothing

Given the fact that you cannot see any scans, do your own interview/exam etc.....

What is the sensitivity for MRI for meningeal carcinomatosis around the skull base?
What arteries supply the cranial nerves and could this be 2/2 some vascular encroachment by cancer?
What do you think and what would you do next?

3 things come to mind:

1: As suggested by you, carcinomatosis. Would repeat LP and send cytology
2: You didn’t mention whether he had chemo/radiation but that can cause some toxicity
3: Check autoimmune antibodies (neurologists love that sh*t)

2 Cents - 13 March 2009 12:20 PM

3 things come to mind:

1: As suggested by you, carcinomatosis. Would repeat LP and send cytology
2: You didn’t mention whether he had chemo/radiation but that can cause some toxicity
3: Check autoimmune antibodies (neurologists love that sh*t)

I hope other people are doing what I’m doing, which is getting out of as much work as possible and showing up only enough to get ‘Pass’.

i’d call hospice.

Myempire1 - 13 March 2009 09:24 AM

What is the sensitivity for MRI for meningeal carcinomatosis around the skull base?
What arteries supply the cranial nerves and could this be 2/2 some vascular encroachment by cancer?
What do you think and what would you do next?

Sounds like perineural metastasis of V and VI on the R. Of course, there’s probably a lot more of it in there that is clinically silent.

I’ve done some MR imaging of tumors in preclinical models and I was really surprised at how insensitive it is for micromets. Part of it is resolution and part of it is lack of angiogenesis in micromets. The limit of detection for our 7 tesla research magnet was about 150 um. That is missing a lot considering that would be equivalent to around 15 cell layers thick of tumor cells covering the nerves. A clinical magnet is probably worse. This is also small enough that the cells probably have not yet induced appreciable angiogenesis and so would evade Gd enhancement.

Would guess primarily extra axial spread so initial LP results not surprising. I would deal with pain issues, order high res MR of the skull base/nerves to confirm, and, as Kenny states, an ominous prognosis so open the team dialogue to palliative chemo/radiation, experimental protocols, or hospice.

[With all the usual disclaimers of ‘net diagnosis by non-neurosurgeons...]

What was the opening pressure on the LP?

Feculence - 13 March 2009 05:50 PM

What was the opening pressure on the LP?

of course the ED docs didn’t record it. when I harassed them they said it was “normal” but couldn’t recall a #.

I think Colin Powel said it best....

Blackbird - 14 March 2009 11:28 AM

I think Colin Powel said it best....

Blackbird, you’ve made some meaningful contributions to UH, but that kind of reply really reflects poorly on all of us here at UH.

Yikes

i’ve seen stuff like this before...deficits will probably wax and wane for a few days, and you’ll never find anything on imaging. i’m seeing comfort care in this guy’s future

Blackbird - 14 March 2009 11:28 AM

I think Colin Powel said it best....

ddx:
- misplaced post
- reactive psychosis
- other brief psychotic disorder
- identity theft

P: Trial of seroquel, re-evaluate post-Thursday.

j/k

Get over your bad self.  That picture is hilarious.

My guess is that it’s all due to encroachment of the tumor on the right VIth, left IXth/Xth, and left XIIth cranial nerves.  All of those nerves are intimately associated with the skull base and could be involved without intra-axial spread.  The sixth nerve is vulnerable as it passes through Dorello’s canal, IX and X through the jugular foramen and twelve through the hypoglossal canal.  Obviously tough to say anything for certain without seeing images, but that seems much more likely to me than some other strange explanation.  I agree with Kenny, though - there’s nothing curative to be done at this point.

Assuming LP is negative. Imaging not conclusive. Is there a role for surgery - assuming the rest of mets is under good control and lifeexpectancy from onco specialist is more than 2 years ( biopsy of a nerve (CN?) twig ?). OPENING up the posterior fossa for a CN biopsy ? sounds barbaric, but any thoughts?

If this were the oral boards, biopsying a cranial nerve in this situation might not help you pass.  While it’s hard for surgeons to do, this might be one of those times to just sit back and watch what happens.