Third Nerve Palsy as the Initial Presenting Sign of Metastatic Prostate Cancer

Abstract

A 73-year-old male came to our institution with a history of right ptosis and intermittent double vision of 1 week's duration. He had been diagnosed with diabetes mellitus 5 years earlier and had chronic smoking and alcohol abuse history. Physical examination revealed right ptosis and outward ocular deviation with no evidence of pupillary asymmetry. There were no others abnormal findings on neurologic examination. With these finding, a third nerve palsy caused by an ischemic lesion of the nerve because of diabetes was suspected. Emergent computed tomography (CT) of the head revealed cortical-subcortical atrophy and no ischemic lesions. A cranial magnetic resonance showed a mass with a soft tissue component invading the right cavernous sinus. The mass displace the carotide and the intraselar structures (Figs. 1 and 2). With these results, a tumoral disease was suspected and for thus extensive systemic workup was initiated. Chest X-ray, routine blood values, and urinalysis results were normal. The serum PSA level was elevated (1000 ng/mL). Abdomen and chest CT detected hepatic and bone metastases. Findings on bone scintigraphy were compatible with extensive diffuse metastases throughout the skeleton, including the cranial lesion. Prostatic FNAB was indicated based on these findings, the result of which was prostatic adenocarcinoma (Fig. 3). Hormone therapy treatment was initiated with LH-RH agonist and Flutamide followed by Bifosfonates.Prostate carcinoma can metastasize to any organ especially bone but cranial nerve palsies secondary to metastatic prostate to the base of the skull are uncommon situations, most of them presented several years after the diagnosed is made. 1 The cause of the neuropathy is the direct compression of nerves by tumor in this strategic location. The involvement of the cavernous sinus area by malignant neoplasm may occur generally through local extension of a nearby locally advanced primary head and neck tumor or more rarely, through hematogenus spread of tumors located outside including breast and prostate cancer. 2 In most of the previous reports the cranial nerve palsy appears in the context of a widespread metastatic prostate disease diagnosed several years before. 3 The initial diagnosed is usually established by magnetic resonance images. 3 Treatment of skull metastases depends largely of patient symptoms as well as the radiologic findings. Two therapeutic approaches can be performed: systemic treatment with hormonal therapy; and a local therapy with surgery or radiotherapy. It has been reported that hormone therapy treatment can decrease the mass and improve the symptoms. 4 Radiation therapy often is performed in an attempt to palliate symptoms and surgery is occasionally necessary. 3 In conclusion, we describe an uncommon presentation of a metastatic prostate cancer. It should be mention that as more effective therapy for advanced prostate cancer becomes available and patients live longer, skull metastases can be expected to be encountered more frequently. Clinicians caring for pat...

Isolated Oculomotor Nerve Palsy Due to Metastasis of Prostatic Cancer to the Cavernous Sinus

“…Metastatic tumour of prostatic cancer was detected in the vicinity of the cavernous sinus in all six reported cases. [1][2][3][4][5][6] In our patient, based on cranial MRI finding, metastatic tumour in the cavernous sinus might invade through the superior orbital fissure to the orbital apex and along to the orbital lateral wall. Therefore, because metastatic tumour might stimulate the lacrimal nerve on the right side, and right-sided persistent ocular pain developed.…”

“…As a result, among these six reported cases, [1][2][3][4][5][6] pupillary impairment was detected in one case, 3 and pupil was spared in one case. 4 However, in four cases, 1,2,5,6 pupillary finding was not noted. Although headache developed in two cases, 3,6 there were no reported cases of ocular pain.…”

“…[1][2][3][4][5][6] In 1988, Svare et al 1 noted a first reported case of isolated unilateral oculomotor nerve palsy secondary to prostatic cancer. Detailed finding of oculomotor nerve palsy and accompanied symptoms were not described.…”

“…Cranial MRI demonstrated a massive lesion arising from the left-sided aspect of the pituitary gland extending laterally into the left-sided cavernous sinus. Navarro et al 4 described a case of isolated rightsided oculomotor nerve palsy without pupillary involvement as an initial manifestation of prostatic cancer. Whether there was headache or not was not noted.…”

Diplopia and Ptosis: An Unusual Case of Prostate Cancer Metastasis to the Sphenoid Bone Treated With Palliative Radiotherapy

“…Two previous case reports have reported oculomotor nerve palsies as the presenting symptom of prostate cancer, but neither describes adenocarcinoma histology or the use of palliative radiotherapy [ 7 , 8 ]. Among 27 previously diagnosed prostate cancer patients who received bone scintigraphy, only 1 (3.1%) had skull metastasis [ 9 ].…”