Journal of Otology & RhinologyISSN: 2324-8785

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Case Report, J Otol Rhinol Vol: 4 Issue: 5

Sphenoid wing Metastasis from Occult Prostatic Carcinoma

Mai Katto1,2*, Go Inokuchi2, Hisami Fujio2, Shingo Hasegawa2,Naoki Otsuki2 and Ken-ichi Nibu2
1Department of Otorhinolaryngology, Nishi-Kobe Medical Center, Kobe City,Hyogo, Japan
2Department of Otolaryngology-Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe City, Hyogo, Japan
Corresponding author : Mai Katto
Department of Otorhinolaryngology, Nishi-Kobe Medical Center, 5-7-1, Kouji-dai, Nishi-ku, Kobe City, Hyogo, 651-2273, Japan
Tel: +81-78-997-2200; Fax: + 81-78-997-2220
E-mail: [email protected]
Received: April 13, 2015 Accepted: July 17, 2015 Published: July 23, 2015
Citation: Katto M, Inokuchi G, Fujio H, Hasegawa S, Otsuki N, et al. (2015) Sphenoid wing Metastasis from Occult Prostatic Carcinoma. J Otol Rhinol 4:4. doi:10.4172/2324-8785.1000241

Abstract

Prostatic carcinoma commonly metastasizes to skeletal bone or vertebral bodies, forming osteosclerotic bone metastases, also it metastasizes to the head and neck region. This is the case of prostatic carcinoma presenting with an osteosclerotic metastasis to the sphenoid wing. A 64-year-old man complained of progressive left visual loss and exophthalmos. Computed tomography (CT) revealed a clear soft-density mass in the left sphenoid wing and fluorodeoxyglucose-positron emission tomography (FDG-PET) showed almost no uptake of FDG in this lesion. Biopsy from the sphenoid wing was obtained with the canine fossa approach. Pathological diagnosis was prostate adenocarcinoma. This case serves as a reminder that prostate carcinoma should be considered whenever osteosclerotic bone changes are observed on CT. FDGPET proved to be less sensitive than scintigraphy for the diagnosis of osteosclerotic metastasis from prostate carcinoma.

Keywords: Sphenoid wing; Prostate carcinoma; Bone metastasis; Visual loss

Keywords

Sphenoid wing; Prostate carcinoma; Bone metastasis; Visual loss

Introduction

Prostate carcinoma commonly metastases to skeletal bone or vertebral bodies [1], but rarely to the sphenoid wings. Since delayed diagnosis of sphenoid wing tumor can lead to severe functional disorders such as diplopia and visual loss [2], early diagnosis is essential to obtain favourable functional results. FDG-PET is commonly used for diagnosis of head and neck tumors including metastatic tumors. However, FDG-PET, unlike bone scintigraphy [3], is less useful for the diagnosis of metastatic prostate carcinoma since accumulation of FDG is not specific in the prostate carcinoma [1]. This paper describes the characteristics of imaging and symptoms of prostate carcinoma metastasis to the sphenoid wing.

Case Report

The patient was a 64-year-old man with a 7-month history of progressive left visual loss and exophthalmos was referred to the otolaryngology department. His left visual acuity got worse from 0.7 to blind in these 3 months. Computed tomography (CT) revealed a 38×39 mm soft-density mass lesion with a clear margin in the left sphenoid wing. The uniformly enhanced tumor protruded into the left orbit and maxillary sinus, and the bone of the sphenoid wing was thickened (Figure 1).
Figure 1: (A) Axial bone window CT image shows a 38×39 mm soft tissue mass on the left sphenoid wing; (B) The tumor is enhanced uniformly and the bone of the left sphenoid wing got was thicker than on the right side; (C) Part of the tumor has invaded the left maxillary sinus; (D) The tumor has decreased in size 3 months after the hormone therapy (*).
A fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed a slight increase in the uptake of FDG in the 10th thoracic vertebra and the left sciatic bone. However, almost no accumulation of FDG was observed in the left sphenoid wing mass (Figure 2) and, although FDG a slight uptake in FDG was observed in the left side of the prostate gland, it was so minor as to have initially been considered to be an artefact.
Figure 2: (A) Accumulation of FDG in the left extraocular muscle, but not in the tumor on the sphenoid wing; (B) Strong accumulation of FDG in the 10th and 11th thoracic vertebrae; (C) Slight uptake of FDG was observed in the left side of the prostate gland, which was initially thought to be an artefact; (D) Slight accumulation of FDG in the left sciatic bone. The maximum standardized uptake value (SUV) was 4.3.
To determine the pathological diagnosis of this lesion, the sphenoid mass protruding into the maxillary sinus was biopsied with the canine fossa approach. The pathological diagnosis was adenocarcinoma, and immunostaining for prostate-specific antigen (PSA) was positive (Figure 3), the diagnosis was modified to metastatic prostate adenocarcinoma. The serum PSA level was also significantly elevated to 1.310 μg/L. The urological work-up and prostate magnetic resonance imaging (MRI) eventually identified the primary prostate tumor. Bone scintigraphy revealed major accumulation in the left sphenoid bone, right occipital bone, left sciatic and 10th-11th thoracic vertebra. The patient was treated with anti-androgenic hormone therapy. The sphenoid mass decreased 6 weeks later (Figure 1D). 3 months later, the serum PSA level decreased to 14 μg/L. However, there was no recovery of the left visual loss. The patient has been alive for 15 months with stable disease.
Figure 3: (A) Accumulation of FDG in the left extraocular muscle, but not in the tumor on the sphenoid wing; (B) Strong accumulation of FDG in the 10th and 11th thoracic vertebrae; (C) Slight uptake of FDG was observed in the left side of the prostate gland, which was initially thought to be an artefact; (D) Slight accumulation of FDG in the left sciatic bone. The maximum standardized uptake value (SUV) was 4.3.

Discussion

A bone metastasis from a solid tumor to the sphenoid bone is relatively uncommon, but occasionally observed in clinical practice. According to previous reviews of sphenoid sinus metastasis [4,5], were lung cancer accounted for 19% (5/26) of the primary lesions and prostate carcinoma for 19% (5/26). While the sphenoid sinus and clivus are the sites of metastases owing to their relatively rich blood supply, sphenoid wing metastasis is rare. Differential diagnosis of the sphenoid wing mass should include both the primary and metastasis. Primary benign lesions located in the sphenoid wing are fibrous dysplasia, osteoma and meningioma, while malignant lesions are condrosarcoma and lymphoma [6-8]. Especially, metastasis of sphenoid wing may radiologically mimic a skull base meningiomas [9]. To date, only 7 metastatic cases to the sphenoid wing have been reported in the English literature: 3 hepatocellular carcinomas [2,10], 2 prostate carcinomas [9,11], 1 malignant fibrous tumor [6], and 1 thyroid carcinoma [12] (Table 1). While metastatic tumors are usually accompanied by destruction of the surrounding bone [2,6,10,12], the CT image of the case presented here was an round osteosclerotic mass with uniform enhancement (Figure 1A and B). 5 cases showed osteolytic bone metastases, and cases of prostate carcinoma showed osteosclerotic bone metastasis to the sphenoid wing.
Table 1: Cases of Sphenoid wing metastasis.
Bone metastasis has been classified into osteolytic, osteosclerotic, mixed and intertrabecular [13], and 60% of osteosclerotic metastasis has been ascribed to prostate carcinoma. Osteosclerotic changes are caused by an increased activity of osteoblasts, which is attributable to the local bone environment involving osteoblasts, osteoclasts and metastatic cancer cells [14]. Although the precise mechanisms of osteosclerotic bone metastasis remain unknown, Yasuda et al. have suggested that PSA and parathyroid hormone-related peptide (PTHrP) produced by prostate carcinoma may be involved [15]. PSA decomposes parathyroid hormone-related peptide (PTHrP) and activates growth factors [16]. While osteoblasts are stimulated by PTHrP in the early phase of metastasis, in the late phase, osteosclerotic changes occur due to the activation of growth factors [17].
FDG-PET seems to be ineffective for the diagnosis of osteosclerotic metastasis from prostate carcinoma as was found in our case. The reported increase in uptake of FDG associated with osteosclerotic change is only 15%, while the sensitivity is 38% for osteolytic changes [1]. On the other hand, reflecting the conventional bone scintigraphy, which shows bone metabolism, is more sensitive for detecting osteosclerotic metastasis of prostate carcinoma [3]. Our case serves as a reminder that the possibility of prostate carcinoma metastasis should be taken into consideration when we observe osteosclerotic changes on facial CT images. Serum PSA level measurement, urological examination and conventional bone scintigraphy proved to be useful in the case presented here. Physicians should therefore bear in mind the limitations of FDG-PET for the diagnosis of metastatic prostate carcinoma.

Conclusion

This is reported case of osteosclerotic metastasis to the sphenoid wing originating from prostate carcinoma. Prostate carcinoma should be taken into consideration whenever osteosclerotic bone changes are encountered. FDG-PET is less effective than scintigraphy for the diagnosis of osteosclerotic metastasis of prostate carcinoma.

References

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  15. Yasuda H, Shima N, Nakagawa N, Yamaguchi K, Kinosaki M, et al. (1998) Osteoclast differentiation factor is a ligand for osteoprotegerin/osteoclastogenesis-inhibitory factor and is identical to TRANCE/RANKL. Proc Natl Acad Sci USA 95:3597-3602.

  16. Killian CS, Corral DA, Kawinski E, Constantine RI (1993) Mitogenic response of osteoblast cells to prostate-specific antigen suggests an activation of cell adhesion receptors. Biochem Biophys Res Commun 192: 940-947.

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