Distant metastasis of hepatocellular carcinoma to Meckel’s cave and cranial nerves: A case report and review of literature

Introduction Large and even moderate sized, extra-axial cerebellopontine angle (CPA) tumors may fill this restricted space and distort the regional anatomy. It may be difficult to determine even with high resolution magnetic resonance imaging (MRI) if the tumor is dural-based, or what the nerve of origin is if a schwannoma. While clinical history and exam are helpful, they are not unequivocal, particularly since many patients present with a myriad of symptoms, or conversely an incidental finding. We present an atypical appearing, asymptomatic CPA tumor, ultimately identified at surgery to be a trigeminal schwannoma. Case History A 40-year-old man presented with new-onset seizure. MRI identified an incidental heterogeneously contrast-enhancing CPA lesion (Fig. 1A–D). The tumor was centered on the internal auditory canal (IAC) with no tumor extension into Meckel's cave, IAC or jugular foramen. Audiometry demonstrated 10db of relative left-sided hearing loss with 100% word recognition. Physical examination was negative for focal neurologic deficits. A retrosigmoid craniotomy was performed and an extra-axial, yellow-hued mass was encountered and resected, which was ultimately confirmed to originate from the trigeminal nerve (Video 1). Gross total resection was achieved, and the patient recovered from surgery with partial ipsilateral trigeminal sensory loss and no other new neurologic deficits. Conclusion Pure CPA trigeminal schwannomas are rare, but should be considered in the differential for enhancing CPA lesions. Although, Meckel's cave involvement is frequently observed, it is not universal, and pure CPA schwannomas of all cranial nerves IV–XII have been reported in the literature.The link to the video can be found at: https://youtu.be/AlodYCu70F8.

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Unusual presentation of hepatocellular carcinoma: Case report and review of literature

BJR|case reports ◽

10.1259/bjrcr.20210033 ◽

2021 ◽

pp. 20210033

Author(s):

Poonamjeet Loyal ◽

Samuel Gitau ◽

Soraiya Manji ◽

Sitna Mwanzi ◽

John Weru

Keyword(s):

Hepatocellular Carcinoma ◽

Chronic Hepatitis ◽

Case Report ◽

Rare Case ◽

Anterior Abdominal Wall ◽

Atypical Presentation ◽

Primary Cancer ◽

Review Of Literature ◽

Diagnostic Challenge ◽

Positive Chronic Hepatitis

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver and a major cause of mortality globally. Atypical presentation of HCC can present a diagnostic challenge. We, therefore, present a rare case of hepatocellular carcinoma fungating through the anterior abdominal wall with concomitant lung and brain metastases in a young patient with non-cirrhotic liver but positive chronic hepatitis B serology.

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Microsurgical Resection of a Petroclival Epidermoid Cyst Using an Anterior Petrosectomy Approach: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab364 ◽

2021 ◽

Author(s):

Kunal V Vakharia ◽

Ryan M Naylor ◽

Ashley M Nassiri ◽

Colin L W Driscoll ◽

Michael J Link

Keyword(s):

Epidermoid Cyst ◽

Cranial Nerves ◽

Residual Tumor ◽

Middle Meningeal Artery ◽

Neural Tube Closure ◽

Petrous Apex ◽

Meckel’S Cave ◽

Postoperative Mri ◽

Meckel's Cave ◽

Anterior Petrosectomy

Abstract Epidermoid cysts are rare, benign lesions that result from inclusion of ectodermal elements during neural tube closure.1 Cysts are composed of desquamated epithelial cells and restrict diffusion on magnetic resonance imaging (MRI).2,3 Symptoms are attributable to anatomic location.4,5 In this video, we illustrate the surgical treatment of an epidermoid cyst located in the right cerebellopontine angle, petrous apex, and Meckel's cave. The patient, a 33-yr-old female with right-sided V1 trigeminal hypoesthesia, underwent surveillance imaging for 2 yr. However, she developed progressive V1 and V2 trigeminal hypoesthesia and imaging revealed enlargement of the lesion. Therefore, surgical resection was pursued. The patient consented to the procedure. The patient underwent a right middle fossa craniotomy and anterior petrosectomy. After identifying the greater superficial petrosal nerve and cutting the middle meningeal artery as it exited foramen spinosum, Kawase's triangle was drilled, and the dura over Meckel's cave and the subtemporal dura were opened. The lesion was resected, taking care to preserve the trigeminal nerve and the basilar artery. A retrosigmoid craniotomy was then fashioned. The cyst and its capsule were dissected off the brainstem and cranial nerves utilizing natural corridors between the trigeminal and vestibulocochlear nerves as well as between the facial and lower cranial nerves. Gross total resection was confirmed on postoperative MRI, and she was discharged home on postoperative day 5. Three months after surgery, she underwent formal pinprick testing, which revealed 95% loss of sensation in V1, 20% loss in V2, and normal sensation in V3. Three-month postoperative MRI showed no residual tumor.

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A Side Door to Meckel's Cave: Anatomic Feasibility Study for the Lateral Transorbital Approach

Operative Neurosurgery ◽

10.1093/ons/opx042 ◽

2017 ◽

Vol 13 (5) ◽

pp. 614-621 ◽

Cited By ~ 17

Author(s):

Blake Harrison Priddy ◽

Cristian Ferrareze Nunes ◽

Andre Beer-Furlan ◽

Ricardo Carrau ◽

Iacopo Dallan ◽

...

Keyword(s):

Skull Base ◽

Surgical Navigation ◽

Cranial Nerves ◽

Anatomical Study ◽

Middle Cranial Fossa ◽

Middle Fossa ◽

Meckel’S Cave ◽

Side Door ◽

Meckel's Cave ◽

Brain Retraction

Abstract BACKGROUND: In the last decade, endoscopic skull base surgery has significantly developed and generated a plethora of techniques and approaches for access to the cranial ventral floor. However, the exploration for the least-aggressive, maximally efficient approach continues. OBJECTIVE: To describe in detail an anatomical study, along with the technical nuances of a novel endoscopic approach to Meckel's Cave (MC) using a lateral transorbital (LTO) route. METHODS: Eighteen orbits of injected cadaveric specimens were operated on, using an endoscopic LTO approach to MC, middle cranial fossa, and paramedian skull base preserving the orbital rim. Surgical navigation and an after-the-fact infratemporal craniectomy were utilized to identify the limits of the approach. RESULTS: Following a transorbital approach opening a trapezoid window at the superolateral aspect (average 166.7 mm2), a middle fossa “peeling” and full visualization of MC was accomplished with no difficulties in all specimens. The entire approach was performed extradurally without the need to expose the temporal lobe. CONCLUSION: In a cadaveric model, the endoscopic LTO approach affords a direct route to access MC. Its main advantage is that it is minimally disruptive in nature, less brain retraction is required, and it reaches the middle fossa in an anterolateral perspective. It also requires no manipulation of the temporalis muscle, limited cosmetic incision, and rapid recovery. It seems a viable alternative to traditional approaches for lesions lateral to the cranial nerves at the cavernous sinus and MC, that is, schwannomas. Clinical utilization of this approach will challenge its efficacy and identify limitations.

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Posterior Approach to Meckel's Cave: Retrosigmoid Craniectomy with Endoscopic Assistance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1677851 ◽

2019 ◽

Vol 80 (S 03) ◽

pp. S331-S332

Author(s):

Paramita Das ◽

Hamid Borghei-Razavi ◽

Nina Z. Moore ◽

Pablo F. Recinos

Keyword(s):

Tumor Resection ◽

Cranial Nerves ◽

Auditory Brainstem ◽

Technical Note ◽

Auditory Brainstem Responses ◽

Case Review ◽

Meckel’S Cave ◽

Meckel's Cave ◽

Endoscopic Assistance ◽

Loss Of Hearing

Background Meckel's cave involvement in tumors pose a challenge due to their surrounding neurovascular structure and deep location. Case Review A 24-year-old male presented with progressive headaches and right sided trigeminal neuralgia with a large epidermoid. The tumor extended from the ambient cistern to the cerebellomedullary cistern and involved Meckel's cave (Fig. 1). Technical Note/Video Description A retrosigmoid craniectomy was performed. Cranial nerves 3, 4, 6, 7, and 10, and auditory brainstem responses were monitored. Once the craniectomy was completed the dura was opened and cerebrospinal fluid (CSF) was released from the cisterna magna to allow for the tumor resection to be done without the use of any retractors (Fig. 2). Care was taken to ensure that cranial nerves in the posterior fossa were detethered to prevent any traction injury. Using ring curettes the pearly white epidermoid tumor was able to be debulked. After all the possible tumor was resected with the microscope, the 30-degree endoscope was used to identify the porus trigeminus. Malleable ring curettes and a malleable suction were used to remove the soft tumor from this location. The patient transiently had loss of hearing but this returned within 2 weeks after surgery. Conclusions The retrosigmoid approach is familiar to all neurosurgeons and with the adjunct of an angled endoscope, the posterior Meckel's cave can be easily reached. This is particularly useful for tumors with soft consistency. The assistance of the endoscope allows Meckel's cave visualization without additional drilling while still allowing safe resection of tumor from around the trigeminal nerve.The link to the video can be found at: https://youtu.be/01aqOyUmSW0.

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Malignant Phyllodes Tumor of the Breast with Metastasis to the Pancreas: A Case Report and Review of Literature

Case Reports in Oncological Medicine ◽

10.1155/2018/6491675 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

R. A. Amir ◽

Rola S. Rabah ◽

S. S. Sheikh

Keyword(s):

Case Report ◽

Breast Neoplasms ◽

Distant Metastasis ◽

Case Reports ◽

Phyllodes Tumor ◽

Pancreatic Metastasis ◽

Rare Tumor ◽

Review Of Literature ◽

Malignant Phyllodes Tumor ◽

Phyllodes Tumors

Phyllodes tumor (PT) is a rare tumor of the breast accounting for approximately 1% of all breast neoplasms. In 1838, J. Muller coined the term “cystosarcoma phyllodes” based on the leaf-like projections of the tumor extending into the cystic spaces and sarcomatous stromal growth. However, seeing as up to 70% of phyllodes tumors are benign, “cystosarcoma” was removed, and the tumor is now recognized simply as phyllodes tumor. It is mainly seen in females between the ages of 35 and 55. Although most phyllodes tumors are benign, malignant cases do uncommonly occur, 22% of which have distant metastasis typically to the lungs and bones. Rarely, this tumor metastasizes to other locations. Herein, we report a case of malignant phyllodes tumor with metastasis to the pancreas. According to our knowledge, only 3 case reports of pancreatic metastasis from malignant phyllodes tumor have been reported in literature thus far. We aim to increase awareness among physicians of this rare metastasic potential of the uncommonly encountered malignant phyllodes tumor.

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