Management of calvarial tumors - a retrospective analysis and literature review

Abstract

Hematogenous metastases to the calvarium can be caused by nearly all types of tumors (8). Most metastatic skull lesions being asymptomatic and less important clinically than intraparenchymal metastatic lesions, they are rarely diagnosed clinically but are frequently found in autopsies. Literature on the skull tumors consists mostly of individual case reports and a scarce number of case series. Only a few articles are available on skull metastases, especially calvarial metastases (3,4,13,15,16). Calvarial metastases signify an advanced stage of disease (16). █ INTRODUCTIONT umors of various organs and tissues that tend to metastasize to bony structures do not neglect the skull vault as a target. There are autopsy series of carcinoma breast cases reporting occasional skull metastases even from the end of 18 th century. Today and in the near future, we may expect more cases with skull metastasis as a result of advanced radiological imaging and prolonged survival of cancer patients. AIM:Tumors of various organs that metastasize to bone do not neglect calvarium as a target. The aim of this study was to characterize the calvarial tumors. MATERIAL and METhODS:We retrospectively reviewed 45 consecutive patients operated for calvarial masses from January 2002 till May 2012 at our hospital. Skull base tumors and patients ≤18 years were excluded. RESULTS:Three groups of lesions were found -calvarial metastases (15/45), primary tumors (5/45) and tumor-like lesions (25/45). Malignant lesions were equitable by gender distribution, higher age of onset (median age of primary =55; secondary = 60 years) and benign lesions by younger age (median = 35) and female bias (18/25). Calvarial metastases mostly presented with local swelling (10/15), local pain (6/15) and rarely neurologic deficit. There was associated dural sinus thrombosis (4/20 of malignant; 1/25 of benign lesions) and osteolysis (3/5 primary malignant, 13/15 secondary and 18/25 of benign lesions). Complete surgical excision was possible with minimal morbidity in all except one patient and nil mortality. CONCLUSION:Nearly half (20/45) of the calvarial lesions tend to be malignant with most of them presenting as silent painless masses. Surgical excision should be considered only after suitable investigation and appropriate neurosurgical set-up.

5-aminolevulinic Acid and Surgical Margin Analysis in Calvarial Metastasis with Pericranium or Dural Extension: Technical Note

“…Dissemination may occur due to direct extension or by hematogenic pathway, with cancer cells adhering to the endosteal surface and invading the bone marrow. 2,3,6 Breast, lung and prostate adenocarcinoma are the commonest primary lesions to metastasize to the skull due to a distinct bone tropism, but various other histologies have been reported. 14,15 Mitsuya et al reported 55% of skull metastases from breast cancer in a series of 175 patients, with a preponderance female versus male of 7:3 patients.…”

“…Fat subtraction is important to determine tumor margins. 4,6 Management of calvarial metastases may depend on symptomatology, patient KPS, relationship with dural sinuses and eloquent cortex, histopathology, extent of spread and scalp infiltration. 3,5,6,16 Surgical treatment can be a safe palliative option for symptomatic patients, even when indicated after failed attempt with irradiation and/or chemotherapy.…”

“…4 Proximity to dural sinuses, cranial nerves or eloquent cortex can cause severe neurological impairment, compromising treatment efficacy and survival prognosis. 5,6 In patients with controlled systemic disease and Karnofsky performance status (KPS) 70%, surgical management can be a safe treatment modality aiming total removal with oncological margins, 4,6 possibly avoiding the necessity of local adjuvant irradiation.…”

Successful Treatment of Anal Canal Cancer Metastasis to the Cranial Bones: A Case Report and Literature Review

“…With CT, calvarial metastasis often presented as an osteolytic lesion. To better delineate lesion boundaries, as well as soft tissue and dural invasion, magnetic resonance imaging (MRI) with noncontrasted sequences was performed in several cases (2,(37)(38)(39). Cranial bone metastasis showed hypo-intensity on nonenhanced T1-weighted images and a variable appearance on T2-weighted images, in contrast with the hyper-intensity of normal bone marrow (21,28,31).…”

“…Metastases to the cranial bones are relatively rare, accounting for less than 5% of all secondary bone locations (1). At present, they remain a challenging disease to treat and current guidelines are mainly designed to address improvement in patients' quality of life (QoL) (2). Actually, there is lack of specific guidelines regarding the best therapeutic approach in cranial bone metastasis.…”