Journal of Cranio-Maxillofacial Surgery (2000) 28, 161164

# 2000 European Association for Cranio-Maxillofacial Surgery

doi:10.1054/jcms.2000.0130, available online at http://www.idealibrary.com on

Involvement of the cavernous sinus by malignant (extracranial) tumour:

palliation in six cases without surgery
Federico L. Ampil, Maureen Heldmann, Amir M. Ibrahim, Eric L. Balfour
Department of Radiology (Head: Prof. H. R. D'Agostino. MD),
Louisiana State University, Health Sciences Center Shreveport, Louisiana, USA
SUMMARY. Involvement of the cavernous sinus region due to haematogenous spread or by local extension of a
malignant head and neck tumour does not occur frequently. Six patients were treated by external beam radiation
with (n=3) or without neoadjuvant chemotherapy between December 1989 and February 1996. Manifestations of
the condition mainly consisted of fth and sixth cranial nerve decits (n=4). Complete resolution of cranial nerve
decits after therapy occurred in two of the four patients with only three individuals having been evaluable.
Three of the six patients survived for more than 3 years. Thus, palliation can be achieved by chemoradiation or
radiotherapy alone, and long term survival is not precluded. # 2000 European Association for CranioMaxillofacial Surgery

INTRODUCTION

neck, breast, prostate gland, and non-Hodgkin's

lymphoma. Six individuals (four men and two
women) with a mean age of 48 years were not
operated on but treated by external beam radiation of
the cavernous sinus region (Table 1). The clinical
diagnosis of invasion of the cavernous sinus was
supported by ndings from computed tomography or
magnetic resonance imaging (Figs 1 & 2); histological
conrmation of intracranial involvement was not
considered necessary.
External beam irradiation was applied on ve
consecutive days each week using a 6 million volt
linear accelerator. Our previously reported technique
of irradiation for head and neck neoplasms (Ampil
et al., 1988) was modied to include the cavernous
sinus area with at least a 2 cm margin of normal brain
tissue. In the two patients with haematogenously
derived metastasis, parallel opposed lateral portals
encompassing the imaged cavernous sinus region also
had a 2 cm margin of normal tissue. Total doses
ranged from 30 Gy to 64 Gy (Table 2).
Three patients with head and neck malignancies
also received neoadjuvant induction chemotherapy,
intravenously administered; the regimen consisted of
cisplatin (20 mg/m2/day on days 1 to 5), 5-uorouracil (800 mg/m2 continuous infusion on days 1 to
4), and etoposide (60 mg/m2/day on days 1 to 3); this

Tumour involvement of the cavernous sinus region

due to metastasis from a remote malignant neoplasm
or by local extension of an adjacent malignant lesion
in the head and neck is uncommon. Its occurrence as
a secondary complication of all malignancies in
various parts of the body has accounted for less than
1% of the reported cases (Ahmad et al., 1987). A case
recently encountered prompted this review of cases
and the literature. A 55-year-old woman developed
progressive disease in the initially uninvolved cavernous sinus region approximately a year after induction chemotherapy followed by concomitant
chemoradiation for stage III T1N1M0 nasopharyngeal squamous cell carcinoma (in the absence of
locoregional tumour recurrence).
The purpose of this communication is to describe
our experience of the non-operative palliative management of neoplastic involvement of the cavernous
sinus by malignant extracranial tumours diagnosed
during a period of approximately 6 years.
MATERIAL AND METHODS
Between December 1989 and February 1996, 1077
patients were diagnosed with cancer of the head and

Table 1 Characteristics of patients with involvement of the cavernous sinus region by malignant extracranial tumours
Tumour
Patient no.

Age (years)/sex

Site

Histology

Other extracranial
metastases

Manner of ICSR

1
2
3
4
5
6

28/M
38/M
57/F
62/M
62/M
41/F

Maxillary sinus
Nasopharynx
Nasopharynx
Nasopharynx
Prostate gland
Breast

NHL
SCC
SCC
SCC
ADC
ADC

+*

LE
LE
LE
LE
HS
HS

NHL=Non-Hodgkin's lymphoma; SCC=squamous cell carcinoma; ADC=adenocarcinoma; ICSR=involvement of cavernous sinus

region; LE=local extension; HS=haematogenous spread; *Bone metastases.
161

162 Journal of Cranio-Maxillofacial Surgery

Fig. 1 Coronal contrast enhanced CT image, mass extending

through sphenoid bone into right cavernous sinus (arrows) and
elevating internal carotid artery (arrowhead).

regimen was repeated every 21 days for three cycles.

Radiotherapy began on the second cycle of the threedrug chemotherapy plan and was administered in the
prescribed full dose with the exception of one patient
who died and therefore the full course was not
completed.
Subjective and objective responses were assessed at
completion of radiotherapy or at follow-up a month
later. Survival time was measured from the time of
diagnosis until death or last follow-up.

Fig. 2 Axial T1 weighted contrast-enhanced MRI, direct invasion

of the right cavernous sinus by tumour (arrows).

on imaging studies performed for staging of the

malignant head and neck neoplasm. The more
commonly aected cranial nerves were the fth and
sixth nerves. Involvement of the cavernous sinus area
was due to adjacent local extension in four patients
with head and neck cancer; intracranial involvement
was by haematogenous spread in the two patients
with primary tumours outside of the head and neck.
The average interval between diagnosis of the tumour
located outside of the head and neck region and of
intracranial involvement was 35 months.
Complete resolution of the manifested cranial
nerve decits was observed in two of the four patients

RESULTS
Clinical manifestations of cavernous sinus involvement were ipsilateral facial numbness (n=2), impaired vision (n=2), and ophthalmoplegia (n=2).
Two patients were asymptomatic and did not present
with signs of cranial nerve(s) decit (Table 2); their
intracranial lesions were inadvertently detected
Table 2 Additional features
Patient no.

Cranial nerve(s)
involved

Neoadjuvant
chemotherapy

Total dose of
radiotherapy

Post-treatment
response

Survival in
months

1
2
3
4
5
6

Fifth
None
None
Fifth
Sixth
Third, Sixth

+
7
+
+
7
7

40
56
64
36
30
36

CR
NA
NA
NE
CR
NR

7 Alive
5
64 Alive
2
36
39

Gy/20
Gy/28
Gy/32
Gy/18
Gy/10
Gy/12

fractions
fractions
fractions
fractions*
fractions
fractions

CR=complete response/resolution of manifested symptom or decit; NA=not applicable because of absence of decit; NE=nonevaluable; NR=no response; survival estimated from time of diagnosis of cancer; *Dose received was not the prescribed total dose because
patient died.

Involvement of the cavernous sinus by malignant tumour 163

aected; no response occurred in the third individual,

while the fourth one died during treatment. The
overall crude survival rate at 3 years was three out of
the six patients. Four had died by the time the cases
were reviewed; their median period of survival was
20.5 months. Two individuals were alive at 7 months
and 64 months after the onset of their neoplastic
illness (Table 2). However, when evaluating the three
patients with squamous cell carcinomas of the
nasopharynx separately, long-term survival was
observed in this subgroup of individuals.
DISCUSSION
The cavernous sinus region of the base of the skull
is of clinical importance because it contains four
cranial nerves, namely oculomotor, trochlear, abducens, and trigeminal nerve (the rst two divisions) as
well as the oculosympathetic bres and the carotid
artery (Delpassand and Kirkpatrick, 1988).
Involvement of the cavernous sinus area by
malignant neoplasms may occur through local
extension of a nearby locally advanced primary head
and neck lesion or through haematogenous spread
of tumours located outside of the head and neck
region.
Our study conrms several clinical features observed in prior reports about neoplastic involvement
of the cavernous sinus region. In this limited
experience, the majority of patients were at least 40
years of age or older as were the cases reported by
others (Unsold et al., 1980; Koh et al., 1983; Julien
et al., 1984; Zahra et al., 1986; Ahmad et al., 1987;
Delpassand and Kirkpatrick, 1988; Supler and Friedman, 1992; Bumpous et al., 1993). Also, the fth and
sixth cranial nerves were often the nerves with
manifested decits (Unsold et al., 1980; Julien et al.,
1984; Bitoh et al., 1985; Zahra et al., 1986; Ahmad
et al., 1987; Delpassand and Kirkpatrick, 1988;
Bumpous et al., 1993). Moreover, men were predominant in our series as they were in the others reports
(Unsold et al., 1980; Koh et al., 1983; Julien et al.,
1984; Bitoh et al., 1985; Zahra et al., 1986; Ahmad et
al., 1987; Delpassand and Kirkpatrick, 1988; Supler
and Friedman, 1992; Bumpous et al., 1993).
On the other hand, the average intervals between
the diagnoses of the primary and intracranial lesions
in two equally small series of patients were 11 months
(Ahmad et al., 1987) and 4 months (Bumpous et al.,
1993) unlike the 35 months for non-head and neck
tumours in our study.
Traditionally, invasion of the cavernous sinus by
extracranial tumours is not treated surgically because
of the danger of bleeding from the cavernous venous
plexus or injury to the internal carotid artery or the
third, fourth, and sixth cranial nerves (Sekhar and
Moller, 1986). Today, surgical management of
cavernous sinus lesions has now been facilitated by
the use of new surgical approaches, the use of the
surgical microscope, and intraoperative electromyographic monitoring of cranial nerve function (Close

et al., 1985; Sekhar and Moller, 1986). Nonetheless,

radiotherapy alone or chemoradiation gave satisfactory results in our cases as has been reported by
others (Unsold et al., 1980; Koh et al., 1983; Julien
et al., 1984; Bitoh et al., 1985; Zahra et al., 1986;
Ahmad et al., 1987; Supler and Friedman, 1992;
Bumpous et al., 1993). Responses to treatment have
been noted (as in our series) either at completion of
therapy or at a later follow-up (Unsold et al., 1980;
Bitoh et al., 1985; Zahra et al., 1986; Ahmad et al.,
1987; Supler and Friedman, 1992). A dose-response
relationship could not be discerned in these reports of
given total doses ranging from 20 to 65 Gy.
With respect to length of survival of patients
with tumour invasion of the cavernous sinus region
as reported in the literature, most individuals lived
no longer than six months (Julien et al., 1984;
Bitoh et al., 1985; Delpassand and Kirkpatrick,
1988; Supler and Friedman, 1992) with occasional
one year survivors (Unsold et al., 1980; Julien et al.,
1984).
We recognize the limitations of a retrospective
study. It permits us, however, to show that worthwhile palliation of involvement of the cavernous sinus
area by malignant extracranial tumours can be
achieved by non-operative treatment-thereby promoting an improvement in the quality of remaining
life which may not be necessarily short. This is
especially so when considering metastasizing tumours
of the breast and prostate.
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164 Journal of Cranio-Maxillofacial Surgery

Zahra M, Tewk HH, McCabe BF: Metastases to the cavernous
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Federico L. Ampil MD
Division of Therapeutic Radiology
Louisiana State University Health Sciences Center
1501 Kings Highway
Shreveport
Louisiana 71130
USA

Tel: +1 318 675 5329

Fax: +1 318 675 4697
Paper received 20 September 1999
Accepted 4 April 2000