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Clival Metastasis

Summary

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  • Clival metastasis is a rare occurrence of tumour spread to the clivus bone at the skull base
  • Typically presents with cranial nerve palsies and headache
  • Imaging shows a destructive lesion in the clivus, often with soft tissue extension1

Pathophysiology

  • Hematogenous spread of primary malignancy to the clivus
  • Common primary sites include:
    • Prostate cancer
    • Breast cancer
    • Lung cancer
    • Thyroid cancer
    • Renal cell carcinoma
  • Metastatic cells invade and replace normal bone marrow in the clivus
  • Local destruction of bone and potential extension into surrounding structures

Demographics

  • Rare condition, exact incidence unknown
  • More common in adults with known primary malignancies
  • Slight male predominance reported in some studies
  • Peak incidence in 5th to 7th decades of life

Diagnosis

  • Clinical presentation:
    • Headache (most common symptom)
    • Cranial nerve palsies (particularly VI, IX, X, XI, XII)
    • Diplopia
    • Facial numbness or pain
    • Dysphagia
  • Laboratory tests:
    • Elevated tumour markers specific to primary malignancy
    • Complete blood count may show anaemia or thrombocytopenia
  • Biopsy:
    • Often required for definitive diagnosis
    • Performed under image guidance (CT or MRI)

Imaging

  • CT:
    • Lytic lesion in the clivus with cortical destruction
    • Soft tissue mass may be visible
    • Useful for assessing bony involvement and planning biopsy
  • MRI:
    • T1: Hypointense lesion replacing normal hyperintense bone marrow
    • T2: Variable signal intensity
    • Post-contrast: Heterogeneous enhancement
    • DWI: Often shows restricted diffusion
    • Superior for evaluating soft tissue extension and cranial nerve involvement
  • Nuclear Medicine:
    • PET/CT: Increased FDG uptake in the clival lesion
    • Bone scan: Focal increased uptake in the clivus

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  • 55-year-old patient with lung cancer presented with diplopia.
  • MRI showed a destructive and enhancing clival lesion that extended into the pituitary fossa and suprasellar space.

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  • A 60-year-old patient with a recent lung cancer diagnosis presented with headache and diplopia.
  • CT showed a destructive lesion in the clivus and pituitary fossa.
  • MRI showed a heterogeneously enhancing lesion invading the left cavernous sinus.

Treatment

  • Palliative: radiotherapy and systemic therapy directed at the primary; generally indicates advanced disease

Differential diagnosis

Differential Diagnosis Differentiating Feature
Chordoma Typically midline and expansile; may show characteristic T2 hyperintensity
Meningioma Usually has a dural tail; homogeneous enhancement
Pituitary macroadenoma Centered in sella turcica; may have suprasellar extension
Nasopharyngeal carcinoma Originates from nasopharynx; often with lateral extension
Lymphoma More homogeneous appearance; may have restricted diffusion
Plasmacytoma Typically hyperdense on CT; may have associated bone destruction
Chondrosarcoma Off-midline location; may show characteristic calcifications
Osteomyelitis May show surrounding bone oedema; clinical history of infection
Fibrous dysplasia Ground-glass appearance on CT; typically expands bone
Eosinophilic granuloma Typically occurs in younger patients; may have beveled edge appearance

  1. Huq et al. Gamma knife radiosurgery for clival metastasis: case series and systematic review. 2024. Journal of neuro-oncology - Open in new tab. ↩