Breast cancer metastasis to the gasserian ganglion.

To the Editor: In an autopsy study of 309 patients with breast carcinoma metastases to the central nervous system, the brain was most frequently affected, followed by the meninges and the spinal cord. (1) In this letter, we describe a patient with breast cancer who had metastatic tumor in the gasserian ganglion.

A 37-year-old woman came to her oncologist with numbness on the right side of her face of 1 month's duration. Several years before, she underwent right modified radical mastectomy followed by adjuvant chemotherapy and locoregional radiotherapy for stage IIIA breast cancer. More than 1 year later, she was treated by radiation for palliation of symptomatic osseous metastatic disease in the spine.

On physical examination, sensation was significantly impaired in all three divisions of the fifth cranial nerve on the right side.

The presence of metastatic neoplasm in the gasserian ganglion area (right side) of the skull base was demonstrated (Fig. 1, A and B) by MRI.

After intracranial clivus metastasis was diagnosed, 4 mg dexamethasone (3 times daily p.o.) and local irradiation was started. After completion of radiotherapy (30 Gy/10 fractions), there was some degree of improvement of the hemifacial sensory dysfunction. The patient died of her illness 5 months later.

[FIGURE 1 OMITTED]

In a report of 10 patients with breast cancer with metastatic tumor causing cranial nerve palsies in the absence of intracranial tumor, Hall et al (2) found extensive disease at the skull base compressing the nerves; there was no instance of trigeminal ganglion involvement.

Metastatic tumor involving the gasserian ganglion was reported by Power in 1886 and then by Parves-Stuart in 1927. (3) Iniguez et al (4) described a case of neuropathy of the chin as the presenting symptom of breast cancer; the manifestation was explained on the basis of a metastatic lesion in the trigeminal ganglion shown on MRI as enlargement of the gasserian ganglion (an exhibited abnormality akin to that of our patient). Other reported manifestations of the secondary affliction are paresthesia of the mental and infraorbital regions or unilateral decreased sensation to pinprick in all three divisions of the fifth cranial nerve.

Radiotherapy is the treatment of choice for skull base metastases because it is effective in achieving palliation (5) (such therapy was partly successful in our case). The role of surgery or chemotherapy for this special disease condition is not well established.

In conclusion, the trigeminal ganglion is a rare site of metastasis. Oncologists should have a heightened awareness of the unpredictable behavior of carcinoma of the breast, particularly in terms of body locations of neo-plastic spread. This example represents only the second case known to us to be reported in the English literature. Thus, definitive conclusions concerning therapeutic management and prognosis have not been ascertained. The unique occurrence of metastatic tumor in the gasserian ganglion was a preterminal event in our patient.

Federico L. Ampil, MD

Gary V. Burton, MD

Mardjohan Hardjasudarma, MD

Travis Henley, MD

Departments of Radiology and Medicine

Louisiana State University Health

Sciences Center

Shreveport, LA

References

1. Tsukada Y, Fouad A, Pickren JW, et al. Central nervous system metastases from breast carcinoma: autopsy study. Cancer 1983;52:2349-2354.

2. Hall SM, Buzdar AU, Blumenschein GR. Cranial nerve palsies in metastatic breast cancer due to osseous metastasis without intracranial involvement. Cancer 1983;52:180-184.

3. Willis RA. The spread of tumours in the human body. St. Louis, CV Mosby, 1952, p. 257.

4. Iniguez C, Mauri JA, Larrode P, et al. Mandibular neuropathy due to infiltration of the gasserian ganglion. Rev Neurol 1997;25:1092-1094.

5. Greenberg HS, Deck MDF, Vikram B, et al. Metastases to the base of skull: clinical findings in 43 patients. Neurology 1981;31:530-537.

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