Elsevier

World Neurosurgery

Volume 108, December 2017, Pages 992.e11-992.e14
World Neurosurgery

Case Report
Cerebrospinal Fluid Leak Rhinorrhea after Systemic Erlotinib Chemotherapy for Metastatic Lung Cancer: A Familiar Problem from an Unfamiliar Culprit

https://doi.org/10.1016/j.wneu.2017.08.183Get rights and content

Background

Cerebrospinal fluid (CSF) rhinorrhea after medical therapy for pituitary prolactinoma is a rare but well-described phenomenon. To our knowledge, no CSF leaks have been reported after targeted medical treatment of pituitary or anterior skull base metastases. We report this unusual case to raise awareness of spontaneous CSF leaks in the setting of skull base metastatic disease.

Case Presentation

A 66-year-old woman presented with epidermal growth factor receptor–mutant stage IV adenocarcinoma of the lung. Headache workup revealed a large sellar and clival lesion consistent with metastatic disease. Systemic erlotinib chemotherapy was initiated with a robust positive response. Approximately 1 week after chemotherapy initiation, the patient noted clear discharge from the right nostril. Her oncologist first diagnosed her with allergic rhinitis, but she presented with meningitis 4 days after diagnosis of CSF leak and was admitted for intravenous antibiotics and definitive repair of a CSF leak via an endoscopic endonasal approach. An erosion of bone and dura was found at the dorsum sellae where tumor had regressed due to the chemotherapy. A multilayer skull base repair was made uneventfully, and she recovered fully with no leakage seen at 2-month follow-up.

Conclusions

All members of the treatment team should be aware of this possibility of CSF leak after initiation of systemic chemotherapy and tumor regression and urgently refer patients for repair if a leak should develop before the development of meningitis.

Section snippets

Background

Cerebrospinal fluid (CSF) rhinorrhea is a rare but well-described entity after the medical therapy of a pituitary prolactinoma.1, 2 A robust response to dopamine agonist therapy leads to rapid shrinkage of the tumor, which, in the event of an eroded sellar floor skull base dura and/or bony structures, can lead to a conduit between the nasal passages and the subarachnoid space. Interestingly, although the mechanism for most cases is due to tumor shrinkage from medical management, allowing the

History

The patient was a 66-year-old woman with an extensive smoking history who presented to her pulmonologist with shortness of breath and subsequently was diagnosed with a pulmonary embolism as well as a new lung mass and multiple smaller systemic lesions. A diagnosis of stage IV EGFR-mutant adenocarcinoma of the lung was made after biopsy of the chest mass. She noted continual headaches, and so magnetic resonance imaging of the brain was performed, which showed and an enhancing mass of the sella

Discussion

CSF rhinorrhea is a potential serious complication of endoscopic endonasal surgery and also rarely of medical management of prolactinoma. To our knowledge, no report of metastatic lung adenocarcinoma complicated by CSF rhinorrhea arising from targeted therapy (e.g., erlotinib) has been published. The complication of CSF rhinorrhea is not a process strictly inherent to pituitary pathology such as prolactinoma. Rather, any neoplastic process that creates a fistula, when treated and after

Conclusions

We report a case of systemic erlotinib therapy leading to CSF rhinorrhea in a patient with stage IV adenocarcinoma of the lung due to rapid shrinkage of a sellar/clival metastasis. This mechanism appears similar when compared with other treatment modalities, whereby a tumor regresses quickly, allowing exposure of a previously created CSF fistula from tumor invasion of bone and dura. Surgical repair of these leaks is technically simple and is crucial to perform before the development of

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Conflict of interest statement: Daniel Prevedello is a consultant for Medtronic and Codman (J&J) and has received an honorarium from Leica Microsystems. All other authors do not have any conflict of interests.

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