Garcin syndrome is defined as meeting the following four diagnostic criteria: (1) unilateral palsies of the cranial nerves, (2) neither sensory nor motor long-tract disturbance, (3) no intracranial hypertension, and (4) an osteoblastic lesion in the skull base [
1]. It has unique clinical symptoms and is a rare syndrome. There are Collet-Sicard syndrome, cavernous sinus syndrome, Tolosa-Hunt syndrome which have similar clinical findings with Garcin syndrome, but these syndromes are paralysis of a certain cranial nerve (e.g., Collet-Sicard is IX to XII) and are defined also by nerve inflammation. Garcin syndrome, as shown, distinguishes it from those syndromes in that it can occur in all cranial nerves and cannot be diagnosed without osteoclastic lesions. The sphenoid sinus is a cavity inside the butterfly bone in the midline of the skull base and is one of the paranasal sinuses. The sphenoid sinus is located in the medial of the superior orbital fissure which the III, IV, V1, and VI cranial nerves pass, and in this case, the cranial nerves were compressed by the tumor. Many reports of Garcin syndrome assume that it originates from a bone invading malignant tumor, such as a tumor of the nucleus of the skull base and nasopharynx or metastatic tumor from a remote organ to the skull. Lung cancer is the third most likely to develop bone metastasis following breast cancer and prostate cancer [
12]. The rate of bone metastasis at necropsy of lung cancer is reported to be about 20–50 [
13]. Furthermore, the histopathological diagnosis of this case was pleomorphic carcinoma, which is reported to be more likely to cause distant metastasis than other types of non-small cell lung cancer [
14]. Skull metastasis of lung cancer are reported to be 5 cases in 611 cases (0.4%) of single bone metastasis of lung cancer [
12]. Since skull base bone metastasis is rarer than skull metastasis, the overall incidence of Garcin syndrome caused by lung cancer is estimated to be much less than 0.4%. In the previous reports, there were six cases with Garcin syndrome due to lung cancer, including subtypes that did not satisfy all diagnostic criteria (Table
1) [
5‐
10]. To date, there is no specific therapy for Garcin syndrome. In the present case, radiotherapy and zoledronic acid were given as a treatment for bone metastasis, but there was no neurological improvement. A case of small cell lung cancer with neurological improvement after only carboplatin + etoposide therapy has been reported [
10]. There are few cases reporting neurological improvement, but there is a possibility that symptoms can be improved by correctly diagnosing Garcin syndrome.
Table 1
Characteristics of cases of lung cancer with Garcin syndrome
1 | 69/F | Adenocarcinoma | Rt. II, V,·VI Lt. II, III, IV, V, VI | Metastasis to the skull base | |
2 | 52/F | Adenocarcinoma | Rt. X, XI, XII | Metastasis to the skull base | |
3 | 60/F | Adenocarcinoma | Rt. VII, VIII | Metastasis to the skull base | |
4 | 50/M | Adenocarcinoma | Lt. V, VII, VIII, IX, X, XII | Cancerous meningitis | |
5 | 65/F | Non-small cell carcinoma | Rt. III, IV, VII Lt. IX, X | Cancer invasion to the dura mater | Nagashima et al. 2011 [ 9] |
6 | 61/F | Small cell carcinoma | Lt. IX, XI, XII | Metastasis to the left posterior cranial fossa | Moriyama et al. 2013 [ 10] |
Present case | 76/F | Pleomorphic carcinoma | Rt. IV, V1, VI | Metastasis to the sphenoid bone | |
A case of recurrence of lung cancer resulting in sphenoid bone metastasis and Garcin syndrome was described. If a patient with lung cancer develops strange neurological manifestations, Garcin syndrome with skull base metastasis must be considered, even though it is an uncommon syndrome. If Garcin syndrome is suspected, it is necessary first to perform contrast MRI and to consult with neurology to clarify neurological findings. Although there is no treatment to be done in an emergency, neurosurgery and radiotherapy are considered next depending on the cause of the disease.