Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2013) 14, 143–146

Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied

Sciences

www.ejentas.com

CASE REPORT

Nasopharynx – A rare site of metastases from

carcinoma breast

Anshu Tewari *, Padma Subramanyam, Shanmuga Sundaram Palaniswamy,

T.S. Satheesh

Department of Nuclear Medicine & PET CT, Amrita Institute of Medical Sciences, Cochin 6802041, Kerala, India

Received 20 October 2012; accepted 10 November 2012

Available online 10 May 2013

*

28

E

Pe

Th

20

ht

KEYWORDS

Nasopharynx metastasis;

Breast cancer;

Computed tomography;

Magnetic resonance imaging;

18 FDG PET/CT

Corresponding author. Te

52003.

-mail address: anshut@aims

er review under responsibili

roat and Allied Sciences.

Production an

90-0740 ª 2012 Production

tp://dx.doi.org/10.1016/j.ejen

l.: +91

.amrita.a

ty of Eg

d hostin

and hosti

ta.2012.1

Abstract We report a case of a 62-year old Indian female with a history of breast cancer treated

with surgery, chemotherapy and radiation three years ago, now presenting with diplopia on the

right eye for three weeks. CT showed a diffuse infiltrating lesion in the right cranial fossa. MRI

reported meningeal and orbital wall involvement also. The patient was referred for 18 FDG

PET/CT to assess the extent of disease and also to look for other distant metastases. 18 FDG

PET/CT revealed an exact extent of lesion, from the right orbital apex, destroying greater wall

of the sphenoid, extending to the nasopharynx and the right nasal cavity with extensive skeletal

metastases. We present symptoms, signs and imaging modalities that aided in localization of metas-

tases, while in the available literature such presentation of carcinoma breast secondaries in the naso-

pharynx is extremely rare.ª 2012 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and

Allied Sciences.

1. Introduction

Nasopharyngeal metastases from breast carcinoma is extre-mely rare with only three cases previously reported in the liter-ature.1–3 We present a case of breast cancer with distant

metastases to orbital apex, greater wing of the sphenoid and

484 2852001; fax: +91 484

c.in (A. Tewari).

yptian Society of Ear, Nose,

g by Elsevier

ng by Elsevier B.V. on behalf of E

1.004

extending to the nasopharynx with extensive skeletal metasta-

ses. We discuss the diagnostic role of whole body 18 FDGPET/CT (18-Flourodeoxyglucose positron emission tomogra-phy/computed tomography) to assess the extent of disease

and its implications in staging breast cancer and itsmanagement.

2. Case report

A 62-year old woman presented with a 3 weeks’ history ofblurring of vision and proptosis in the right eye. Three yearsearlier the patient had been diagnosed with infiltrating ductal

carcinoma. The tumor was ER/PR positive and HER2-neunegative. The initial treatment consisted of left mastectomy,flap reconstruction and neoadjuvant chemotherapy. Postoper-

gyptian Society of Ear, Nose, Throat and Allied Sciences.

Figure 1 PET/CT (positron emission tomography), Transaxial images show no abnormal FDG uptake in the reconstructed left breast

flap, right breast, bilateral internal mammary and axillary lymph nodes.

144 A. Tewari et al.

ative external beam radiation of the left chest wall was also gi-ven. A whole body 18 FDG PET/CT to assess the therapy re-

sponse was done which was normal (Fig. 1), suggestive of agood response to chemotherapy.

After three years, the patient complained of right sided dip-

lopia for 3 weeks. She was seen by an ophthalmologist whodiagnosed horizontal diplopia and abducent (VI) nerve palsy.On clinical examination, the patient had right supraorbitalswelling and grade I proptosis with conjunctival injection or

papilloedema. CT of the head showed right orbital metastasiswith a tumor mass, a size of 3.7 · 4.2 · 2 cm, with infiltrationof the orbital roof and lateral orbital wall and greater wing of

the sphenoid (Fig. 2). MRI study further reported meningealand bony metastatic deposits involving the walls of the rightorbit (Fig. 3), middle and anterior cranial fossa with no asso-

ciated parenchymal brain lesion (Fig. 4). She underwent followup whole body 18 FDG PET/CT which revealed FDG avidheterogeneously enhancing soft tissue lesion in right orbital

apex causing destruction of greater wing of the sphenoid,lateral wall of orbit, right zygoma and extending to the naso-pharynx and right nasal cavity (Fig. 5). Multiple metabolicallyactive skeletal metastases were also noted in C5 vertebra, right

5th and 11th ribs, pelvic bones (bilateral iliac bones, inferior lipof right acetabulum) and left femur (Fig. 6). She received an-

other course of chemotherapy and bisphosphonate treatment.Local radiotherapy of the right orbit and the skull base is re-served if there is further progression of symptoms.

3. Discussion

Metastatic spread to nasal cavity, nasopharynx and hypophar-ynx is extremely rare, and if it occurs, the primary site ofmalignancy is usually a renal cell carcinoma.5 To our knowl-

edge, our case is the fourth case with nasopharyngeal involve-ment from breast carcinoma and second as nasal cavityinvolvement.1–3 The first case presented as a choanal polyp,1

the second as a solitary nasal cavity metastasis,2 the third casepresented with diplopia and found to have partial nasalobstruction on ENT examination only.3

Breast cancer metastases have a relatively wide distribution,

the most common sites of spread are bone, regional lymphnodes, lung, liver and brain.4 Incidence of breast carcinomato head and neck is unknown, usually metastases of this region

Figure 2 Post contrast CT images showing enhancing lesion in

the right orbital apex extending laterally causing destruction of

greater wing of the sphenoid, lateral wall of orbit and zygoma.

Medially it extends to pharyngeal mucosal space and posterior

part of nasal cavity.

Figure 3 T1 weighted contrast MRI images showing enhancing

lesion involving walls of orbit.

Figure 4 T2 weighted coronal images showing meningeal and

bony metastastic lesion involving right anterior and middle cranial

fossa.

Figure 5 Follow up 18 FDG PET/CT revealed FDG avid

heterogeneously enhancing soft tissue lesion in the right orbital

apex causing destruction of greater wing of the sphenoid, lateral

wall of orbit, right zygoma and extending to the nasopharynx and

right nasal cavity.

Nasopharynx – A rare site of metastases from carcinoma breast 145

coexist with other distant sites of metastases, therefore thesehead and neck lesions usually remain occult. But now withthe wider availability of whole body 18 FDG PET/CT, wecan spotlight multiple obscured lesions from the head to toe.

Investigating nasopharyngeal lesions starts with clinical his-tory and examination and includes tissue diagnosis via biopsyand histopathological analysis. Computed tomography (CT) is

the initial radiological investigation of choice and should in-

clude the thorax, abdomen and pelvis. MRI provides a better

delineation and higher resolution when there is need to inves-tigate intracranial and soft tissue spread. 18 FDG PET/CT

Figure 6 18 FDG PET/CT MIP (maximum intensity projection)

images showing multiple metabolically active extensive skeletal

metastases in C5 vertebra, 5th and 11th right ribs, bilateral iliac

bones, inferior lip of right acetabulum and left femur.

146 A. Tewari et al.

scanning is potentially useful in cases of breast cancer in detect-ing distant metastases.3 In some cases it may be necessary tohave one baseline 18 FDG PET/CT to assess the therapeutic re-

sponse and monitor treatment modification in follow up.So, when an ophthalmologist has a patient with unilateral

painful ophthalmopathy and proptosis, orbital metastases6

must be considered and detailed multidisciplinary team exam-inations specially of the ENT should be performed,7 definitelyat the same time whole body 18 FDG PET/CT must be consid-ered to correctly upstage or downstage the disease and to mod-

ify treatment plan.Nasopharyngeal metastases respond well to radiation, some

tumors may be successfully treated with debulking or surgical

resection. Chemotherapy is usually needed for systemic dis-ease. Recognizing metastatic disease and prompt early treat-ment are very important to improve the quality of life.8.

In summary, although rare, breast cancer patients can de-velop metastases to the nasopharynx. Patients with a historyof breast cancer presenting with eye symptoms such as propto-

sis, diplopia, pain, exophthalmos should not only be evaluatedfor orbital metastases but for nasopharyngeal involvementalso. Once the diagnosis is confirmed, the treatment of naso-

pharyngeal metastases is multidisciplinary.

Conflicts of interest

There were no conflicts of interest.

References

1. Sismanis A, Ruffy ML, Polisar IA, Torno R. Metastatic breast

carcinoma presenting as a choanal polyp. Ear Nose Throat J.

1980;59(3):130–133.

2. Liao HS, Hsueh C, Chen SC, Chen IH, Liao CT, Huang SF.

Solitary nasal cavity metastasis of breast cancer. Breast J.

2010;16(3):321–322.

3. Shaun Davey, Simon Baer. A rare case of breast cancer metasta-

sizing to the nasopharynx and paranasal sinuses. Int J Surg Case

Rep. 2012;3(9):460–462.

4. Matsumoto Y, Yanagihara N. Renal clear cell carcinoma meta-

static to the nose and paranasal sinuses. Laryngoscope. 1982;92(10

Pt 1):1190–1193.

5. Klein A, Olendrowitz C, Schmutzler R, Hampl J, Schlag PM,

Maass N. Identification of brain- and bone-specific breast cancer

metastasis genes. Cancer Lett. 2009;276(2):212–220.

6. Ahmad SM, Esmaeli B. Metastatic tumors of the orbit and ocular

adnexa. Curr Opin Ophthalmol. 2007;18:405–413.

7. Fenton S, Kemp EG, Harnett AN. Screening for ophthalmic

involvement in asymptomatic patients with metastatic breast

carcinoma. Eye. 2004;18:38–40.

8. Buchanan CL, Morris EA, Dorn PL, Borgen PI, Van Zee KJ.

Utility of breast magnetic resonance imaging in patients with occult

prima breast cancer. Ann Surg Oncol. 2005;12:1045–1053.