Nasopharyngeal carcinoma

Case contributed by Dr Yair Glick

Presentation

Nasal obstruction, snoring, plugged ears.

Patient Data

Age: 15 years
Gender: Male
MRI

Nasopharyngeal mass inseparable from lymphatic tissue, measuring 4.0 x 3.6 x 3.0 (TRV x AP x CC) cm, slightly hypointense on T2WI, showing diffusion restriction, and enhancing quite homogeneously. The mass bulges into the right choana. Markedly enlarged retropharyngeal lymph nodes (up to 3 cm on left). Enlarged jugular (stations II and III) lymph nodes, bilateral. Fluid in right mastoid air cells, most probably representing blocked drainage. Asymmetrical enhancement of the pterygoid venous plexus, appearing more engorged on the right. Enhancement involving tail of right parotid gland, the significance of which is not entirely clear; possibly enhancement of the plexus itself.

In summary:

  • nasopharyngeal mass, possibly of lymphatic origin
  • substantially enlarged cervical lymph nodes, as depicted above - lymphoma?

Case Discussion

The patient went in for an ENT consultation for severe nasal congestion.

From the endoscopy report:
Nasopharynx: obstructive fleshy lesion in midline, extending more to the right, obstructing the ipsilateral choana. The lesion is highly vascular. Profuse mucoid excretion. Rest of exam - free valleculae, epiglottis and arytenoids with no edema, freely moving vocal cords, open glottis, free subglottis, normal hypopharynx.

The following step was an MRI, which showed the mass, plus cervical lymphadenopathy which was not palpated on a physical exam. The mass's location and characteristics were suspicious for lymphoma.

The mass was duly biopsied.

Histopathology report:

Nasopharyngeal biopsy:
Extensively involved by non-keratinizing nasopharyngeal carcinoma, undifferentiated type, EBV-positive.
Immunohistochemical stains for P40, CK5/6, CK MNF, and CD20 confirmed the diagnosis.
Immunostain for Epstein-Barr virus (EBER) CISH was strongly positive.
Proliferative index, according to Ki67 - up to 30%.
P16 was negative.

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