Presentation
History of nasal obstruction and epistaxis.
Patient Data
Within the left side and the nasal cavity a partially enhancing mass is demonstrated associated with bony destruction/remodeling. The left side of the sphenoid sinus is opacified, presumably obstructed. It extends superiorly to involve the ethmoidal air cells and the cribriform plate.
It does not appear to clearly transgress the medial and intra walls of the orbit although there are thinned and somewhat irregular.
No convincing intracranial pathology identified.
MRI sequences show a left side nasal cavity a partially enhancing mass is demonstrated associated with bony destruction/remodeling. The left side of the sphenoid sinus is opacified, presumably obstructed. It extends superiorly to involve the ethmoidal air cells and the cribriform plate.
It does not appear to clearly transgress the medial and intra walls of the orbit although there are thinned and somewhat irregular.
No convincing intracranial pathology identified.
This lesion was resected and pathology study revealed a moderately differentiated sinonasal intestinal-type adenocarcinoma.
Asymmetrical intermediate T1 and enhancing tissue extends from the right side of the nasopharynx in the region of the torus tubarius posteriorly and laterally, expanding the pharyngeal mucosal space and extending into ipsilateral longus coli, clivus and occipital condyle. Tissue also involves at least 270° of the high cervical internal carotid artery circumference with the artery passing horizontally along the superior margin of the remaining tissue. Its lumen is not particularly narrowed. This has likely developed and at least progressed since CT. Presumably this reflects the biopsy proven recurrence ( on the right rather than left ). Enlarged right lateral retropharyngeal node is also present, measuring 22 x 5 x 5 mm.
Mastoid air cells are opacified bilaterally, previously aerated on CT.
In addition, there is some poorly enhancing tissue extending from the anterior aspect of the surgical cavity into the expected location of the frontal sinuses with areas of bony deficiency in these regions. This has not significantly changed from the previous CT and may reflect iatrogenic surgical material.
New and markedly irregular plaque-like enhancing dural thickening which has a T2 hypointense component laterally and a more medial T2 hyperintense component which overlies the left cerebral convexity, not clearly continuous with enhancing tumor extracranially. In addition there is extensive edema in the underlying white matter and some areas where normal cortex cannot be defined between the enhancing lesion and white matter, highly suspicious for direct parenchymal invasion.
Associated mass effect with distortion and partial flattening of the left lateral ventricle and 2-3 mm subfalcine herniation to the right.
Right frontal encephalomalacia is noted, unchanged and presumably related to previous therapy.
Conclusion:
Direct tumor extension from the right nasopharynx to involve right skull base with broad based contact of the high right cervical ICA.
Aggressive dural based lesion over the left convexity with almost certain associated underlying parenchymal invasion. Dural metastasis and invasive meningioma are the main differentials, the former favored given disease progression elsewhere.
CLINICAL NOTES: Previous sinonasal adenocarcinoma on left ethmoid resected two years ago. Current left extra-axial brain lesion: metastasis? invasion?
MICROSCOPIC DESCRIPTION: The sections show dense hyalinised collagenous tissue which is extensively infiltrated by a moderately hypercellular tumor. This consists of moderately well-formed glandular structures lined by a stratified arrangement of pleomorphic cuboidal and columnar epithelial cells as well as small numbers of goblet cells. Scattered mitotic figures are identified. There is extensive tumor necrosis. No brain parenchyma is identified. Large aggregates of mucin are noted within which are scattered small solid aggregates of tumor cells. The features are of moderately differentiated sinonasal adenocarcinoma of intestinal type and are similar to those seen in the specimens from previous tumor resection. Dura is infiltrated by tumor with features as described in above. The dural margins are clear of tumor.
DIAGNOSIS: Brain tissue & Dura: Moderately differentiated sinonasal adenocarcinoma of intestinal type; dural; margins clear of tumor.
COMMENT: It is not possible to distinguish between metastatic tumor and direct extension of tumor from paranasal sinus.
Case Discussion
The intestinal-type sinonasal adenocarcinoma is the second most common type of adenocarcinoma of the sinonasal tract, after adenoid cystic carcinoma.
These tumors commonly involves the ethmoid sinus and/or nasal cavity. In advanced cases, like this one, local spread can affect the orbit, the pterygopalatine and infratemporal fossae, as well as the cranial cavity.
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