Nasopharyngeal carcinoma presenting as an inconspicuous primary lesion with extensive cavernous sinus involvement and temporal lobe extension: a case report and review of literature

Abstract

Detection of nodal metastasis in the neck or adjacent structures is common in nasopharyngeal carcinoma (NPC) when there is frank primary disease. Intracranial extension without obvious nasopharyngeal disease is not common. Here, we discuss a patient with NPC that presented with extensive intracranial disease with subtle findings in the nasopharynx.

Keywords: Cavernous sinus; magnetic resonance imaging; nasopharyngeal carcinoma; radiosurgery; skull base.

Figure 1

Post‐Gammaknife MRI‐Brain and Cavernous Sinus/Orbital Apex. Axial T2 precontrast slice, white‐dashed arrow identifies residual right cavernous sinus disease. Solid white arrow identifies right temporal lobe mass.

Figure 2

Histological Specimen from Nasopharynx Biopsy. (A) 10X magnification hematoxylin‐ and eosin‐stained pathologic specimen of nasopharynx biopsy. Image identifies sheets of cancerous cells with high nucleus‐to‐cytoplasmic ratio. (B) 20X magnification hematoxylin‐ and eosin‐stained pathologic specimen of nasopharynx biopsy. Large nuclei of cancerous cells are better visualized.

Figure 3

Postchemotherapy MRI‐Brain and Cavernous Sinus/Orbital Apex. (A) Coronal T1 postcontrast slice, solid white arrow identifies right temporal lobe mass. Dashed white arrow identifies residual cavernous sinus disease. White bracket indicates the likely path of spread from the right cavernous sinus to the right temporal lobe. A hyperintense track is observed between the inferior right cavernous sinus and temporal lobe lesions. (B) Axial T1 postcontrast slice, white asterisk identifies no evidence of disease in nasopharynx. Solid white arrow identifies right masticator space enhancement. (C) Fused PET/CT. FDG avidity is demonstrated in the right foramen ovale and right masticator space. (D) CT of the bilateral neck demonstrating involved left level II (white‐dashed circle) and right retropharyngeal lymph nodes (dashed arrow).

Figure 4

Histological Specimen from Temporal Lobe Resection. 10X magnification hematoxylin‐ and eosin‐stained pathologic specimen from the patient's temporal lobe resection. Image identifies densely packed cancerous cells with high nucleus‐to‐cytoplasmic ratios embedded with endothelial cells.

Figure 5

Radiation Treatment Plan. (A) Radiation treatment plan identifying gross disease in the right cavernous sinus region receiving 66 Gy while right temporal postoperative bed receives 60 Gy. (B) Radiation treatment plan identifying gross disease in the left masticator space region receiving 70 Gy.

Figure 6

Postradiation Therapy MRI‐Brain and Cavernous Sinus/Orbital Apex. (A) Coronal T1 postcontrast slice, solid white arrow identifies grossly resected right temporal lobe mass. Dashed white arrow identifies treated right cavernous sinus disease. (B) Axial T1 postcontrast slice, white bidirectional arrow shows no significant enhancement in right and left masticator space.