Metastases to the nose from clear cell renal cell carcinoma: A case report

RATIONALE

Patients with nasal metastases are seldom seen among clear cell renal cell carcinoma (CCRCC). We report a rare case presenting as a solitary nasal cutaneous nodule, and summarize the therapeutic experience of tyrosine kinase inhibitors (TKIs).

PATIENT CONCERNS

A 86-year-old man with a chief complaint of continuous back pain for 3 months and discovery of a cutaneous nodule on the nose for a month visited the oncology department of our hospital. Maxillofacial computed tomography (CT) scans demonstrated a 1.5 × 0.9 cm and ovoid soft tissue density shade at dorsum of the nose. CT of abdomen revealed a 3.5 × 2.7 cm mass in right kidney and presenting an obvious heterogeneous enhancement.

DIAGNOSES

The pathological examination of nasal excision biopsy confirmed the diagnosis of nasal clear cell carcinoma. Immunohistochemical analysis indicated that the nasal metastatic tumor had a renal origin.

INTERVENTIONS

Sunitinib at a dose of 50 mg/day was administered initially, while the serious cutaneous toxicities, especially hand-foot syndrome, occurred to the patient. Subsequently, axitinib at a dose of 5 mg twice daily was accepted as second-line treatment.

OUTCOMES

The nasal mass shrinked significantly after 8-week treatment of axitinib, and the primary tumor has been stable till now.

LESSONS

Axitinib successfully controlled the nasal cutaneous metastasis with mild adverse reactions, and did not aggravate the cutaneous toxicities resulting from sunitinib. The incidence of cutaneous adverse events were low which had been reported by previous studies; however, it is difficult to say that axitinib is a more effective treatment modality for RCC with nasal metastases, which requires further studies.

Multiple metastases of clear-cell renal cell carcinoma to different region of the nasal cavity and paranasal sinus 3 times successively: A case report and literature review

RATIONALE

Distant metastasis of clear-cell renal cell carcinoma (ccRCC) to the nasal cavity and paranasal sinus is rare. Endoscopic biopsy used to be performed for diagnosis when it is difficult for complete resection due to intense bleeding during surgery. According to previous literature, the outcomes of metastasis after endoscopic surgery remain unclear.

PATIENT CONCERNS

A 62-year-old man with a history of epistaxis was referred to our institution. The clinical, computed tomography (CT) and magnetic resonance imaging (MRI) examination indicate metastasis to sinonasal sinuses.Diagnoses: He was histopathologically diagnosed with different anatomical structures of nasal cavity and paranasal sinus metastases 6, 14, and 15 years after the initial nephrectomy for ccRCC.

INTERVENTIONS

He underwent endoscopic surgery 3 times, once at the time of each metastasis.

OUTCOMES

He survived for 20 years despite of multitransfers and died due to multiple organ failure.

LESSONS

Metastasis of ccRCC to the nasal cavity and paranasal sinus is characterized by varied growth rates, metastatic times and spreading patterns; ccRCC metastasis should be considered with the presence of hemorrhagic lesions in the nasal cavity and paranasal sinus. Endoscopic surgery is the first-line treatment.

Nasal metastasis as the first manifestation of a metachronous bilateral renal cell carcinoma

Renal cell carcinoma is one of the most common tumours to spread by extranodal metastases to the head and neck. Metastatic renal cell carcinoma to the head and neck area has been demonstrated mostly in the paranasal sinuses, parotid gland, the mandible, larynx and hypopharinx. Renal cell carcinoma should be excluded whenever a metastatic lesion is encountered in the head and neck area, even if the metastatic lesion is the first clinical presentation. The diagnosis of metastatic RCC should be suspected in any patient with even a remote history of renal cell carcinoma. We report a case of 79 year old woman with recurrent episodes of rhinorrhea, headache, hyposmia and monolateral right epistaxis, with a history of RCC. We describe RCC nasal metastases in a metachronous bilateral neoplasm, in which a second occult lesion debuted with a homolateral nasal metastases, ten years after left nephrectomy.

[Distant metastases to maxillary sinus from an unknown lung adenocarcinoma: a cases report]

A 59-year-old man was admitted to the Department of Ear, Nose and Throat with a complaint of six-month history of left facial numbness and toothache. There was no special previous medical history in addition to smoking. No obvious abnormality in routine electrocardiogram, chest X-ray, abdominal B ultrasound were found. (1) CT scans showed heterogeneous shadows in maxillary sinus with the lesions on the left max- illary bone and evidently destruction of alveolar bone. The histopathological examination revealed bone tissue which was partly covered by an intact adenocarcinoma cell. (2) Immunohistochemical staining foe CK7, CD117, thyroid transcription factor-1, and novel aspartic proteinase A were positive and thus compatible with metastatic lung adenocarcinoma. (3) Chest CT scans showed a 1 cm x 2 cm mass on the superior lobe of the left lung, with destruction of sternum and rib, confirming that the lesions in the paranasal sinuses were lung cancer metastases. Therefore, this patient conclusively diagnosed as lung adenocarcinoma with multiple bone metastases.

Nephrogenic epistaxis

Metastatic renal cell carcinoma (RCC) in the nose and paranasal sinuses is very rare. We report an unusual case of metastatic RCC that presented as recurrent epistaxis ten years after curative nephrectomy. The purpose of this report is to draw the attention of clinicians to the possibility of metastatic RCC in patients with recurrent epistaxis and nasal mass. We also discuss treatment options and review the relevant literature.

[Digestive system carcinoma metastatic to the nasal cavity: two case report]

Metastatic tumors to the nasal cavity and paranasal sinuses are far less common than primary cancer in this location. The digestive system malignant tumor metastasis to the nose is rarer. The clinical presentation of metastases is similar to that of primary tumors and common symptoms include recurrent epistaxis, nasal obstruction and facial pain. Metastases to the nose and paranasal sinuses usually respond poorly to treatment and have a poor prognosis.

RENAL CELL CARCINOMA METASTASIS TO THE SINONASAL CAVITY: CASE REPORT

Renal cell carcinoma accounts for 3% of all adult malignant tumors. Common sites of metastases are lungs, bone, liver, brain and adrenal glands. Metastatic disease to the head and neck ranges from 15% to 30%. The 5-year survival rate after nephrectomy is 60%-75%, but with multiorgan metastases the 5-year survival rate is significantly lower, 0-7%. A case is presented of a female patient diagnosed with renal cell carcinoma metastases to the paranasal sinuses, diagnosed and treated at the Department of ENT and Head and Neck Surgery, Zadar General Hospital, Zadar, Croatia. The tumor was surgically removed. Unfortunately, the patient died one year after the procedure due to multiorgan failure. Although metastases of renal cell carcinoma to the head and neck are very rare, it should be first suspected when investigating a metastatic tumor in this region. Surgical excision offers the best hope for long term survival. In case of unresectable tumor, other treatment options should be considered such as radiotherapy, immunotherapy and chemotherapy.

Nasal cavity metastasis of breast cancer: a case report and review of the literature

OBJECTIVE

The nasal cavity is an uncommon site for metastasis to develop and thus metastases arising from breast cancer are rarely observed. We report a case of a 61-year-old female with two-year history of breast cancer who presented with a nasal cavity that was diagnosed as metastatic breast carcinoma by histopathological analysis of the nasal cavity specimen.

METHODS

We reviewed the clinical records of the patient and the appropriate world literature.

RESULTS

The patient had been diagnosed with breast cancer two years before. Her present complain was oculus dexter visual acuity decreased. CT and MRI scan revealed a palpable mass on the right nasal cavity. PET/CT demonstrated no additional uptake at the level of other organ. ER and PR demonstrated a similar expression pattern in primary breast carcinoma and nasal cavity lesions. As further treatment she received systemic palliative chemotherapy in addition to intravenous treatment with bisphosphonates, and a total dose of 36 Gy of X-ray (3 Gy per day, 12 fractions) was given to the local site of the right nasal cavity.

CONCLUSION

In patient with a previous history of breast cancer who complains even of ophthalmologic symptoms such as visual acuity decreased, it is important to consider nasal cavity metastatic disease. 18FDG-PET/CT is useful to rule out the presence of other organ metastasis. Histopathological analysis may aid the diagnosis. The establishment of treatment strategies based on a comprehensive understanding of both etiology and pathophysiology is needed for rare cases such as this.

Clival chordoma of the nasal septum secondary to surgical pathway seeding

EDUCATIONAL OBJECTIVE

At the conclusion of this presentation, the participants should be able to recognize seeding as a form of treatment failure in transseptal resection of clival chordomas.

OBJECTIVES

The purpose is to present a case of implanted metastases in the nasal septum after a transseptal approach for resection of clival chordoma and to compare it with other reported cases in the literature.

STUDY DESIGN

Case report and literature review.

METHODS

The clinical history, radiologic imaging, and pathology of a single patient are reviewed.

RESULTS

A 35-year-old female presented with a left intranasal mass that completely occluded the left nasal passage. The patient had a history of clival chordoma treated at an outside institution with multiple partial resections via a transseptal approach and postoperative Gamma Knife radiotherapy. A 2.5 cm mass in the left nasal cavity as well as a 4 cm sellar mass was identified on MRI. Biopsy of the left nasal mass confirmed the diagnosis of chordoma, which was presumed to be secondary to seeding from a previous resection attempt. The patient received no further treatment due to multiple comorbidities.

CONCLUSIONS

Recurrence of clival chordoma due to seeding along the surgical pathway is an infrequent mechanism of treatment failure, with only rare cases documented in the literature. When deciding on the appropriate surgical approach, the surgeon must consider the risk of septal seeding during a transseptal approach. The emergence of transnasal endoscopic skull base approaches may reduce the likelihood of surgical pathway tumor seeding.

Head and neck cutaneous squamous cell carcinoma metastatic to cervical sublevel IIb lymph nodes occurred from primary sites involving the auricle and adjacent neck

PURPOSE

Neck dissections that include sublevel IIb increase the risk of postoperative shoulder dysfunction. The purpose of this investigation was to document the incidence of level IIb metastatic lymphatic spread in a group of patients undergoing neck dissection as part of the surgical management of cutaneous squamous cell carcinoma of the head and neck.

MATERIALS AND METHODS

A retrospective review of the pathology records taken from 1 surgeon from June 2006 through June 2013 was carried out. The predictor variable was the primary tumor site. The outcome variable was the metastatic nodal involvement according to neck level and sublevel. Secondary variables included T stage, pathologist, tumor depth, and the presence of perineural, perilymphatic, and perivascular invasion. Data analyses were by descriptive statistics.

RESULTS

Thirty-six patients with a total of 40 neck dissections met the inclusion criteria. The average primary site tumor depth was 14.7 mm, and there were 16 cases of poorly differentiated squamous cell carcinoma. Sublevel IIb was involved in 7.5% of cases, all of which occurred from lateralized primary sites of the head and neck.

CONCLUSIONS

Cutaneous squamous cell carcinoma arising from the auricle and neck sites adjacent to sublevel IIb may have increased risk of metastatic involvement of sublevel IIb nodes. Further studies with larger numbers are required to determine the risk of metastasis to sublevel IIb from midline sites of the face.

Nasal tip cutaneous metastases secondary to lung carcinoma: three case reports and a review of the literature

Cutaneous metastatic carcinoma of the nose is a rare presentation associated with lung cancer. We report here 3 cases of cutaneous metastatic carcinoma of the nose that originated from lung cancer. Two men, age 61 and 76 years, with lung cancers were referred for evaluation of a tumour on the tip of the nose. The third patient, a 57-year-old man, had developed a rosacea-like tumour on the tip of the nose; although he had no history of internal cancer, whole-body positron-emission tomography-computed tomography revealed a primary lung cancer. Skin biopsies of all 3 cases showed metastatic squamous cell carcinoma, and all primary lung cancers were squamous cell carcinomas. Only 3 patients are described here, and further reports are needed to substantiate this interesting phenomenon. When an elderly patient presents to dermatology with a tumour on the nose with or without known internal cancer, it is necessary to approach the diagnosis with caution.

Late metastasis from renal cell carcinoma to the thyroid and nasal cavity: report of a case

Multifocal cervico-facial metastases are very rare. Medical history of the patient and clinical context make easier the diagnosis. A 54-year-old woman presenting with a nasal obstruction, was referred to our department. She had a past medical history of an operated renal cancer 12 years ago and a right hemithyroidectomy 30 years ago. Clinical examination revealed a polypoid lesion obstructing the right nasal cavity and a thyroid goiter. Fine-needle aspiration was positive for a renal metastasis. Computed tomography confirmed the nasal lesion without bone destruction and a cervical cystic lesion into the left thyroid lobe. Completion thyroidectomy and polyp excision were performed. The final histologic examination revealed a metastasis from a renal cancer. The association of intra-thyroid and nasal cavity metastases is uncommon and not related in the literature, the practitioner must suspect the diagnosis if the patient had a thyroid tumor, a suspicious nasal lesion and a past history of cancer. The surgical management is recommended for isolated metastasis to the nasal cavity and the thyroid gland especially in renal cancer.

Renal cell carcinoma metastatic to the nasal cavity

Metastatic renal cell carcinoma of the nasal cavity is very rare. A 76-year-old man presented with epistaxis and admitted to our hospital. His past histories were right radical nephrectomy for renal cell carcinomas at the age of 68 years and brain infarction at the age of 75 years. Laryngoscopic examination revealed a red polyp of the right nasal cavity. Imaging modalities including CT and MRI also revealed a tumor measuring 2 x 3 x 2 cm. Angiography showed that the tumor is very hypervascular. Clinical diagnosis was angiogenic tumors including hemangioma, sinonasal hemangiopericytoma, and paraganglioma. A blood data showed anemia and low platerets, and bone marrow biopsy revealed myelodysplastic syndrome. A coiling embolization of the feeding artery was performed, and the tumor reduced markedly. The tumor was resected almost entirely. Pathologically, the tumor was 2 x 1.5 x 1.5 cm red tumor. The tumor cells had clear cytoplasm, and arranged in a trabecular pattern lined by a layer of endothelial cells. Atypia is mild. Immunohistochemically, the tumor cells were positive for pancytokeratin (AE1/3, CAM5.2), RCC ma, CD10, and Ki-67 (labeling=20%), but negative for CD34, factor-VIII-related antigen, CEA, EMA, melanosome (HMB45), S100 protein, p53, and HepPar-1. The pathological diagnosis was made without knowledge of kidney status. A pathological diagnosis of metastatic renal cell carcinoma of clear cell type (grade 1) was made. The patient is now free from tumor, and palliative chemoradiation is considered.

[Metastatic tumors in nasal cavity and pharynx: a clinicopathological analysis of 11 cases]

OBJECTIVE

To investigate the clinicopathological characteristics, diagnosis and differential diagnosis of metastatic tumors in nasal cavity and pharynx.

METHODS

The clinicopathological data of 11 patients was studied retrospectively with a literature review. Among 11 cases, 7 patients were males and 4 females. Ages ranged from 46 to 78 years old. The sites of the metastatic tumor involvement included 5 cases of nasal cavity (3 cases derived from kidney, 1 case from lung, 1 case from liver), 3 cases of nasopharynx (1 case derived from rectum, 1 case from lung, 1 case from eyelid), 2 cases of palatine tonsil (1 case derived from lung, 1 case from liver) and 1 case of laryngopharynx (1 case derived from liver). All cases were lack of specific clinical symptoms related to metastatic sites. The treatment was primarily based on radical metastasectomy and systemic therapy.

RESULTS

Histopathologically, clear cell carcinoma was the most common (4/11), followed by adenocarcinoma (2/11), hepatocellular carcinoma (2/11), tubular adenocarcinoma (1/11), intrahepatic bile duct carcinoma (1/11) and eyelid board carcinoma (1/11).

CONCLUSIONS

The incidence of metastatic tumors in nasal cavity and pharynx is extremely low. The definite diagnosis mainly relies on the history of primary cancer and the morphological characteristics of metastatic tumor. The treatment is primarily based on radical metastasectomy and systemic therapy.

[Metastasizing esthesioneuroblastoma]

Esthesioneuroblastoma is a rare malignant tumour that originates from the olfactory region. Its incidence is about 0.4 per million per year. The most common symptoms include epistaxis, headache, nasal obstruction, hyposmia and eye symptoms. Diagnosis of this rare tumour is often delayed. We present a case in which a 61-year-old male was referred due to proptosis and loss of vision. Magnetic resonance imaging showed a tumour in the nasal cavity involving the orbit, the frontal lope of the brain and lymph nodes in the neck. The case was staged according to Kadish as a stage C. Surgery was performed and postoperative radiotherapy planned.

Cytologic findings of metastatic hepatocellular carcinoma of the nasal cavity: a report of 2 cases

BACKGROUND

Hepatocellular carcinoma metastasizing to the nasal cavity is rare, but nasal bleeding caused by it is difficult to treat. The reason is that a large majority of patients have a bleeding tendency due to liver cirrhosis. Accordingly, early and correct diagnosis is essential.

CASES

Case 1, a Japanese man in therapy for C type liver cirrhosis and hepatocellular carcinoma, was diagnosed as metastasis to the bones, and then he was admitted. After hospitalization, he complained of nasal obstruction. Fine needle aspiration biopsy from a tumor occupying nasal and maxillary cavities showed overlapped cells and scattered cells having a round to oval nucleus containing one or a few large nucleoli. The characteristics of cells indicated metastasis of hepatocellular carcinoma. In case 2, a Japanese man under treatment for liver cancer visited our hospital with a complaint of nasal obstruction. In fine needle aspiration biopsy from a mass in the right nasal cavity, cohesive clusters and sparse neoplastic cells similar to those observed in the first case were found.

CONCLUSION

Aspiration cytology is useful in the diagnosis and treatment of hepatocellular carcinoma metastatic to the nasal cavity. Finding characteristic cells is important in the diagnosis. Clinical information is sure to be a convincing clue.

Metastatic cutaneous head and neck renal cell carcinoma with no known primary: case report

Renal cell carcinoma represents 2-3% of all adult malignancies, and metastasis to the head and neck is a presenting complaint in 8% of these patients. Cutaneous facial renal cell carcinoma with no known primary renal tumour is unusual. We report a case of renal cell carcinoma of the nose with no known primary.

Adenoid cystic carcinoma of the trachea metastatic to the nasal cavity: a case report

Cases of carcinoma metastatic to the nasal cavity are rare. We report the case of a 63-year-old woman with a metastasis to the nasal cavity from a primary tracheal adenoid cystic carcinoma (ACC). The nasal tumor was treated with surgical resection. No evidence of any local recurrence was observed at 4 years of follow-up. To the best of our knowledge, no case of a tracheal ACC metastatic to the nasal cavity has been previously reported in the literature. Although rare, metastatic disease to the nasal cavity should be considered in patients who have a known primary carcinoma elsewhere and who present with nasal symptoms.

Sinonasal metastatic tumors in Taiwan

BACKGROUND

To analyze the incidence of the metastatic tumors within sinonasal tract in Taiwan and review the data in the English literature.

METHODS

Retrospective reviewed of patients from 1990 to 2005 with a histologically proven diagnosis of metastatic malignancies in the sinonasal tract.

RESULTS

Among seventeen enrolled patients, 9 were men and 8 were women, with ages ranging from 24 to 76 years old, with a mean of 50.8 years. In order of frequency, sinonasal metastatic tumors originated from the gastrointestinal tract (30%), liver (18%), kidney (18%), breast (18%), thyroid gland (12%) and lung (6%).

CONCLUSION

The incidence and characteristics of metastatic neoplasms in Taiwanese patients are comparable to other countries in East Asia, except for Japan. However, our data are very different when compared with European and North American reports. Different incidences of malignant neoplasms in the primary site may explain the result of different incidences of sinonasal metastatic tumor.

[Face cancer infiltrating of ethmoid-orbito-nasal complex]

Face cancer is one of the most common skin tumors and because of its locations is usually early diagnosed. In spite of this a lot of recurrence after surgical treatment are observed. It is caused a lack of proper margins in sequence of limitation excision because of esthetic and functional reasons. The recurrence of skin cancer primarily localized in periocular region and infiltrating intraorbital, ethmoidal and nasal tissues demand extensive and injurious surgical procedures. The authors present their experience in diagnostic and treatment patients with recurrent cancers infiltrating of ethmoid-orbito-nasal complex.

Solitary metastasis in a nasal fossa as the first manifestation of a renal carcinoma

Renal cell carcinoma is an uncommon tumor in adults. Metastasis in the nasal fossa is rare, and can become apparent as a result of repeated epistaxis. We report a patient with renal cell carcinoma presenting with epistaxis secondary to a metastasis in the right nasal fossa. The primary tumor was treated with nephrectomy and the nasal fossa metastasis was treated successfully with embolization, chemoimmunotherapy, surgery, and radiotherapy. The presence of repeated epistaxis may very occasionally be the first symptom of renal cell carcinoma, and systemic treatment combined with local treatment may enable adequate control of the disease.

Metastatic renal cell carcinoma to the nose and ethmoid sinus

We report a rare case of metastatic renal cell carcinoma involving the nose and ethmoid sinus, 17 years after initial nephrectomy and diagnosis of Stage T1N0 clear cell renal cell carcinoma. The patient complained of nasal obstruction and epistaxis. Intensity-modulated radiotherapy (IMRT) was delivered using a higher-than-conventional daily fraction size concurrently with interferon and thalidomide. The patient achieved a complete response both clinically and by magnetic resonance imaging, without any side effects. Late and rare sites of recurrences and treatment options are discussed.

A case of metastatic hepatocellular carcinoma in the nasal cavity

Metastatic hepatocellular carcinoma in the nasal cavity and paranasal sinuses is rare. We report the case of a 71-year-old male afflicted with hepatocellular carcinoma with metastasis in the maxillary sinus and nasal cavity. He underwent radiation therapy with a total dose of 36 Gy, but he died of terminal liver failure. The possible metastatic route and prognosis of metastatic hepatocellular carcinoma in the sinonasal tract are discussed.

[Testicular choriocarcinoma presenting as cutaneous metastasis. A case report and review of the literature]

Choriocarcinoma are germinal tumors from testicular cells in men or foetal trophoblast in women. Cutaneous metastasis are very rare. The authors report a case of angioma-like tumor in a 22-year-old man which was a cutaneous metastasis of a testicular carcinoma. Diagnosis was of course histologic. Testicular echography showed an intra testicular tumor, pulmonary and abdominal CT-scan showed multiple metastases. Orchidectomy and retroperitoneal lymphadenectomy were performed before a general chemotherapy. Patient died 14 months after diagnosis. Only 11 cases of cutaneous metastasis of choriocarcinoma were found in the world literature (7 men and 4 women). All cases showed diagnosis trap for plastic surgeon.

[Extrahepatic metastasis of hepatocellular carcinoma to the nasal cavity manifested as massive epistaxis: a case report]

Extrahepatic metastasis of hepatocellular carcinoma (HCC) is not infrequently found during the later stage, regarding that the autopsy report described its prevalence to be up to 50%. The most frequent sites are known to be the abdominal lymph nodes, lung and bone. However, metastasis to the nasal cavity and paranasal sinuses has been seldom reported, and to out knowledge, there is no Korean report describing extrahepatic metastasis of HCC to these sites. Recently we experienced a case of extrahepatic metastasis of HCC to the nasal cavity in a 50 year-old man with massive epistaxis refractory to conservative treatment. He was found to have a mass of soft tissue attenuation occupying the right nasal cavity at CT, which was biopsy-proven as metastatic HCC. Epistaxis was successfully treated by transcatheter arterial embolization.

Prostatic metastases in the nose and paranasal sinuses

Prostatic metastases in the nose and paranasal sinuses are rare. Seven cases have previously been reported in the world literature. We describe the clinical presentation of a patient with prostatic metastases and the use of prostate specific antigen in confirming the diagnosis. We also review the literature about metastases involving the nose and paranasal sinuses.

Nasal carcinoma--a rare indication for a permanent pacemaker

Cardiac sinus syncope is a recognised but rare complication of head and neck cancers. Although electrical pacing remains an important treatment to prevent further syncopal episodes related to bradycardia, vasopressor-related syncope remains a more difficult management problem. The article describes the case of a 66-year-old patient with metastatic squamous cell carcinoma of the nose, who presented with syncope and exhibited carotid sinus syncope related to both carotid body invasion and vasopressor mechanisms. Successful management by the insertion of a permanent pacemaker is described, and a review of the literature on this rare complication is given.

Metastatic renal cell carcinoma presenting as epistaxis

Metastatic tumors in the nasal and paranasal sinuses are very rare. The origin of metastatic tumors in the nasal or paranasal sinuses is often renal cancer. Renal cell carcinomas are known for their tendency to early metastasis, and symptoms due to the metastatic lesion may be the only initial manifestation. In this paper we deal with the case of a 73-year-old patient who presented with recurrent epistaxis. The presence of a primary renal cell carcinoma was recognized only after surgical removal of the metastatic tumor. The presentation, difficulties in diagnosis and treatment of this tumor are discussed, with a review of the literature.

Sinonasal adenocarcinoma: evidence for histogenetic divergence of the enteric and nonenteric phenotypes

Adenocarcinomas of nonsalivary origin represent approximately 10% to 20% of all sinonasal malignancies and are characterized by varying histopathologic features and uncertain histogenesis. To better understand the histogenesis and phenotypic heterogeneity of these tumors, we performed immunohistochemical analyses for cytokeratin (CK) 7 and CK20 on 12 primary sinonasal adenocarcinomas (SNACs) representing the histopathologic spectrum of these tumors, adjacent normal mucosa, and 2 metastatic adenocarcinomas from colonic primaries. The demographic and clinicopathologic characteristics of our cohort were similar to those in previously published series. Our results indicate that histologically normal respiratory-type epithelium and submucosal seromucous glands show restricted reactivity to CK7. Epithelial metaplasia of surface epithelium associated with enteric SNACs was accompanied by a conversion from CK7 positivity to CK20 positivity. All primary enteric-type carcinomas and the 2 colonic metastases were reactive to CK20, but all nonenteric-type tumors were negative for CK20 (P=0.003) and positive for CK7. In some of the enteric types, coexpression of CK7 and CK20 was noted. We conclude that (1) nonenteric-type (seromucinous) adenocarcinoma may originate directly from surface respiratory-type epithelium or from seromucous glands, (2) metaplastic transformation of surface respiratory to enteric-type epithelium precedes the development of enteric adenocarcinoma, and (3) coordinate analyses of CK7 and CK20 reactivity may aid the differential diagnosis of adenocarcinoma in the sinonasal tract.

[Renal cell carcinoma metastases to nose and paranasal sinuses presenting as recurrent epistaxis]

Distant metastases in head and neck region are very uncommon. Nasal bleeding was the first symptom in a patient with metastasis from renal cell carcinoma. Nasal tumour biopsy revealed renal carcinoma to be the primary lesion. Initially the patient refused surgery and nephrectomy was performed 8 months later. MR scans demonstrated diffuse intracranial invasion which made complete removal impossible. Potential routes of renal carcinoma spread are presented. Renal cell carcinoma should be considered in the diagnosis of nose and paranasal tumours. Epistaxis can be the first symptom of renal carcinoma metastasis to the nose and paranasal sinuses.

Fine needle aspiration cytology of metastatic choriocarcinoma presenting as a breast lump. A case report

BACKGROUND

While choriocarcinoma is a rapidly invasive, widely metastasizing malignancy, it responds well to chemotherapy, so it is important to obtain an early diagnosis. We report the fine needle aspiration cytology (FNAC) of a case of choriocarcinoma metastatic to the breast.

CASE

A 48-year-old female presented with a cough, hemoptysis and epistaxis. Chest computed tomography revealed multiple nodules in both lung fields. Also, a firm, slightly tender mass in the lower outer quadrant of the left breast was palpated. The breast mass was clinically suspected to be a metastatic lung cancer. FNAC of the breast showed a malignant tumor that had been misdiagnosed as a metastatic non-small cell carcinoma of the lung. Histologic examination of a nasal biopsy revealed metastatic choriocarcinoma.

CONCLUSION

The cytologic features of choriocarcinoma are quite characteristic, with side-by-side, malignant, mononucleated cells and multinucleated giant cells corresponding to cytotrophoblasts and syncytiotrophoblasts, respectively. The disease is possible to diagnose by a careful examination of FNAC samples.

Metastatic hepatocellular carcinoma in the nasal septum: report of a case

Metastatic hepatocellular carcinoma (HCC) in the sinonasal region is rare. We report the case of a 45-year-old male hepatitis B carrier who had metastatic HCC 2 years after resection of the primary tumor. The patient died of terminal hepatic failure 6 weeks after the discovery of nasal septal metastasis. The clinical and histopathologic characteristics of the primary and metastatic hepatocellular tumors are described. This is the first reported case of nasal septal metastasis from HCC.