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A Very Rare Case of Metastases to the Nasal Cavity from Primary Rectal Adenocarcinoma
Nishant Lohia1, Harish Sadashiva2, Sankalp Singh3*, Samir Agarwal4, Vikas Gupta5, Manoj Prashar6, Gaurav Trivedi7
1Department of Radiation Oncology, Command Hospital (Air Force), Bengaluru, India. 2Department of Surgical Oncology, Army Hospital (Research & Referral), Delhi, India. 3Department of Radiation Oncology, Army Hospital (Research & Referral), Delhi, India. 4Department of Pathology, Army Hospital (Research & Referral), Delhi, India. 5Department of ENT and Head & Neck Surgery, Army Hospital (Research & Referral), Delhi, India. 6Department of Medical Oncology, Command Hospital (Southern Command), Pune, India. 7Department of Radiation Oncology, Command Hospital (Central Command), Lucknow, India.
Abstract
Nasal cavity as the first site of metastases from colorectal adenocarcinoma without metastases elsewhere is generally unheard of and very rare with only a few cases reported in world literature. The diagnostic dilemma and therapeutic challenge are significant when encountered in clinical practice, especially to differentiate it from a primary nasal pathology. Histopathological examination and immunohistochemistry play an important role. We report an unusual and interesting case of adenocarcinoma rectum with nasal metastases. A 65-year-old male was treated for adenocarcinoma rectum with radiotherapy, surgery and chemotherapy and was disease-free for 9 months post-treatment completion. Subsequently, he presented with nasal bleeding and on evaluation was found to have a nasal mass. Histopathological examination and immunohistochemistry confirmed the mass to be a metastasis from the earlier rectal adenocarcinoma. He received palliative haemostatic radiotherapy for bleeding from the nasal mass and was then treated with 6 cycles of 5-fluorouracil and irinotecan-based palliative chemotherapy. The patient achieved a good level of palliation, had near-complete regression of nasal mass on imaging with no new sites of metastases and hence was placed on regular follow up.
Keywords: Metastases, Nasal cavity, Adenocarcinoma, Radiotherapy
Colorectal cancer (CRC) is one of the most common malignancies in India with approximately 65,000 patients diagnosed with it and 38,000 deaths attributable to it annually.[1] Colon is the more common site with involvement in around two-thirds of the cases with the remaining one-third of cases occurring in the rectum. Adenocarcinoma is the predominant histology in >90% of cases. Approximately 30% of patients with colorectal cancer present with colorectal liver metastases.[2] Metastasis to the nasal cavity from primary rectal lesions is very rare. To the best of our knowledge and online search of the literature, to date, only five cases have been reported. In a clinical setting, it is difficult to distinguish it from a primary pathology of the nasal cavity. Therefore, we would like to present the diagnostic dilemma that we faced when we came across a patient with rectal adenocarcinoma who subsequently developed metastasis to the right nasal cavity.
In October 2017, a 65-year-old male patient, with no known co-morbidities, reported to our oncology centre with complaints of altered bowel habits of constipation for the past three months. A digital rectal examination (DRE) and colonoscopy revealed an indurated growth just above the anal verge. Contrast-Enhanced Computed Tomography (CECT) scans showed a circumferential wall thickening in the distal rectum and anal canal along with multiple, subcentimetric mesenteric and retroperitoneal lymph nodes. Metastatic workup in form of CECT thorax and abdomen revealed no lung or liver secondaries. He then underwent a diagnostic laparoscopy and biopsy from the rectal lesion. No peritoneal deposits were seen on the diagnostic laparoscopy. A diversion colostomy was done as the patient was symptomatic with intestinal obstruction. Biopsy from the rectal growth was suggestive of adenocarcinoma. A final diagnosis of locally advanced adenocarcinoma of the rectum was arrived at.
In December 2017, he was treated with neoadjuvant radiotherapy on an Elite-100 Telecobalt machine using two-dimensional (2D) treatment planning and delivery using a three-field set-up (posterior and bilateral
pelvic fields). He also received oral capecitabine at a dose of 750 mg twice a day concurrently with radiotherapy. Four weeks after completion of the neoadjuvant therapy, the patient underwent an abdominoperineal resection in January 2018. Postoperative histopathological examination showed a 5cm x 5cm x 5cm ulcerated mass in the rectum extending into the anal canal. Microscopically, the tumour was a moderately differentiated adenocarcinoma with the invasion of the muscularis propria. There were signs of chemoradiation-induced tumour necrosis but no evidence of lymphovascular emboli or any perineural invasion. 03 out of the 07 lymph nodes that were dissected were positive for tumour deposits. On immunohistochemical (IHC) analysis, the tumour positively expressed CK20 and CDX2 while it was negative for CK7 which is commensurate with an intestinal-type adenocarcinoma (ITAC). The patient was then treated with five cycles of adjuvant chemotherapy (capecitabine and oxaliplatin) which he completed in September 2018.
After a disease-free interval of around 9 months, he presented again in July 2019 to our centre with complaints of nasal bleeding. An Ear Nose Throat (ENT) evaluation revealed a bleeding mass in the right nostril (Figure 1). No enlarged neck nodes or any other significant positive finding was detected on clinical examination. A CECT of paranasal sinuses (PNS) found a 4.2cm x 3.2cm x 3.3cm soft tissue mass lesion with the destruction of surrounding bone and was also seen opacifying the right maxillary antrum and nasal cavity (Figure 2). CECT Chest, abdomen and pelvis was essentially normal with no evidence of any local recurrence of primary or any other distant metastases. Microscopic examination of the hematoxylin and eosin (H & E) stained nasopharyngeal biopsy tissue revealed deposits of tumour cells arranged in trabecular, sheets and a glandular pattern that was suggestive of adenocarcinoma (Figure 3a). Further, on IHC analysis nasal biopsy of the lesion expressed Pan cytokeratin (CK), CK20 and CDX2 but CK7, CK5/6 and P40 were negative (Figure 3). Thus, the nasal mass's histopathology and the IHC profile were identical to the patient’s previous primary tumour from the rectum.
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Figure 1. The patient presented with bleeding from the nasal mass. |
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Figure 2. A Computed Tomography scan showing soft tissue mass in the right maxillary antrum and nasal cavity |
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