Case Reports in Otolaryngology

Case Reports in Otolaryngology / 2018 / Article

Case Report | Open Access

Volume 2018 |Article ID 5428975 | 5 pages | https://doi.org/10.1155/2018/5428975

Metastasis to Paranasal Sinuses from Carcinoma of Prostate: Report of a Case and Review of the Literature

Academic Editor: Richard T. Miyamoto
Received21 Dec 2017
Accepted08 Mar 2018
Published25 Mar 2018

Abstract

Metastasis from distant primary tumors is extremely rare in the paranasal sinuses with few hundred cases in the literature. Metastatic carcinoma of the prostate is even rarer, despite being one of the most common tumors, with only 24 cases published. In this article, we report a case of a 58-year-old male presenting with epistaxis and nasal obstruction as initial symptoms of a metastatic prostate carcinoma in the ethmoid cells and maxillary sinus.

1. Introduction

Paranasal sinus cancer represents a small portion of the head and neck cancer, approximately 5% of all head and neck tumors [1]. These tumors may arise from multiple tissues present in the nose and paranasal sinuses [2] or more rarely be a metastasis from a distant primary cancer.

Prostate adenocarcinoma is the most prevalent malignant cancer in the male population. In Europe, the incidence rate is 214 cases per 1000 men [3]. Metastases from prostate tumors are a major determinant of survival rates, and prostate-specific antigen tests decrease the incidence of metastatic disease at diagnosis [4].

In this article, we presented the rare case of a patient with a distant metastasis in the right ethmoid cells from a prostate adenocarcinoma.

2. Case Report

A 58-year-old male patient was referred to the Otolaryngology Emergency Service because of important unilateral epistaxis, the third episode in the previous month. He also presented with ipsilateral nasal obstruction and diplopia with a three-month evolution. In his medical report, there was a record of penile squamous cell carcinoma treated with surgery and radiotherapy in 2014 and stage IV prostate adenocarcinoma (iliac, lumbar, and encephalic metastasis) refractory to hormone therapy and chemotherapy, submitted to palliative radiotherapy one month earlier.

During endoscopy, a polypoid, papilloma-like mass originated from the middle meatus was visible, occupying the entire right nasal fossa. No other abnormality was seen in the left nasal fossa. The epistaxis was controlled; the patient was stabilized and referred to biopsy.

The computed tomography (CT) and magnetic resonance imaging (MRI) showed soft tissue density lesion in the right nasal fossa, ethmoid cells, and maxillary sinus with extension into the inferior portion of the orbit through the lamina papyracea and posteriorly to the pterygomaxillary fissure (Figures 1 and 2).

The biopsy resulted in adenocarcinoma (Figures 3(a) and 3(b)). Since the patient had a medical report of prostate adenocarcinoma, the sample was submitted to an immunohistochemical panel. The prostate-specific antigen (PSA) was highly positive, and the diagnosis was confirmed as metastatic prostate adenocarcinoma (Figures 4(a) and 4(b)).

Because of the clinical status of the patient, a few symptoms presented, and the fact that he was already submitted to radiotherapy at the same field, it was opted for a clinical follow-up. After two months of the diagnosis, the patient deceased.

3. Discussion

Paranasal sinuses are a complex anatomic area, surrounding important structures such as the orbit and skull base. The most incident tumors are the squamous cell carcinoma, followed by adenocarcinoma and adenoid cystic carcinoma [5].

In a review, Prescher and Brors reported 169 cases of metastatic tumor to the paranasal sinuses [6]. Most cases originated from the kidney, followed by the lung, breast, thyroid, and prostate. Prescher and Brors also reported that the maxillary sinus was the most affected, followed by the sphenoid, ethmoid, and frontal sinuses [6]. These data are similar to those published by Bernstein [7]. In 77% of the cases, just one paranasal sinus was affected [6].

The nonspecific symptoms are similar to those of primary tumors. The nasal symptoms are usually nasal mass, nasal obstruction, facial deformity, and epistaxis. Orbital symptoms may also occur, such as proptosis, ptosis, decreased vision, and diplopia. Occasionally, these symptoms may be the first presentation of an occult primary tumor [8, 9].

The most frequent sites involved in prostate metastasis are the bone (90%), lung (46%), and liver (25%) [10]. The head and neck are rare locations for metastasis, and it occurs more frequently in the brain, dura, and lymph nodes [11]. The treatment may be hormone therapy, chemotherapy, radioisotopes, and radiotherapy [12].

Metastasis may reach the paranasal sinuses by hematogenous, lymphogenous, or vertebral venous plexus pathways. First postulated by Batson [13], this low-pressure valveless system is a connection between deep pelvic veins, intercostal veins, vena cava, and the azygos system. A rise in the abdominal pressure might redirect the blood flux from the vena cava system to the vertebral venous plexus. This flux alteration can allow the tumor to reach the paranasal sinuses [14].

This is the twenty-fifth reported case of metastatic prostate adenocarcinoma in the paranasal sinuses. The majority of cases involved patients with known prostate cancer, with a mean age of 63.15 years, and the most affected sinus was the sphenoid (44.5%). Radiotherapy was the preferred treatment option (40.7%). In Table 1, we describe the cases reported in full text, available online so far.


AuthorAgeSinusSymptomsTreatmentSurvival

Barrs et al. [15]61SphenoidDiplopiaUnknownDied 2 years after presentation
Barrs et al. [15]57SphenoidDiplopia, decreased visual acuity, ptosis, and numbness of the left faceUnknownDied 2 years after presentation
McClatchey et al. [16]54SphenoidFrontal headache and blurring of the right eyeRadiotherapyAlive 1 year after presentation
Leduc et al. [17]75SphenoidDiplopia and ptosis of the right eyePulpectomyAlive 19 months after presentation
Matsumoto et al. [18]79SphenoidHeadache and diplopiaOrchiectomyUnknown
Har-el et al. [19]77MaxillaryExophthalmos of the right eyeOrchiectomy and hormonal blockUnknown
Mickel and Zimmerman [20]67SphenoidDiplopia and numbness on the right side of the noseRadiotherapyDied 2 and a half months after presentation
Saleh et al. [21]71SphenoidBilateral exophthalmos and hemoptysisNoneDied 1 month after biopsy
Fortson et al. [22]50EthmoidNasal obstruction, diplopia, proptosis, and blurred visionChemotherapy and radiotherapyDied 7 months after presentation
Telera et al. [23]61SphenoidPtosis and diplopia of the right eyeRadiotherapyDied 13 months after presentation
Oliver et al. [8]72Maxillary, frontal, and ethmoidFrontal headache and retro-orbital painHormonal blockAlive three months after presentation
Hunt et al. [11]76SphenoidUnknownRadiotherapy and hormonal blockAlive 14 months after presentation
Lavasani et al. [24]67SphenoidDecreased visual acuityRadiotherapyAlive 6 months after presentation
Başeskioglu et al. [25]69MaxillarySinus fullnessRadiotherapyDied 32 months after diagnosis
Ibarguren et al. [26]64Maxillary and frontalPtosis, proptosis, and facial numbnessHormonal block and chemotherapyAlive 8 months after presentation
El Khatib et al. [27]57MaxillaryFacial swellingPulpectomy and hormonal blockDied 9 months after presentation
Viswanatha [28]68Ethmoid and frontalFacial swelling and epistaxisRadiotherapyLost to follow-up after 3 months of presentation
Tunio et al. [29]65EthmoidNasal obstruction, diplopia, and proptosisRadiotherapy and hormonal blockAlive until article publication
Azarpira et al. [30]74MaxillaryNasal obstructionChemotherapy and radiotherapyDied 11 months after presentation
Petersson et al. [31]55SphenoidHeadache, diplopia, and blurred visionHormonal blockUnknown
Puche-Sanz et al. [32]56SphenoidDecreased visual acuity and facial numbnessRadiotherapy and hormonal blockAlive 5 years after presentation
Akdemir et al. [33]73Frontal and ethmoidHeadache and exophthalmosHormonal blockUnknown
Evarts et al. [34]59Maxillary and ethmoidCheek numbness, headache, decreased visual acuity, nasal obstruction, and drainageChemotherapyDied 2 months after biopsy
Lechien et al. [35]67FrontalDiplopia, facial pain, and headacheHormonal blockDied a few months after presentation
Present case58Ethmoid and maxillaryEpistaxis, nasal obstruction, and diplopiaNoneDied 2 months after diagnosis

Imaging is not able to differentiate a local tumor from a metastasis; however, it is essential to determine location and extension and for surgical planning. CT may show enhancement, bone erosion, remodeling, and invasion. Magnetic resonance imaging (MRI) has an important role to help, defining leptomeningeal and orbital invasion [13]. Positron emission tomography (PET-CT) might be useful in the primary occult tumor.

Histopathology has an essential role in the diagnosis. When metastasizing to the paranasal sinuses, normally prostate carcinoma is not well differentiated. Immunohistochemical panel is also important, with positivity of prostate-specific antigen, prostate acid phosphatase, EpCam, NKX3.1, and prostein [36].

Usually, the diagnosis of a metastasis to the paranasal sinuses means a poor prognosis. An important factor that can be crucial is whether the metastasis is isolated or part of a widespread disease.

Normally, the treatment involving the metastasis to the paranasal sinuses is palliative, with the exception of an isolated metastasis, for which the radical surgery may be a viable option. The patient’s quality of life should be a priority. The main goal is pain relief and bleeding prevention. Management has not changed greatly over the years, and therapy options include radiotherapy, chemotherapy, immunotherapy, and, more recently, endoscopic surgery [37].

Endoscopic surgery may provide symptom relief faster, with lower systemic and local side effects [37]. Tabaee et al. suggested three criteria to help in the decision of the surgery: reasonable expectation of improvement, possible prolongation of life, and survivability after anesthesia [38].

4. Conclusion

Despite being a rare entity, metastatic prostatic tumor in the paranasal sinuses should always be part of the differential diagnosis in patients with known prostatic tumor and recently developed nasal or orbital symptoms.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

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Copyright © 2018 Elio Bittar Barbosa et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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