INTERESTING IMAGE
Isolated Nasal Tip Metastasis From Esophageal Squamous Cell Carcinoma Aisheng Dong, MD,* Changjing Zuo, MSc,* Yang Wang, MSc,Þ Zhijun Zhai, BSc,* and Wu Wen, MDþ Abstract: Cutaneous metastatic tumors to the nasal tip are very rare. A 74-yearold woman presented with progressive dysphagia for 4 months and a painless red violaceous nodule in the nasal tip for the last 6 weeks. Gastroendoscopy showed midesophageal wall thickening, which corresponded to esophageal squamous cell carcinoma confirmed by endoscopic biopsy. 18F-FDG PET/CT showed intense FDG uptake of the esophageal carcinoma (SUVmax, 19.0) and the nasal tip nodule (SUVmax, 29.1). The patient underwent biopsy of the nasal tip nodule. Nasal tip metastasis from the esophageal squamous cell carcinoma was confirmed by pathologic examination. Key Words: esophagus, carcinoma, metastasis, CT, FDG, PET/CT (Clin Nucl Med 2015;40: 65Y67)
Received for publication October 28, 2013; revision accepted January 10, 2014. From the Departments of *Nuclear Medicine, †Pathology, and ‡Otorhinolaryngology, Changhai Hospital, Second Military Medical University, Shanghai, China. Aisheng Dong and Changjing Zuo contributed equally to the article. Conflicts of interest and sources of funding: Aisheng Dong was sponsored by the Young Scholar Grant from the National Natural Science Foundation of China (81000601). Reprints: Wu Wen, MD, Department of Otorhinolaryngology, Changhai Hospital, 168 Changhai Rd, Yangpu District, Shanghai 200433, China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/15/4001Y0065
Clinical Nuclear Medicine
& Volume 40, Number 1, January 2015
REFERENCES 1. Hammert WC, Champagne L, Heckler FR. Metastatic squamous cell carcinoma of the nasal tip: a case report. J Oral Maxillofac Surg. 1999;57:186Y189. 2. Rosen T. Cutaneous metastases. Med Clin North Am. 1980;64:885Y900. 3. Brownstein MH, Helwig EB. Patterns of cutaneous metastasis. Arch Dermatol. 1972;105:862Y868. 4. Lee HM, Kang HJ, Lee SH. Metastatic renal cell carcinoma presenting as epistaxis. Eur Arch Otorhinolaryngol. 2005;262:69Y71. 5. Quint LE, Hepburn LM, Francis IR, et al. Incidence and distribution of distant metastases from newly diagnosed esophageal carcinoma. Cancer. 1995;76: 1120Y1125. 6. Al-Ani SA, Hernon C, Sillitoe AT, et al. An unusual skin metastasis: esophageal squamous cell carcinoma metastasizing to the nose following nasogastric tube suture. Plast Reconstr Surg. 2005;116:683Y685. 7. Chau CH, Siu WT, Li MK. Nasal tip metastasis from esophageal carcinoma. Can J Surg. 2002;45:224Y225. 8. Bruzzi JF, Swisher SG, Truong MT, et al. Detection of interval distant metastases: clinical utility of integrated CT-PET imaging in patients with esophageal carcinoma after neoadjuvant therapy. Cancer. 2007;109:125Y134. 9. Bruzzi JF, Munden RF, Truong MT, et al. PET/CT of esophageal cancer: its role in clinical management. Radiographics. 2007;27:1635Y1652. 10. Bruzzi JF, Truong MT, Macapinlac H, et al. Integrated CT-PET imaging of esophageal cancer: unexpected and unusual distribution of distant organ metastases. Curr Probl Diagn Radiol. 2007;36:21Y29.
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Clinical Nuclear Medicine
Dong et al
& Volume 40, Number 1, January 2015
FIGURE 1. A 74-year-old woman presented with progressive dysphagia for 4 months and a painless red violaceous nodule in the nasal tip for the last 6 weeks. She had no history of preexisting nasal or paranasal diseases. Gastroendoscopy showed midesophageal wall thickening, which corresponded to esophageal squamous cell carcinoma confirmed by endoscopic biopsy. For staging of the esophageal carcinoma, FDG PET/CT (Biograph 64; Siemens, Germany) was performed 1 hour after the injection of 352 MBq (9.5 mCi) of 18F-FDG with a blood glucose level of 5.7 mmol/L (102.6 mg/dL). Maximum intensity projection PET (A), sagittal CT (B), corresponding PET (C), and fused (D) images showed intense FDG uptake of the esophageal carcinoma (arrow) with an SUVmax of 19.0. Maximum intensity projection PET (A), sagittal (B) and transverse (E) CT, corresponding PET (C and F), and fused (D and G) images showed intense FDG uptake of the nasal tip nodule (arrowhead) measuring 1.6 1.4 cm with an SUVmax of 29.1.
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 40, Number 1, January 2015
Isolated Nasal Tip Metastasis
FIGURE 2. The patient underwent biopsy of the nasal tip nodule. Photomicrograph (A, hematoxylin-eosin, original magnification 100) revealed nests (arrows) of tumor cells from the dermis to the subcutaneous tissue. These infiltrating nests of tumor cells have abundant pink cytoplasm and distinct cell borders. These findings were consistent with metastatic squamous cell carcinoma. Proliferation-related Ki-67 antigen staining showed that the proportion of the positive tumor cells was about 50% (B, original magnification 100). Cutaneous metastases are rare. About 2% of the patients with malignant tumor have cutaneous metastases.1,2 Cutaneous metastases can occur as a single lesion or multiple lesions anywhere on the body but are found predominantly on the anterior trunk or in the head and neck region.1,3 The most common primary tumor is lung cancer in men and breast cancer in women.3 Renal cell carcinoma is the most frequent infraclavicular tumor to metastasize to the nasal cavity and paranasal sinus.4 Cutaneous metastasis of esophageal carcinoma is rare, accounting for only 1% of distant disease.5 Nasal tip metastasis from esophageal cancer is very rare.6,7 PET/CT has limited utility in primary tumor staging of esophageal cancer and relatively limited utility in the detection of dissemination to locoregional lymph nodes. However, PET/CT allows detection of metastatic disease that may not be identifiable with other methods.8Y10 About 18% of patients with newly diagnosed esophageal carcinoma have distant metastases.5 The commonest sites of visceral metastases include the liver, lung, bone, and adrenal gland.5 However, metastases from esophageal cancer can occur in unusual and unexpected locations and can be radiologically occult when traditional imaging methods such as CT are used for detection.9,10 Uncommon sites of organ metastases include the peritoneum, brain, stomach, pancreas, pleura, skin/body wall, pericardium, and spleen.5,9 This case indicates that when interpreting initial staging PET/CT scans in patients with esophageal cancer, in addition to know the most common sites of metastatic disease, it is important to be aware of the possibility of the more uncommon sites of distant metastases.9
* 2014 Lippincott Williams & Wilkins
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67
Isolated Nasal Tip Metastasis From Esophageal Squamous Cell Carcinoma Aisheng Dong, MD,* Changjing Zuo, MSc,* Yang Wang, MSc,Þ Zhijun Zhai, BSc,* and Wu Wen, MDþ Abstract: Cutaneous metastatic tumors to the nasal tip are very rare. A 74-yearold woman presented with progressive dysphagia for 4 months and a painless red violaceous nodule in the nasal tip for the last 6 weeks. Gastroendoscopy showed midesophageal wall thickening, which corresponded to esophageal squamous cell carcinoma confirmed by endoscopic biopsy. 18F-FDG PET/CT showed intense FDG uptake of the esophageal carcinoma (SUVmax, 19.0) and the nasal tip nodule (SUVmax, 29.1). The patient underwent biopsy of the nasal tip nodule. Nasal tip metastasis from the esophageal squamous cell carcinoma was confirmed by pathologic examination. Key Words: esophagus, carcinoma, metastasis, CT, FDG, PET/CT (Clin Nucl Med 2015;40: 65Y67)
Received for publication October 28, 2013; revision accepted January 10, 2014. From the Departments of *Nuclear Medicine, †Pathology, and ‡Otorhinolaryngology, Changhai Hospital, Second Military Medical University, Shanghai, China. Aisheng Dong and Changjing Zuo contributed equally to the article. Conflicts of interest and sources of funding: Aisheng Dong was sponsored by the Young Scholar Grant from the National Natural Science Foundation of China (81000601). Reprints: Wu Wen, MD, Department of Otorhinolaryngology, Changhai Hospital, 168 Changhai Rd, Yangpu District, Shanghai 200433, China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/15/4001Y0065
Clinical Nuclear Medicine
& Volume 40, Number 1, January 2015
REFERENCES 1. Hammert WC, Champagne L, Heckler FR. Metastatic squamous cell carcinoma of the nasal tip: a case report. J Oral Maxillofac Surg. 1999;57:186Y189. 2. Rosen T. Cutaneous metastases. Med Clin North Am. 1980;64:885Y900. 3. Brownstein MH, Helwig EB. Patterns of cutaneous metastasis. Arch Dermatol. 1972;105:862Y868. 4. Lee HM, Kang HJ, Lee SH. Metastatic renal cell carcinoma presenting as epistaxis. Eur Arch Otorhinolaryngol. 2005;262:69Y71. 5. Quint LE, Hepburn LM, Francis IR, et al. Incidence and distribution of distant metastases from newly diagnosed esophageal carcinoma. Cancer. 1995;76: 1120Y1125. 6. Al-Ani SA, Hernon C, Sillitoe AT, et al. An unusual skin metastasis: esophageal squamous cell carcinoma metastasizing to the nose following nasogastric tube suture. Plast Reconstr Surg. 2005;116:683Y685. 7. Chau CH, Siu WT, Li MK. Nasal tip metastasis from esophageal carcinoma. Can J Surg. 2002;45:224Y225. 8. Bruzzi JF, Swisher SG, Truong MT, et al. Detection of interval distant metastases: clinical utility of integrated CT-PET imaging in patients with esophageal carcinoma after neoadjuvant therapy. Cancer. 2007;109:125Y134. 9. Bruzzi JF, Munden RF, Truong MT, et al. PET/CT of esophageal cancer: its role in clinical management. Radiographics. 2007;27:1635Y1652. 10. Bruzzi JF, Truong MT, Macapinlac H, et al. Integrated CT-PET imaging of esophageal cancer: unexpected and unusual distribution of distant organ metastases. Curr Probl Diagn Radiol. 2007;36:21Y29.
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
65
Clinical Nuclear Medicine
Dong et al
& Volume 40, Number 1, January 2015
FIGURE 1. A 74-year-old woman presented with progressive dysphagia for 4 months and a painless red violaceous nodule in the nasal tip for the last 6 weeks. She had no history of preexisting nasal or paranasal diseases. Gastroendoscopy showed midesophageal wall thickening, which corresponded to esophageal squamous cell carcinoma confirmed by endoscopic biopsy. For staging of the esophageal carcinoma, FDG PET/CT (Biograph 64; Siemens, Germany) was performed 1 hour after the injection of 352 MBq (9.5 mCi) of 18F-FDG with a blood glucose level of 5.7 mmol/L (102.6 mg/dL). Maximum intensity projection PET (A), sagittal CT (B), corresponding PET (C), and fused (D) images showed intense FDG uptake of the esophageal carcinoma (arrow) with an SUVmax of 19.0. Maximum intensity projection PET (A), sagittal (B) and transverse (E) CT, corresponding PET (C and F), and fused (D and G) images showed intense FDG uptake of the nasal tip nodule (arrowhead) measuring 1.6 1.4 cm with an SUVmax of 29.1.
66
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 40, Number 1, January 2015
Isolated Nasal Tip Metastasis
FIGURE 2. The patient underwent biopsy of the nasal tip nodule. Photomicrograph (A, hematoxylin-eosin, original magnification 100) revealed nests (arrows) of tumor cells from the dermis to the subcutaneous tissue. These infiltrating nests of tumor cells have abundant pink cytoplasm and distinct cell borders. These findings were consistent with metastatic squamous cell carcinoma. Proliferation-related Ki-67 antigen staining showed that the proportion of the positive tumor cells was about 50% (B, original magnification 100). Cutaneous metastases are rare. About 2% of the patients with malignant tumor have cutaneous metastases.1,2 Cutaneous metastases can occur as a single lesion or multiple lesions anywhere on the body but are found predominantly on the anterior trunk or in the head and neck region.1,3 The most common primary tumor is lung cancer in men and breast cancer in women.3 Renal cell carcinoma is the most frequent infraclavicular tumor to metastasize to the nasal cavity and paranasal sinus.4 Cutaneous metastasis of esophageal carcinoma is rare, accounting for only 1% of distant disease.5 Nasal tip metastasis from esophageal cancer is very rare.6,7 PET/CT has limited utility in primary tumor staging of esophageal cancer and relatively limited utility in the detection of dissemination to locoregional lymph nodes. However, PET/CT allows detection of metastatic disease that may not be identifiable with other methods.8Y10 About 18% of patients with newly diagnosed esophageal carcinoma have distant metastases.5 The commonest sites of visceral metastases include the liver, lung, bone, and adrenal gland.5 However, metastases from esophageal cancer can occur in unusual and unexpected locations and can be radiologically occult when traditional imaging methods such as CT are used for detection.9,10 Uncommon sites of organ metastases include the peritoneum, brain, stomach, pancreas, pleura, skin/body wall, pericardium, and spleen.5,9 This case indicates that when interpreting initial staging PET/CT scans in patients with esophageal cancer, in addition to know the most common sites of metastatic disease, it is important to be aware of the possibility of the more uncommon sites of distant metastases.9
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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