The Journal of Laryngology and Otology January 1990, Vol. 104, pp. 41-42
Nasopharyngeal carcinoma with secondaries at the porta hepatis presenting as obstructive jaundice S. ELANGO, M.S.,* C. R. JAYAKUMAR, M.D.t (Kota Bharu, Malaysia)
Abstract Recent reports have dispelled the previously held concept that head and neck cancer rarely metastases beyond the cervical lymph nodes. Nasopharyngeal cancer has been reported to have a higher incidence of distant metastases compared to other head and neck cancers, the common sites being bone, lung and liver. A case of nasopharyngeal carcinoma presenting as obstructive jaundice because of secondaries at the porta hepatis is presented here.
Introduction Distant metastases from head and neck cancers which was previously considered to be a rare occurrence has been reported in the recent literature to be occurring more often than was thought originally. This report presents a case of nasopharyngeal carcinoma presenting as obstructive jaundice because of secondaries at porta hepatis, which is a rarity.
University Hospital, Kota Bharu, as a case of obstructive jaundice with neck swelling. The patient was admitted into a surgical ward and a provisional diagnosis of carcinoma of the head of the pancreas with secondaries in the neck was made. The patient apparently had bilateral neck swellings for eight months with symptoms of obstructive jaundice for two weeks. On examination, there was a clinical evidence of jaundice, with a firm, regular and palpable liver. Hard, fixed lymph nodes were present on both sides of the neck. Liver function tests confirmed an obstructive type of jaundice. An ultrasound examination of the abdomen showed a tumour mass at the porta hepatis with dilatation of the intra hepatic biliary radicles. There was no mass in the liver. Cholangiography (PTC) (Fig. 1) showed grossly dilated intra-hepatic biliary radicles on the left side, whereas the right hepatic duct and common hepatic duct were not filled. These features suggested an extrinsic obstruction in the region of the porta hepatis. The patient was referred for ENT opinion to rule out a primary in the head and neck region. On examination, an ulcerative growth was found in the roof of the nasopharynx. Biopsy from the growth was reported as undifferentiated carcinoma (Type 3 WHO). A laparotomy was performed which revealed a tumour mass at the porta hepatis; the duodenum and pylorus were adherent to the tumour. One litre of blood stained fluid was found in the peritoneal cavity. The liver was enlarged; the pancreas and ampulla of Vater were normal. The tumour mass was removed and the common bile duct was dilated. A cannula was inserted via the ampulla of Vater into the common bile duct to
Case report A 44-year-old man was referred from a district hospital to the
TABLE I DISTANT METASTASES IN NASOPHARYNGEAL CARCINOMA
No of patients
Frequency %
Series Organ Bones Liver Lung Distant lymph nodes FIG.
1
2
1
45 33 29 40
48 29 30 6
48% 36% 31% 43%
Series 1: Ahmad and Stefani, 1986. Series 2: Khoretal., 1978.
1
"Lecturer in ENT. tAssociate Professor in Radiology, University Hospital, Kota Bharu, Malaysia. Accepted for publication: 8 August 1989. 41
2
48.5% 29.3% 30.3% 6.6%
42 the level of the porta hepatis. A biopsy from the tumour was reported as an undifferentiated carcinoma. There was no evidence of a primary anywhere else in the body. The final diagnosis was of a nasopharyngeal carcinoma with secondaries in the neck and distant metastases at porta hepatis. When the patient was told about the nature of the disease, and prognosis he preferred to try traditional healing ('Bomohs'—for medicine) and was lost for follow-up. Discussion Distant metastases from head and neck cancers used to be considered a rare occurrence, but recent reports (Khor et al., 1978; Ahmad and Stefani, 1986) have dispelled that concept. Compared to other head and neck cancers, nasopharyngeal carcinoma has been reported (O'Brien etal., 1971; Probert et al., 1974) to have a higher incidence of distant metastases, varying from 17 to 54 per cent (Ahmad and Stefani 1986). Among the distant metastatic sites skeletal metastases was found to be the commonest (48.5 per cent) (Khor et al., 1978). The other common sites are the lung and liver (Table I). Though hepatic secondaries have been reported previously in nasopharyngeal carcinoma (Khor et al., 1978; Ahmad and Stefani, 1986), there is no case report in the literature of nasopharyngeal carcinoma with secondaries at porta hepatis presenting as obstructive jaundice. The porta hepatis is a region situated on the inferior surface of the liver between the quadrate lobe anteriorly and caudate lobe posteriorly. It is a deep fissure running tranversely between the upper ends of the fissure for the ligamentum teres and the fossa for the gall bladder.
S. ELANGO AND C. R. JAYAKUMAR
Through the porta hepatis, the portal vein, hepatic artery, the hepatic plexus of nerves enter the liver, the right and left hepatic ducts and some lymph vessels emerge. The presence of secondaries in the region of the porta hepatis led to obstruction of the hepatic duct resulting in j aundice of the obstructive type. Acknowledgements We wish to thank the Dean, School of Medical Sciences, Universiti Sains Malaysia for allowing us to publish this paper and Miss Zaiton for typing the manuscript. References Ahmad A. and Stefani, S. (1986). Distant metastases of nasopharyngeal carcinoma. A study of 256 male patients. Journal of Surgical Oncology, 33: 194-197. Khor, T. H., Tan, B. C , Chua, E. J. and Chia, K. B. (1978). Distant metastases in nasopharyngeal carcinoma. Clinical Radiology, 29: 27-30. O'Brien, P. H., Carlson, R., Steubner, E. A. and Stantley, C. T. (1971). Distant metastases in epidermoid cell carcinoma of the head and neck. Cancer, 27: 304-307. Probert, J. C., Thompson, R. W. and Bagshaw, M. A. (1974). Patterns of spread of distant metastases in head and neck cancer. Cancer, 33: 127-133. Address for correspondence: Dr S. Elango, Lecturer in ENT, School of Medical Sciences, Universiti Sains Malaysia, Penang, Malaysia.
Nasopharyngeal carcinoma with secondaries at the porta hepatis presenting as obstructive jaundice S. ELANGO, M.S.,* C. R. JAYAKUMAR, M.D.t (Kota Bharu, Malaysia)
Abstract Recent reports have dispelled the previously held concept that head and neck cancer rarely metastases beyond the cervical lymph nodes. Nasopharyngeal cancer has been reported to have a higher incidence of distant metastases compared to other head and neck cancers, the common sites being bone, lung and liver. A case of nasopharyngeal carcinoma presenting as obstructive jaundice because of secondaries at the porta hepatis is presented here.
Introduction Distant metastases from head and neck cancers which was previously considered to be a rare occurrence has been reported in the recent literature to be occurring more often than was thought originally. This report presents a case of nasopharyngeal carcinoma presenting as obstructive jaundice because of secondaries at porta hepatis, which is a rarity.
University Hospital, Kota Bharu, as a case of obstructive jaundice with neck swelling. The patient was admitted into a surgical ward and a provisional diagnosis of carcinoma of the head of the pancreas with secondaries in the neck was made. The patient apparently had bilateral neck swellings for eight months with symptoms of obstructive jaundice for two weeks. On examination, there was a clinical evidence of jaundice, with a firm, regular and palpable liver. Hard, fixed lymph nodes were present on both sides of the neck. Liver function tests confirmed an obstructive type of jaundice. An ultrasound examination of the abdomen showed a tumour mass at the porta hepatis with dilatation of the intra hepatic biliary radicles. There was no mass in the liver. Cholangiography (PTC) (Fig. 1) showed grossly dilated intra-hepatic biliary radicles on the left side, whereas the right hepatic duct and common hepatic duct were not filled. These features suggested an extrinsic obstruction in the region of the porta hepatis. The patient was referred for ENT opinion to rule out a primary in the head and neck region. On examination, an ulcerative growth was found in the roof of the nasopharynx. Biopsy from the growth was reported as undifferentiated carcinoma (Type 3 WHO). A laparotomy was performed which revealed a tumour mass at the porta hepatis; the duodenum and pylorus were adherent to the tumour. One litre of blood stained fluid was found in the peritoneal cavity. The liver was enlarged; the pancreas and ampulla of Vater were normal. The tumour mass was removed and the common bile duct was dilated. A cannula was inserted via the ampulla of Vater into the common bile duct to
Case report A 44-year-old man was referred from a district hospital to the
TABLE I DISTANT METASTASES IN NASOPHARYNGEAL CARCINOMA
No of patients
Frequency %
Series Organ Bones Liver Lung Distant lymph nodes FIG.
1
2
1
45 33 29 40
48 29 30 6
48% 36% 31% 43%
Series 1: Ahmad and Stefani, 1986. Series 2: Khoretal., 1978.
1
"Lecturer in ENT. tAssociate Professor in Radiology, University Hospital, Kota Bharu, Malaysia. Accepted for publication: 8 August 1989. 41
2
48.5% 29.3% 30.3% 6.6%
42 the level of the porta hepatis. A biopsy from the tumour was reported as an undifferentiated carcinoma. There was no evidence of a primary anywhere else in the body. The final diagnosis was of a nasopharyngeal carcinoma with secondaries in the neck and distant metastases at porta hepatis. When the patient was told about the nature of the disease, and prognosis he preferred to try traditional healing ('Bomohs'—for medicine) and was lost for follow-up. Discussion Distant metastases from head and neck cancers used to be considered a rare occurrence, but recent reports (Khor et al., 1978; Ahmad and Stefani, 1986) have dispelled that concept. Compared to other head and neck cancers, nasopharyngeal carcinoma has been reported (O'Brien etal., 1971; Probert et al., 1974) to have a higher incidence of distant metastases, varying from 17 to 54 per cent (Ahmad and Stefani 1986). Among the distant metastatic sites skeletal metastases was found to be the commonest (48.5 per cent) (Khor et al., 1978). The other common sites are the lung and liver (Table I). Though hepatic secondaries have been reported previously in nasopharyngeal carcinoma (Khor et al., 1978; Ahmad and Stefani, 1986), there is no case report in the literature of nasopharyngeal carcinoma with secondaries at porta hepatis presenting as obstructive jaundice. The porta hepatis is a region situated on the inferior surface of the liver between the quadrate lobe anteriorly and caudate lobe posteriorly. It is a deep fissure running tranversely between the upper ends of the fissure for the ligamentum teres and the fossa for the gall bladder.
S. ELANGO AND C. R. JAYAKUMAR
Through the porta hepatis, the portal vein, hepatic artery, the hepatic plexus of nerves enter the liver, the right and left hepatic ducts and some lymph vessels emerge. The presence of secondaries in the region of the porta hepatis led to obstruction of the hepatic duct resulting in j aundice of the obstructive type. Acknowledgements We wish to thank the Dean, School of Medical Sciences, Universiti Sains Malaysia for allowing us to publish this paper and Miss Zaiton for typing the manuscript. References Ahmad A. and Stefani, S. (1986). Distant metastases of nasopharyngeal carcinoma. A study of 256 male patients. Journal of Surgical Oncology, 33: 194-197. Khor, T. H., Tan, B. C , Chua, E. J. and Chia, K. B. (1978). Distant metastases in nasopharyngeal carcinoma. Clinical Radiology, 29: 27-30. O'Brien, P. H., Carlson, R., Steubner, E. A. and Stantley, C. T. (1971). Distant metastases in epidermoid cell carcinoma of the head and neck. Cancer, 27: 304-307. Probert, J. C., Thompson, R. W. and Bagshaw, M. A. (1974). Patterns of spread of distant metastases in head and neck cancer. Cancer, 33: 127-133. Address for correspondence: Dr S. Elango, Lecturer in ENT, School of Medical Sciences, Universiti Sains Malaysia, Penang, Malaysia.
