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In the paranasal sinuses, a metastatic tumor is far less common than primary tumor. Metastasis of penile lymphoma to the paranasal sinuses is very rare. The authors describes a case penile Non Hodgkin’s lymphoma that metastasized to the paranasal sinuses in a 60-year-old man. The patient was treated with chemo - radiotherapy but was lost to follow-up after 3 months.
Paranasal sinus malignancies represents a small portion of the head and neck malignancies, approximately 5% of all head and neck tumors .Metastatic tumors of the paranasal sinuses are much less common . In a review of the world literature published in 2001, Prescher and Brors found 123 reports of 169 cases of metastatic carcinoma of the paranasal sinuses .In this article, we are reporting a rare case of a patient with distant metastasis of Non Hodgkin’s lymphoma into the paranasal sinuses from the penis.
A 60yr old male patient presented with complaints of swelling over the penis from 2 months for which the patient underwent debridement and incisional biopsy. Examination showed swollen and inflamed glans with multiple openings and slough over it. Corpora spongiosa, corpora cavernosa and proximal penile shaft appeared normal. Biopsy of the lesion, on histopathological examination revealed T cell non-Hodgkin’s lymphoma (Figure 1). The patient was referred to the otolaryngology department with the complaints of bilateral nasal obstruction, epistaxis and severe frontal headache. Diagnostic nasal endoscopy showed a fleshy friable mass occupying bilateral nasal cavities up to the vestibule. Next day patient developed rapidly progressive proptosis and loss of vision in both the eyes. Emergency Ophthalmology consultation was taken. Fundoscopic examination revealed progressive central retinal artery occlusion.A contrast enhanced CT scan and MRI of the paranasal sinuses and orbits was performed. It showed soft tissue lesion completely filling bilateral frontal, ethmoidal, maxillary, sphenoid sinuses. Widening of ethmoidal
infundibulum and erosion of bilateral turbinates. The lesion had eroded the posterior wall of left maxillary sinus and extending to the infra-temporal fossa. The lesion had eroded the lamina papyracea on both the sides and extending into the orbit (Figure 2).
MRI scan showed soft tissue attenuation involving
bilateral nasal cavities, maxillary, ethmoidal, sphenoidal
sinuses with involvement of the medial aspect of bilateral
orbit with infiltration of left medial and inferior recti and
inferior oblique muscle (Figure 3).Nasal mass biopsy was done.
Histopathological examination showed tissue fragments lined
by respiratory epithelium exhibiting areas of ulceration with an
underlying tumor composed of atypical lymphoid cells which
are arranged in diffuse sheets and clusters. These lymphoid
cells are intermediate sized and showed large hyper chromatic
nucleus with scanty eosinophilic cytoplasm and are mitotically
active (Figure 4).The histopathological picture was suggestive
of Non Hodgkin’s Lymphoma.The patient was referred to the
Oncology department for further management. The patient was
treated with chemo - radiotherapy but was lost to follow-up
after 3 months.
Paranasal sinuses are a complex anatomic area, surrounding
important structures such as the orbit and skull base. The most
incident tumours are the squamous cell carcinoma, followed by
adenocarcinoma and adenoid cystic carcinoma .In a review,
Prescher and Brors reported 169 cases of metastatic tumour to
the paranasal sinuses . 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
[3,5]. These data are similar to those published by Bernstein .
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[7,8].Metastasis may reach the paranasal
sinuses by hematogenous, lymphogenous, or vertebral venous
plexus pathways. First postulated by Batson , this low-pressure
valve less 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 .Imaging
is essential to determine location and extension of the lesion 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 .Studies have shown that with the combined
treatment of chemotherapy and local radiation, patients with
lymphoma of the nasal cavity and paranasal sinuses have a better
prognosis [11,12]. Early diagnosis and staging are essential for
effective treatment, and lymphomas must always be included
in the differential diagnosis of lesions of the nasal cavity and