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Breast cancer metastasis presenting as ethmoiditis

Authors:
A Pitkäranta
A Pitkäranta
A Pitkäranta
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Antti Markkola at Helsinki University Central Hospital
Antti Markkola
H Malmberg
H Malmberg
H Malmberg
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Abstract

Metastasis from primary tumours to the paranasal sinuses is infrequent. We report an unusual case of breast cancer metastasis presenting as ethmoiditis in MRI. MRI changes are unspecific and sometimes inflammatory lesions can not be distinguished from neoplastic lesions. Inflammatory changes in the paranasal sinuses are also frequently noted on MRI even in normal persons without disease. A high index of metastasis suspicion in any patient with breast cancer must be kept in mind.
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On admission, a slight soft tissue edema was observed around
the left eye. Her ear-, nose- and throat status was normal with
no signs of upper respiratory tract infection. MRI showed
changes suggesting ethmoidal sinusitis especially on the left
side (Figure 1). Mucosal changes suggesting polypous thicke-
ning of the mucosa was also seen in the maxillary sinuses and
sphenoids (Figure 1). Ethmoidectomy and sphenotomy was
made on the left side. Only mucosal thickening in the ethmoi-
dal area and mucus in the sphenoidal sinus was seen. Biopsy
specimens from the ethmoidal sinus, but not from the sphenoi-
dal sinus, proved to be metastatic intraductal breast adenocarci-
noma.
DISCUSSION
Our patient had soft tissue swelling around the left eye and
mucosal thickening in her paranasal sinuses which was thought
to represent ethmoiditis with possible orbital irritation on the
left side and thus at risk for inflammatory orbital complications.
MRI abnormalities in the paranasal sinuses are often seen even
in normal persons. According to the literature, the percentage
of patients with incidental radiological abnormal paranasal sinu-
ses may raise over 50% in adults (Jones et al., 1997). During the
winter-time and especially if the subject has symptoms of com-
mon colds morphological mucosal changes in the paranasal
sinuses are regularly noted both in CT and MRI (Rak et al.,
1991; Gwaltney et al., 1994; Puhakka et al., 1998; Tarp et al.,
2000). However, MRI is unspecific and diagnosis and treatment
of possible sinusitis needs further coexisting signs, symptoms
and findings. Sometimes inflammatory lesions can not be dis-
Rhinology, 39, 107-108, 2001
INTRODUCTION
Metastasis from primary tumours to the paranasal sinuses is
infrequent. Only a few cases of paranasal breast cancer metasta-
sis have previously been published (Nelson et al., 1990; Austin
et al., 1995). The mechanism of metastasis to the paranasal sinu-
ses is unclear. The hematogenous spread through the vertebral
venous plexus has been speculated (Batson, 1988). The Valsalva
maneuver may cause a retrograde flow through a valveless low-
pressure system, which communicates with the venous system
of the thorax, and carries tumour emboli to the pterygoid plexus
and paranasal sinuses (Batson, 1988; Nelson et al., 1990). Of
note, it is not known if paranasal sinus metastasis ever occurs as
the only metastasis of breast cancer. We describe one patient
with breast cancer metastasis presenting as ethmoiditis.
CASE REPORT
A 44 years-old woman was admitted to the department of Oto-
rhinolaryngology from the department of Radiotherapy, Uni-
versity of Helsinki, because of mild soft tissue edema around
her left eye and findings suggesting ethmoidal sinusitis changes
in the paranasal MRI in December 1999. No signs of acute or
prolonged rhinitis were apparent. Her medical history included
no previous sinusitis or chronic sinusitis. Seven years earlier the
patient had undergone left mastectomy, axillary node dissection
and had received adjuvant radiation and cytostatic therapy
because of receptor positive intraductal adenocarcinoma.
Despite the treatments, cancer had disseminated into the bones
and brain. The metastatic condition was treated by adjuvant
tamoxifen therapy.
SUMMARY
Metastasis from primary tumours to the paranasal sinuses is infrequent. We report an unusu-
al case of breast cancer metastasis presenting as ethmoiditis in MRI. MRI changes are unspe-
cific and sometimes inflammatory lesions can not be distinguished from neoplastic lesions.
Inflammatory changes in the paranasal sinuses are also frequently noted on MRI even in nor-
mal persons without disease. A high index of metastasis suspicion in any patient with breast
cancer must be kept in mind.
Key words: breast cancer, metastasis, ethmoiditis
* Received for publication: June 5, 2000; accepted: September 6, 2000.
Breast cancer metastasis presenting as
ethmoiditis*
A. Pitkäranta
1
, A. Markkola
2
, H. Malmberg
1
1
Department of Otorhinolaryngology, Helsinki University Hospital, Finland
2
Department of Diagnostic Radiology, Helsinki University Hospital, Finland
CASE REPORT
Opmaak pitkaranta 6/15/01 2:31 PM Pagina 107
108 Pitkäranta et al.
than enhancement of the inflammatory mucosa (Chow et al.,
1993). On T2-weighted scans the signal intensity of metastasis is
usually hypointense compared to inflammatory lesions (Chow
et al., 1993). In our case, the left ethmoid region was T2 hyper-
intense and enhanced significantly with Gd-DTPA which is
suggestive of an inflammatory mucosal tissue. Inflammatory
etiology was further supported by the soft tissue eyelid-edema,
which is not usual in an uncomplicated adult ethmoiditis and
raises suspicion of possible orbital complication and indicates
surgical drainage. Patients with breast cancer represent a small
percentage of patients with ethmoidal metastasis. Sinusitis
changes are common findings which may often be seen inci-
dental in patients. However, a high index of metastasis suspi-
cion in any patient with breast cancer must be kept in mind.
REFERENCES
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Anne Pitkäranta, MD, PhD
Department of Otorhinolaryngology
University of Helsinki
PL 220, 00029 HYKS
Finland
tinguished from neoplastic lesions. In most instances Gadolini-
um-diethylenetriamine pentaacetic acid (Gd-DTPA) enhance-
ment of the paranasal sinus tumour or metastasis is less intense
Figure 1. T1-weighted coronal MR scan (a) after administration of
Gd-DTPA shows highly enhanced lesion in the left ethmoid air cells
(arrow). On the T2-weighted axial scan (b) the lesion is relatively hy-
perintense (arrow) which together with enhancement pattern is sugges-
tive of inflammatory mucosal tissue. The T1-weighted scan (a) also
demonstrates two hypointense cystic lesions in both maxillary sinuses
(arrows).
Opmaak pitkaranta 6/15/01 2:31 PM Pagina 108
... Nasosinus metastases from breast cancer are exceptional. Only a few cases of paranasal breast cancer metastases have ever been published [2] [3] [4]. The mechanism of paranasal sinus metastases is unclear. ...
... The proximity to the orbit can then cause compression or invasion leading to ocular symptoms: exophthalmos, diplopia and blindness [7]. In some cases reported in the literature, the symptomatology has wrongly suggested the diagnosis of ethmoiditis [2], treatment-resistant subacute sinusitis, or cavernous sinus thrombophlebitis with neurological and ophthalmological signs [8]. The diagnosis of these secondary nasosinus localizations is often concomitant with other metastatic bone and visceral lesions which largely determine the patient's prognosis. ...
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... Breast cancer metastases to the sino-nasal-orbital area is an infrequent occurrence; with only five reported cases in the English literature [5,1,4,6,2]. This is an unprecedented case of orbital apex syndrome from metastatic breast cancer. ...
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... 1Y8 Metastasis from primary tumors to the paranasal sinuses is infrequent and clinical symptoms are nonspecific and can mimic an acute or chronic sinusitis. 4 Despite of that, concerning the paranasal metastases, breast cancer is the fourth most frequent carcinoma to localize in this area following renal cell carcinoma, lung carcinoma, and thyroid cancer. 6 Regarding breast cancer, paranasal and orbital region metastases occur at a late stage of disease with poor prognosis. ...
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