Jurnal reading

1. Journal Reading
Thoracic Metastases from Carcinoma of the
Nasopharynx: High Frequency of Hilar and
Mediastinal Lymphadenopathy
dr. Ekky Rizky Maulana
Supervisor: dr. Irma Hassan Hikmat, Sp.Rad(K)., M.Kes.
Departement of Otolaryngology,
Head and Neck Surgery
Faculty of Medicine,
Padjadjaran University

2. ABSTRACT
•Nasopharyngeal carcinoma is a malignant tumor.
•This article describes the previously unreported radiologic
appearances of thoracic metastases from nasopharyngeal
carcinoma.
OBJECTIVE
•The radiographic (33 patients) and CT (eight patients) appearances of
thoracic metastases from nasopharyngeal carcinoma were studied
retrospectively.
•Radiologic and clinical evidence of metastases was unequivocal In 26
others, 16 of whom had synchronous spread to cervical lymph nodes,
bone, or liver.
MATERIALS AND METHODS

3. ABSTRACT
•Twenty-one patients (64%) had evidence of thoracic lymphadenopathy.
•Seventeen patients (52%) had evidence of multiple parenchymal pulmonary metastases.
•Enlargement of lymph nodes without multiple pulmonary deposits was seen in 12 patients
(36%), seven of whom had radiologic signs of bronchial obstruction, hemoptysis, or a single
pulmonary lesion simulating a synchronous bronchial neoplasm.
•Pleural effusions or deposits (n = 6), lymphangitis carcinomatosa (n = 5), and rib metastases
(n = 4) also were seen.
RESULTS
•Metastases from nasopharyngeal carcinoma may be detected in a wide range of thoracic
sites.
•This disease appears to be as likely to disseminate to the mediastinal or hilar lymph
nodes as to the pulmonary parenchyma, and it can simulate a primary bronchial tumor
or lymphoma.
CONCLUSION

4. Introduction
1.
Methods
2.
Results
3.
Discussion
4.
Conclusion
5.
Table of contents

5. INTRODUCTION
1.

6. Introduction
Nasopharyngeal carcinoma (lymphoepithelioma, Schmincke tumor) is an epithelial
cell tumor that is frequently encountered in young and middle-aged Chinese adults
living in or originating from Hong Kong or southern China.
It is also seen with moderate frequency among the populations of North and East
Africa and in the Eskimos of North America.
It has a strong association with the Epstein-Barr virus and a traditional diet of
dried salted fish, which has been shown to contain high levels of carcinogenic
nitrosamines.
Nasopharyngeal carcinoma is an important cause of morbidity and mortality in Hong
Kong, accounting for 9% of all malignant neoplasms in male patients.

7. Introduction
Distant metastases occur more frequently in nasopharyngeal
carcinoma than in other tumors of the head and neck.
The most commonly affected sites are:
•Bone
•Lung
•Liver
•Distant lymph nodes
Dissemination of tumor has been noted in up to 51% of patients,
and intrathoracic metastases have been recorded in 8-13%.

8. This study were aimed to:
Describe the spectrum of appearances encountered in
patients with thoracic metastases of nasopharyngeal
carcinoma
However, the appearance of thoracic metastases of nasopharyngeal
carcinoma on chest radiographs or CT scans has not been described.

9. METHODS
2.

10. Study Design and Participants
The study group comprised 33 patients who had radiologic signs of
thoracic metastases on follow-up after radiotherapy (with or without
adjuvant chemotherapy) for primary nasopharyngeal carcinoma.
All 33 patients had histopathologically proved primary nasopharyngeal
carcinoma.
Of the 33
patients:
27 were men (average age, 40 years; age range, 22-62 years)
Six were women (average age, 38 years; age range, 28- 60
years).
None had evidence of thoracic metastasis on chest radiographs
when the initial diagnosis was made.
The mean interval between initial radiotherapy for primary
nasopharyngeal carcinoma and detection of thoracic metastasis was 26
months (range, 5-72 months).
Biopsy evidence of metastases was obtained in seven patients.
Three patients had biopsy-proved metastasis to the neck.
Smokers were excluded from the study, except for two patients
with biopsy-proved metastasis.
Only patients whose chest radiographs were available for
review were included in the study.
Twelve CT scans of the thorax in eight patients also were
reviewed.

11. RESULTS
3.

12. RESULTS
More than half the patients had hilar and/or
mediastinal lymphadenopathy, often without
evidence of multiple pulmonary deposits.
Enlarged nodes were seen most often in the hilar
regions.
In seven patients (21%), thoracic
lymphadenopathy was associated with
atelectasis, consolidation, or a single
pulmonary lesion.

13. RESULTS
Four of six patients who had bronchoscopy to assess hilar or
mediastinal masses had evidence of extrinsic bronchial
compression, with endobronchial metastases
Lymphangitis carcinomatosa was seen in association with
mediastinal or hilar lymphadenopathy in five patients.
Intrapulmonary metastases were seen in half the group,
nine of whom had hilar or mediastinal lymphadenopathy also.
•Well-defined metastatic nodules  nine patients,
•Cavitating nodules  four patient
•Poorly defined nodules  three patient
•Miliary lesions  one patient.
Evidence of rib deposits, pleural effusions, and a single
pleural mass also was noted.

14. RESULTS
Twelve CT scans in eight patients showed
mediastinal lymphadenopathy;
• One of the eight patients had normal findings
on a chest radiograph
• Seven others had nodal or pulmonary lesions
shown on CT scans in addition to those seen on
synchronous radiographs.
One CT study did not show additional disease.

15. RESULTS

16. DISCUSSION
4.

17. DISCUSSION
The most important finding in our study is the high frequency of
enlarged hilar or mediastinal glands (63%)
McLoud et al. noted thoracic lymph node metastases in only 25
(2%) of 1071 patients followed up for known extrathoracic
primary malignant tumors.
One third of the 25 patients seen in that study had metastases from
primary sites in the head and neck.

18. DISCUSSION
Seminoma of the testis is the only other extrathoracic primary malignant tumor
that is as likely to metastasize to thoracic lymph nodes as to the lung.
Of the 21 patients with radiologic evidence of thoracic lymphadenopathy in our
study, nine had associated multiple intrapulmonary deposits when nodal
enlargement was detected.
Seven patients had thoracic lymphadenopathy with associated
•Consolidation
•Atelectasis
•or a single distal lung nodule that simulated primary bronchogenic tumor or
lymphoma.

19. DISCUSSION
Typical metastatic sites are usually
multifocal and involves:
•Bones
•Lungs
•Liver
•Distant lymph nodes
Atypical metastatic sites are:
•External auditory canal
•Middle ear
•Mammary gland

20. DISCUSSION
Bronchoscopy was not very helpful, as endobronchial metastasis was found in
only two of six cases.
Extrinsic compression of bronchi by lymph node enlargement was seen in the
remainder.
Lymphangitis carcinomatosa was noted in five cases in our study group, all of
which were associated with hilar or mediastinal lymphadenopathy.
This may have arisen from the recognized pathways of either retrograde
dissemination via involved hilar nodes or hematogenous seeding of
capillaries.

21. DISCUSSION
Most of the intrapulmonary
metastases seen in 17 patients
(52%) in our group were well-
defined, rounded lesions
distributed in typical locations on
both chest radiographs and CT
scans.
Four patients (12%) had the
cavitating type of pulmonary
deposits often associated with
squamous cell primary tumor.
Four cases of lytic (two) or
mixed lytic/sclerotic (two) rib
lesions typical of metastatic
deposits from nasopharyngeal
carcinoma were seen on chest
radiographs in our study.

22. DISCUSSION
Thoracic CT is not currently
a routine procedure for
examination of patients with
nasopharyngeal carcinoma at
our hospital, although we
stress its value in assessment
of suspected hilar or
mediastinal enlargement on
chest radiographs in patients
with nasopharyngeal
carcinoma.
It added useful information in
all but one study, which was
of a patient with hypertrophic
pulmonary osteoarthropathy
in whom findings on the initial
CT scan were normal and a
follow-up scan showed
posterior mediastinal
lymphadenopathy.

23. CONCLUSION
Nasopharyngeal carcinoma can
disseminate to a wide range of
locations in the thorax and that
mediastinal or hilar lymph nodes
are as likely to be the site of deposits
as is the pulmonary parenchyma.
Recognition of the unusual spectrum
of dissemination of nasopharyngeal
carcinoma to the thorax is important
both for radiologists working in
endemic areas and for those who may
encounter the disease among Chinese
immigrants.

24. THANK YOU