I. Preface
Nasopharyngeal carcinoma is one of the common malignant tumors in China, and the first symptoms are mainly neck masses, blood in the ears, ear symptoms and symptoms caused by local invasion of tumor into other adjacent structures. The first presentation of nasopharyngeal carcinoma with left parotid gland swelling has not been reported, but we encountered a patient who presented with a swelling in the left parotid area and was finally diagnosed with nasopharyngeal carcinoma with extensive systemic metastasis. This case is reported as follows.
Case description
1. General information: ××××, male, 79 years old, married, Shandong nationality, Han nationality, currently residing in Fengtai, Beijing, was admitted to the hospital on November 10, 2006.
2. Complaint: Painless swelling in the left cheek for more than 1 month.
3. History: The patient was unintentionally found a small finger-sized swelling on the left cheek one month ago, with no pain or other discomfort. Since the onset of the disease, the patient had no history of fever or night sweats, and her urine and stool were normal. There was no weight loss. No special medical history.
4. Admission examination: body temperature: 36.7℃, pulse: 78 beats/min, respiration: 19 breaths/min, blood pressure: 139/65mmHg. normal development, good nutrition, clear consciousness, automatic posture, cooperation in physical examination, clear language, and relevant answers. The skin color was normal, without yellowing or pallor. Superficial lymph nodes were not palpated throughout the body. The eyes were not protruding, the eyelids were not swollen, the conjunctiva was not congested, and the sclera was not yellowish. The pupils were equally large and rounded bilaterally, with a sensitive reflex to light and normal gross visual acuity. There was no deformity of the auricle, no purulent discharge from the external auditory canal, and no pressure pain in the bilateral mastoid process. The nasal cavity was clear, no purulent secretions were seen, and there was no pressure pain in the paranasal sinus area. Oral and maxillofacial details were seen in the specialist. The neck was soft, with no jugular vein irritation or arterial pulsation. The trachea was centered and the thyroid gland was not large. There was no deformity of the thorax, the respiratory motion was bilaterally symmetrical, the fibrillation was consistent on both sides, and the percussion of both lungs was clear. Breath sounds were clear in both lungs, and no dry or wet rales or pleural friction sounds were heard. The precordial region was not elevated, the apical pulsation was not obvious, and no tremor was palpable. The cardiac border was not large. The heart rate was 78 beats per minute, and the rhythm was uniform. No murmurs or pericardial friction sounds were heard in the valve auscultation area. The abdomen was flat and soft, no mass was found, and there was no pressure pain or rebound pain throughout the abdomen. The liver and spleen were not palpable under the ribs. There was no percussion pain in both kidney areas. Mobile turbid sounds were negative. Bowel sounds were normal. There was no deformity of the spine and extremities, no redness, swelling and pressure pain in the joints, and normal activity. The anus and external genitalia were not examined. Physiological reflexes were normal and pathological reflexes were not elicited. There was no abnormality in the surface skin, and a 2.5 cm x 2.0 cm x 2.0 cm size swelling was palpable in the deep part, slightly hard, clear and movable, with negative pressure pain and no fluctuation or pulsation sensation. Frowning, eye closure and cheek puffing were normal. There was no pressure pain in the joint area. There was no abnormal mouth opening, poor oral hygiene, free tongue movement, no redness or swelling of the pharynx, no enlargement of the tonsils bilaterally, and the uvula was in the middle. There was no redness or swelling in the ducts of the parotid and submaxillary glands, and no abnormal secretions were seen. No enlarged lymph nodes were detected in the bilateral preauricular, postauricular and full neck areas.
5. Auxiliary examination: routine admission examination was not abnormal, CT showed: enlarged left maxillofacial lymph nodes, biopsy was suggested to confirm the diagnosis; left nasopharynx was slightly elevated, mucous membrane was thickened, nasal crypt became shallow, please combine with other clinical examination. The third cervical vertebra was destroyed, and metastasis was considered.
6. Diagnosis:The patient was initially diagnosed as: left parotid gland swelling at the time of admission. After routine postoperative examination, enlarged resection of the left parotid mass and facial nerve dissection were performed under general anesthesia, and it was seen that the mass had no obvious envelope, and its location was connected to the parotid gland and closely adhered to the upper and lower buccal branches, with the parotid duct passing through the mass and the deep side of the mass adhering to the occlusal muscle. Postoperative pathology: (left parotid gland) hypofractionated squamous cell carcinoma. Immunohistochemical staining showed tumor cells: AE1(+), AE3(+), CEA(-), CK17(-), TTF-1(++). A whole-body examination was performed to understand the source of the lesion and systemic metastasis. A biopsy of the nasal cigarette was performed and reported: hypofractionated nasopharyngeal carcinoma. Magnetic resonance imaging of the neck showed: 1. abnormal signal of cervical 1, 3, 6 and 7 vertebrae, and the possibility of metastasis was considered in combination with medical history; 2. degenerative degeneration of the cervical spine with bulging discs in cervical 4-7 vertebrae. Direct enhancement CT scan of the abdomen showed: multiple small nodular hypodense foci with blurred margins were seen in the liver; after enhancement, they were significantly enhanced and still showed relatively hypodense foci. The right lobe of the liver showed multiple cystic watery foci of variable size with clear margins; no significant enhancement after enhancement. The gallbladder, pancreas, spleen and both kidneys showed no obvious abnormalities. No obvious enlarged lymph nodes were seen in the retroperitoneum. No significant bone destruction was seen in the bones shown. Impression: 1. multiple cysts in the right lobe of the liver; 2. possible liver metastases. Cranial CT shows: No significant metastases are seen on the enhanced cranial CT scan. Age-related brain changes. Direct enhancement scan of lung CT showed: right hilar and bilateral lower lung metastases; right lower lobe obstructive inflammation with incomplete expansion; bilateral pleural effusion; and bilateral upper lobe emphysema. Ultrasound of the face and neck showed: multiple hypoechoic nodules were seen in the neck bilaterally, the large one on the right side was 0.8×0.4cm and the large one on the left side was 0.7×0.5cm with indistinct dermal medullary demarcation. Impression: 1. Bilateral multiple hypoechoic nodules in the neck with enlarged lymph nodes. Whole-body bone scan showed: whole-body bone visualization was performed 2 hours after static tracer injection. Bone visualization was clear. The skull was accessible, and the scapulae were symmetrical bilaterally. The sternum, both ribs, spine, left sacroiliac and right femur can be seen as multiple abnormal radiological concentrations. Both kidneys were visible. Because of the presence of metastases to both lungs, liver, sternum, both ribs, spine, femur and iliosacral, orthopedic and oncology consultation was requested to recommend radiotherapy to some segments of the spine to delay the patient’s paraplegia.
7. Diagnosis: nasopharyngeal cancer with extensive metastasis throughout the body
8. Treatment result: improved
III. Diagnosis and treatment thinking process
The patient was admitted to the hospital with a painless progressive swelling in front of the left earlobe for more than a month. Since the swelling was located in the location of the parotid gland, the diagnosis considered a tumor of parotid origin, and because of the rapid growth, malignant tumor or benign tumor was firstly considered as a rematch now metastatic malignant at noon. After admission, routine chest X-ray examination showed no abnormality. CT of maxillofacial showed: enlarged left maxillofacial lymph nodes, biopsy was suggested to confirm the diagnosis; left nasopharynx was slightly elevated, mucous membrane thickened, nasal crypt became shallow, please combine with other clinical examination. The third cervical vertebral body is destroyed and metastasis is considered. Because the surgery is relatively simple so consider the surgical removal of the mass after the pathology can be denied down the parotid swelling as the primary. The postoperative pathology reported hypofractionated squamous carcinoma, because squamous carcinoma of parotid origin is relatively rare, and CT showed changes in the left parapharynx, so a nasopharyngeal biopsy was performed and reported: hypofractionated squamous carcinoma. Considering that metastasis was suspected in the third cervical vertebra, a whole-body examination was performed, and finally, extensive metastases were found in the hilum, both lungs, liver, sternum, both ribs, spine, femur, and iliosacral. The preoperative chest X-ray showed no abnormality in the rest of the lung and rib-diaphragm angle except for a high-density shadow at the hilum, and the chest CT about a week later showed: metastases in the right hilum and both lower lungs; obstructive inflammation in the lower lobe of the right lung with incomplete expansion; bilateral pleural effusion; and emphysema in the upper lobe of both lungs. In connection with the fact that the patient’s mass grew on the face should be relatively easy to find, which means that the patient’s history of jaw and face is likely to be one to two months, thus it can be seen that the patient’s tumor growth and metastasis are still very fast. In terms of treatment, because of the extensive systemic metastasis and the patient’s age, he was treated with spinal radiotherapy to delay the fracture and improve the patient’s survival quality.
IV. Review
The first symptoms are neck mass, retractable blood, ear symptoms (tinnitus, deafness), and nasal congestion,
Among them, neck masses are the most common. In oral and maxillofacial surgery, the first manifestation of nasopharyngeal cancer is metastasis of cervical lymph nodes. Therefore, nasopharyngeal carcinoma is not usually considered when there is a maxillofacial mass. Moreover, the masses of the parotid gland are often malignant, and the patient had no symptoms in other parts of the body, and the cervical destruction was considered to be caused by malignant tumor of the parotid gland at the beginning. From the CT, the left nasopharyngeal tumor showed atypical performance, so the possibility of nasopharyngeal cancer was not considered. When the tumor was found to have metastasized systemically, the patient was then examined in relation to the nasopharyngeal manifestation of CT, and it was found that submucosal nasopharyngeal carcinoma is often atypical in imaging and prone to liver, lung, and bone metastases, so the case was considered to be most likely to be nasopharyngeal carcinoma, which was later confirmed by nasopharyngeal biopsy. In terms of treatment, because of the extensive systemic metastasis and the patient’s age, only palliative treatment could be performed.
V. Disease profile
The parotid gland, which is only found in some humans, has a tip attached to the superficial lobe of the parotid gland, often located between the anterior border of the parotid gland and the anterior border of the occlusal muscle, above the parotid duct, and varies in size, merging into the parotid duct through one or more small branching ducts [1]. Parotid tumors are much less common clinically, accounting for only 1% to 7.7% of all parotid tumors [3]. Of the 23 parotid tumors reported by Johnson et al [4], 11 were benign and 12 were malignant. Regarding the surgical approach, it is generally considered that the conventional parotid surgical approach is more appropriate, otherwise there is a risk of damaging the buccal branch of the facial nerve and parotid ducts.
Nasopharyngeal carcinoma is a common malignant tumor in southern China, accounting for 90% of nasopharyngeal malignant tumors. CT scan can show the morphology of the nasopharyngeal cavity and adjacent tissues, clarify the location of the tumor and the extent of deeper spread of the lesion, and show the changes of the surrounding bone [5]. Because of the good density resolution and the absence of overlapping tissue shadows, nasopharyngeal carcinoma may be well visualized in the early stage, such as shallowing of the pharyngeal fossa, thickening of the pharyngeal wall or parapharyngeal tissues, and local elevation. When the lesion develops further, the nasopharyngeal cavity may change in shape, such as the disappearance of the pharyngeal fossa and eustachian tube, thickening of the nasopharyngeal mucosa and formation of soft tissue masses, and spreading to adjacent tissue structures.
The mucosal abnormalities usually reflect only a small part of the tumor area, and occasionally there is no mucosal abnormality, but the tumor may exist in the submucosa or invade the area outside the nasopharynx [6]. Because the parietal wall of the nasopharynx and the crypt of the pharynx are directly adjacent to the skull base, and most nasopharyngeal carcinomas are poorly differentiated or undifferentiated carcinomas, they are characterized by strong infiltration, rapid spread, extensive invasion, and early metastasis. There are three main metastatic pathways: firstly, direct infiltration; secondly, lymphatic tract metastasis; and thirdly, hematogenous metastasis. The probability of distant metastasis is also high when cancer cells enter the bloodstream and metastasize to various tissues or organs throughout the body with blood flow [7]. The common metastatic sites are bone 38.7%, lung 19.7%, and liver 17.5%, and the prognosis of nasopharyngeal cancer is very poor once metastasis occurs, with a median survival of only 4 months [8]. Some foreign reports also suggest that distant metastases from nasopharyngeal cancer are not curable and only have a short survival [9].
Lack of awareness and vigilance of nasopharyngeal carcinoma is the main reason for misdiagnosis. The disease has obvious characteristics of geographical distribution and ethnic distribution, with the highest incidence in Guangdong Province, followed by Guangxi, Hunan, Fujian and other provinces, and relatively low incidence in the central and western regions, so physicians do not pay high attention to it ideologically. The nasopharyngeal cancer is excluded from the logical thinking of diagnosis. As the nasopharynx is superior to the skull, inferior to the throat, anterior to the nasal cavity and adjacent to the ear, early symptoms are few and lacking in characteristics, so it is easy to be ignored, and the sequence of symptoms is closely related to the primary site and development of cancer, so patients may not go to ENT department first when symptoms appear, which is another reason for the delay in diagnosis and treatment of nasopharyngeal cancer. For example, when nasopharyngeal carcinoma infiltrates into the rupture hole of skull base, symptoms and signs of cranial nerve damage, such as migraine, blurred vision, diplopia and limited eye movement, appear. Patients often consult neurology, ophthalmology, internal medicine and surgery, etc., but some physicians tend to examine and analyze them from the perspective of specialties, and only treat them according to the disease of their specialty, without considering that these symptoms and signs are actually cranial nerve damage syndrome of nasopharyngeal carcinoma, resulting in long-term misdiagnosis and mistreatment [10].
Indirect nasopharyngoscopy is a simple, rapid and effective screening method, and nasopharyngeal fiberoptic examination is feasible for patients with small nasopharyngeal cavity and difficult to cooperate, which is helpful for detecting microscopic lesions. CT scan and M R I examination of the nasopharynx can clearly show nasopharyngeal lesions, parapharyngeal space invasion and skull base destruction, and guide the treatment. Pathological diagnosis is the basis for confirming the diagnosis of nasopharyngeal cancer. Patients with high suspicion of early nasopharyngeal cancer, especially those with submucosal type, should be closely followed up and multiple nasopharyngeal punctures and biopsies should be performed when necessary to reduce misdiagnosis and provide timely treatment [11].
The 5-year survival rate of nasopharyngeal carcinoma is mainly radiotherapy, and the main reasons for failure are distant metastasis (45. 5%) and local recurrence (34. 3%) [12]. He Man et al [13] analyzed 17 cases of distant metastases of nasopharyngeal carcinoma, 14 cases were bone, liver and lung, and 3 cases were spleen metastases. Radiotherapy is the main treatment for nasopharyngeal carcinoma, but due to the limitation of radiotherapy by anatomical characteristics of nasopharynx, nasopharyngeal carcinoma has recurrence and metastasis in the field after radiotherapy, and it is more difficult to re-radiotherapy, so how to choose appropriate treatment measures to prolong survival is the key to treat these patients. He Man et al [13] analyzed 17 patients with distant metastases of nasopharyngeal carcinoma treated with paclitaxel and isocyclophosphamide chemotherapy, with an efficiency of 82%. Zhang Li et al [14] reported 22 cases of advanced nasopharyngeal carcinoma treated with single agent paclitaxel chemotherapy, with an efficiency of 31.82
The efficiency was 31.82%. Therefore, nasopharyngeal carcinoma should be reviewed regularly after radiotherapy, and further examination should be performed if non-visible lesions are found. For patients with distant metastases, chemotherapy should be the main treatment, and for patients with localized metastases, radiotherapy can be considered. For patients with high-risk metastases, adjuvant chemotherapy should be given after radiotherapy to control distant metastases, which can effectively control the lesions, reduce patients’ pain, and prolong the survival of patients with advanced disease.
For metastases in the abdominal lymph nodes, liver and spleen, B-ultrasound combined with analog positioning machine can be used to locate the metastases, while lung and bone metastases can be located by analog positioning machine and local irradiation should be performed, including 2 cm outside the outer edge of the metastases. The radiation should be selected according to the location of the metastases, and a linear gas pedal or 60Co should be used for those located deep in the body cavity, while electron beam or deep X-ray should be used for superficial sites, DT50-60Gy/ 5-6 weeks.
Chemotherapy (DDP-based regimen) should be given at the same time as radiotherapy (for better health) or after radiotherapy. In case of extensive metastasis or recurrence of primary foci, chemotherapy should be given first, and then radiotherapy should be given to the residual foci. Both radiotherapy and chemotherapy should be given in adequate amounts to achieve complete remission in order to prolong the survival of patients. The application of radiotherapy and chemotherapy for nasopharyngeal carcinoma has been mostly reported [15,16] to control distant metastases, but it has failed to improve survival and prognosis.