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 Table of Contents     
CASE REPORT
Year : 2014  |  Volume : 29  |  Issue : 3  |  Page : 177-178  

Asymptomatic cauda equina metastasis in a patient with nasopharyngeal carcinoma: Detection by 18 F-FDG PET/CT


Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication11-Jul-2014

Correspondence Address:
Rakesh Kumar
E-81, All India Institute of Medical Sciences Campus, Ansari Nagar (East), New Delhi -110029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.136581

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   Abstract 

The central nervous system metastasis from nasopharyngeal carcinoma (NPC) is an extremely rare occurrence, although direct intracranial invasion is not infrequent in patients with NPC. Herein we report a case of a 62-year-old male with NPC, in whom the asymptomatic cauda equina metastasis was detected on staging 18 F-Fluordeoxyglucose positron emission tomography-computed tomography (F-FDG PET/CT). By demonstrating distant metastasis to cauda equina, 18 F-FDG PET/CT detection helped in change of management in this patient.

Keywords: Cauda equine, metastasis, nasopharyngeal carcinoma, PET/CT


How to cite this article:
Karunanithi S, Jain S, Sharma P, Bal C, Kumar R. Asymptomatic cauda equina metastasis in a patient with nasopharyngeal carcinoma: Detection by 18 F-FDG PET/CT. Indian J Nucl Med 2014;29:177-8

How to cite this URL:
Karunanithi S, Jain S, Sharma P, Bal C, Kumar R. Asymptomatic cauda equina metastasis in a patient with nasopharyngeal carcinoma: Detection by 18 F-FDG PET/CT. Indian J Nucl Med [serial online] 2014 [cited 2019 Dec 10];29:177-8. Available from: http://www.ijnm.in/text.asp?2014/29/3/177/136581


   Introduction Top


The central nervous system (CNS) metastasis from nasopharyngeal carcinoma (NPC) is an extremely rare occurrence, although direct intracranial invasion is not infrequent in patients with NPC. 18 F-Fluordeoxyglucose ( 18 F-FDG) positron emission tomography-computed tomography (PET-CT) is an excellent tool for staging NPC. Here we present a case where 18 F-FDG PET/CT scan detected an asymptomatic cauda equina metastatic lesion in a patient with NPC and helped in change of management.


   Case report Top


A 62-year-old male was presented with history of neck swelling, nasal obstruction and epistaxis. On examination, bilateral cervical lymphadenopathy was noted. A well-defined soft tissue density lesion at nasopharyngeal region abutting the posterior pharyngeal wall was also noted. Biopsy from the nasopharyngeal mass was done and it showed undifferentiated carcinoma. The patient was referred for whole body 18 F-FDG PET/CT for staging.

PET/CT revealed 18 F-FDG avid primary malignant disease involving the roof and posterior wall of nasopharynx and bilateral fossa of rossenmuller, with metastases to bilateral cervical and left supraclavicular lymph nodes. Interestingly, a discrete 18 F-FDG avid (SUVmax-8.6) nodular lesion was noted in the cauda equina region at the level of L4-L5 vertebrae, which was highly suggestive of metastasis [Figure 1]. This lesion was later confirmed to be metastatic at contrast-enhanced magnetic resonance imaging (MRI) and the patient was referred for regional radiotherapy. The patient then underwent chemotherapy and regional radiotherapy to cauda equina lesion.
Figure 1: 18F-FDG PET/CT study for staging. PET/CT revealed 18F-FDG avid primary malignant disease involving the roof and posterior wall of nasopharynx and bilateral fossa of rossenmuller (a and b; broken arrow), with metastases to bilateral cervical and left supraclavicular lymph nodes (a and c; arrows). A discrete 18F-FDG avid nodular lesion was noted in the cauda equina region at the level of L4-L5 vertebrae (a,d-g; bold arrow)

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   Discussion Top


Nasopharyngeal cancer is the head and neck cancer with the highest incidence of distant spread. The most common distant metastatic sites are bone, lung and liver in descending order. [1] While intracranial invasion by direct extension from the nasopharynx is a common finding in locally advanced NPC, CNS metastasis of NPC is an extremely rare occurrence. [2],[3] All the reported cases of spinal cord metastases have been associated with locally advanced disease. [3],[4],[5] The possible mechanism of metastases is hypothesized to be dissemination through the cerebrospinal fluid. Because of complications associated with tissue diagnosis, imaging plays a vital role in diagnosis of spinal cord metastasis. 18 F-FDG PET/CT can play an important role in this aspect. [6] Also, in our case 18 F-FDG PET/CT played a critical role in detection of the metastatic cauda equina lesion.

Although, cauda equina metastasis in NPC has been documented in literature, [7] to the best of our knowledge, the present case is the first one reporting the utility of 18 F-FDG PET/CT for detecting asymptomatic spinal cauda equina metastasis in nasopharyngeal carcinoma. By demonstrating distant metastasis to cauda equina, 18 F-FDG PET/CT detection changes the management in this patient.

 
   References Top

1.Teo PM, Kwan WH, Lee WY, Leung SF, Johnson PJ. Prognosticators determining survival subsequent to distant metastasis from nasopharyngeal carcinoma. Cancer 1996;77:2423-31.  Back to cited text no. 1
    
2.Ozyar E, Atahan IL, Akyol FH, Gürkaynak M, Zorlu AF. Cranial nerve involvement in nasopharyngeal carcinoma: Its prognostic role and response to radiotherapy. Radiat Med 1994;12:65-8.  Back to cited text no. 2
    
3.Ngan RK, Yiu HH, Cheng HK, Chan JK, Sin VC, Lau WH. Central nervous system metastasis from nasopharyngeal carcinoma: A report of two patients and review of the literature. Cancer 2002;94:398-405.  Back to cited text no. 3
    
4.Morariu MA, Serban M. Intramedullary cervical cord metastasis from a nasopharynx carcinoma. Eur Neurol 1974;11:317-22.  Back to cited text no. 4
    
5.Lii FN, Chen YM, Shu CH, Liu JM, Whang-Peng J. Metastatic nasopharyngeal carcinoma with epidural spinal cord compression: Report of an unusual and catastrophic event. Zhonghua Yi Xue Za Zhi (Taipei) 1995;55:195-8.  Back to cited text no. 5
    
6.Mostardi PM, Diehn FE, Rykken JB, Eckel LJ, Schwartz KM, Kaufmann TJ, et al. Intramedullary Spinal Cord Metastases: Visibility on PET and Correlation with MRI Features. AJNR Am J Neuroradiol 2013;35:196-201.  Back to cited text no. 6
    
7.Simpson RK Jr, Goodman JC, Ehni G. Nasopharyngeal carcinoma metastatic to the cauda equina. Surg Neurol 1986;26:306-10.  Back to cited text no. 7
    


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