Pancreas-only metastasis from nasopharyngeal carcinoma.

Dear Editor, A 51-year-old Chinese man presented with a 3 month’s history of left cervical lymphadenopathy, rhinorrhoea, tinnitus and nasal congestion. On nasopharyngoscopy, a fungating mass was found in his nasopharynx and was biopsied. Histopathological examination revealed an undifferentiated, non-keratinising carcinoma of the nasopharynx (WHO III). A biopsy of the left cervical lymph nodes showed a similar pathological finding of metastatic undifferentiated carcinoma. A computed tomographic (CT) scan of the head and neck showed a large left nasopharyngeal mass which extended across the midline, laterally and inferiorly towards the deep lobe of the left parotid gland. There was early erosion of the left pterygoid plate (T3) and encasement of the left internal carotid artery but no signs of intracranial invasion. There was bilateral cervical lymphadenopathy measuring up to 5 cm (N2) deep to both right and left sternomastoid muscles. A triphasic CT scan of the abdomen revealed a 3.0 x 2.3 cm pancreatic lesion (arrow, Fig. 1A) in the superior aspect of the neck of the pancreas with a few enlarged lymph nodes around the pancreatic head, one of which had a necrotic centre. These findings were suggestive of malignancy. Several liver cysts and hemangiomas were also present. Bone scan showed negative results. To further evaluate the pancreatic lesion, an endoscopic ultrasound (EUS) was performed which confirmed a 2.5 cm inhomogeneous hypoechoic mass (MASS) at the pancreatic genu/neck adjacent to the portal confluence (PC) and splenic vein (SV) (Fig. 1B). There was a hypoechoic lymph node adjacent to the pancreatic body and multiple enlarged lymph nodes adjacent to the pancreatic head. EUS-guided fine needle aspirate (EUS-FNA) of 2 lymph nodes adjacent to the pancreatic head; one of which measured 3.3 x 2.4 cm containing areas of cystic degeneration, yielded smears and cell blocks with malignant cells consisting of metastatic non-keratinising, undifferentiated carcinoma with morphological similarity to the tumour in the previous nasopharyngeal and cervical lymph nodes biopsy specimens. Sampling of the peri-pancreatic lymph nodes instead of the pancreatic lesion was performed in order to optimise assessment of locoregional disease extent should curative surgery be required for a possible primary pancreatic carcinoma. According to the American Joint Committee on Cancer (AJCC) Staging, this was a Stage IVC nasopharyngeal carcinoma (NPC). The patient is currently undergoing palliative chemotherapy with cisplatin and infusional 5-fluorouracil every 4 weeks with good Pancreas-only Metastasis from Nasopharyngeal Carcinoma