PMC5294429_01
(a) A sagittal and coronal computed tomography scan showing a left parapharyngeal mass in the region of the tonsil. (b) Axial sections of computed tomography scan showing a soft tissue mass in the right nasopharynx.
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F1
Computed tomography (CT) scan showed heterogeneous-enhancing mass in the left parapharyngeal space measuring 2.4 cm x 2.3 cm x 5 cm with multiple ipsilateral levels II and III lymph nodes [Figure 1a]. A positron emission tomography-CT (PET-CT) was done which showed a localized soft tissue mass in the right nasopharynx, along with a bulky right axillary nodal mass of 4.8 cm x 3.4 cm with no evidence of disease in the oropharynx and neck [Figure 1b].
Positron emission tomography-computed tomography on a routine follow-up showing a nodule in the right lobe of thyroid (a) and a prevascular node (b).
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F2
After a DFI of 1 year and 3 months, a routine follow-up PET-CT revealed a 9 mm nodule in the right lobe of thyroid (standardized uptake value [SUV]: 6.73) and a pretracheal node (SUV: 4.53) [Figure 2a and b].
Cellular smears showing clusters of malignant cells with many lymphocytes in the background. The tumor cells were oval to spindle with scanty cytoplasm, vesicular nuclei, and prominent nucleoli (PAP stain; [a] x40 and [b] x200).
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F3
A USG-guided FNAC showed poorly differentiated carcinoma cells consistent with metastasis from the nasopharynx [Figure 3].
(a-d) Photomicrograph showing metastatic deposits of undifferentiated nasopharyngeal carcinoma in thyroid with interspersed lymphoid cells (a and b; H and E, x100 and x 200). The tumor cells were immunopositive for high molecular weight cytokeratin (c; DAB: x100) and revealed moderate-to-strong diffuse nuclear positivity for Epstein-Barr-encoded RNA/in situ hybridization (d; DAB; x100).
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F4
Both pretracheal nodes showed metastatic carcinoma with perinodal extension [Figure 4a-d].
Axial slice of the planning computed tomography cuts showing adequate coverage of tumor bed (a) and pretracheal node in superior mediastinum (b).
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F5
Treatment was delivered by a 9-field IMRT plan with 6 MV photons along with concurrent weekly nimotuzumab over 42 days with no gaps in treatment [Figure 5a and b].