Medical and Pediatric Oncology 32:75–76 (1999) BRIEF REPORT Multiple Chest Wall Masses Presenting in Nasopharyngeal Carcinoma Ahmet Baydur, MD,1,3* Augustine Iluore, MD,2,3 Thomas Fisher, MD,2,3 Nadeznalyn Ang, MD,2,3 and Gayle Lucas, MD4 Key words: nasopharyngeal carcinoma; chest wall metastases; head and neck cancer; needle biopsy Bone is the most common site of deposits in patients with nasopharyngeal carcinoma (NPC) in whom metastases are diagnosed clinically. The presentation of chest wall metastases arising from ribs in patients with NPC has not been previously described. A 39-year-old Vietnamese man presented with dyspnea, weight loss, left facial paralysis, back pain, progressive leg weakness and multiple chest wall growths progressive over a 3-month period. Physical examination revealed an afebrile, pale, cachectic man with drooping of the left face and maxillary sinus tenderness. The chest wall was studded with several hard, non-tender masses, the largest of which were 4 to 6 cm in size and located over the sternum (Fig. 1). Neurologic examination revealed a left facial and bilateral lower extremity paralysis, and fine touch reduced in the left lower extremity. Serum IgG antibody titer to Epstein-Barr virus was 1:5,120. Chest roentgenogram showed multiple pulmonary and chest wall densities. Computed tomography of the head revealed a hypodense area in the left temporal lobe. Magnetic resonance imaging of the thoracolumbar spine showed metastatic deposits involving all vertebral bodies and posterior elements, associated with cord and nerve root compression at multiple lower thoracic and lumbar levels. Percutaneous fine needle aspiration of the largest of the sternal masses showed cellular smears with cohesive clusters of markedly pleomorphic cells consistent with poorly differentiated squamous cell carcinoma (Fig. 2). The patient was treated with intravenous fluids, steroids and opioids, and started on radiation treatments to the spine. After radiotherapy totaling 2,800 cGy, he was lost to follow-up. The incidence of distant metastases in nasopharyngeal cancer (NPC) is from 17% to 53% clinically, and from 38% to 87% on necropsy [1,2]. These occur more frequently in NPC than in other tumors of the head and neck . Bone is the most common site of deposits in patients in whom metastases are diagnosed clinically. Rib and sternal lesions can appear as lytic or sclerotic deposits on chest roentgenogram [4,5]. Since the incidence of skeletal metastasis in the patient with an extraskeletal primary malignancy ranges from 25% to 30% , a meta© 1999 Wiley-Liss, Inc. Fig. 1. Multiple hard, fixed masses arising from sternum and ribs. A: Anterior view. B: Lateral view. 1 Division of Pulmonary and Critical Care, University of Southern California, Los Angeles, California 2 Division of General Internal Medicine, University of Southern California, Los Angeles, California 3 Department of Medicine, University of Southern California, Los Angeles, California 4 Department of Pathology, University of Southern California, Los Angeles, California *Correspondence to: Dr. Ahmet Baydur, Pulmonary and Critical Care Division, University of Southern California, School of Medicine, 2025 Zonal Avenue, GNH 11-900, Los Angeles, CA 90033. Received 11 May 1998; Accepted 23 June 1998 76 Baydur et al. priate diagnostic step. An inconclusive needle aspiration should be followed by an incisional biopsy for definitive diagnosis. REFERENCES Fig. 2. Fine needle aspiration of subcutaneous sternal lesion showing tumor cells with marked pleomorphism, coarse nuclear chromatin, and prominent nucleoli. Poorly differentiated carcinoma. Hematoxylin and eosin, Diff-Quick stain, ×425. static lesion must be considered in any patient who presents with a chest wall mass. Therefore, needle biopsy by the core technique or aspiration cytology is an appro- 1. Armstrong RW, Armstrong MJ, Yu MC, Henderson BC. Salted fish and inhalants as risk factors for nasopharyngeal carcinoma in Malaysian Chinese. Cancer Res 1983;43:2967–2970. 2. Ahmad A, Stefani S. Distant metastases of nasopharyngeal carcinoma: A study of 256 male patients. J Surg Oncol 1986;33:194– 197. 3. Probert JC, Thompson RW, Bagshaw MA. Patterns of spread of distant metastases in head and neck cancer. Cancer 1974;33:127– 133. 4. Daly BD, Leung SF, Cheung H, Metreweli C. Thoracic metastases from carcinoma of the nasopharynx: High frequency of hilar and mediastinal lymphadenopathy. AJR 1993;160:241–244. 5. Sham JST, Cheung YK, Chan FL, Choy D. Nasopharyngeal carcinoma: Pattern of skeletal metastases. Br J Radiol 1990;63:202– 205. 6. Moser RP, Madewell JE. An approach to primary bone tumors. Radiol Clin North Am 1987;25:1049–1093.