Cavernous sinus involvement in human papillomavirus associated oropharyngeal squamous cell carcinoma: Case report of an atypical site of distant metastasis

Abstract

BackgroundHPV-associated OSCC (HPV-OSCC) has been determined to be a distinct disease entity from non-HPV associated OSCC. Patients affected by HPV-OSCC generally have a more favourable prognosis, with improved rates of locoregional control and survival compared with their non-HPV counterparts. Despite this, HPV-OSCC has a similar rate of distant metastases. Interestingly, recent evidence has emerged that demonstrates more frequent atypical metastasis patterns when compared to non-HPV associated disease. To the best of our knowledge, this report describes the first case of a confirmed HPV-OSCC with distant metastasis to the cavernous sinus.Case PresentationA 62-year-old non-smoking male presented to the head and neck oncology clinic with a five-month history of enlarging right neck mass causing neck pain, dysphagia, and dysphonia. HPV-associated base of tongue squamous cell carcinoma (cT4aN2c) was diagnosed, and he was treated with primary chemoradiation. Shortly after treatment, he presented with progressive bilateral cranial nerve palsies including left cranial nerve III and right cranial nerve VI involvement. Imaging identified masses in the left cavernous sinus with extension of tumor into the sella and in the right cavernous sinus at the level of Dorello’s canal. Endoscopic Image Guided Transsphenoidal biopsy of the left sellar mass confirmed distant metastases from the previously treated HPV-OSCC primary to the cavernous sinus. The patient was palliated with carboplatin and paclitaxel.ConclusionThe presented report is the first documented case of confirmed HPV-associated oropharyngeal squamous cell carcinoma metastasizing to the cavernous sinus, and the only HPV confirmed head and neck cancer case to present with metastasis to the cavernous sinus and limited extracranial disease. This case demonstrates the importance of recognizing presentations of atypical metastasis that are possible in HPV-associated oropharyngeal cancer. Given the rarity of metastasis to this region, vigilance in follow up is instrumental in early identification and treatment for these patients.

PET/CTversus triple endoscopy in initial workup ofHPV+ oropharyngeal squamous cell carcinoma

“…PET/CT was the sole modality that detected SPTs in our patient population and demonstrated 100% NPV in ruling out SPTs of the UADT. The utility of PET/CT in the HPV+ OPSCC population is further supported by reports of a tendency for this malignancy to metastasize to atypical sites outside the UADT (e.g., liver, pancreas, vertebrae, cavernous sinus) 36–38 . While we did not detect any atypical metastatic sites within our cohort, which may be a result of insufficient sampling, a review of the cases by Muller et al revealed that all metastatic lesions were detectable on PET/CT 37 .…”

“…The utility of PET/CT in the HPV+ OPSCC population is further supported by reports of a tendency for this malignancy to metastasize to atypical sites outside the UADT (e.g., liver, pancreas, vertebrae, cavernous sinus). [36][37][38] While we did not detect any atypical metastatic sites within our cohort, which may be a result of insufficient sampling, a review of the cases by Muller et al revealed that all metastatic lesions were detectable on PET/CT. 37 Previous prospective head to head comparison of PET/CT to different combinations of X-ray, conventional CT, and magnetic resonance imaging (MRI) has shown superiority of PET/CT in detecting both SPTs and distant metastases across HNSCC subsites.…”

Epidermotropic metastasis of squamous cell carcinoma of the tonsil: A case report with molecular confirmation

“…5,6 HPVpositive oropharyngeal SCC has been recognized as a distinct disease entity from its HPV-negative counterpart, and is associated with better prognosis. 7,8 While both entities carry a similar rate of distant metastasis, HPV-positive oropharyngeal SCC has shown atypical metastatic patterns and is more probable to involve unusual sites. 8,9 We present here a case of primary HPV+ tonsillar SCC in a 77year-old man, who subsequently developed a skin lesion of the neck.…”

“…7,8 While both entities carry a similar rate of distant metastasis, HPV-positive oropharyngeal SCC has shown atypical metastatic patterns and is more probable to involve unusual sites. 8,9 We present here a case of primary HPV+ tonsillar SCC in a 77year-old man, who subsequently developed a skin lesion of the neck.…”

A Case of Oculomotor Nerve Paralysis Caused by Cavernous Sinus Metastasis of Tonsil Cancer

“…metastases to the common locations. Very few cases of OSCC metastasis to the cavernous sinus have been reported in the English literature [5][6][7]. Physicians must maintain a high index of suspicion in patients with a history of malignancy who present with symptoms involving the cavernous sinus.…”