European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 157–159

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Case report

Liver metastasis of ethmoid sinus adenocarcinoma

S. Caselhos a,∗ , C. Ferreira b , M. Jácome c , E. Monteiro d
a
Service ORL et chirurgie cervico-faciale, centre hospitalier Alto Ave, rue dos Cutileiros, Creixomil, Guimarães, Portugal
b
Service radiothérapie, institut Portugais d’oncologie, Porto, Portugal
c
Service d’anatomie pathologique, institut Portugais d’oncologie, Porto, Portugal
d
Service ORL et chirurgie cervico-faciale, institut Portugais d’oncologie, Porto, Portugal

a r t i c l e i n f o a b s t r a c t

Keywords: Introduction: Sinonasal cancer is an uncommon neoplasm, often associated with exposure to occupational
Sinonasal malignant tumours hazards and delayed diagnosis.
Ethmoid sinus adenocarcinoma Case report: The authors report a rare case of solitary liver metastasis from ethmoid sinus adenocarcinoma
Liver metastasis
treated by surgical resection. No clinical or radiological sign of recurrence was observed with a follow-up
Endonasal surgery
of 3 months.
Vertebral venous plexus
Discussion: Adenocarcinoma of the ethmoid sinus is characterized by its aggressiveness and its tendency
to recurrence. Metastases are rare and can be found in unexpected organs due to dissemination via
collateral venous plexuses. The role of chemotherapy has not been clearly established. Due to their rarity,
the treatment of metastases has not yet been defined.
© 2014 Elsevier Masson SAS. All rights reserved.

1. Introduction
Sinonasal cancers represent less than 1% of all cancers and are
associated with occupational exposure in 25 to 41% of cases [1].
Adenocarcinoma is a malignant glandular tumour, accounting for
between 10 and 20% of all sinonasal cancers [1,2]. Due to the poor
lymphatic drainage of the paranasal sinuses, lymph node metas-
tases are rare, detected in only 2 to 3% of cases [3]. Bone, lung and
brain metastases have been described [4].
Local control of these tumours is ensured by a combination of
surgery and radiotherapy. The prognosis is generally poor with an
overall survival rate of 51% ± 14% [5]. Exclusive radiotherapy or
chemoradiotherapy are reserved for very advanced and inopera-
ble stages, such as extensive orbital and/or intracranial invasion
[6].
We report a case of isolated liver metastasis from an ethmoid
sinus adenocarcinoma.
2. Case report
A 61-year-old man with no notable medical history was referred
by his general practitioner with unilateral left bloody rhinorrhoea
∗ Corresponding author. Tel.: +351938610746.
E-mail address: caselhos@msn.com (S. Caselhos).
for two months. Clinical interview revealed blocked nose and anos-
mia, as well as prolonged exposure to wood dust, as the patient had
worked as a carpenter for 34 years.
Endoscopic examination revealed a tumour of the left nasal cav-
ity, extending from the olfactory cleft to the floor of the nasal cavity.
Biopsy under local anesthesia confirmed the diagnosis of moder-
ately well differentiated intestinal-type adenocarcinoma.
Contrast-enhanced CT scan (Fig. 1) and MRI demonstrated a
tumour of the left nasal cavity with displacement of the nasal
septum and the turbinal wall of the ethmoid sinus and minimal
extradural extension to the anterior cranial fossa and sphenoid
sinus. No metastatic lymphadenopathy was suspected. The cancer
was staged as T4a N0 M0.
In December 2009, endonasal tumour resection comprising total
ethmoidectomy with middle turbinectomy and resection of the
olfactory cavity was then performed, followed by skull base recon-
struction by nasal mucosa flap with fixation by fibrin glue and a
fragment of synthetic dura mater. External beam radiotherapy was
then delivered to the tumour bed with a dose fractionation of 60 Gy
in 30 fractions over 6 weeks.
Subsequent follow-up comprised nasal endoscopy every three
months and MRI at three months, and then annually.
In April 2012, abdominal ultrasound followed by MRI were per-
formed in a context of abdominal pain, and revealed a tumour in
the left lobe of the liver (Fig. 2). Ultrasound-guided fine-needle
aspiration cytology revealed the presence of intestinal-type ade-
nocarcinoma.

http://dx.doi.org/10.1016/j.anorl.2014.07.006
1879-7296/© 2014 Elsevier Masson SAS. All rights reserved.
158 S. Caselhos et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 157–159

Fig. 1. CT scan, frontal section of the nasal cavity and paranasal sinuses.

Fig. 2. Abdominal MRI, axial and frontal sections: lesion with an intense signal on the T2-weighted sequence, measuring 9 × 4 cm in axial diameter and 5 cm in longitudinal
diameter (arrows).

After discussion of this patient’s case at a multidisciplinary

consultation meeting, upper and lower gastrointestinal endoscopy
was performed to exclude a second primary tumour, and did not
reveal any other lesions. Comparative examination of histologi-
cal slides was requested and revealed immunohistochemical and
morphological features compatible with metastasis from the ade-
nocarcinoma detected during nasal surgery (Fig. 3).
In August 2012, after exclusion of other metastatic lesions on
imaging examination, the patient was treated by partial hepate-
ctomy with no adjuvant therapy. The current survival with no
clinical or MRI signs of recurrence is six months.

3. Discussion

Adenocarcinoma of the ethmoid sinus is rare. Most patients

present with an advanced tumour at the time of diagnosis and the
clinical stage is generally not predictive of prognosis. These patients
often die as a result of local recurrence [1–4].
Distant metastases are detected in only less than 2% of cases,
mostly involving bone [4]. Haematogenous spread of metastases to
the liver would typically require passage through the lungs before
entering the liver via the hepatic artery; exclusion of the presence of
other metastases is therefore essential. The absence of lung metas-
tases in the present case could be explained by dissemination via
the vertebral venous plexus and its numerous anastomoses with
the azygos veins, which constitute a longitudinal network paral-
lel to the inferior vena cava [7]. Tumour cells may therefore have
reached the liver via the portal system through the azygos and
peri-oesophageal veins. Many other collateral pathways are also
possible.
The sinus mucosa has an ectodermal origin and therefore does
not present any features of intestinal differentiation. Sinonasal
adenocarcinoma of the intestinal-type would appear to be due to
transformation of a normal phenotype into an intestinal phenotype Fig. 3. A. Primary tumour with intestinal-type glandular differentiation (HE stain,
× 100). B. Liver metastasis from the ethmoid sinus adenocarcinoma (HE stain, × 100).
[8].
 S. Caselhos et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 157–159
According to Kennedy et al., exposure to wood dust and
other agents induces either squamous cell metaplasia or cuboidal
cell metaplasia of the respiratory mucosa. Activation of CDX-2
(caudal-related homeobox 2), a transcription factor specific to adult
intestinal epithelium, can induce and maintain this metaplasia,
with acquisition of a complete intestinal phenotype [8].
Ethmoid sinus adenocarcinoma has a variable morphological
appearance and can resemble normal intestinal mucosa, gastric
intestinal metaplasia, Barrett’s oesophagus, villous adenoma or
colorectal adenocarcinoma. Similarities between ethmoid sinus
and colorectal adenocarcinomas are not only histological, but
also ultrastructural and immunohistochemical [8]. The differential
diagnosis must therefore be carefully evaluated, with exclusion of
an intestinal disease by intestinal endoscopy.
The treatment of advanced cancer of the ethmoid sinus has not
been clearly defined. Adjuvant chemotherapy can be proposed, but
its efficacy has not been demonstrated [4]. However, on the basis
of the similarities between ethmoid sinus and colorectal adeno-
carcinoma and the results obtained in the treatment of advanced
stages of these cancers, treatment with anti-epidermal growth fac-
tor (EGFR) monoclonal antibody could possibly be considered in
the future.
This case has a limited follow-up and careful local and distant
surveillance remains essential.
4. Conclusion
Distant metastases from ethmoid sinus adenocarcinoma are
rare and can involve unexpected organs via collateral venous
159
plexuses. The intestinal phenotypes of ethmoid sinus and colorectal
adenocarcinomas are very similar, possibly raising a difficult differ-
ential diagnosis and allowing a common treatment to be proposed
for advanced stages.
Disclosure of interest
The authors declare that they have no conflicts of interest con-
cerning this article.
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