A 67-year-old man presents with diplopia, blurred vision in his left eye, and an intermittent headache, all for around two weeks. Further questioning reveals recurrent left-sided nasal stuffiness with a blood-streaked mucus discharge for around six months.
He has refused to obtain medical attention thus far, and it was only today that his family members were able to persuade him to see a doctor. His medical, surgical, and family histories are otherwise unremarkable, and he is not on any medications.
Select Relevant Investigations
Rhinoscopy reveals a voluminous mass in the lateral wall of the left nasal cavity, which is friable, and bleeds to the touch. Multiple biopsies are subsequently obtained.
Histological analysis of the biopsy specimens reveals large epithelioid cells with hyperchromatic pleomorphic nuclei and prominent nucleoli. Immunohistochemistry is positive for S-100 protein, Melan-A, and HMB-45.
Contrast MRI head + neck
MRI reveals a mass measuring 2.8 × 2.1 × 4.2 cm in the left nasal cavity, which is invading the ipsilateral ethmoidal sinus and orbital wall. The lesion is hyperintense in T1 weighted images, and intermediate-hypointense on T2-weighted images.
Mild to moderate enhancement is noted followed administration of gadolinium contrast. There is no evidence of regional lymphadenopathy.
F-18 FDG PET/CT
There is a hypermetabolic lesion within the left nasal cavity, as well as multiple diffuse foci of abnormal uptake in the axial skeleton compatible with osseous metastasis, and multiple foci in both lobes of the liver compatible with hepatic metastasis.
The lymph nodes of the head and neck appear normal.