Case Report
An 80-year-old healthy male with no history of tobacco or alcohol use presented to an otolaryngologist for throat pain, fever, right otalgia and right maxillary sinus tenderness. He had previously been identified with a germline BRCA2 mutation in the course of successful management of intraductal breast carcinoma, prostatic adenocarcinoma and pancreatic adenocarcinoma. His initial physical exam was normal, and he was empirically treated for bacterial sinusitis. On follow up, the patient had improvement of initial symptoms but had developed a non-productive cough. His exam at that time was remarkable for a small pharyngeal ulcer, and anti-gastroesophageal reflux therapy was started.
Subsequently the patient underwent CT larynx without contrast by his Oncologist for additional workup of fatigue in the context of ongoing otalgia, sinus tenderness and cough. This imaging revealed an asymmetric soft tissue prominence at the larynx with thickening along the adjacent right hypopharynx, a 1.3 cm lymph node and fat stranding at the right carotid space. Laryngopharyngitis was diagnosed based on repeat exam and review of imaging. A primary care physician then obtained a non-contrast MRI for new headaches incidentally identifying a transglottic mass invading thyroid cartilage with encasement of the right carotid, and a 1.6 cm right level IIA lymph node (figure 1). The patient was referred to our tertiary care center for concern of hypopharyngeal malignancy.
Evaluation with flexible fiberoptic laryngoscopy revealed a mass at the right pharyngeal wall extending to the right pyriform sinus (figure 2). Ultrasound-guided needle biopsy was attempted twice revealing acute inflammation and keratinized squamous cell epithelium of the right piriform sinus, respectively. Biopsy of the right level II lymph node showed chronic lymphocytic leukemia. A biopsy of the right piriform sinus under general anesthesia was then completed revealing well-differentiated keratinizing squamous cell carcinoma.
A diagnostic PET/CT showed an FDG-avid soft tissue mass centered on the right piriform sinus with extension into the right parapharyngeal soft tissues, thyroid cartilage, and prevertebral space to the level of the cricoid cartilage. Chemoradiation (using weekly carboplatin and paclitaxel) was successfully completed for the stage IVa (cT4b, cN0, M0) disease. A twelve-week post-chemoradiation PET/CT revealed complete resolution of cancer and the patient remained disease-free at most recent 3-year follow up.