Carcinosarcoma of the Maxillary Sinus
A 62-year-old male was admitted to the emergency room due to uncontrolled epistaxis and complaining of swelling and tenderness in the right cheek. The patient was receiving warfarin as an anticoagulative measure, having previously suffered a stroke. An examination of the nasal cavity was not possible at the emergency room due to the severity of bleeding. Nasal packing was applied to staunch the bleeding. Two days later, when the nasal packing was removed and endoscopic examination performed, a mass in the middle meatus and bulging of the medial wall of the maxillary sinus were observed (). Computed tomography (CT) and magnetic resonance imaging (MRI) scans revealed a large mass comprised of soft tissue with an ill-defined outline and an irregular peripheral enhancement on the right maxillary sinus. The mass had pushed against the right inferior wall of the maxillary sinus; destroyed the infraorbital foramen; completely destroyed the medial wall of the maxillary sinus; partially damaged the superior, middle and inferior turbinate; and obstructed the entire right nasal cavity. The lateral, anterior, and inferior walls of the right maxillary sinus were focally destroyed and a focal tumor extension was exposed. The mass extended superiorly to some part of the ethmoid sinus but did not involve the sphenoid sinus and frontal sinus ().\nAn endoscopic biopsy revealed a carcinosarcoma with an osteosarcomatous element by Hematoxylin-eosin staining and immunohistochemical stain (). Fluorodeoxyglucose positron emission tomography (FDG PET)-CT was used to evaluate metastasis to adjacent organs. FDG PET-CT revealed the presence of large mass of soft tissues with increased FDG uptake accompanied by bony erosion in the right maxillary sinus. Also, nodular lung lesions with increased FDG uptake in lateral basal and posterior basal segment of right lower lung were observed. CT-guided lung biopsy for metastasis evaluation indicated only chronic inflammation. Hence, the clinical TNM staging of this patient was T3N0M0 (stage III).\nA surgical resection with postoperative chemoradiation therapy was planned and the patient underwent a total maxillectomy on the right side. Examination in the operating room revealed a large tumor filling the nasal cavity, maxillary sinus, and ethmoid sinus. The tumor had eroded through the inferior and medial orbital walls, however, periorbital invasion was not evident. The tumor had also eroded the lateral bony wall of the maxillary sinus. After the surgical resection, frozen biopsies of all margins were grossly clear.\nThe patient's postoperative course was uncomplicated, and he received postoperative radiation therapy with a total dose of 5,580 cGy. However, during the radiation therapy, a mass lesion in the periorbital area was found in an endoscopic examination. The pathology was indicative of carcinosarcoma. As a consequence, wide local excision was performed on the mass and the patient received a full course of irradiation, followed by chemotherapy (Cisplatin+5 fluorouracil+Taxotere). Two months later, the patient developed a massive recurrence infiltrating the orbit, cheek, and the masseter muscle. The patient decided not to receive further surgical treatment or chemotherapy, and was lost to follow-up.