Abstract:
Sinonasal squamous cell carcinoma (SNSCC) is a rare head and neck malignancy that often presents at an advanced stage because initial symptoms mimic benign inflammatory disease. In high tuberculosis (TB) burden countries such as Indonesia, therapeutic decision-making may be further complicated by coexisting or suspected pulmonary TB, especially when intensive multimodal oncologic therapy is required.
We report a 43-year-old male Indonesian firefighter and long-term smoker who presented with a rapidly enlarging midfacial mass, severe nasal obstruction, purulent and blood-streaked rhinorrhea, diplopia, headache, and weight loss. Imaging showed a destructive mass involving both nasal cavities and multiple paranasal sinuses with bone erosion and bilateral cervical lymphadenopathy. Histopathology of nasal and ethmoidal specimens confirmed non-keratinizing SNSCC, staged cT4aN2cM0 (stage IVA, AJCC 8th edition). The patient underwent debulking surgery followed by maxillectomy and orbitotomy, but CT simulation one month later demonstrated a 33% increase in tumour volume, consistent with early postoperative progression.
A multimodal plan was formulated consisting of three cycles of induction modified TPF (docetaxel, cisplatin, 5-fluorouracil) followed by intensity-modulated radiotherapy (IMRT). Two cycles of chemotherapy were well tolerated and led to symptomatic improvement. However, chest imaging then revealed left-lung consolidation with cavitation and nodular opacity, raising strong suspicion of pulmonary TB in addition to possible metastasis. In this TB-endemic context, concerns about infectious complications, further immunosuppression, and the need for anti-TB therapy complicated decisions regarding continuation of chemotherapy, timing and dose of IMRT, and placement of a feeding gastrostomy. The patient declined further systemic treatment, did not complete radiotherapy, and was eventually lost to follow-up.
This case illustrates not only the diagnostic and surgical complexities of advanced SNSCC but also the profound ethical and clinical dilemma of balancing aggressive, curative-intent therapy against the risk of fatal tuberculosis reactivation. It underscores the critical need for integrated oncologic and infectious disease services, rapid microbiological work-up, and coordinated multidisciplinary care to navigate this double burden of disease in low- and middle-income countries.
