| Japanese Journal of Clinical Oncology | Pages |
Nasopharyngeal Cancer with Neck Recurrence at 8 Years and a Lung Metastasis at 15 Years After the First Definitive Radiotherapy: A Case Report
Introduction
Case Report
Discussion
References
Nasopharyngeal Cancer with Neck Recurrence at 8 Years and a Lung Metastasis at 15 Years After the First Definitive Radiotherapy: A Case Report
We report a patient with nasopharyngeal cancer with long-term follow-up of more than 16 years after the first course of radiotherapy in 1981. He developed a lung metastasis in 1996 after having a second course of radiotherapy for neck recurrence in 1989. The patient was a 42-year-old man with a nasopharyngeal tumor and a fixed upper neck metastasis (T1N1M0), which was treated with definitive radiotherapy. He manifested regional recurrence, at the margin of the radiation portal, with an 8 year disease-free interval, which was treated successfully by definitive re-irradiation. He developed a solitary lung metastasis, which was treated by video-assisted thoracoscopic lung resection, 7 years disease-free after the second course of radiotherapy. For 20 months after the removal of the lung metastasis he has been generally well without any signs of recurrence or sequelae. This case indicates the efficacy of definitive re-irradiation for regional recurrence and the necessity for long-term observation after radiation therapy for nasopharyngeal cancer.
INTRODUCTION
Poorly differentiated squamous cell carcinoma of the nasopharynx is a good candidate for radiation therapy because of its radiosensitivity and anatomical location. Despite definitive radiation therapy, loco-regional recurrence is observed in 10-58% of patients with nasopharyngeal cancer (NPC) and the majority of all recurrences develop within 3 years after radiation therapy (1-4). We report a case who had not only had a regional recurrence after 8 years disease-free following the first course of radiation therapy but also a solitary lung metastasis after 7 years disease-free following the second course of radiation therapy for the first recurrence.
CASE REPORT
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Figure 1. (a) Histological examination of a primary nasopharyngeal tumor showed a typical feature of poorly differentiated non-keratinizing squamous cell carcinoma with infiltration of small lymphocytes and plasma cells (H&E stain; original magnification, ×200). (b) Histological examination of a regional recurrence showed a typical feature of non-keratinizing squamous cell carcinoma with partial necrosis (H&E stain; original magnification, ×100). (c) Histological examination of a solitary lung tumor showed a typical feature of non-keratinizing squamous cell carcinoma with infiltration of small lymphocytes and plasma cells (H&E stain; original magnification, ×200).
A 42-year-old Japanese man was admitted to our hospital with a complaint of a large, fixed mass in the right neck. Endoscopic examination revealed a mass lesion involving the posterior and lateral wall of the nasopharynx. He was diagnosed as having UICC stage IIB (T1N1M0) nasopharyngeal cancer (NPC), the histology of which was poorly differentiated squamous cell carcinoma with lymphocytic infiltration (Fig. 1). From September 1981, he received external radiation therapy to the nasopharynx and upper neck with a total dose of 60 Gy in 30 fractions over 47 days. The spinal cord was spared after 40 Gy. He remained free of any signs of recurrence until December 1989, when a hard, fixed mass in the left upper posterior neck was recognized. Computed tomography showed a large mass with muscular invasion (Fig. 2). Histological examination revealed regional recurrence of NPC without any local failure and distant metastasis (Fig. 1). He received a second course of conventional radiotherapy to the left neck with a total dose of 66 Gy (40 Gy in 20 fractions using 60Co gamma-rays and an additional 26 Gy in four fractions using an 8 MeV electron beam). Oral UFT (tegafur and uracil in a molar ratio of 1:4) was given with a dose of 600 mg daily for 2 years following the second course of radiation therapy. He was followed up at monthly intervals. Chest radiography, abdominal sonography and serum examinations were performed once a year and there was no evidence of disease. In October 1996, a round tumor shadow was observed in the left lower lung field by radiography and computed tomography of the chest revealed a well demarcated tumor in the left posterior basal segment (Fig. 3). Bronchofiberscopy failed to identify a tumor because the tumor showed no invasion to either bronchus. No additional abnormalities were found on careful screening, including bone and gallium scintigraphy and brain and abdominal computed tomography. Video-assisted thoracoscopic (VAT) tumor resection was performed on the solitary lung tumor. Histological examination of the tumor revealed a typical feature of poorly differentiated squamous cell carcinoma to be the same as that of the primary nasopharyngeal and secondary neck lesions (Fig. 1). After removal of the lung metastasis, UFT of 600 mg daily was given orally for 6 months. He has been followed up closely and has been free of disease and sequelae for 20 months.
Figure 2. Neck computed tomography shows a mass with muscular invasion in the left upper posterior region. Figure 3. Chest computed tomography with contrast medium shows a well demarcated round tumor with a central low-density area in the left lateral basal segment. Radiation therapy is the first choice of treatment for NPC owing to an anatomical restriction and a high degree of radiosensitivity. Despite definitive radiation therapy, a relatively high incidence of loco-regional recurrences has been reported (1-4). Although the majority of all loco-regional recurrences develop outside or at the margin of the treatment portal within 3 years after radiation therapy, some recurrences have been observed after a long latent period (5-7). Most of the distant metastases also occur within 3 years after treatment and the common sites of distant metastases are the bones and/or the lungs (4,6,8-10). Our patient had a regional recurrence at the margin of the irradiation portal after being 8 years disease-free after the first course of radiation therapy and a solitary lung metastasis appeared 7 years after the second course of radiation therapy for regional recurrence. Wang (5) reported that 12% of patients had recurrences manifested after [ge]5 years disease-free following the initial radiation therapy. Chen et al. (6) reported that some of the loco-regional and distant recurrences appeared between 6 and 10 years. They emphasized the importance of frequent careful follow-up examinations for at least 10 years (5,6). Many investigators have reported treatment for recurrent NPC and recommended re-irradiation for loco-regional recurrence (1,5,7,11). Wang (7) stated that aggressive re-irradiation at [ge]60 Gy for loco-regional recurrence might be attempted with some hope of local control and long-term survival. Mitsuhashi et al. (1) reported that patients with nasopharyngeal recurrence and those with regional recurrence could be salvaged by re-irradiation, with 5 year survival rates of 44 and 100%, respectively. The role of chemotherapy for NPC remains controversial. Although promising results have been reported in pilot or retrospective studies, prospective randomized trials have not yet achieved significant results (3,4,9-14). The regimen, timing and candidates for chemotherapy remain unclear. Some investigators referred to a strong association between nodal disease and the development of distant disease and recommended systemic chemotherapy for patients with advanced neck disease, such as N-3 in UICC TNM classifications (2,9,10,14). A patient with loco-regional recurrence and/or distant metastases might be a candidate for chemotherapy. Mitsuhashi et al. (1), however, demonstrated that the loco-regional recurrence was not able to influence the development of distant metastasis. On the other hand, Wang (5) reported the patients with recurrence after a long period of freedom from the disease survived significantly better than those with recurrence after a short period. We therefore treated our patient with radiation therapy either alone or in combination with surgery without aggressive chemotherapy. He was able to be discharged 2 weeks after VAT operation and to return to his professional post immediately. Although he may have a probability of development of new metastatic lesions, we have some expectation for his long-term survival, because he had long disease-free intervals not only between the initial disease and regional recurrence but also between regional failure and distant metastasis and because there has been no deterioration in his performance status for 20 months after the complete resection of a lung metastasis. This case suggests the efficacy of definitive re-irradiation for regional recurrence and the necessity for a long-term careful follow-up examination for NPC.
DISCUSSION
References
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Last modification: 24 Nov 1998
Copyright©Japanese Journal of Clinical Oncology, 1998.
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