Feb 20, 2011 - Nasopharyngeal Carcinoma With a Solitary. Bone Metastasis. A 24-year-old man presented with a 2-month history of a pain- less left neck lump ...
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Prolonged Remission in a Patient With Nasopharyngeal Carcinoma With a Solitary Bone Metastasis A 24-year-old man presented with a 2-month history of a painless left neck lump. Clinical examination revealed diffuse thickening of the left neck without a discernable mass and a single right-sided 1.5-cm jugulodigastric node, but no abnormalities elsewhere. Nasendoscopy demonstrated an ulcerated tumor involving bilateral posterior nasopharyngeal walls and roof, blocking the left Eustachian cushion and abutting the right Eustachian cushion. Biopsy of the primary confirmed the diagnosis of nonkeratinising nasopharyngeal carcinoma (NPC), WHO grade 2. The patient denied any other symptoms on further questioning. He was of Chinese-Malaysian origin and had lived in Australia from the age of 8 years. He had no significant past medical history, was on no medications, and had no family history of NPC. Computed tomography (CT) of the neck confirmed a nasopharyngeal lesion involving the left torus tuberous, multiple leftsided necrotic lymph nodes and a solitary posterior right triangle lymph node. Chest and abdominal CT did not demonstrate disease elsewhere. He was initially staged as T2 N2 WHO grade 2 NPC. To complete his staging, fused positron emission tomography (PET)/CT was organized, which revealed metabolic avidity in the primary nasopharyngeal lesion (Fig 1A, baseline fused PET/CT axial image of nasopharynx), bilateral cervical neck nodes as described (Fig 1B, baseline PET in maximum intensity projection) and a mildly metabolically active right posterior iliac bone lesion (Fig 1C, baseline fused PET/CT axial image showing right ilium). Subsequent magnetic resonance imaging demonstrated a 15- ⫻ 15-mm hypointense T1 signal lesion with hyperintense T2 signal in the corresponding area, with imageguided biopsy proving the presence of metastatic carcinoma consistent with nasopharyngeal primary. He was thus upstaged to T2 N2 M1 disease. He was commenced on carboplatin and infusional fluorouracil chemotherapy and was restaged after three cycles. Examination revealed resolution of his cervical lymphadenopathy. Nasendoscopy revealed overall reduction in size of the primary tumor. Initial PET/CT demonstrated a partial metabolic response in all sites of his tumor. The patient completed six cycles of induction chemotherapy. This was followed by concomitant chemoradiotherapy with conventionally fractionated radiotherapy to a dose of 70 Gy to the primary tumor and neck and 60 Gy in 30 fractions to the right iliac crest lesion, with cisplatin 20 mg/m2 days 1 to 5 in weeks 1, 4, and 7. Post-treatment PET/CT demonstrated a complete metabolic response (Fig 2A, restaging fused PET/CT axial image of nasopharynx; Fig 2B, restaging PET maximum intensity projection; Fig 2C, restaging fused PET/CT axial image showing right ilium). The patient has now survived 5 years after original diagnosis of metastatic disease, with recent PET/CT confirming that there is no evidence of disease recurrence. NPC is recognized to have a propensity for distant metastases.1 The presence of distant metastases at diagnosis approaches 5% of paJournal of Clinical Oncology, Vol 29, No 6 (February 20), 2011: pp e135-e137
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tients when using conventional imaging.2,3 Platinum-based chemotherapy regimens are effective in previously untreated patients in both the neoadjuvant and metastatic/relapsed settings.4-9 The response rate for platinum-based combinations in the metastatic setting is approximately 40% to 70% with a median survival of 1 year. While locoregionally advanced NPC is frequently curable with an intensive course of chemoradiotherapy, the identification of distant metastases on staging investigations would generally deem a patient to be incurable and a more palliative approach would be adopted. However, it has been recognized that the clinical course of metastatic patients can vary with occasional long-term survivors.10-12 It is of interest that in the largest series of long-term survivors reported, patients with bone metastases were treated with combination chemotherapy followed by consolidation low-dose radiotherapy to the bone metastases. PET/CT is well recognized as a superior staging modality for M-stage compared with conventional staging work-up, in terms of specificity, sensitivity, and accuracy.13-17 Approximately 20% of cases will be found to have distant metastases on PET at diagnosis.13 Some of these patients presenting with locoregionally advanced disease will be found to have asymptomatic low-volume single or oligometastases. Based on our case and other reports, it would seem reasonable to treat such patients with curative intent using combination chemotherapy followed by radical radiotherapy to the primary and nodes with concurrent cisplatin, as well as high-dose radiation to the bone metastases.
Annette Lim Peter MacCallum Cancer Centre, Melbourne, Australia
June Corry Peter MacCallum Cancer Center; University of Melbourne, Australia
Eddie Lau Centre for Cancer Imaging, Peter MacCallum Cancer Center; University of Melbourne, Australia
Danny Rischin Peter MacCallum Cancer Center; University of Melbourne, Australia
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest. REFERENCES 1. Chan AT, Teo PM, Johnson PJ: Nasopharyngeal carcinoma. Ann Oncol 13:1007-1015, 2002 2. Teo PM, Kwan WH, Lee WY, et al: Prognosticators determining survival subsequent to distant metastasis from nasopharyngeal carcinoma. Cancer 77: 2423-2431, 1996 3. Lee A, Poon YF, Foo W, et al: Retrospective analysis of 5,037 patients with nasopharyngeal carcinoma treated during 1976-1985: Overall survival and patterns of failure. Int J Radiat Oncol Biol Phys 23:261-270, 1992 4. Su WC, Chen TY, Kao RH, et al: Chemotherapy with cisplatin and continuous infusion of 5-fluorouracil and bleomycin for recurrent and metastatic nasopharyngeal carcinoma in Taiwan. Oncology 50:205-208, 1993 5. Choo R, Tannock I: Chemotherapy for recurrent or metastatic carcinoma of the nasopharynx. Cancer 68:2120-2124, 1991 6. Caponigro F, Longo F, Ionna F, et al: Treatment approaches to nasopharyngeal carcinoma: A review. Anticancer Drugs 21:471-477, 2010
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Diagnosis in Oncology
7. Yeo W, Leung TW, Leung SF, et al: Phase II study of the combination of carboplatin and 5-fluorouracil in metastatic nasopharyngeal carcinoma. Cancer Chemother Pharmacol 38:466-470, 1996 8. Li Y, Wang F, Jiang W, et al: Phase II study of capecitabine and cisplatin combination as first-line chemotherapy in Chinese patients with metastatic nasopharyngeal carcinoma. Cancer Chemother Pharmacol 62:539-544, 2008 9. Chi KH, Chan WK, Cooper DL, et al: A phase II study of outpatient chemotherapy with cisplatin, 5-fluorouracil, and leucovorin in nasopharyngeal carcinoma. Cancer 73:247-252, 1994 10. Fandi A, Bachouchi M, Azli N, et al: Long-term disease free survivors in metastatic undifferentiated carcinoma of nasopharyngeal type. J Clin Oncol 18:1324-1330, 2000 11. Hui EP, Leung SF, Au JS, et al: Lung metastasis alone in nasopharyngeal carcinoma: A relatively favorable prognostic group—A Study by the Hong Kong Nasopharyngeal Carcinoma Study Group. Cancer 101:300-306, 2004 12. Chan SL, Hui EP, Leung SF, et al: Radiological, pathological and DNA remission in recurrent metastatic nasopharyngeal carcinoma. BMC Cancer 6:259-261, 2006
13. Liu F, Lin C, Chang JT, et al: 18F-FDG PET can replace conventional work-up in primary m staging of nonkeratinizing nasopharyngeal carcinoma. J Nucl Med 48:1614-1619, 2007 14. King AD, Ma BB, Yau YY, et al: The impact of 18 F-FDG PET/CT on assessment of nasopharyngeal carcinoma at diagnosis. Br J Radiol 81:291-298, 2008 15. Ng S, Chan S, Yen T, et al: Staging of untreated nasopharyngeal carcinoma with PET/CT: Comparison with conventional imaging work-up. Eur J Nucl Med Mol Imaging 36:12-22, 2009 16. Wang G, Lau EW, Shakher R, et al: Clinical application of 18F-FDG PET/CT to staging and treatment effectiveness monitoring of nasopharyngeal carcinoma. Chin J Cancer 26:3-10, 2007 17. Chua ML, Ong SC, Wee JT, et al: Comparison of 4 modalities for distant metastasis staging in endemic nasopharyngeal carcinoma. Head Neck 31:346354, 2009
DOI: 10.1200/JCO.2010.31.9053; published online ahead of print at www.jco.org on December 6, 2010
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Acknowledgment Annette Lim, MBBS (Hons), is supported by the Spotlight Charitable Foundation Fellowship in Head and Neck Oncology.
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