Nasopharyngeal Carcinoma, Case Study Example

Abstract

The case study below presents the data and treatment for nasopharyngeal carcinoma as found in a white Caucasian female in 2011. The carcinoma was found in the septum and completely obstructed the right side of the nasal cavity with partial obstruction of the left side. Surgical removal was not necessary due to current treatment protocol and a treatment of concurrent chemotherapy and radiation were chosen due to its noninvasiveness of other areas of the body. The patient, at the conclusion of the reports, was responding effectively to treatment and recovering with no significant side effects. Nasopharyngeal carcinoma has shown evidence of successful treatment potential if treated in early stages; advanced stage treatment could require surgical measures afterward.

Introduction

The following case study encompasses the efforts of physicians and surgeons to remove and treat a squamous cell carcinoma of the right nasal cavity. The patient of interest is a Caucasian female with no further metastasis to local or advanced regions and any complicated blood or radiological tests other than the primary diagnosis. Review of the literature will indicate this case to be of value due to the number of studies related to extreme and advanced nasopharyngeal carcinomas or those with reoccurrence after a relatively lengthy time frame.

Case Study

The patient is a 64 year old Caucasian female returning for a two-month follow up visit after the initial diagnosis of a T2N0M0 squamous cell carcinoma of the right nasal cavity. The patient presented initially with a complaint of the inability to breathe out of her nose correctly as well as pain and ‘water’ in her ears. She complained of the inability to smell and taste. She also indicated an instance of a nosebleed in the recent past.

The initial physical examination was conducted on August 10, 2011. The patient’s blood pressure was 105/68, pulse 92, temperature 97.3; all of clinical insignificance. She was reportedly awake and alert with an appearance of no acute distress. Her head appeared normocephacalic and atraumatic and both pupils were equally dilated and reactant to light in a proper manner. Upon examination of her oral mucosa, heart, and lungs, all appeared normal. The abdomen and extremities appeared normal as well. All laboratory blood tests were insignificant and radiology testing was ordered.

Upon review of a PET scan and MRI, initial results revealed the presence of a lesion in the nasal cavity, mostly directed to the right side a sufficiently adhering to the nasal septum. There was so nigh of distant metastatic disease noted. The treatment prescribed was one of chemo-sensitizing radiation therapy. There was no need for surgical resection due to the noninvasive occurrence of the carcinoma.

Further testing reports on September 1, 2011, indicated a nasal septal bone involvement and the PET findings of the supraclavicular and axitulary were benign. This appeared to only be a primary tumor of the nasal cavity with no other bone involvement. The tumor measured about 2 cm in diameter and showed a poorly differentiated non-keratinizing invasive squamous cell carcinoma. There was focal tissue necrosis and no normal squamous cells were present at that time.

The patient returned on September 12 and there were signs of improvement with her respiration as well as a decrease in her pain level and improvement in smell and taste. She was receiving a concurrent dosage of cisplatinum with radiation as well as using Afrin and Flonase as needed for breathing purposes. Chemotherapy and radiation therapy were finished on October 11, 2011. One month prior, a notation was made regarding scarring of the nasal cavity on the left side and also crusting on the anterior wall of the ethmoid region.

A PET and CT were taken again on December 19 and documentation was made of thickening of the right-sided ethmoidal air cells. It was noted that the PET avidity within the brain could have masked small avidities within the ethmoid area. The patient had no new complaints since the beginning of her treatment.

Literature Review

An extensive literature search was conducted on PubMed and journal articles were included from various sources throughout the world. An extensive review of the literature has found nasopharyngeal carcinoma to actually be rather rare in the Western region of the globe. There appears to be a much more increased incidence among Chinese and other Asian ethnicities (Baron-Hay, Clifford, Jackson, & Clarke, 1999; Rajendra, Lee, Leo, Kumar, & Chumpon, 2004). Although this has been the documented statistical evidence, our patient is a Caucasian female and treatment options have relatively remained the same throughout the world no matter the ethnicity.

Studies reported by Delis, Biliatis, Bourli, Kapranos, & Dervenis (2006) and Sun, et al. (2002), believe the liver to be the third most frequent site of metastases for those cases of NPC that do show advanced symptoms. The bones and lungs are rated first and second, respectively, and all of the previous metastasis origins equilibrate with poor prognosis and increased mortality for the patient. However, our patient was found to not have metastasis to any of these regions and has not shown metastasis at this point in her post treatment phase.

Radiotherapy was the preferred method; however, a multi-treatment approach is proving more effective and causing an overall increased survival rate. Three years post therapy; the survival was 24% for a study group of participants in a radiotherapy only group versus 69% for those in the chemoradiotherapy group. Minimum toxicity was reported for both groups and upon completion of the study, concurrent cisplatin and radiotherapy became the standard treatment method for NPC without advanced metastasis (Baron-Hay, Clifford, Jackson, & Clarke, 1999; Boruban, Yavas, Altundag, & Sencan, 2006).

In studies performed by Ferrari et al (2012), it was determined that even advanced stage nasopharyngeal carcinomas, were possible to be remitted by the combination of concurrent chemotherapy and radiotherapy. A study in 2008 treated nasopharyngeal carcinoma by radiotherapy delivered via a limited amount to the mass and the normal surrounding tissues. The study further indicated recurrences of NPC were often treated with palliative chemotherapy unless advanced metastasis was present; thus, in those cases a resection or further irradiation would be the most beneficial to the patient and achieved moderately successful results (O’Donnell, Plowman, Khaira, & Alusi, 2008). The three-year post chemoradiotherapy rate of reoccurrence is around 31% (Wu, Yang, Willey, Ely, Garrett, & Cmelak, 2009).

One important note to mention, as with all chemotherapeutic treatment, the ability to ward off bacterial infections of the central nervous system are important to the mortality of the patient. There is normally, however, a longer incubation period with lymphoma patients and in some occurrences of nasopharyngeal carcinoma. For this reason, it is imperative for patients to maintain a balanced diet and lifestyle as to ward off any infection possible (Tang, Chen, & Ng, 1996).

There also have been additional life threatening complications in addition to bacterial infections. Blindness has been reported as well as invasion of the sinus cavity and the imminent invasion of the brain (Lu, Yang, Yang, Liu, & Chen, 2010). Both of these can be most likely related to the bacterial aspects which would cause the infections occurring at later stages of post treatment success as mentioned above (Roh, Kim, Song, & Oum, 1990; Shambhu & Vose, 2004).

Studies now are concentrating on genetics and other adaptations with various immune specific antigens and mutations which might have different responses in the body and make treatment options more feasible as far as side effects and mortality is concerned. (Chan, Hui, Leung, Chan, & By, 2006; Ferris & Koch, 2003; Murray & Eady, 1981). Genetic content and the usage of alleles to compare the primary tumor with other nodules in the patient’s body could be helpful for future cases pertaining to metastasis (Petersson, Seng, & Lim, 2011).

Literature also indicates if the primary lesion is not detectable, NPC should be considered to be an underlying cause in some secondary autoimmune conditions. This correlates with future research objectives for scientists to uncover more specific genetic based mechanisms to help treat lesions and other metastases in order to improve mortality (Uramatsu, et al., 2010).

Summary of the Case

Ng, Chong, Tan, & Hwang reported in 2003 that almost all nasopharyngeal malignancies are carcinomas. Typically, as evident from the clinical symptoms experienced from our subject, features of NPC include a nasal obstruction with bloody discharge (she only experienced this once) and hearing loss or serous otitis (she complained of having ‘water in her ears’). Unfortunately, more than 90% of these patients have an advanced state of the disease when diagnosis is made, although our patient was not among that group (Tan, Wong, Thamboo, Chang, & Khor, 2008).

As explained in the literature, the reoccurrence rate and mortality rate increase if the carcinoma is found in an advanced stage. With our patient, however, the nasopharyngeal carcinoma was found before it had metastasized to any other locations and she presently has not had indications of any reoccurrence. The treatment of her NPC is indicative of the current treatment protocol method as defined in the literature review. This method, as discussed, has been shown to successfully remit most NPCs if caught in the earlier stages. Our patient is fortunate because she was healthy and did not have underlying conditions which would have further exposed her to bacterial infections or other immosuppressive illnesses that could have caused mortality or other hindrances with the remittance of the carcinoma.

Conclusion

 In conclusion, our patient underwent a relatively safe routine of chemotherapy and radiation for treatment of a nasopharyngeal carcinoma. Had this advanced to include other areas of the body, surgery would have most likely been recommended and the mortality and remittance statistics would not have been as high as they were due to the fact it was caught in the earlier stages. Nasopharyngeal carcinoma is not routinely seen in the Caucasian ethnicity, but can be present. It should never be overlooked because treatment options are available and sufficient to meet most of the needs if caught in time.

References

Baron-Hay, S., Clifford, A., Jackson, M., & Clarke, S. (1999). Life threatening laryngeal toxicity following treatment with combined chemoradiotherapy for nasopharyngeal cancer: A case report with review of the literature. Annals of Oncology , 10, 1109-1112.

Boruban, C., Yavas, O., Altundag, K., & Sencan, O. (2006). Synchronous presentation of nasopharyngeal and renal cell carcinomas. International Brazilian Journal of Urology , 32 (3), 310-312.

Chan, S., Hui, E., Leung, S., Chan, A., & By, B. (2006). Radiological, pathological and DNA remission in recurrent metastatic nasopharyngeal carcinoma. BMC Cancer , 6 (259).

Delis, S., Biliatis, I., Bourli, A., Kapranos, N., & Dervenis, C. (2006). Surgical resection of a solitary liver metastasis from nasopharyngeal carcinoma: A case report. Hepatobiliary Pancreat Dis Int , 5 (4), 610-612.

Ferrari, D., Codeca, C., Bertuzzi, C., Broggio, F., Crepaldi, F., Luciani, A., et al. (2012).

Role of plasma EBV DNA levels in predicting recurrence of nasopharyngeal carcinoma in a Western population. BMC Cancer , 12 (208).

Ferris, R., & Koch, W. (2003). Connective tissue disease coincident with nasopharyngeal carcinoma. Arch Ololaryngol Head Neck Surg , 129, 101-105.

Lu, C., Yang, C., Yang, C., Liu, H., & Chen, Y. (2010). Imaging of nasopharyngeal inflammatory pseudotumours:Differential from nasopharyngeal carcinoma. British Journal of Radiology , 83, 8-16.

Mokhtari, S. (2012). Mechanisms of cyst formation in metastatic lymph nodes of head and neck squamous cell carcinoma. Diagnostic Pathology , 7 (6).

Murray, D., & Eady, R. (1981). Migratory erythema and eosinophilic cellulitis associated with nasopharyngeal carcinoma. Journal of the Royal Society of Medicine , 71, 845-847.

Ng, B., Chong, C., Tan, A., & Hwang, W. (2003). Clinics in diagnostic imaging. Singapore Medical Journal , 44 (10), 542-549.

O’Donnell, H., Plowman, N., Khaira, M., & Alusi, G. (2008). PET scanning and Gamma Knife radiosurgery in the early diagnosis and salvage ‘‘cure’’ of locally recurrent nasopharyngeal carcinoma. British Journal of Radiology , 81, e26-e30.

Petersson, F., Seng, K., & Lim, D. (2011). Paucilymphoid non-keratinizing nasopharyngeal carcinoma with prominent stromal desmoplasia: An unusual case reported with brief comments on uncommon histological variants. Int J Clin Exp Pathol , 4 (4), 410-415.

Rajendra, T., Lee, K., Leo, K., Kumar, K., & Chumpon, C. (2004). Previously-treated nasopharyngeal carcinoma with cystic lesions in the temporal lobe. Singapore Medical Journal , 45 (12), 590-593.

Roh, Y., Kim, J., Song, J., & Oum, B. (1990). Painful ophthalmoplegia secondary to nasopharyngeal carcinoma: A case study report. Korean Journal of Ophthalmology , 4, 112-113.

Shambhu, S., & Vose, M. (2004). High grade lymphoma in the nasopharynx presented as sudden onset of bilateral blindness. BMC Ophthalmology , 4 (2).

Sun, L., Chen, T., Chen, W., Hsieh, M., Liu, J., Huang, C., et al. (2002). Cryptococcus infection in a patient with nasopharyngeal carcinoma: Imaging findings mimicking pulmonary metastases. The British Journal of Radiology , 75, 275-278.

Tan, S., Wong, A., Thamboo, T., Chang, S., & Khor, C. (2008). Pancreas-only metastasis from nasopharyngeal carcinoma. Annals Academy of Medicine , 37 (5), 444-445.

Tang, L., Chen, S., & Ng, S. (1996). Bacterial meningitis in patients with nasopharyngeal carcinoma. Q J Med , 89, 71-76. Uramatsu, T., Furusu, A., Nishino, T., Obata, Y., Kanamoto, Y., Komuro, S., et al.

(2010). Membranous nephropathy complicating nasopharyngeal carcinoma. Internal Medicine , 585-588. Wu, F., Yang, E., Willey, C., Ely, K., Garrett, G., & Cmelak, A. (2009). Refractory

lympho-epithelial carcinoma of the nasopharynx: A case report illustrating a protracted clinical course. Head and Neck Oncology , 1 (18).