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Abstract: This 48-year-old middle-aged male patient was more than 5 years after radiotherapy for nasopharyngeal carcinoma, and routine review suggested local recurrence of nasopharynx. After perfect examination of the patient and adequate evaluation, it was concluded that the recurrent lesion could be surgically removed, thus avoiding various serious complications caused by radiation therapy. The patient was followed up regularly for two years. The patient’s condition was controlled stably without recurrence of metastasis.
Basic information】Male, 48 years old
Type of disease】Nasopharyngeal carcinoma
Hospital】Tumor Hospital of Sun Yat-sen University
Consultation time】November 2019
Treatment plan】Surgical treatment (transnasal endoscopic minimally invasive nasopharyngeal mass excision and mucosal flap repair)
Treatment Period】Hospitalization for half a month, regular review
【Treatment effect】Tumor completely removed, no recurrence for more than 2 years after review
I. Initial consultation
The patient was diagnosed with nasopharyngeal undifferentiated non-keratinizing carcinoma 5 years ago as T3N2M0, i.e. cancer stage III, and underwent integrated radiotherapy treatment, which was clinically cured at that time and then reviewed regularly. in November 2019, the patient was reviewed again and pathological biopsy confirmed the recurrence of nasopharyngeal carcinoma after radiotherapy, so he was given to improve relevant examinations.
The patient underwent nasal endoscopy and found that soft tissue was visible in the right posterior parietal wall of the nasopharynx and the right pharyngeal crypt, and pathological examination showed that the lesion was consistent with undifferentiated non-keratinizing carcinoma, and PET-CT was performed, which showed that the mucosal thickening of the right posterior parietal wall of the nasopharynx and the right wall had a denser distribution of radioactivity, and the SUV (i.e., standard uptake value, SUV = radioactive concentration of the lesion (kBq/ml)/(injected dose (MBq)/body weight (kg)) was about 4.5, and the lesion invaded the right palatal sail raphe and was poorly defined from the basal part of the pterygoid bone. Combining the above findings, the possibility of recurrence was clinically considered. The diagnosis was: nasopharyngeal undifferentiated non-keratinizing carcinoma (nasopharyngeal carcinoma) recurring 5 years after radiotherapy, stage III.
Nasal endoscopy
Pathological findings
Magnetic resonance examination
PET-CT
II. Treatment history
The patient was reluctant to undergo a second course of radiation therapy because of the obvious sequelae of dry mouth, hearing impairment and neck stiffness after previous radiation therapy. After considering the patient’s actual situation and combining the MRI and PET-CT examination results, it was considered that the patient could be treated surgically with the hope of complete removal of the recurrent nasopharyngeal tumor after a thorough evaluation. After discussing with the patient and his family, they agreed to the surgical treatment, so a transnasal endoscopic minimally invasive nasopharyngeal mass resection and mucosal flap repair were performed under general anesthesia to remove the tumor. Half a month after the operation, the patient was examined by nasal endoscopy, and it was found that the repaired mucosal flap had covered most of the operated field and the recovery was good.
III. Treatment effect
Postoperative pathological examination showed that the patient’s tumor was completely resected and the marginal cut of the operative field was pathologically negative. Half a month after surgery, the patient was examined by nasal endoscopy, which showed that the repaired mucosal flap had covered most of the surgical field and the recovery was good. One year after surgery, a nasal endoscopy of the patient showed that all walls of the nasopharynx were already covered with mucosa and no other discomfort was observed. The patient has been followed up for two years as of May 2022, and the patient’s condition is now stable. The patient’s tinnitus, nasal congestion and other uncomfortable symptoms have been relieved, and no recurrence of metastasis has been found, indicating that the surgical treatment is effective.
IV. Notes
We are glad that the patient has recovered well after surgical treatment and no recurrence of metastasis has occurred. However, it does not mean that the patient is done with the surgery once and for all. It is still important to follow up the patient regularly after the surgery. This recurrence was detected in time and resected before the tumor grew, which is less difficult to treat. Therefore, patients still need to pay attention to follow-up after this surgical treatment.
In addition, patients should pay attention to develop good living habits in daily life, avoid staying up late, sleeping early and waking up early, and exercising properly, which are beneficial to prevent recurrence again. At the same time, patients should also pay attention to maintain a good state of mind and face life positively, which plays a great role in preventing the recurrence of nasopharyngeal cancer.
V. Personal insight
For the treatment of recurrence of nasopharyngeal carcinoma after radiotherapy, there are several options, especially for early recurrence, and the current evidence is that after comprehensive evaluation, if complete surgical resection is possible, surgical treatment is recommended. In this case, the patient is a recurrent rT3N0M0, and the diagnosis of T3 is an abnormality of the low cranial bone (localized at the base of the pterygoid bone) near the midline suspected by imaging. Such lesions can be completely resected by surgery to avoid various sequelae caused by the second course of radiotherapy.
It should be emphasized that the indications for surgery should be strictly grasped for recurrence of nasopharyngeal cancer after radiotherapy, and a comprehensive imaging evaluation should be performed to understand the extent of recurrent tumor invasion. For patients who cannot be completely removed by surgery, forced surgery is not the best choice.