Managing Stage IV Nasopharyngeal Cancer: One and a Half Years Post-Treatment

One and a half years after treatment for stage IV nasopharyngeal carcinoma?

My husband has stage IV nasopharyngeal carcinoma (T4N3M0), located in the supraclavicular fossa and the longus colli muscle area.
After a year and a half of treatment, he is doing well.
Recently, during a check-up, there were still lymph nodes in the neck that had been present since radiation therapy, initially measuring 1.2 cm.
It had decreased to 0.6 cm during follow-up every three months, but a recent ultrasound showed it had increased back to 0.96 cm.
Therefore, a PET scan CT was performed, which showed no hypermetabolic activity (no SUV), but there was hypermetabolism in the nasopharyngeal area with an SUV of 5.3, indicating inflammation.
Both CT and MRI reports indicated inflammation without any malignancy, and the nasopharyngoscopy was normal.
1.
Is there a possibility of recurrence?
2.
The neck node still exists without SUV; what could be the reason for its increase in size, and what should we do?
3.
Is it normal for the nasopharynx to show hypermetabolism while the reports indicate inflammation?
4.
Occasionally, he has small hard clumps of nasal mucus with traces of blood; what could be the reason for this?
Thank you for your help.

Mei, 40~49 year old female. Ask Date: 2017/09/19

Dr. Lai Yicheng reply Oncology

1.
Please perform a blood test to check the EBV DNA PCR levels, and then assess for any recurrence.

2.
The cervical lymph nodes have decreased from 1.2 cm to 0.6 cm and then increased to 0.96 cm; I recommend surgical excision for pathological examination.

3.
Is the nasopharyngeal SUVmax: 5.3 the first or second reading? Generally, two readings are required to determine if it is inflammation (the second reading is lower than the first) or tumor recurrence (the second reading is higher than the first).

4.
Over the past 1-2 days, there has been some blood-streaked nasal mucus; could blowing the nose have caused microvascular rupture in the nasopharyngeal mucosa? Wishing you all the best,
Radiation Oncology, Dr.
Lai Yi-Cheng.

Reply Date: 2017/09/19

More Info

Managing Stage IV Nasopharyngeal Cancer, especially after a year and a half of treatment, can be a complex and nuanced process. Your husband's case, characterized by T4N3M0 nasopharyngeal cancer, indicates that the cancer was locally advanced but without distant metastasis at the time of diagnosis. The treatment typically involves a combination of chemotherapy and radiation therapy, which can lead to significant changes in the body and the cancer's behavior over time.

1. Possibility of Recurrence: The concern about recurrence is valid, especially in the context of nasopharyngeal cancer, which can have a tendency to recur in the same region. The fact that there is a history of lymphadenopathy (enlarged lymph nodes) and that the PET scan shows activity in the nasopharyngeal area with an SUV of 5.3 suggests that there may be some residual activity. However, the absence of significant uptake in the neck lymph nodes is reassuring. It is essential to continue monitoring these areas closely, as changes in size or metabolic activity can indicate a need for further intervention.

2. Persistent Neck Node: The lymph node that remains at 0.96 cm without increased SUV may be a reactive lymph node rather than one that is cancerous. Reactive lymph nodes can occur due to inflammation, infection, or post-radiation changes. It is crucial to discuss with your oncologist whether a biopsy of this lymph node is warranted, especially if there are changes in size or if it becomes symptomatic.

3. Inflammation in the Nasopharynx: The finding of increased uptake in the nasopharynx but interpreted as inflammation is not uncommon after treatment for nasopharyngeal cancer. Radiation therapy can lead to changes in the tissue, resulting in inflammation that may mimic cancer recurrence on imaging studies. Regular follow-up with imaging and clinical evaluations is essential to differentiate between post-treatment changes and actual recurrence.

4. Nasal Symptoms: The presence of blood-tinged nasal discharge can be concerning but is not uncommon after radiation therapy. This could be due to several factors, including radiation-induced changes to the mucosal lining, dryness, or even minor trauma to the nasal passages. It is advisable to maintain good nasal hygiene and possibly use saline nasal sprays to keep the nasal passages moist. If the bleeding persists or worsens, a consultation with an ENT specialist may be necessary to evaluate for any underlying issues.

In summary, while there are concerns regarding recurrence and the status of the lymph nodes, the current imaging suggests that there are no definitive signs of active disease. Continuous monitoring and open communication with your healthcare team are vital. They can provide tailored advice based on the latest imaging results and any symptoms that arise. It is also essential to maintain a healthy lifestyle, manage any side effects from treatment, and seek support for both physical and emotional well-being during this journey.

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