Treatment Options for Local Recurrence of Nasopharyngeal Cancer

What treatment options should be considered for local recurrence of nasopharyngeal carcinoma?

My husband is currently 32 years old and was diagnosed with nasopharyngeal carcinoma (T4N2) at the end of 2006.
He immediately underwent radiation therapy and chemotherapy.
However, the MRI report after the entire treatment indicated the presence of an unknown soft tissue mass.
Initially, the radiation oncologist stated that the treatment was very successful, but the otolaryngologist pointed out that this area seemed suspicious and advised us to monitor it closely.
Later, in April 2008, the MRI indicated a possibility of recurrence.
We consulted the radiation oncologist who treated him, and he explained that to protect the optic nerve, the radiation dose in that area was only 5600 cGy, hoping that chemotherapy would compensate for the deficiency.
However, the suspicious location is near the skull base (which is deeper), making it difficult to obtain a sample, requiring multiple surgical biopsies.
We visited several major hospitals in Taiwan, and most recommended that we continue to actively monitor or consider direct radiation therapy.
Now, nearly a year later, he has undergone two PET scans, two MRIs, and two CT scans, with the conclusion being that the mass has slightly increased in size (some doctors even said it has nearly doubled), and the enhancement is becoming increasingly pronounced, raising high suspicion of cancer cells (according to the MRI results from March of this year).
Additionally, since February of this year, my husband has experienced noticeable swelling in his head and episodes of nosebleeds, leading to hospitalization.
The doctors diagnosed it as edema and prescribed some steroids, which have indeed improved his condition.

Here are my questions:
1.
Currently, the only suspicious area has a maximum diameter of about 2 cm.
Can we directly determine if it is cancerous?
2.
Could his current discomfort be due to radiation-induced edema?
3.
If a biopsy is not performed to confirm the diagnosis, is it acceptable to proceed with treatment directly? (He has already undergone radiation therapy totaling 7000 cGy.)
4.
Can you recommend options for radiation therapy and hospitals/doctors? (Traditional surgery, CyberKnife, helical knife, photon knife, etc.)

Xiao Cheng, 30~39 year old female. Ask Date: 2009/04/02

Dr. Chen Sirong reply Oncology

Dear Xiao Cheng,
1.
The final determination of cancer recurrence still relies on confirmation through pathological biopsy.
However, this case has supporting evidence from PET scans and MRIs, along with the presence of clinical symptoms, indicating a high likelihood of cancer recurrence.
2.
The current discomfort is likely due to swelling causing pressure, and the chance of this swelling being caused by tumor recurrence is higher than that caused by radiation-induced edema.
3.
In the presence of sufficient indirect evidence, directly opting for treatment remains appropriate.
Obtaining biopsy confirmation is certainly ideal, but there are challenges in obtaining accurate samples from that location (which is quite deep).
4.
Recurrence of nasopharyngeal cancer at the skull base and undergoing radiation therapy again is indeed more challenging, as there are the eyes' lenses in front and the brainstem nerves behind that need protection.
It is advisable to choose more precise treatment methods, such as CyberKnife or TomoTherapy.
Wishing you safety and health.
Sincerely,
Dr.
Kao Chung-Shu
Attending Physician, Department of Oncology
Taoyuan General Hospital, Ministry of Health and Welfare

Reply Date: 2009/04/02

More Info

When dealing with local recurrence of nasopharyngeal cancer, especially in a case like your husband's, it is crucial to approach treatment options with careful consideration of the patient's medical history, the characteristics of the tumor, and the potential risks and benefits of various therapies.

1. Diagnosis of Cancer Cells: While imaging studies such as MRI and PET scans can provide significant information about the presence and behavior of tumors, they cannot definitively diagnose cancer. The presence of a suspicious soft tissue mass, especially one that is enlarging and showing increased uptake on PET scans, raises the suspicion for malignancy. However, a biopsy is the gold standard for confirming the presence of cancer cells. In your husband's case, given the location near the skull base and previous radiation therapy, obtaining a biopsy may be challenging but is essential for accurate diagnosis and treatment planning.

2. Symptoms and Radiation Edema: The symptoms your husband is experiencing, such as head swelling and nosebleeds, could be attributed to several factors. Radiation therapy can lead to radiation-induced edema, which may cause swelling and discomfort. However, given the context of a possible tumor recurrence, it is essential to consider that these symptoms could also be related to tumor growth or progression. A thorough evaluation by his healthcare team is necessary to differentiate between these possibilities.

3. Treatment Without Biopsy Confirmation: In cases where obtaining a biopsy is difficult, and there is strong clinical and imaging evidence suggesting recurrence, some oncologists may recommend proceeding with treatment based on the likelihood of malignancy. This approach can be justified, especially if the risks of delaying treatment outweigh the benefits of obtaining a definitive diagnosis. However, this should be a carefully considered decision made in consultation with a multidisciplinary team, including oncologists, radiologists, and possibly neurosurgeons.

4. Radiation Therapy Options: Given your husband's history of receiving 7000 cGy of radiation, re-irradiation presents unique challenges. Traditional external beam radiation may not be advisable due to the risk of further damage to surrounding tissues. More advanced techniques such as stereotactic radiosurgery (e.g., CyberKnife or Gamma Knife) or intensity-modulated radiation therapy (IMRT) may be more suitable. These methods allow for more precise targeting of the tumor while sparing healthy tissue, which is especially important in areas close to critical structures like the optic nerve and brainstem.

In conclusion, the management of local recurrence of nasopharyngeal cancer requires a nuanced approach that balances the need for definitive diagnosis with the urgency of treatment. Engaging in a thorough discussion with a multidisciplinary team will help determine the best course of action tailored to your husband's specific situation. It is also advisable to seek a second opinion if there are uncertainties about the proposed treatment plan. Your husband's health and quality of life should remain the primary focus throughout this process.

Similar Q&A

Understanding Nasopharyngeal Cancer Recurrence: Treatment Options Explained

Doctor, this is the 10th year since my nasopharyngeal carcinoma recurrence. An MRI has revealed lymph nodes behind my right ear and neck. I underwent a traditional lymphadenectomy, and the Epstein-Barr virus test came back normal. Why is it necessary to continue with radiation an...

Dr. Chen Sirong reply Oncology
Cai Cai / 40 years old / Female The recommendation from the hospital you visited is reasonable. For neck recurrence, surgery followed by chemotherapy and radiation therapy should be considered to reduce the chances of further recurrence. Of course, choosing between the two optio...

Understanding Nasopharyngeal Cancer Survival Rates and Recurrence Risks

Hello Dr. Chen, my uncle has been diagnosed with nasopharyngeal carcinoma and has completed chemotherapy and radiation therapy. He is in stage III, and he still feels a slight hard lump; the doctor said it's normal. Is this true? My uncle took a year off to rest and has now ...

Dr. Chen Jianzhi reply Otolaryngology
Dear Inquirer, Hello. In patients with nasopharyngeal carcinoma, neck lumps may occur after radiation therapy. This is due to the death of tumor cells, which temporarily leaves the space previously occupied by the tumor filled with scar tissue, resulting in a firm and slightly s...

Targeted Therapy for Nasopharyngeal Cancer: Efficacy and Prognosis

Hello Dr. Chen: Recently, a friend of mine was diagnosed with nasopharyngeal carcinoma, and the pathology report indicates it is stage II. Aside from a hard mass in the neck measuring about 3 cm, there are no other clinical symptoms. I would like to ask you: 1. What is the cure r...

Dr. Chen Sirong reply Oncology
1. Due to the high sensitivity of nasopharyngeal carcinoma cells to radiation, radiation therapy has been the primary treatment for nasopharyngeal carcinoma. While radiation therapy can effectively control local tumor cells, nasopharyngeal carcinoma is prone to metastasis; theref...

Understanding Nasopharyngeal Cancer and Left Neck Tumors: Key Concerns

Hello Dr. Chen, My mother is 64 years old and was diagnosed with stage II nasopharyngeal carcinoma 23 years ago. She underwent cobalt-60 radiation therapy at that time, and her condition has been under control since then. Currently, she suffers from osteonecrosis of both mandib...

Dr. Chen Sirong reply Oncology
Ms. Zhao / 32 / 1 Hello! 1.1 The medical history has lasted for 23 years, with regular check-ups and blood tests at the hospital every year showing no issues. Is there a high chance that this tumor is due to a recurrence of nasopharyngeal carcinoma? A: The likelihood is low, but ...