Case Report
A 42 year old Caucasian male presented with two months of left sided
otalgia, odynophagia and increasing left sided lymphadenopathy. He had a
25 pack year smoking history. Initial FDG-PET/CT scan showed increased
avidity in the left BOT and within multiple bilateral neck nodes. There
was also increased FDG uptake within the left fossa of
rosenmuller
(FoR) (Figure 1). MR imaging showed only mild asymmetry in FoR
without a definite structural abnormality. Panendoscopy revealed a 4cm
ipsilateral left BOT mass and fullness in the left FoR with prominent
midline adenoid tissue (Figure 2 ). Initial biopsy was negative
for malignancy at the left BOT and positive for a p16+/EBV- SCC from the
nasopharynx (Figure 3) . In the setting of an obvious BOT
lesion, there was a concern regarding mislabelling and a second
panendoscopy with biopsies demonstrated a p16+ SCC of the left BOT and
normal nasopharyngeal tissue. A repeat PET/CT revealed ongoing avidity
in the BOT and neck nodes, with reduced uptake in the nasopharynx (SUV
max 6.15 vs initial SUV max 11.51). A repeat panendoscopy with
nasopharyngeal adenoidectomy and deep biopsies of the left FoR confirmed
the diagnosis of p16+/EBV- NPC.
Final clinical staging was T3 OPC and T1 NPC with bilateral neck nodal
involvement (N2). Noteworthy in this case was the location of two nodal
deposits identified on both PET/CT and cross-sectional imaging which
were located outside the usual prophylactic clinical target volumes
(Figure 4 ): (1) a node deep to levator scapulae and (2) a
parapharyngeal node at the level of the hypopharynx. A recommendation
was made for radical intent chemoradiotherapy, 70Gy in 35 fractions to
both primaries and bilateral necks with concomitant three-weekly
cisplatin (100mg/m2). Following percutaneous endoscopic gastrostomy
insertion (PEG), treatment was completed without a break and with the
anticipated acute treatment toxicities. PET/CT, three months post
treatment confirmed complete metabolic response (figure 5). On
last review (three months post treatment), he remains PEG
dependent able to swallow small amounts of thin fluids.