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.