Nasopharyngeal carcinoma in children

Radiographic assessment of the sinuses in patients treated for nasopharyngeal carcinoma

INTRODUCTION

Patients undergoing therapy for nasopharyngeal carcinoma (NPC) often experience dysfunction of the sinonasal mucosa as a side effect of radiotherapy and chemotherapy. Sinonasal mucosal changes may vary throughout the treatment and posttreatment periods, but little objective data exist characterizing such changes. We evaluated serial radiologic changes of the paranasal sinus mucosa in patients with NPC undergoing treatment.

METHODS

Medical and radiographic records were reviewed for all patients treated for NPC between 2004 and 2006 at Stanford University Medical Center. Pretreatment computed tomography (CT) images served as the baseline images for comparison, and posttreatment CT and magnetic resonance imaging (MRI) images were categorized temporally into 3-month intervals, up to 25 months after initiation of treatment. Images were scored in a blinded fashion using the Lund-Mackay (LM) staging system.

RESULTS

Thirty-five patients received treatment for NPC during the study period, of whom 27 had adequate data for analysis and inclusion in the study. The mean pretreatment LM score was 1.41, and a statistically significant increase in LM score was observed at 3, 6, 9, 12, 15, and 18, 22, and 28 months. There was continued progression of radiologic sinus opacification over the first 30 months after treatment.

CONCLUSIONS

The treatment of NPC with radiotherapy and chemotherapy is associated with radiologic evidence of sinus mucosal thickening. The extent of mucosal thickening can be expected to progress after treatment for up to 30 months. Patients undergoing treatment for NPC should be monitored carefully throughout the posttreatment period for clinical manifestations of dysfunctional sinonasal mucosa.

Nasopharyngeal carcinoma in young patients: a systematic review of racial demographics

OBJECTIVES

To evaluate patients 25 years of age or younger who were treated for nasopharyngeal carcinoma.

STUDY DESIGN

Retrospective review, systematic literature review.

METHODS

Nasopharyngeal carcinoma (NPC) is rare in the Western world. In people younger than 30 years, it is even less common, with an incidence of 1 to 2 per million. This retrospective study was designed to analyze the outcomes of patients 25 years of age or younger who were treated for NPC at a tertiary care academic medical center. Between November 1982 and December 2004, 15 patients meeting the above criteria were treated. These patients form the basis for this report. A systematic review of all NPC trials published in the United States since 1990 was done and the results compared with those of our cohort.

RESULTS

Young African Americans represented 67% of the 15 cases seen at our institution and between 55% and 67% of the patients in the United States. With a mean follow-up of 5.36 years, disease-free survival and overall survival rates were 67% and 87%, respectively. Locoregional control was excellent after treatment with cisplatin-based combination chemoradiotherapy; however, four patients (27%) developed distant metastasis. Despite this, no patients died of disease. Toxicity was significant but manageable, and retreatment met with good success.

CONCLUSIONS

In patients 25 years of age or younger, NPC is more common in African Americans. This may represent a genetic and racial predisposition of this unusual disease in the United States. Late-stage presentations and distant recurrences are common. Platinum-based combination chemoradiotherapy and aggressive management of metastatic disease, however, is associated with good long-term survival. Further study of the possibly changing epidemiology and racial genetics of this unusual tumor is warranted.

Nasopharynx

NPC represents 0.2% of malignant disease in the white population but is more common in southern China, among Chinese in East Asia and the United [figure: see text] States, and in North Africa, including Saudi Arabia. NPC in these ethnic groups tends to manifest at a younger age. Undifferentiated carcinoma is the most common histopathologic type and is associated with EBV. The tumor is optimally assessed with CT and MR imaging for staging; PET scanning provides optimal assessment of recurrent tumor or small lymph node metastases. The primary tumor in the nasopharynx may be small and infiltrating, causing no or only a small mass effect in the nasopharynx. In these cases, obliteration of fat planes and loss of muscle boundaries are important diagnostic findings, which are best evaluated with MR imaging including, Gd-DTPA with fat suppression. The size of the NPC varies from 1 to 2 cm to large tumors that extend to the oropharynx, PPS, nasal cavities, paranasal sinuses, and orbits. Skull base erosion is independent of the size of the nasopharyngeal tumor and ranges from slight erosion to extensive destruction. A concomitant finding is intracranial invasion, predominantly to the basal cisterns and cavernous sinuses associated with cranial nerve palsies. Intracranial invasion should be assessed with contrast MR imaging. Lymph node metastases in the neck are present in 90% of cases and are bilateral in 50% of cases. In a small percentage of cases, extension of lymph node metastases to the mediastinum and hilar areas are encountered. Distant metastases involve the lungs, skeleton, and liver, and occasionally the choroid. They are usually present at the initial presentation [figure: see text] and increase in frequency in advanced disease and in recurrent tumors. In addition, the metastatic lymph nodes in the neck reveal no specific imaging features that would allow differentiation from other lymph node metastases. They may be discrete, often multiple, and large and bulky displaying a variable degree of necrosis and enhancement following introduction of contrast material. Local recurrence manifests commonly within the first 2 to 3 years posttherapy and is optimally evaluated by MR imaging and PET scanning.