One patient--three head and neck primaries: nasopharyngeal, tongue and thyroid cancers.

BACKGROUND: We report a rare case of three head and neck malignancies in one patient. Squamous cell carcinoma of tongue and papillary thyroid carcinoma occurred as metachronous cancers in a patient with primary nasopharyngeal carcinoma. These three pathologically distinct malignancies of head and neck region in one patient is a rare phenomenon and is not reported so far. CASE PRESENTATION: A 60 year old Saudi female patient presented in March 2011 with locally advanced nasopharyngeal carcinoma. After completion of concurrent chemoradiation in June 2011, she developed two new primaries i-e thyroid cancer and tongue cancer in May 2012 along with recurrent nasopharyngeal carcinoma. We discuss histopathologic features, diagnostic tools and treatment modalities for this rarely existing case. CONCLUSION: High index of suspicion and thorough work up is essential in follow up of patients with head and neck primary cancers. The effect of field cancerization and environmental factors need to be explored in greater depths in such selected cases. However, which patients are at increased risk of triplet primaries, is still unknown.

Parapharyngeal space hemangiopericytoma treated with surgery and postoperative radiation--a case report.

Hemangiopericytoma (HPC) is a rare tumor of uncertain malignant potential arising from mesenchymal cells with pericytic differentiation. It accounts for 3-5% of soft tissue sarcomas and 1% of vascular tumors. It usually presents in 5th to 6th decade of life. Most common sites are limbs, pelvis and head and neck. About 20% of all hemangiopericytomas are seen in head and neck, mostly in adults. Usually it presents in orbit, nasal cavity, oral cavity, jaw, parotid gland, parapharyngeal space, masticator space and jugular foramen. Long term follow up is important because of imprecise nature of the histological criteria for prediction of biologic behavior.We report herein a case of HPC in 66-year-old man, who presented in our department with headache, nasal obstruction and dysphagia. A neck computer tomography scan and magnetic resonance imaging showed a large left parapharyngeal mass bulging into nasopharynx and oropharynx with extension to pharyngeal mucosal surface and causing narrowing of airways and total obstruction of left posterior nostril. Angiography showed a highly vascular neoplasm. Initially he was managed as a case of schwannoma and embolization was done but with no response. An attempt to do complete surgical resection was made, but due to its critical position, it was not possible. During surgery, highly vascularised tumor was found. The histopathologic examination revealed a vascular tumor consistent with hemangiopericytoma G-II. The patient had normal postoperative course of healing and was given adjuvant radiation. He is on regular follow up without signs of recurrence or metastases.In summary, parapharyngeal space is a rare site of presentation for hemangiopericytoma which is highly vascular tumor, requiring extensive work up including magnetic resonance imaging, computed tomography scan and angiography. Complete surgical excision should be attempted. Postoperative radiation is indicated in cases of incomplete resection.

Cerebellar mass as a primary presentation of papillary thyroid carcinoma: case report and literature review.

BACKGROUND: Papillary carcinoma is the most common differentiated malignant thyroid neoplasm. The biological course of this cancer is typically indolent with a protracted clinical course. Metastases commonly occur in regional lymph nodes, and distant metastasis is a late and rare occurrence. We report a patient who presented with cerebellar metastasis prior to the diagnosis of papillary thyroid carcinoma and review the literature of brain metastasis from papillary thyroid carcinoma. RESULTS: A 75-year old female presented at the emergency room with progressive dizziness, headache and vomiting, where a brain CT and MRI showed a posterior cerebellar tumor. Surgical resection revealed papillary carcinoma consistent with thyroid origin. Subsequent ultrasound and CT-scan revealed a thyroid nodule, after which the patient underwent total thyroidectomy. Pathologic evaluation was consistent with papillary thyroid carcinoma. CONCLUSION: Brain metastasis may rarely be the initial presentation of papillary thyroid carcinoma. Solitary brain metastasis can completely be resected with better prognosis.

The Role of 18-FDG Positron Emission Tomography (FDG-PET) in Detecting Post- Radiotherapy Loco Regional Relapse/Residual Disease in Nasopharyngeal Cancer.

BACKGROUND: Post-radiotherapy nasopharyngeal changes represent a diagnostic dilemma. Early detection of persistent or recurrent disease may be translated to better cure rate if salvage therapy is implemented. Neither clinical exam nor current radiological anatomical studies (CT/MRI) can differentiate between benign post therapy changes and recurrence. PET scan is a functional study capable of identifying viable tumors as areas of increased radiotracer uptake. METHODS: Fifty-five patients underwent 18-FDG PET scans post radiation therapy for nasopharyngeal carcinoma at King Faisal Specialist Hospital and Research Centre. We compared the 18-FDG PET scan with the clinical, radiological and pathological findings. RESULTS: Clinical examination and CT of the head and neck showed post-treatment abnormality in the nasopharynx in 40 patients. Among these, 28 patients had asymmetry in the CT scan. Three out of the 28 patients had positive PET scan. Out of the 12 patients with positive primary disease in the CT scan, 3 had negative PET scan which was also confirmed by biopsy in 2 patients. Eleven patients had positive PET scan in the primary site; this was pathologically confirmed to be recurrent disease in 5 patients. In 2 patients repeat PET scan was converted to negative. The remaining 4 patients did not have biopsy due to the presence of concurrent distant disease. None of the patients with negative PET scan in the neck exhibit recurrence or persistent neck disease to the day of reporting the study. PET scan showed persistent higher sensitivity, specificity, positive and negative predictive values at both the primary site and the neck region than the CT did. CONCLUSION: PET scan is a useful tool in differentiating between post radiotherapy fibrosis and recurrent nasopharyngeal cancer. KEY WORDS: Nasopharyngeal cancer - FDG/PET - Post therapy changes.

Neoadjuvant chemotherapy followed by concurrent chemo-radiation therapy in locally advanced nasopharyngeal carcinoma.

PURPOSE: To evaluate the efficacy and outcomes of neoadjuvant cisplatinum and epirubicin chemotherapy followed by concurrent cisplatinum chemotherapy with radiotherapy in patients with locally advanced nasopharyngeal carcinoma. METHODS AND MATERIALS: One hundred ten patients (80 male, 30 female) with locally advanced nasopharyngeal carcinoma, staged according to the 1997 International Union Against Cancer/American Joint Committee on Cancer classification system as IIB (n = 9), III (n = 20), IVA (n = 32), and IVB (n = 49), World Health Organization types II (n = 25) and III (n = 85), were included in this protocol between January 1998 and July 2000 at King Faisal Specialist Hospital and Research Centre. Patients underwent two cycles of induction chemotherapy with cisplatinum 100 mg/m(2) and epirubicin 70 mg/m(2) on Days 1 and 21, followed by a radical course of radiotherapy (6,600 cGy in 6.5 weeks, 200 cGy/fraction) starting on Day 42, with three cycles of concurrent cisplatinum 25 mg/m(2) for 4 days on Days 42, 63, and 84. RESULTS: Of 110 patients included in this study, intracranial extension was present in 32 (29%), and nodal stage was N3 in 49 (45%). Complete remission and partial remission were achieved in 87 patients (79%) and 23 patients (21%), respectively. At a median follow-up for surviving patients of 37 months (22-55 months), 49 of 110 patients (44%) had failed treatment: 12 with local, 9 with regional nodes, 4 locoregional, 5 locoregional plus distant areas, and 19 with distant metastases. At the time of writing, 34 patients had died; all deaths were related to the patients' cancer except for 1 patient with treatment-related toxicity. Three-year actuarial overall survival, relapse-free survival, locoregional control, and distant metastasis-free survival rates were 89%, 78%, 88%, and 89% for patients with stage IIB; 71%, 70%, 89%, and 74% for stage III; 68%, 49%, 61%, and 77% for stage IVA; and 70%, 45%, 60%, and 69% for stage IVB, respectively. One patient received only one induction cycle; all others received two cycles; however, 9 of them required 20% reduction in the second cycle dose. Ninety patients (82%) completed two or more concurrent cycles of cisplatinum. Rates of Grade 3 and 4 reactions after induction chemotherapy were as follows: anemia 1% and 0%, leukopenia 8% and 4%, nausea 27% and 0%, vomiting 25% and 0%, and infection 4% and 4%, respectively. Acute Grade 3 and 4 reactions were also observed during chemoradiotherapy: anemia 1% and 0%, leukopenia 31% and 4%, nausea 35% and 0%, vomiting 26% and 2%, infection in 4% and 2%, mucositis in 49% and 0%, and skin reaction in 39% and 0%, respectively. CONCLUSIONS: Neoadjuvant chemotherapy followed by concurrent chemoradiotherapy is a safe and effective method of treatment for locally advanced nasopharyngeal carcinoma. Further investigations in prospective studies are required to evaluate this regimen.

Maxillary sinus carcinoma. Natural history and outcome.

OBJECTIVE: To assess natural history, treatment outcome and pattern of relapse in patients with maxillary sinus carcinoma. METHODS: A review was conducted of the medical records of all adult patients with maxillary sinus carcinoma, who were treated at King Faisal Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia, between January 1990 and December 1999. A total of 60 patients were identified for analysis, 36 men and 24 women; the median age was 58-years (range 23-95). Major presenting symptoms were facial swelling 55%, facial pain 50%, and nasal obstruction 43.4%, with a median duration of 5-months (range 1-24). Histology was squamous cell carcinoma in 71.7% and adenoid cystic in 16.7%. They were restaged according to American Joint Committee on Cancer classification 1997 as II, III and IV in 1, 10 and 49. Thirty patients received treatment with curative intent (surgery in 4 patients, radiotherapy in 2, and combined modality in 24), 6 patients refused treatment and 24 were treated palliatively. RESULTS: With a median follow up of 50-months (range 2-128) in surviving patients treated with a curative intent, 12/30 failed locally, 4/30 in the regional neck nodes and 2/30 had systemic relapse. The actuarial 5-year overall survival (OS), relapse free survival (RFS) and local control rate (LC) were 55%, 39% and 51%. Treatment modality was the only significant prognostic factor for outcome, with 5 year OS, RFS and LC of 72%, 49% and 61%, for combined modality using surgery followed by radiotherapy compared to 0% for single approach (p=0.0003, p=0.0052 and p=0.0098) CONCLUSION: This study indicates that the majority of our patients presented with advanced disease, resulting in poor outcome to conventional treatment modalities. Efforts should be directed to minimize the delay in diagnosis at the primary care level. Combined modality treatment should be offered to all patients with locally advanced disease. New approaches such as neoadjuvant or concurrent chemoradiotherapy with or without surgery need to be considered and evaluated in prospective studies.

A study comparing different approaches in managing neck nodes in early carcinoma of the tongue.

OBJECTIVE: To evaluate elective neck treatment in patients with early stage (T1-2 negative neck node [N0]) squamous cell carcinoma of the oral tongue. METHODS: The medical records of all patients with early stage (T1-2 N0) of oral tongue cancer at the King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia, between January 1980 and December 1997, were identified and retrospectively reviewed. RESULTS: Our cohort consisted of 93 patients: 45 males and 48 females, with a median age of 60 years. All patients received treatment with curative intent. Partial glossectomy was carried out, except for 8 patients who underwent tongue brachytherapy. The neck was observed in 29 patients, 36 were treated by modified neck dissection, and 28 by elective neck irradiation. With a median follow-up of 62 months, 29 patients had documented neck node recurrence. Ninety six percent (28/29) of recurrences occurred within 22 months from treatment completion. The 5 year actuarial event free survival with regard to nodal relapse in observed was 59%, dissected was 79% and irradiated neck was 63%. Our results showed a trend toward better neck node control in patients managed by elective neck dissection compared to those observed (p=0.07) or receiving elective neck irradiation (p=0.18). Tumor thickness of more than 10 mm was associated with increased risk of nodal relapse (p=0.0004). Neck node recurrence has a poor prognosis with a 5 year disease specific survival of 16%. CONCLUSION: A trend for higher neck control was observed after neck dissection in patients with T1-2 N0 squamous cell carcinoma of the oral tongue. Elective neck dissection should be considered particularly for patients with tumor thickness of more than 10 mm.

Stage IV oral cavity carcinoma. Is conventional radical treatment an option?

OBJECTIVE: To evaluate the outcome of radical treatment for patients with stage IV squamous cell carcinoma of the oral cavity. METHODS: Using head and neck tumor database, 57 patients with stage IV non-metastatic invasive squamous cell carcinoma of the oral cavity treated with curative intent at King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia, between July 1992 and June 1998, were identified and retrospectively reviewed. RESULTS: Our cohort of patients consisted of 33 males and 24 females, with a median age of 65 years. The primary sites were alveolus (26), tongue (22), buccal mucosa (6), floor of mouth (2) and retromolar trigone (one). Definitive radiotherapy was used in 7 patients, surgery in 17 and combined modality in 33. With a median follow-up for surviving patients of 53-months, the actuarial 5-year overall survival and relapse free survival was 20% and 14%. Tumors arising from the alveolus showed a better outcome as compared to the rest of oral cavity sites with an overall survival and relapse free survival of 32% and 26% compared to 8% and 4% (p value=0.0057 and 0.0038). CONCLUSION: Advanced oral cavity tumors are aggressive neoplasms with a poor outcome to conventional treatment modalities. New approaches like neoadjuvant or concurrent chemoradiotherapy with or without surgery need to be considered and evaluated in prospective studies.

Appraisal of communication skills and patients' satisfaction in cross-language encounters in oncology practice.

OBJECTIVE: Communication skills are the most important determinant of patients' satisfaction with care. Data about the adverse effects of cross-language encounters are scarce. This prospective study was designed to examine the association between the communication language and patients' satisfaction in oncology practice. PATIENTS AND METHODS: The Art of Medicine questionnaire was used to assess patients' perceptions of clinicians' communication behaviors and patients' global satisfaction. Mean scores of patients cared for by Arabic-speaking oncologists were compared with those of patients who had communications translated from English by interpreters. RESULTS: 255 patients were eligible. Patients' median age was 44 years (95% CI, 42.8-46.2). Communication was in Arabic and interpreted English for 136 (53%) and 119 (47%) patients, respectively. The two groups were comparable for various demographic and clinical variables. On a nine-point scale, mean scores for the eight questionnaire items ranged from 6.24 (95% CI, 5.91-6.56) to 8.24 (95% CI, 8.03-8.45). There was no significant difference in communication skills between Arabic- and English-speaking clinicians for any questionnaire item. Moreover, a multiple regression analysis failed to identify any variable that independently influenced overall patients' satisfaction with the delivered care. CONCLUSIONS: The findings do not support a disadvantageous effect on interpersonal skills and patients' satisfaction as a result of cross-language communication.