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CASE REPORT
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Nasopharyngeal Carcinoma with Bone Marrow Metastasis: Positive Response to Weekly Paclitaxel Chemotherapy Sae Miyaushiro 1, Akira Kitanaka 2, Yoko Kubuki 2, Tomonori Hidaka 2, Kotaro Shide 2, Takuro Kameda 2, Masaaki Sekine 2, Ayako Kamiunten 2, Yoshiko Umekita 3, Takayuki Kawabata 4, Yoriko Ishiguro 5 and Kazuya Shimoda 2
Abstract A 51-year-old man with nasopharyngeal carcinoma underwent chemoradiotherapy with cisplatin and 5fluorouracil, followed by a left cervical lymphadenectomy. Distant metastatic disease was excluded using fluoro-deoxyglucose positron emission tomography. Seven months later, bone marrow metastasis and disseminated intravascular coagulation were diagnosed. The patient received weekly paclitaxel therapy and maintained a good performance status for seven months. During the treatment period, the patient developed no severe organ toxicity except for neutropenia. Weekly paclitaxel may therefore be considered as the treatment of choice in patients with advanced or recurrent nasopharyngeal carcinoma with bone marrow metastasis. Key words: nasopharyngeal carcinoma, bone marrow metastasis, paclitaxel, disseminated intravascular coagulation, CA125 (Intern Med 54: 1455-1459, 2015) (DOI: 10.2169/internalmedicine.54.3917)
toms were successfully controlled by weekly paclitaxel chemotherapy.
Introduction Bone marrow metastasis is a late-stage consequence of several types of solid tumors, including those of the lung, breast, prostate, and gastrointestinal tract (1-3). In general, bone marrow metastasis results in rapidly progressive disease with a poor prognosis (1). A recent study in 83 consecutive patients with solid tumors and bone marrow metastasis reported a median overall survival of 49 days (3). In a cohort of 255 consecutive patients with nasopharyngeal carcinoma, bone marrow metastasis was found in 28 (11%) cases (4). Although bone marrow metastasis in patients with nasopharyngeal carcinoma is not rare, there have been few published studies on the clinical course in this population, and no effective chemotherapeutic regimen has yet been defined (5-8). In this report, we describe a case of nasopharyngeal carcinoma with bone marrow metastasis and disseminated intravascular coagulation (DIC) in whom the symp-
Case Report A 51-year-old man presented to our hospital in November 2011 with a lump in the left upper neck region. A magnetic resonance imaging (MRI) of the head and neck showed a 2cm tumor on the left wall of the nasopharynx, and a left cervical lymphadenopathy with a maximum node size of 3.4×1.9 cm. Histology of the nasopharyngeal biopsy specimen resulted in a diagnosis of nasopharyngeal carcinoma (lymphoepithelial carcinoma). The patient was free of distant metastases at the initial examination, which included a MRI, computed tomography (CT), and fluoro-deoxyglucose positron emission tomography/CT (FDG-PET/CT). The FDG-PET/CT is the most accurate modality for the staging of distant metastases of nasopharyngeal carcinoma (9), so therefore, the patient was considered to have stage IIb
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Clinical Training Center after Graduation, University of Miyazaki Hospital, Japan, ２Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, Japan, ３Department of Pathology, Faculty of Medicine, University of Miyazaki, Japan, ４Department of Otorhinolaryngology, Faculty of Medicine, University of Miyazaki, Japan and ５Takesako Clinic, Japan Received for publication August 17, 2014; Accepted for publication January 6, 2015 Correspondence to Dr. Akira Kitanaka, [email protected]
1455
Intern Med 54: 1455-1459, 2015
DOI: 10.2169/internalmedicine.54.3917
(T1N1M0) disease. Chemotherapy consisting of 5fluorouracil (5-FU) at a dose of 800 mg/m2/day for 5 days (days 1-5) and cisplatin at a dose of 50 mg/m2/day for 2 days (days 6-7) was initially administered, followed by radiotherapy (40 Gy in 20 fractions). The same chemotherapy regimen was used in the remaining treatments. Subsequently chemotherapy, radiotherapy (30 Gy in 15 fractions), and chemotherapy were alternately performed, with a curative intent (10, 11). The assessment of the therapeutic response using CT and MRI at two months after alternating chemoradiotherapy revealed a complete reduction of the primary tumor as well as smaller, but remaining, cervical lymph nodes. Whether the residual lymph nodes observed by the imaging results were viable was not clear. Cervical lymphadenectomy was performed and no microscopic residual tumor was present. Therefore, the patient was considered to have had a complete clinical response. Seven months later, the patient was referred to our hospital with persistent fever. The vital signs showed a temperature of 38.1°C, a blood pressure of 111/67 mmHg, and a heart rate of 103 beats/min. The results of the laboratory investigations were as follows: hemoglobin 10.4 g/dL, hematocrit 31.4%, platelet count 198×109/ L, white blood cell count 12.9×109/L, C-reactive protein 19.70 mg/dL (normal range: ! 0.3), fibrinogen 392 mg/dL (normal range: 200-400), fibrin degradation products (FDP) 95.8 μg/mL (normal range: 1-10), aspartate aminotransferase 161 IU/L (normal range: 13-33), alanine aminotransferase 31 IU/L (normal range: 8-42), lactate dehydrogenase (LDH) 5,877 IU/L (normal range: 119-229), alkaline phosphatase 655 IU/L (normal range: 115-359), creatinine 0.82 mg/dL (normal range: 0.6-1.1), blood urea nitrogen 19.0 mg/dL (normal range: 8.3-22.2), total protein 6.10 g/dL (normal range: 6.64-8.13), and albumin 2.6 g/dL (normal range: 3.70-5.17). The levels of a broad range of serum tumor markers were normal, except for a significantly elevated CA125 concentration of 601.8 U/mL (normal range:
CASE REPORT
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Nasopharyngeal Carcinoma with Bone Marrow Metastasis: Positive Response to Weekly Paclitaxel Chemotherapy Sae Miyaushiro 1, Akira Kitanaka 2, Yoko Kubuki 2, Tomonori Hidaka 2, Kotaro Shide 2, Takuro Kameda 2, Masaaki Sekine 2, Ayako Kamiunten 2, Yoshiko Umekita 3, Takayuki Kawabata 4, Yoriko Ishiguro 5 and Kazuya Shimoda 2
Abstract A 51-year-old man with nasopharyngeal carcinoma underwent chemoradiotherapy with cisplatin and 5fluorouracil, followed by a left cervical lymphadenectomy. Distant metastatic disease was excluded using fluoro-deoxyglucose positron emission tomography. Seven months later, bone marrow metastasis and disseminated intravascular coagulation were diagnosed. The patient received weekly paclitaxel therapy and maintained a good performance status for seven months. During the treatment period, the patient developed no severe organ toxicity except for neutropenia. Weekly paclitaxel may therefore be considered as the treatment of choice in patients with advanced or recurrent nasopharyngeal carcinoma with bone marrow metastasis. Key words: nasopharyngeal carcinoma, bone marrow metastasis, paclitaxel, disseminated intravascular coagulation, CA125 (Intern Med 54: 1455-1459, 2015) (DOI: 10.2169/internalmedicine.54.3917)
toms were successfully controlled by weekly paclitaxel chemotherapy.
Introduction Bone marrow metastasis is a late-stage consequence of several types of solid tumors, including those of the lung, breast, prostate, and gastrointestinal tract (1-3). In general, bone marrow metastasis results in rapidly progressive disease with a poor prognosis (1). A recent study in 83 consecutive patients with solid tumors and bone marrow metastasis reported a median overall survival of 49 days (3). In a cohort of 255 consecutive patients with nasopharyngeal carcinoma, bone marrow metastasis was found in 28 (11%) cases (4). Although bone marrow metastasis in patients with nasopharyngeal carcinoma is not rare, there have been few published studies on the clinical course in this population, and no effective chemotherapeutic regimen has yet been defined (5-8). In this report, we describe a case of nasopharyngeal carcinoma with bone marrow metastasis and disseminated intravascular coagulation (DIC) in whom the symp-
Case Report A 51-year-old man presented to our hospital in November 2011 with a lump in the left upper neck region. A magnetic resonance imaging (MRI) of the head and neck showed a 2cm tumor on the left wall of the nasopharynx, and a left cervical lymphadenopathy with a maximum node size of 3.4×1.9 cm. Histology of the nasopharyngeal biopsy specimen resulted in a diagnosis of nasopharyngeal carcinoma (lymphoepithelial carcinoma). The patient was free of distant metastases at the initial examination, which included a MRI, computed tomography (CT), and fluoro-deoxyglucose positron emission tomography/CT (FDG-PET/CT). The FDG-PET/CT is the most accurate modality for the staging of distant metastases of nasopharyngeal carcinoma (9), so therefore, the patient was considered to have stage IIb
１
Clinical Training Center after Graduation, University of Miyazaki Hospital, Japan, ２Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, Japan, ３Department of Pathology, Faculty of Medicine, University of Miyazaki, Japan, ４Department of Otorhinolaryngology, Faculty of Medicine, University of Miyazaki, Japan and ５Takesako Clinic, Japan Received for publication August 17, 2014; Accepted for publication January 6, 2015 Correspondence to Dr. Akira Kitanaka, [email protected]
1455
Intern Med 54: 1455-1459, 2015
DOI: 10.2169/internalmedicine.54.3917
(T1N1M0) disease. Chemotherapy consisting of 5fluorouracil (5-FU) at a dose of 800 mg/m2/day for 5 days (days 1-5) and cisplatin at a dose of 50 mg/m2/day for 2 days (days 6-7) was initially administered, followed by radiotherapy (40 Gy in 20 fractions). The same chemotherapy regimen was used in the remaining treatments. Subsequently chemotherapy, radiotherapy (30 Gy in 15 fractions), and chemotherapy were alternately performed, with a curative intent (10, 11). The assessment of the therapeutic response using CT and MRI at two months after alternating chemoradiotherapy revealed a complete reduction of the primary tumor as well as smaller, but remaining, cervical lymph nodes. Whether the residual lymph nodes observed by the imaging results were viable was not clear. Cervical lymphadenectomy was performed and no microscopic residual tumor was present. Therefore, the patient was considered to have had a complete clinical response. Seven months later, the patient was referred to our hospital with persistent fever. The vital signs showed a temperature of 38.1°C, a blood pressure of 111/67 mmHg, and a heart rate of 103 beats/min. The results of the laboratory investigations were as follows: hemoglobin 10.4 g/dL, hematocrit 31.4%, platelet count 198×109/ L, white blood cell count 12.9×109/L, C-reactive protein 19.70 mg/dL (normal range: ! 0.3), fibrinogen 392 mg/dL (normal range: 200-400), fibrin degradation products (FDP) 95.8 μg/mL (normal range: 1-10), aspartate aminotransferase 161 IU/L (normal range: 13-33), alanine aminotransferase 31 IU/L (normal range: 8-42), lactate dehydrogenase (LDH) 5,877 IU/L (normal range: 119-229), alkaline phosphatase 655 IU/L (normal range: 115-359), creatinine 0.82 mg/dL (normal range: 0.6-1.1), blood urea nitrogen 19.0 mg/dL (normal range: 8.3-22.2), total protein 6.10 g/dL (normal range: 6.64-8.13), and albumin 2.6 g/dL (normal range: 3.70-5.17). The levels of a broad range of serum tumor markers were normal, except for a significantly elevated CA125 concentration of 601.8 U/mL (normal range:
